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Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

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52–502 2009

HEARING ON PROPOSALS TO PROVIDE 

FEDERAL FUNDING FOR EARLY 

CHILDHOOD HOME VISITATION PROGRAMS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON INCOME SECURITY 

AND FAMILY SUPPORT 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

JUNE 9, 2009 

Serial No. 111–24 

Printed for the use of the Committee on Ways and Means 

( 


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COMMITTEE ON WAYS AND MEANS 

CHARLES B. RANGEL, New York, Chairman 

FORTNEY PETE STARK, California 

SANDER M. LEVIN, Michigan 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

JOHN S. TANNER, Tennessee 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

EARL POMEROY, North Dakota 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL JR., New Jersey 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

ALLYSON Y. SCHWARTZ, Pennsylvania 

ARTUR DAVIS, Alabama 

DANNY K. DAVIS, Illinois 

BOB ETHERIDGE, North Carolina 

LINDA T. SANCHEZ, California 

BRIAN HIGGINS, New York 

JOHN A. YARMUTH, Kentucky 

DAVE CAMP, Michigan 

WALLY HERGER, California 

SAM JOHNSON, Texas 

KEVIN BRADY, Texas 

PAUL RYAN, Wisconsin 

ERIC CANTOR, Virginia 

JOHN LINDER, Georgia 

DEVIN NUNES, California 

PAT TIBERI, Ohio 

GINNY BROWN-WAITE, Florida 

GEOF DAVIS, Kentucky 

DAVE G. REICHERT, Washington 

CHARLES W. BOUSTANY JR., Louisiana 

DEAN HELLER, Nevada 

PETER J. ROSKAM, Illinois 

Janice Mays, Chief Counsel and Staff Director 

Jon Traub, Minority Staff Director 

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT 

JIM MCDERMOTT, Washington, Chairman 

FORTNEY PETE STARK, California 

ARTUR DAVIS, Alabama 

JOHN LEWIS, Georgia 

SHELLEY BERKLEY, Nevada 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

SANDER M. LEVIN, Michigan 

DANNY K. DAVIS, Illinois 

JOHN LINDER, Georgia 

CHARLES W. BOUSTANY JR., Louisiana 

DEAN HELLER, Nevada 

PETER J. ROSKAM, Illinois 

PAT TIBERI, Ohio 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Ways and Means are also, published in electronic form. The printed 

hearing record remains the official version. Electronic submissions are used to prepare 

both printed and electronic versions of the hearing record, the process of converting between 

various electronic formats may introduce unintentional errors or omissions. Such occurrences 

are inherent in the current publication process and should diminish as the process is further 

refined. 


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C O N T E N T S 

Page 

Advisory of July 02, 2009, announcing the hearing .............................................. 2 

WITNESSES 

Joan Sharp, Executive Director, Council for Children and Families of Washington, Seattle, Washington ................................................................................ 17 

Deborah Daro, Ph.D., Research Fellow, Chapin Hall Center for Children 

at the University of Chicago, Chicago, Illinois .................................................. 25 

Jeanne Brooks-Gunn, Ph.D., Professor of Child Development at Teachers 

College and the College of Physicians and Surgeons, Columbia University, 

New York, New York ........................................................................................... 34 

Cheryl D’Aprix, Senior Family Support Worker, Starting Together Program, 

Canastota, New York ........................................................................................... 38 

Sharon Sprinkle, RN, Nurse Consultant, Nurse Family Partnership, Denver, 

Colorado ................................................................................................................ 41 

SUBMISSIONS FOR THE RECORD 

Alice Kitchen, Statement ........................................................................................ 76 

Children and Family Futures, Statement ............................................................. 77 

Children’s Defense Fund, Statement ..................................................................... 82 

Dan Satterberg, Statement ..................................................................................... 88 

David Mon, Letter ................................................................................................... 90 

Every Child Succeeds, Statement ........................................................................... 90 

Family Violence Prevention Fund, Statement ...................................................... 94 

First 5 Alameda County Every Child Counts, Statement .................................... 95 

Gaylord Gieseke, Statement ................................................................................... 98 

Gladys Carrio ́n, Letter ............................................................................................ 100 

Healthy Families Florida, Statement .................................................................... 101 

Howard S. Garval, Statement ................................................................................. 103 

Kansas Children’s Service League, Statement ...................................................... 104 

Kathee Richter, Statement ..................................................................................... 105 

Lenette Azzi-Lessing, Ph.D., Statement ................................................................ 107 

Marcia Slagle, Statement ........................................................................................ 109 

Matthew Melmed, Letter ........................................................................................ 110 

Nancy Ashley, Statement ........................................................................................ 114 

National Child Abuse Coalition, Statement .......................................................... 115 

National Indian Child Welfare Association, Statement ....................................... 119 

Oneta Templeton McMann, Statement .................................................................. 120 

Ounce of Prevention Fund, Statement ................................................................... 122 

Parents as Teachers, Statement ............................................................................. 122 

Prevent Child Abuse America, Statement ............................................................. 125 

Robin Roberts, Letter .............................................................................................. 129 

Stephanie Gendell, Statement ................................................................................ 130 

The National Conference of State Legislatures, Statement ................................. 131 

The Parent-Child Home Program, Statement ....................................................... 132 

The Pew Center on the States, Statement ............................................................ 137 

Voices for America’s Children, Statement ............................................................. 140 

Child Welfare League of America, Statement ....................................................... 144 

Fight Crime, Statement .......................................................................................... 152 

Sharon Sprinkle, Statement ................................................................................... 154 


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HEARING ON PROPOSALS TO PROVIDE 

FEDERAL FUNDING FOR EARLY 

CHILDHOOD HOME VISITATION PROGRAMS 

TUESDAY, JUNE 9, 2009 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON WAYS AND MEANS, SUBCOMMITTEE ON INCOME SECURITY AND FAMILY SUPPORT, Washington, DC. 

The Subcommittee met, pursuant to call, at 10:03 a.m., in room 

B–318, Cannon House Office Building, Hon. Jim McDermott 

(Chairman of the Subcommittee) presiding. 

[The advisory announcing the hearing follows:] 


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ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON INCOME SECURITY AND FAMILY 

SUPPORT 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–1025 

June 02, 2009 

IFSF–3 

McDermott Announces Hearing on Proposals to 

Provide Federal Funding for Early Childhood 

Home Visitation Programs 

Congressman Jim McDermott (D–WA), Chairman of the Subcommittee on Income 

Security and Family Support of the Committee on Ways and Means, today announced that the Subcommittee will hold a hearing to review proposals to provide 

funding for grants to States to support early childhood home visitation programs. 

The hearing will take place on Tuesday, June 9, 2009, at 10:00 a.m. in B– 

318 Rayburn House Office Building. In view of the limited time available to 

hear witnesses, oral testimony at this hearing will be from invited witnesses only. 

However, any individual or organization not scheduled to appear may submit a written statement for consideration by the Subcommittee and for inclusion in the record 

of the hearing. 

BACKGROUND: 

Early childhood home visitation programs provide instruction and services to families in their homes. These programs are designed to enhance the well-being and development of young children by providing: information on child health, development, 

and care; parental support and training; referral to other services; or a combination 

of these services. Typically visits begin during pregnancy or shortly after a child’s 

birth and may last until a child is age four. Home visits are conducted by nurses, 

social workers, other professionals or paraprofessionals. 

A growing body of research has found strong evidence that early childhood home 

visitation programs are effective in reducing the incidence of child abuse and neglect, and in improving child health and development, parenting skills, and school 

readiness. A majority of States currently provide early childhood home visitation 

services to a relatively small number of families. President Obama’s FY 2010 budget 

includes a proposal to support States in creating and expanding evidence-based 

home visitation services. Consistent with the President’s budget proposal, Subcommittee Chairman Jim McDermott (D–WA) and Representative Danny Davis (D– 

IL) are introducing legislation today, The Early Support for Families Act, that would 

provide mandatory funding to States to create and expand early childhood home visitation programs. The McDermott-Davis bill would support rigorously evaluated programs that utilize nurses, social workers, other professionals and paraprofessionals 

to visit families, especially lower-income families, on a voluntary basis. 

In announcing the hearing, Chairman McDermott stated, ‘‘Home visitation programs have a proven track record of increasing the chances that a child 

will have a safer, healthier, and more productive life. There is considerable 

interest in expanding these programs to reach more families. I look forward to working with all of my colleagues to advance a proposal that will 

achieve that goal.’’ 


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FOCUS OF THE HEARING: 

The hearing will focus on proposals to provide mandatory funding for grants to 

support State efforts to establish and expand early childhood home visitation programs. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee 

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘Committee Hearings’’. Select the hearing for 

which you would like to submit, and click on the link entitled, ‘‘Click here to provide 

a submission for the record.’’ Once you have followed the online instructions, complete all informational forms and click ‘‘submit’’ on the final page. ATTACH your 

submission as a Word or WordPerfect document, in compliance with the formatting 

requirements listed below, by close of business Tuesday, June 23, 2009. Finally, 

please note that due to the change in House mail policy, the U.S. Capitol Police will 

refuse sealed-package deliveries to all House Office Buildings. For questions, or if 

you encounter technical problems, please call (202) 225–1721. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing 

record. As always, submissions will be included in the record according to the discretion of the Committee. The Committee will not alter the content of your submission, 

but we reserve the right to format it according to our guidelines. Any submission 

provided to the Committee by a witness, any supplementary materials submitted for 

the printed record, and any written comments in response to a request for written 

comments must conform to the guidelines listed below. Any submission or supplementary item not in compliance with these guidelines will not be printed, but will 

be maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word or WordPerfect 

format and MUST NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official 

hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

3. All submissions must include a list of all clients, persons, and/or organizations on whose 

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone, and fax numbers of each witness. 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TTD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://waysandmeans.house.gov

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. 

Chairman MCDERMOTT. This Subcommittee has a mission of 

working on a bipartisan basis to ensure the safety and well-being 

of children, and I hope today marks the beginning of our next step 

toward that goal. 

Last year, we produced major legislation to help relatives caring 

for foster children to provide support for tens of thousands of children who are now aged out of foster care on their 18th birthday, 


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to improve the oversight of health and educational needs in children and to increase the support for adoption assistance. 

When we passed that bill, I said at the time our job is far from 

done. We still have a child protection system that is designed primarily as a response program, rather than a prevention and response program. 

Along with Danny Davis and Todd Platts, I put forward legislation last week to take a more proactive approach to helping families. The Early Support for Families Act, H.R. 2667, would provide 

Federal funding for home visitation programs to reduce child maltreatment as well as to improve children’s health and school readiness. As the Federal Department of Health and Human Services 

declared under President Bush, quote, ‘‘There is a growing body of 

evidence that some home visitation programs can be successful as 

a child maltreatment prevention strategy.’’ I agree and I think we 

ought to proceed down that road. 

The Early Support for Families Act follows President Obama’s 

budget recommendation to provide grants to States to help them 

establish or expand their voluntary home visitation programs for 

families with young children and families expecting children. Only 

programs using evidence-based models that have demonstrated 

positive effects on important child and parenting outcomes would 

be eligible for the funding. Home visits could start during pregnancy and could be conducted by nurses or social workers or 

trained paraprofessionals. The visits would focus on providing information on child health, development and care, on parental training and support, and on referrals to other services. 

Many States have home visitation programs funded with State 

dollars and/or a hodgepodge of Federal funding. According to the 

Pew Center on the States, less than 15 percent of families needing 

home visitation are now served. The legislation we put forward 

would provide a dedicated funding source to ensure many more 

children receive the benefits of home visitation. 

Although my colleague, Danny Davis, who is not here yet, I 

want—he is at the Congressional Black Caucus Summit on Health. 

He authored a home visitation bill in the Education and Labor 

Committee during the last Congress, and the principles of that legislation—are really a guiding force in the bill we put forward here 

together. I don’t believe home visitation would be so squarely on 

our agenda without his efforts. 

I also want to add that there is some talk about adding this provision to the health care reform bill that is presently being massaged through the Congress. Whether or not that happens or not 

remains to be seen. 

But I would now like to recognize my Ranking Member, Mr. Linder. 

Mr. LINDER. Thank you, Mr. Chairman. 

Today’s hearing offers a timely reminder of the differences between the fantasyland of Washington, D.C., and the reality of the 

rest of America. Here in fantasyland, we will discuss adding one 

more multibillion dollar entitlement program. This would be on top 

of the new higher education entitlement program created this year, 

and of course, our current health care and retirement entitlement 


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programs whose looming insolvency recently led President Obama 

to say ‘‘we’re broke.’’ 

But we are actually worse than broke. We are massively in debt, 

and it is getting deeper every day. USA Today reported last week 

that in 2008 the average U.S. household owed almost $550,000 in 

Federal debt. That is four times what the same average household 

holds in mortgage, car loan, credit card and other debt combined. 

And that is before this year’s trillion-dollar orgy of so-called stimulus spending. 

Meanwhile, in the real world, the recession is forcing States to 

cut current spending. And California, the Governor proposes eliminating the welfare-to-work program and health insurance for nearly 1 million low-income kids. After their 2009 budgets passed, 42 

States enacted emergency spending cuts totaling $32 billion. 

These are not minor adjustments. Yet the legislation we will discuss today breezily assumes States will find $3 billion in new 

money over the next decade to finance their part of this new entitlement. Where will that money come from? The tooth fairy? Being 

a dentist, I can tell you something about that, but I won’t say it 

out loud. 

I don’t often agree with Robert Greenstein, the head of the liberal Center on Budget and Policy Priorities. But last week in the 

New York Times he said, ‘‘A budget tsunami is coming. That threat 

should be taken a hell of a lot more seriously than it is now ’’. In 

the current budget crisis, he called for ‘‘scrapping marginal programs to save the most essential.’’ 

Today we are ignoring that coming tsunami and strolling along 

the beach contemplating another program. Several of our witnesses 

will discuss how some home visitation programs have shown some 

positive effects. We know that from programs already operating, 

often with Federal and State program money. But obviously our 

colleagues think it is not enough because it is never enough. 

If you added up all the Federal and State funds. States could 

spend on home visitation, it is an incredible $244 billion a year. 

Obviously States don’t spend all that money this way, having other 

priorities or now needing to cut other priorities. So we in Washington will create a new program that forces them to. Not a program that increases child abuse prevention funds that may be 

spent on home visitation, but a program whose funds must be 

spent on home visitation, and nothing else. 

And if States won’t spend this money, or can’t come up with their 

own share, the Federal cash will be given to another State. So it 

is Washington’s way or the highway. Except the children will be 

the ones who will really pay when the upcoming budget tsunami 

washes this and other programs away. 

Mr. Chairman, all of us are interested in making sure every child 

gets a good start in life. I support reviewing current home visitation programs that fall under the Committee’s jurisdiction and how 

they can be improved. However, at this time of massive and growing Federal and State deficits, I simply cannot support the creation 

of a new entitlement that would send another $8.5 billion in unpaid-for Federal spending out the door. 


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To help illustrate the current economic situation, in closing I ask 

unanimous consent to insert three documents into this record at 

this point. 

The first is an Associated Press article from last week that lists 

the massive spending cuts under consideration in California today 

to bring its budget into balance. 

[The information follows:] 


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Mr. LINDER. The second is a Wall Street Journal article from 

last week titled States’ Budget Woes Are Poised to Worsen. 

[The information follows:] 


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Mr. LINDER. And the third is the latest summary of the Federal 

budget situation by the Congressional Budget Office showing that 

the Federal deficit was $180 billion just in the month of May. 

[The information follows:] 


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Mr. LINDER. Thank you, Mr. Chairman. 

[The prepared statement of Mr. Linder follows:] 


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Chairman MCDERMOTT. Without objection, those articles will 

be entered into the record. Thank you, John. 

The first witness will be Joan Sharp, who is the executive director of the Council for Children & Families of Washington, my home 


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State, one of the few States that has actually an organization set 

up for the specific purpose of trying to prevent child abuse. 

Ms. Sharp. 

STATEMENT OF JOAN SHARP, EXECUTIVE DIRECTOR, COUNCIL FOR CHILDREN & FAMILIES, SEATTLE, WASHINGTON 

Ms. SHARP. Thank you, Chairman McDermott, Ranking Member Linder, honorable Members of the Committee. My name is 

Joan Sharp. I am the Executive Director of the Council for Children & Families in Washington State. We are a small State agency, an office of the Governor. 

We also serve as the Children’s Trust Fund of Washington and 

the Washington Chapter of Prevent Child Abuse, America. Our 

mission is to prevent child abuse and neglect before it occurs. We 

strongly support this Committee’s efforts to advance home visiting 

legislation. 

I am here today to share with you our experience and expertise 

in funding, monitoring and supporting evidence-based home visitation programs. From our 27 years of leading child abuse and neglect prevention in Washington State, this is what we have come 

to know with great certainty: Child abuse and neglect are preventible. 

To ensure a better future for Washington’s children, we work to 

increase public understanding of child abuse in order to engage individuals, families, communities and systems in becoming part of 

the solution. In the last 5 years, we have increasingly focused on 

evidence-based home visiting as our preferred strategy to decrease 

child maltreatment. 

In 2006, the Council for Children & Families proposed to the 

Washington State legislature a substantial expansion of evidencebased home-visiting programs. This request followed a period of 

significant preparation. 

First, we had quantified the need. Our research suggested that 

50 percent of families under 185 percent of poverty, of the Federal 

poverty level, with children birth-to-5, or a total of about 25,000 

families annually in Washington, would be eligible for appropriate 

for and would voluntarily participate in the home visiting program. 

We also convened a research advisory Committee of academicians, providers and other informed stakeholders to set the criteria 

that we would use to establish a reasonable yet rigorous evidentiary threshold. We are then able to identify a number of home 

visiting models that met these criteria. 

In addition, we conducted statewide outreach. We wanted to ensure that communities understood evidence-based programs before 

they embarked on their own process to determine local interest, resource availability and which model might best meet community 

needs and conditions. 

In 2007, the Washington State legislature appropriated $3.5 million over a 2-year period to fund evidence-based home visiting. We 

then implemented a request for proposal process, identified the 

strongest applicants serving high-need communities and initiated 

performance-based contracted to implement an array of evidencebased home-visiting programs serving diverse communities across 

the State. 


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We have since begun to see the very positive outcomes that these 

programs are developing with Washington’s vulnerable children 

and families. We have also seen that if the strong benefit of these 

programs is to be widely felt, State and local resources alone will 

not get us to our goal. 

The Council for Children & Families supports an array of evidence-based home visiting models. While we want for our children 

and families only the strongest programs, the truth is that with 

limited research dollars available, many promising home-visiting 

programs have not yet had the opportunity to conduct the gold 

standard research. 

The multiple randomized control trials and longitudinal studies 

necessary to prove their effectiveness. And the fact is no one size 

fits all. Families need and want a variety of supports and services 

and communities need and want the strategies that fit best for 

them. 

We also are very concerned about the implementation challenges 

that many organizations have in learning to deliver these evidencebased programs with fidelity to the model. This is an area that requires the technical assistance and training that the legislation allows for in the set-aside for those services. There are many implementation challenges in moving our field to these goals. 

In conclusion, I would like to thank Chairman McDermott, Ranking Member Linder and the Committee Members for inviting us to 

speak with you today. We fully support your efforts to advance 

home visiting legislation and are happy to provide more information as needed to inform your deliberations around House Resolution 2667. 

Thank you again. 

[The prepared statement of Ms. Sharp follows:] 


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Statement of Joan Sharp, Executive Director, Council for Children and 

Families of Washington, Seattle, Washington 


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Chairman MCDERMOTT. Thank you for your testimony. 

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I forgot to say at the start, your entire testimony will be entered 

into the record, and we ask you to limit your comments to 5 minutes. And you were 5 minutes and 6 seconds which is almost perfect. 


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So I am not putting anything on anybody that I wouldn’t put on 

my home State. And I hope that you will all—will try to get to 

whatever else is in your testimony through the questioning period. 

Dr. Daro, who is the research fellow at Chapin Hall at the University of Chicago. Welcome. I trained at the University of Illinois. 

So there is a little bit of rivalry, I suppose, although Chicago is a 

big city; they have two baseball teams. 

STATEMENT OF DEBORAH DARO, PH.D., RESEARCH FELLOW, 

CHAPIN HALL AT THE UNIVERSITY OF CHICAGO, CHICAGO, 

ILLINOIS 

Ms. DARO. You also grew up very close to where I live. 

I want to thank you, Chairman McDermott and the Committee, 

for inviting me this morning to have this opportunity to discuss 

with you about what this important legislation. 

The President’s decision to invest in home visitation for 

newborns and the Congress’ willingness to act on this decision 

demonstrates a commitment to an evidence-informed public policy, 

a commitment essential if we are to successfully confront complex 

problems such as child maltreatment. Although no legislation 

comes with absolute guarantees, the Early Support for Families 

Act builds on an impressive array of empirical evidence and creates 

an implementation culture that emphasizes quality and continuous 

program improvement. 

In my time this morning I want to briefly summarize this evidence base, talk about the program elements associated with more 

positive outcomes, and underscore the importance of using this legislation not simply to deliver a product, but also to enhance learning. 

With respect to the evidence, confidence in the efficacy of early, 

home-based interventions rests on a diverse and expanding number 

of high-quality program evaluations. This includes the seminal 

work of David Olds and his colleagues, showing initial and longterm benefits from early nurse home visitation when provided to 

first time moms early in their pregnancy, the expanding research 

including both randomized clinical trials and other strong research 

designs that support the efficacy and efficiency of several national 

home visitation models serving more diverse populations and the 

ongoing investment and experimentation at the State and local 

level across this country to create the infrastructure necessary to 

ensure such services are sustainable and integrated into existing 

health and early education systems. 

The consistent message from this large and growing body of research is that the chances of success, regardless of the model, are 

improved when programs have certain features. It is improved 

when programs have: 

Solid internal consistency that links specific program elements to 

specific outcomes; 

Strong provider/participant relationships that extend for a significant period of time to accomplish meaningful change in a parent’s knowledge levels, skills and an ability to establish a positive 

attachment with her infant; 

Well-trained and competent staff; 


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High-quality supervision that includes observation of the home 

visitor interacting with the parent; 

Solid organizational capacity among those community agencies 

delivering this service; and 

Appropriate linkages to other community resources and supports. 

As Congress moves forward toward developing this legislation, 

these parameters, rather than the utility of a given model or research design, should guide your thinking. Unless all of the interventions supported by this initiative are structured around these 

types of core practice principles, the odds of success, regardless of 

the model you use, are greatly diminished. 

Second, defining the evidentiary base necessary for estimating 

the potential impacts of a given intervention is complex. As noted 

in a recent memo to OMB by the American Evaluation Association, 

‘‘There are no simple answers to questions about how well programs work, and there is no single analytic approach or method 

that can decipher the complexities that are inherent within the 

program environment and assess the ultimate value of public programs.’’ Given this reality, this legislation should direct States to 

consider a model’s full research portfolio, not simply count the 

number of randomized clinical trials that have been done. Knowing 

a program can be implemented under ideal circumstances is not 

the same as knowing a program will achieve comparable effects 

when broadly implemented with a more challenged population and 

in communities that are more poorly resourced. 

Fortunately, the research base on which this legislation draws is 

much wider and more nuanced than a handful of clinical trials. 

State planners should be directed to consider all facets of this database in identifying those evidence-based programs best suited to 

their service delivery context, their community challenges and their 

at-risk populations. 

Finally, the act’s emphasis on evaluation and data documentation is perhaps its most important feature. Home visitation, while 

promising, does not produce consistent impacts in all cases. Not all 

families are equally well served by the model. Retention in longterm interventions can be difficult. Identifying, training and retaining competent service providers is challenging, particularly when 

the strategy is made widely available to diverse populations. 

Addressing these and similar questions requires that evidencebased interventions be implemented not only in light of what we 

know, but also in humble recognition of our obligation to do better. 

Improving our ability to identify, engage and effectively serve new 

parents facing the most challenging circumstances requires more 

than implementing a program. Doing better requires a research 

and policy agenda that recognizes the importance of linking learning and practice. Initiatives must be implemented and assessed in 

a manner that maximizes both the ability of researchers to determine the efforts efficacy and the ability of program managers to 

draw on these data to shape their practice and policy decisions. 

The Early Support for Families Act encourages and rewards innovation by providing State planners important incentives to expand the pool of evidence-based programs in ways that will 

strengthen outcomes for family, improve service efficiencies and 

maximize social savings. 


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Thank you. 

Chairman MCDERMOTT. Thank you very much for your testimony. 

[The prepared statement of Ms. Daro follows:] 

Statement of Deborah Daro, Ph.D., Research Fellow, Chapin Hall Center 

for Children at the University of Chicago, Chicago, Illinois 

Early intervention efforts to promote healthy child development have long been 

a central feature of social service and public health reforms. Today, prenatal care, 

well-baby visits, and assessments to detect possible developmental delays are commonplace in most communities. The concept that learning begins at birth, not when 

a child enrolls in kindergarten, has permeated efforts to improve school readiness 

and academic achievement (Kauffman Foundation, 2002). Recently, child abuse prevention advocates have applied a developmental perspective to the structure of prevention systems, placing particular emphasis on efforts to support parents at the 

time a woman becomes pregnant or when she gives birth (Daro & Cohn-Donnelly, 

2002). 

Although a plethora of options exist for providing assistance to parents around the 

time their child is born, home visitation is the flagship program through which 

many states and local communities are reaching out to new parents. Based on data 

from the large, national home visitation models (e.g., Parents as Teachers, Healthy 

Families America, Early Head Start, Parent Child Home Program, HIPPY, and the 

Nurse Family Partnership), it is estimated that somewhere between 400,000 and 

500,000 young children and their families receive home visitation services each year 

(Gomby, 2005). Although the majority of these programs target newborns, it is not 

uncommon for families to begin receiving home visitation services during pregnancy, 

to remain enrolled until their child is 3 to 5 years of age, or to begin home visits 

when their child is a toddler. Given that there are about 23 million children aged 

0–5 in the U.S. (and about 4 million births every year), the proportion of children 

with access to these services is modest but growing. 

This expansion of home visitation services has been fueled by extensive work on 

the part of several national models to both strengthen their research base and improve their capacity to provide ongoing technical assistance and monitoring to local 

agencies adopting their approach. Equally important has been the work in over 40 

states that have invested not only in home visitation but also in the infrastructure 

necessary to insure services are implemented with high quality and integrated into 

a broader system of early intervention and support (Johnson, 2009). Until now, this 

expansion has been largely supported through innovative state funding mechanisms 

and private investment. 

The Early Support for Families Act dramatically increases federal investment in 

home-based services. The President’s decision to invest in home visitation for 

newborns and the Congress’s willingness to act on his decision demonstrate a new 

and important commitment to prevention and to the type of evidence-informed public policy essential for maximizing impacts on important child and family outcomes. 

Although no legislation comes with absolute guarantees, the Early Support for Families Act builds on an impressive array of knowledge regarding the efficacy of home 

visitation programs and creates an implementation culture that emphasizes quality 

and continuous program improvement. Among the bill’s most important features are 

the following: mandatory funding to the states to strengthen the strategy’s sustainability; channeling these dollars to programs demonstrating strong evidence of effectiveness; requiring states to identify how these programs will complement and draw 

upon existing community efforts; and requiring the collection and use of information 

to enhance practice and policy. 

In my time this morning I want to summarize the evidence supporting the expansion of home visitation programs for newborns, identify those program elements associated with more positive outcomes, and underscore the importance of using this 

legislation not simply to deliver a service but also to enhance learning. 

The Broader context of Early Learning 

The rapid expansion of home visitation over the past 20 years has been fueled 

by a broad body of research that highlights the first 3 years of life as an important 

intervention period for influencing a child’s trajectory and the nature of the parentchild relationship (Shonkoff & Phillips, 2000). A child who can avoid trauma and 

experience consistent and nurturing caregiving in their early years has a better 

chance of successfully transitioning to adulthood (i.e., will more likely be physically 

and emotionally healthy, well educated, employable, and engaged in positive social 


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exchange and civic life) than one whose early years are filled with violence and turmoil. 

In addition, longitudinal studies on early intervention efforts implemented in the 

1960s and 1970s found marked improvements in educational outcomes and adult 

earnings among children exposed to high-quality early intervention programs 

(Campbell, et al., 2002; McCormick, et al., 2006; Reynolds, et al., 2001; Schweinhar, 

2004; Seitz, et al., 1985). These data also confirm what child abuse prevention advocates had long believed—getting parents off to a good start in their relationship 

with their infant is important for both the infant’s development and for their relationship with parents and caretakers (Cohn, 1983; Elmer, 1977; Kempe, 1976). 

The key policy messages from this body of research are that learning begins at 

birth, and that to maximize a child’s developmental potential requires comprehensive methods to reach newborns and their parents. Individuals may debate how best 

to reach young children; few dispute the fact that such outreach is essential for insuring children will have safer, healthier, and more productive lives. Over time, 

these individual benefits translate into substantial societal savings on health care, 

education, and welfare expenditures (Heckman, 2000). 

Why Home Visitation? 

A central feature of this emerging developmental approach to addressing child 

abuse and other negative outcomes for children is an increased focus on expanding 

the availability of home visitation services to newborns and their parents. Drawing 

on the experiences of western democracies with a long history of providing universal 

home visitation systems and emerging evidence of the model’s utility in the United 

States, the U.S. Advisory Board on Child Abuse and Neglect concluded that ‘‘no 

other single intervention has the promise of home visitation’’ (U.S. Advisory Board, 

1991: 145). The seminal work of David Olds and his colleagues showing initial and 

long-term benefits from regular nurse visiting during pregnancy and a child’s first 

2 years of life provided the most robust evidence for this intervention (Olds, Sadler 

& Kitzman, 2007). 

Equally important, however, were the growing number of home visitation models 

being developed and successfully implemented within the public and communitybased service sectors. Although initially less rigorous in their evaluation methodologies, these models demonstrated significant gains in parent-child attachment, access 

to preventive medical care, parental capacity and functioning, and early identification of developmental delays (Daro, 2000). This pattern of findings, coupled with 

Hawaii’s success in establishing the first statewide home visitation system, provided 

a compelling empirical and political base for the initial promotion of more extensive 

and coordinated home visitation services. 

The Evidence of Success 

Over the past 15 years, numerous researchers have examined the effects of home 

visitation programs on parent-child relationships, maternal functioning, and child 

development. These evaluations also have addressed such important issues as costs, 

program intensity, staff requirements, training and supervision, and the variation 

in design necessary to meet the differential needs of the nation’s very diverse newparent population. 

Attempts to summarize this research have drawn different conclusions. In some 

cases, the authors conclude that the strategy, when well implemented, does produce 

significant and meaningful reduction in child-abuse risk and improves child and 

family functioning (AAP Council on Child and Adolescent Health, 1998; Coalition for 

Evidence-Based Policy, 2009; Geeraert, et al., 2004; Guterman, 2001; Hahn, et al., 

2003). Other reviews disagree Chaffin, 2004; Gomby, 2005). In some instances, these 

disparate conclusions reflect different expectations regarding what constitutes 

‘‘meaningful’’ change; in other cases, the difference stems from the fact the reviews 

include different studies or place greater emphasis on certain methodological approaches. 

It should not be surprising to find more promising outcomes over time. The database used to assess program effects is continually expanding, with a greater proportion of these evaluations capturing post-termination assessments of models that are 

better specified and better implemented. In their examination of 60 home visiting 

programs, Sweet and Appelbaum (2004) documented a significant reduction in potential abuse and neglect as measured by emergency room visits and treated injuries, ingestions or accidents (ES = .239, p < .001). The effect of home visitation on 

reported or suspected maltreatment was moderate but insignificant (ES = .318, ns), 

though failure to find significance may be due to the limited number of effects sizes 

available for analysis of this outcome (k = 7). 


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Geeraert, et al. (2004) focused their meta-analysis on 43 programs with an explicit 

focus on preventing child abuse and neglect for families with children under 3 years 

of age. Though programs varied in structure and content, 88 percent (n = 38) utilized home visitation as a component of the intervention. This meta-analysis, which 

included 18 post-2000 evaluations not included in the Sweet and Appelbaum (2004) 

summary, notes a significant, positive overall treatment effect on reports of abuse 

and neglect, and on injury data (ES = .26, p < .001), somewhat larger than the effect 

sizes documented by Sweet and Appelbaum. 

Stronger impacts over time also are noted in the effects of home visitation on 

other aspects of child and family functioning. Sweet and Appelbaum (2004) note 

that home visitation produced significant but relatively small effects on the mother’s 

behavior, attitudes, and educational attainment (ES ≤ .18). In contrast, Geeraert et 

al. (2004) find stronger effects on indicators of child and parent functioning, ranging 

from .23 to .38. 

Similar patterns are emerging from recent evaluations conducted on the types of 

home visitation models frequently included within state service systems for children 

aged 0 to 5. Such evaluations are not only more plentiful, but also are increasingly 

sophisticated, utilizing larger samples, more rigorous designs, and stronger measures. Although positive outcomes continue to be far from universal, families enrolled 

in these home visitation programs, as compared to participants in a formal control 

group or relevant comparison population report fewer acts of abuse or neglect toward their children over time (Fergusson, et al., 2005; LeCroy & Milligan, 2005; DuMont et al., 2008; Old, et. al., 1995; William, Stern & Associates, 2005); engage in 

parenting practices that support a child’s positive development (Love, et al., 2009; 

Zigler, et al., 2008); and make life choices that create more stable and nurturing 

environments for their children (Anisfeld, et al., 2004; LeCroy & Milligan, 2005; 

Wagner, et al., 2001). Home visitation participants also report more positive and 

satisfying interactions with their infants (Klagholz, 2005) and more positive health 

outcomes for themselves and their infants (Fergusson, et al., 2005; Kitzman, et al., 

1997). One home visitation model that initiates services during pregnancy has found 

that by age 15 the children who received these visits as infants reported significantly fewer negative events (e.g., running away, juvenile offenses and substance 

abuse) (Olds, et al., 1998). 

Home visits begun later in a child’s development also have produced positive outcomes. Toddlers who have participated in home visitation programs specifically designed to prepare them for school are entering kindergarten demonstrating at least 

three factors correlated with later academic success—social competency, parental involvement, and early literacy skills (Levenstein, et al., 2002; Allen & Sethi, 2003; 

Pfannenstiel, et al., 2002). Longitudinal studies of home visitation services that 

begin at this developmental stage have found positive effects on school performance 

and behaviors through sixth grade (Bradley & Gilkey, 2002) as well as lower high 

school dropout and higher graduation rates (Levenstein, et al., 1998). 

A prime consideration for the unique emphasis on nurse home visitation within 

the President’s proposal is the long-term cost savings found in Nurse Family Partnership’s (NFP) initial trials. These savings were primarily realized through a reduction in the subsequent use of Medicaid and other entitlement programs as a result of women receiving the intervention entering and remaining in the workforce. 

Although comparable data have not been collected on the other home visitation models, the range of outcomes achieved by many of them suggests similar savings could 

accrue from them as well. Additional areas for potential savings include stronger 

birth outcomes among families enrolled prenatally in a sample of Health Families 

New York programs (Mitchel-Herzfeld, et al., 2005), higher monthly household earnings among those who access Early Head Start services (Love, et al., 2009), and better school readiness and a reduced need for special education classes among children 

enrolled in PAT or Parent Child Home Program (Ziegler et al., 2008; Levenstein, 

et al., 2002). 

In short, confidence in the efficacy of early home-based interventions with 

newborns and their parents rests with numerous randomized control trials, quasiexperimental evaluations with strong counterfactuals, and detailed implementation 

studies that have demonstrated both the efficacy and efficiency of this approach. 

Perhaps the most compelling use of these data is not to simply highlight a given 

model’s efficacy but rather to underscore the importance of high-quality implementation and service integration. The full volume of research data across various models clearly shows that the chances of success are improved when any program embraces certain features such as: 

• Solid internal consistency that links specific program elements to specific outcomes 


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• Forming an established relationship with a family that extends for a sufficient 

period of time to accomplish meaningful change in a parent’s knowledge levels, 

skills, and ability to form a strong positive attachment to the infant • Well-trained and competent staff • High-quality supervision that includes observation of the provider and participant • Solid organizational capacity • Linkages to other community resources and supports 

As Congress moves toward developing legislation to act on the President’s promise 

to provide early intervention services to those children facing the most significant 

obstacles, these parameters—rather than the utility of a given model or given workforce structure—should guide policy development. Unless all of the interventions 

supported by this initiative are structured around core practice principles, the odds 

of success, regardless of the model implemented, are greatly diminished. 

Defining Standards for Evidence-Based 

Defining the evidentiary base necessary for estimating the potential impacts of a 

given intervention is complex. In general, two lines of inquiry guide the development of program evaluations: Does the program make a measurable difference with 

participants (efficacy)? And, does a given strategy represent the best course of action 

within a given context (effectiveness)? Randomized control trials are often viewed 

as the best and most reliable method for determining if the changes observed in program participants over time are due primarily to the intervention rather than to 

other factors. Maximizing the utility of program evaluation efforts, however, requires more than just randomized clinical trials. As noted by the American Evaluation Association in a February, 2009 memo to OMB Director Peter Orszag: 

There are no simple answers to questions about how well programs work, and 

there is no single analytic approach or method that can decipher the complexities 

that are inherent within the program environment and assess the ultimate value 

of public programs. (AEA Evaluation Policy Task Force, 2009). 

Well-designed effectiveness evaluations are needed to improve the quality of home 

visitation programs and their successful replication. However, knowing that a program is capable of achieving effects under ideal conditions is not the same as knowing it will achieve effects when broadly implemented with more challenged populations or in more poorly resourced communities. In the real world, the success of 

a home visitation program will depend on how local parents from all points on the 

risk continuum view early intervention services, on what service and provider characteristics will attract new parents into these programs, and on the relation between these efforts and other elements within a community’s existing service continuum. 

In many respects, the core features of a well-done randomized trial—a highly 

specified intervention, consistent implementation, and a specific target population— 

limit the ability to generalize its findings to diverse populations and diverse contexts. In determining which programs constitute the highest level of evidence, states 

should examine a model’s full research portfolio. Although randomized clinical trials 

are excellent for assessing impacts, they offer little guidance in terms of how to integrate such efforts into existing healthcare and educational systems, the vehicles 

through which a truly comprehensive national effort to support new parents needs 

to be based. The knowledge and assurances needed to build this type of integrated 

system for at-risk children and their parents will be found in the evidence being 

generated by diverse analytic and research methods such as those that have been 

and are being incorporated by a number of home visitation efforts throughout the 

country. 

Assuring Continuous Program Improvement 

The emphasis it places on evaluation and program monitoring is an important 

feature of the Early Support for Families Act. Under this legislation, states will be 

required to provide annual reports outlining, among other things, the specific services provided under the grant; the characteristics of each funded program, including 

descriptions of its home visitors and participants; the degree to which services have 

been delivered as designed; and the extent to which the identified outcomes have 

been achieved. This type of systematic data collection and monitoring is particularly 

critical as home visitation programs become more widely available. Home visitation, 

while promising, does not produce consistent impacts in all cases. Not all families 

are equally well served by the model; retention in long-term interventions can be 

difficult; identifying, training, and retaining competent service providers is challenging, particularly when the strategy is designed to be offered widely and integrated into existing early intervention systems. Finally, although home visitation 


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programs are substantial in both dosage and duration, even intensive interventions 

cannot fully address the needs of the most challenged populations—those struggling 

with serious mental illness, domestic violence, and substance abuse as well as those 

rearing children in violence and chaotic neighborhoods. Addressing these and similar questions requires that evidence-based interventions be implemented in light of 

what we know along with a determination to do better. 

Identifying the appropriate investments in home visitation programs will require 

a research and policy agenda that recognizes the importance of linking learning and 

practice. It is not enough for scholars and program evaluators, on the one hand, to 

learn how maltreatment develops and what interventions are effective and for practitioners, on the other, to implement innovative interventions in their work with 

families. Instead, initiatives must be implemented and assessed in a manner that 

maximizes both the ability of researchers to determine the effort’s efficacy and the 

ability of program managers and policymakers to draw on these data to shape their 

practice and policy decisions. Most of the major national home visitation models recognize this objective and have engaged in a series of self-evaluation efforts designed 

to better articulate those factors associated with stronger impacts and to better 

monitor their replication efforts. For example, the Nurse Family Partnership maintains rigorous standards with respect to program site selection. Data collected by 

nurse home visitors at local sites is reported through the NFP’s web-based Clinical 

Information System (CIS), and the NFP national office manages the CIS and provides technical support for data entry and report delivery. Since 1997, Healthy Families America’s (HFA) credentialing system has monitored program adherence to a 

set of research-based critical elements covering various service delivery aspects, program content, and staffing. And, after 3 years of extensive pilot testing and review, 

Parents as Teachers (PAT) released its Standards and Self-Assessment Guide in 

2004. 

In fulfilling their reporting obligations under the Early Support and Education 

Act, state planners should be encouraged to draw on these systems in developing 

a coordinated database that will allow them to look across the models they are implementing. This integrated data system can be used to determine the constellation 

of models and collaborative efforts needed to better identify, engage, and effectively 

serve the communities and families in facing their greatest challenges. 

Achieving Broader Outcomes 

Home visitation is not the singular solution for preventing child abuse, improving 

a child’s developmental trajectory, or establishing a strong and nurturing parentchild relationship. However, the empirical evidence generated so far does support 

the efficacy of the model and its growing capacity to achieve its stated objectives 

with an increasing proportion of new parents. Maintaining this upward trend will 

require continued vigilance to the issues of quality, including staff training, supervision, and content development. It also requires that home visitation be augmented 

by other interventions that provide deeper, more focused support for young children 

and foster the type of contextual change necessary to provide parents adequate support. These additions are particularly important in assisting families facing the significant challenges as a result of extreme poverty, domestic violence, substance 

abuse, or mental health concerns. 

All journeys begin with a single step. The Early Support for Families Act provides 

states an important vehicle for identifying the best way to introduce home visitation 

into its existing system of early intervention services. Chapin Hall’s review of this 

process suggests states are already responding to this challenge by requiring that 

any model being replicated reflect best practice standards, embrace the empirical 

process, and be sustainable over time through strong public-private partnerships 

(Wasserman, 2006). The ultimate success of this legislation will hinge on the willingness of state leaders to continue to support data collection and careful planning 

and on the willingness of program advocates to carefully monitor their implementation process and to modify their efforts in light of emerging findings with respect 

to impacts. 

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January 1999–December 2003. Miami, FL: Author. http:// 

www.healthyfamiliesamerica.org/research/index.shtml 

Zigler, E., Pfannenstiel, J.C., & Steitz, V. (2008). The Parents as Teachers program and school success: A replication and extension. Journal of Primary Prevention, 29, 103–120. 

f 

Chairman MCDERMOTT. Our next witness is Dr. Brooks-Gunn, 

who is a graduate of Connecticut and Harvard and the University 

of Pennsylvania. She has written four books. 

And, Dr. Gunn, we appreciate your testimony. 

STATEMENT OF JEANNE BROOKS, PH.D., PROFESSOR OF 

CHILD DEVELOPMENT AT TEACHERS COLLEGE AND THE 

COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, NEW YORK 

Ms. BROOKS-GUNN. Thank you very much. It is a pleasure to 

be here addressing the Members of this Committee. Thank you, 

Chairman McDermott and Ranking Member Linder. 

I am a developmental psychologist by training. I have been 

spending 30 years following families over time to see what circumstances help them do better and what circumstances impede 

success for both parents and children. I have also been involved in 

the evaluation and design of three different programs that are relevant to this hearing today: the Infant Child and Development Program, the Early Head Start National Evaluation and the Home Instruction For Parents of Preschool Youngsters, affectionately 

known as HIPPY. 

For understanding the review of literature, what we know about 

how home visiting works, I would suggest that all of you turn to 

The Future of Children. This is a particular set of volumes that has 

been looking at what programs are effective for children and families. The Future of Children has an issue on home visiting in 1993, 

1999, 2005 and 2009. I was involved in coauthoring the articles in 

2005 and 2009. But it gives you a really great history over time of 

what we found. 

What I want to do today is talk about the different strategies 

that we have for enhancing young families’ lives. I am particularly 

interested in young, first-time mothers. They are the most vulnerable, as are their children, for later problems in life. I would like 

you to consider also several different kinds of outcomes that programs can have. 


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35 

What we are concerned about for what I will just call first-time 

young mothers and their education success. Clearly, we have to be 

worried about if we can enhance their education, if we want longterm impact on them or on their children. 

The second is their parenting capabilities and capacities, and 

home-visiting programs do address this. Part of this is child abuse 

and neglect, but there are other aspects of parenting capabilities 

that we are interested in. 

And, of course, the third is children’s school readiness. 

So how do these strategies that we all have been looking at over 

the years stack up in terms of the outcomes that we think are important? First, home-visiting programs that offer—are in conjunction with center-based care do seem to have the ability to increase 

these young mother’s education. That is very important. Programs 

that are just home-visiting programs alone, in general, do not increase parents’ education; the nurse home visiting program is an 

exception to this. 

Almost all the programs that you will hear about do seem to influence parenting capabilities and capacities. This is very important when you look at the range of programs that exist. These programs—these effects are modest, but they are consistent across 

programs. 

Very few programs actually reduce the incidence of child abuse 

and neglect, and there are a variety of reasons for that that we can 

talk about later. 

In terms of school readiness for the children, when we are focusing on the children, some, but not all, home-visiting programs have 

shown that they can change the school readiness of children. 

Home-visiting programs often also target child and health safety 

and seem to do a good job of targeting this. 

Some programs are able to change maternal mental health, although that is very, very difficult to change in general. So I also 

focus on the effectiveness factors in programs to try to get the outcomes that we want, the effectiveness factors that I think are important from my review of the literature. Specific curriculum, very 

intensive services, home-visiting programs that provide services 

less than weekly in general are not likely to be effective. There are 

a couple of exceptions to that. But, in general, if it is not intensive, 

it is probably not going to have an effect. 

We need well-trained staff. This includes ongoing evaluation during the home visits themselves. This is typically not done. We need 

well-educated staff. My read of the literature is, the programs 

using paraprofessionals are, in general, not likely to be effective 

when we compare these to programs that use professionals and 

more educated staff. 

And the services provided is very important. Even in programs 

that are designed to be intensive, we have to make sure that people 

receive the expected number of home visits. 

So, in summary, we can make differences. 

What kinds of programs should we be putting in place? There are 

some home-visiting programs that look like they will do what we 

want them to do. I also would urge the Committee to allow States 

to do some sort of demonstrations to see what happens when you 

combine home visiting with programs that offer these young mothVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00039 Fmt 6633 Sfmt 6602 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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36 

ers educational supports so that we can get the mothers to increase 

their education. Since this is a poorly educated group, these firsttime, young mothers. 

States could also try combination programs, if possible, that combine the best of home visiting with child care. Otherwise, if we 

don’t try both to keep the effectiveness factors in place, we will not 

be able to impact the families that are being served. 

Thank you. 

Chairman MCDERMOTT. Thank you very much for your testimony. 

[The prepared statement of Ms. Brooks-Gunn follows:] 

Statement of Jeanne Brooks-Gunn, Ph.D., Professor of Child Development 

at Teachers College and the College of Physicians and Surgeons, Columbia University, New York, New York 

It is a pleasure to be here today, addressing the members of the House Ways and 

Means Subcommittee on Income Security and Family Support. I will be considering 

the evidence for the effectiveness of programs for young, first-time mothers, both in 

terms of their impacts on the mothers themselves and their infants, toddlers and 

preschoolers. A developmental psychologist, I have spent the last 30 years examining the life courses of families, both parents and their children, with a special 

focus on what might be termed vulnerable families. These would include families 

whose parents are young, are poor, are unmarried, and/or have low educational levels. I am interested in identifying what conditions are likely to enhance the success 

of parents who are rearing their children under the often difficult circumstances. I 

have also designed and evaluated a set of programs which aim to enhance the wellbeing of parents and children. These include the Infant Health and Development 

Program, the Early Head Start National Evaluation, and the Home Instruction for 

Parents of Preschool Youngsters (HIPPY). 

References and documentation of the comments made in this testimony may be 

found in articles in The Future of Children (www.futureofchildren.org) from Issue 

15 (2005, on Racial and Ethnic Gaps in School Readiness, edited by C. Rouse, S. 

McLanahan and J. Brooks-Gunn), Issue 9 (1999, on Effectiveness of Home Visiting, 

edited by D. S. Gomby), and Issue 19 (2009, article by K. S. Howard and J. BrooksGunn on The Role of Home-Visiting Programs in Preventing Abuse and Neglect). 

A list of publications by Brooks-Gunn is available at www.policyforchildren.org. 

The Problem 

The families being considered today are those with young, first-time mothers. 

Each year, almost one-half of a million children are born into these families. Young, 

first-time mothers, as a group, have relatively low levels of education, which limits 

their access to stable, well paid employment. These mothers, often living in precarious economic circumstances, are also more likely to exhibit harsh parenting, inconsistent parenting, and insensitive parenting, all of which are associated with lower 

cognitive and emotional capacities of their children than mothers who are older and 

have more education. The children of young mothers are also more likely to experience child abuse or neglect than those born to older, more educated parents. In 

brief, young, first-time mothers are likely to have low levels of education and more 

financial hardship as well as to exhibit less optimal parenting. Their children, in 

turn, are less likely to develop the capacities necessary for success in school and in 

later life. All three outcomes (maternal education, parenting behavior, and child capabilities) have been, and should be, targets of intervention. 

Enhancing the Lives of Young Mothers and Their Children 

Is it possible to help young mothers improve their educational status and/or their 

parenting capabilities? The answer, from both longitudinal studies and intervention 

programs, is yes. 

Is it possible to improve directly the educational success of their children (most 

often measured by how well prepared their children are for entry into school)? The 

answer is yes. Well-developed early childhood education programs do so. 

Is it possible to enhance school readiness of young children by improving maternal 

education and/or parenting capabilities of young mothers? The answer is yes. It is 

most likely that such enhancements will occur if both the young mothers and the 

children are both provided intervention services. 


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Strategies for Enhancing Young Family’s Lives 

Several different types of programs have been developed for improving young 

mothers’ education and parenting capabilities as well as their children’s school readiness. Each has demonstrated effectiveness, although not every program has been 

effective. 

Maternal education programs provide supports and incentives for the continued 

education of young mothers. Welfare demonstration programs focusing on maternal 

education report small to modest impacts on education, as have some home visiting 

programs and some programs offering home-visiting services to the parents and center-based educational services to the children. 

A variety of programs, usually home-based, demonstrate modest consistent effects 

on parenting capabilities (reductions in harsh parenting and increases in sensitive 

parenting). Many but not all programs provide such evidence. 

Some programs also have, as their aim, preventing child abuse and neglect. Of 

those programs that look at child abuse and neglect directly (i.e., substantiated 

cases), only a few have reduced child abuse and neglect. However, given the incidence of child abuse and neglect, program evaluations often do not have the power 

to detect such differences (while they do have the power to detect differences in parenting capabilities). 

Home-visiting programs often target child health and safety, child cognitive development, and maternal mental health. Child health and safety have been enhanced 

by several programs. Fewer home-visiting programs have altered child cognitive development (unless they are coupled with center-based child care; but see, for exceptions, the Nurse Family Partnership in Denver and Memphis and Early Head Start 

and one Healthy Families evaluation). 

Effectiveness Factors 

Effective programs for families with young children (indeed, for programs generally) have the following characteristics—— 

Specific curricula with clearly defined goals and educational methods to achieve 

such goals 

Intensive services (home-visiting programs that provide services less than weekly 

in general are not effective; although see Early Start as an exception) 

Well-trained staff (training prior to implementation as well as on-going training 

including evaluation during home visits themselves) 

Well-educated staff (programs using paraprofessionals are less likely to be effective than those using professionals and more educated staff) 

Services provided (some programs are designed to be intensive, even though most 

families do not receive the expected number of home visits; programs in which the 

delivered dose is low are likely not to be effective) 

Best Bets for Investments 

Based on the current literature, young first-time mothers seem to benefit most 

from home-visiting programs. Thus, targeting this group is a good bet. 

Also, home-visiting programs (if well-developed) are most likely to alter parenting 

practices than child abuse and neglect. Several of the programs also have the potential to enhance school readiness. 

It is likely that two-generation programs, that combine home-visiting programs 

with child care, will be necessary to alter maternal education. Programs might also 

need to provide other specific educational supports (help in the navigation of postsecondary education institutions in a specific community, tuition assistance or conditional tuition assistance). 

It would be ideal if states were allowed to mount demonstration programs that 

combine educational and parenting supports to see if combinations of services provide greater impacts on parents and children than just parenting support alone. The 

same might be true if parenting capabilities were enhanced via home-visiting and, 

at the same time, child care assistance were provided. 

In general, any programs that are implemented must be able to document and 

continue documenting, fidelity to the effectiveness factors outlined above. Otherwise, 

the investments are unlikely to impact the families which are being served. 

National Center for Children and Families (www.policyforchildren.org) 

f 

Chairman MCDERMOTT. Our next witness is Cheryl D’Aprix, 

who brings a combination of having been a recipient of some visitation as well as now being a home visitor herself. 


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Ms. D’Aprix. 

STATEMENT OF CHERYL D’APRIX, SENIOR FAMILY SUPPORT 

WORKER, STARTING TOGETHER PROGRAM, CANASTOTA, 

NEW YORK 

Ms. D’APRIX. Thank you and good morning, Mr. Chairman and 

distinguished Members of the Committee. My name is Cheryl 

D’Aprix and I am a family support worker in the Healthy Families 

America program serving Madison County in New York. It is an 

honor and a privilege to be here today to share my experience, first 

as a participant in Healthy Families America and now as a home 

visitor for the program. 

In 1993, my husband, Jeff, my 3-year-old daughter, and I were 

presented with a new challenge. I received the news that we would 

be expecting another baby and could welcome him in about 71⁄2

months. I gently broke the news to my husband and together we 

sat in silence, each struggling with our own fears and thoughts. 

Jeff had his mind on the already-insufficient funds and how we 

were going to replace all the baby furniture we had just given away 

because we were convinced that we were already blessed and would 

not have any more children. I was busy thinking about having to 

go through postpartum depression with another baby. 

I had suffered with PPD for more than a year after the birth of 

my daughter. I had no clue what was happening to me, but I made 

it through that year with the patience of my husband and kind 

words from my family. I was petrified of going through it again and 

the possibility of it worsening. I had heard the horror stories in the 

news, and I prayed that I could remain well enough to take care 

of our children and hold things together at home. 

Visiting with a friend, I expressed some of my concerns, and she 

recommended I check into a home visiting program that was available in our county through the Community Action agency. The program is called Starting Together, which is part of Healthy Families 

America, New York. The program partners with families who have 

children, prenatal to 3 to 5 years of age. 

During my pregnancy, she would meet with me weekly, and Jeff 

would join us whenever he got the chance. She listened to me and 

she shared information with me. She gave us the support I needed 

to not only feel like a competent parent to the child I already had, 

but she helped me gain the confidence I needed to talk with my 

doctor about the postpartum depression. I was afraid that whichever doctor happened to be on call that day would either just dismiss my concern or tell me it is normal to have the baby blues 

after a baby comes. 

Through the information she brought me, I knew it was much 

more than the baby blues; and I was able to get the help I needed 

with medication and strong shoulders, and I was on my way to a 

healthier life and a more secure attachment with my son. 

Once Damian was born, our home visitor brought us curriculum 

on the stages of development, books and videos on basic care and 

information on community resources that helped our family stay 

afloat. She left information on fatherhood for Jeff so he could feel 

more confident and strong in the vital role that he played in our 

lives. Throughout the course of 3 years, we spent time together 


bjneal on DSKFP91QD1 with HEARING
39 

doing activities with the kids, setting attainable goals for my family and spending countless hours just talking. We talked about everyday stresses, and at that point there were plenty of those. 

We also spent time about talking my life and what it was like 

growing up. She gave me the opportunity to tell my story, and I 

came to see that I too was worth listening to. She laughed with me 

on the good days and she let me cry on the bad days that were so 

overwhelming that I could barely get one foot on the floor. But I 

put that foot on the floor because I knew she was coming to visit. 

It meant so much to me that she understood the importance of nurturing the parent as well as the child. 

When Damian turned 3, my family graduated out of the program. Jeff was working two jobs, I was now working full time and 

our daughter was honing the skill of bossing her baby brother 

around. The job I was doing was unfulfilling, but it helped pay the 

bills. 

On our last home visit, our support worker encouraged me to 

apply for an open position at the program as a home visitor. After 

all she had taught me and all the ways our family had benefited 

from the program, I was excited about applying for the job. I was 

anxious to start lending a helping hand and a supportive ear to 

other parents. One of the greatest gifts she gave me was the belief 

in myself, and I was lucky enough to have the program see my 

strengths, as well, and I was offered the position. 

My home visiting career started out with many, many months of 

training and researching community resources so that I could be 

equipped to meet the diverse needs of each family. The very heart 

of Healthy Families America is promoting healthy parent-child 

interaction and child development. While on the floor doing activities together, we also discussed life challenges such as housing, employment, accessing medical care or transportation. 

Offering referrals and brainstorming ways to remove the barriers 

that families feel interfere with their success is the key part of our 

visits. One recent example is, I visited a young, single mother with 

relationship challenges and insufficient income. I referred her to a 

child care center which she enrolled her child in, enabling her to 

go to work. Once she had a stable income, we were able to connect 

her to a first-time home buyers program, which provided her with 

a financial education to make sure homeownership was appropriate 

for her. 

I am happy to report that she is still successfully employed and 

does own her own home. Outcomes can be amazing when supports 

are identified and goals are attainable. 

So, here I am 8 years and a few home visits later, and I am still 

learning about the benefits and the power of preventive programs, 

and my passion to partner with families is as strong as ever. I 

home visit with low-income families, no-income families and middle-class families who are now finding themselves in positions they 

have never been in before. They all had a multitude of stresses and 

some just need another adult to talk to, each having their own 

story worth listening to, each craving the opportunity to learn and 

grow and each deserving to be nurtured. 

The common bond with each and every one of these families, including myself, is their child. We all want the best for them and 


bjneal on DSKFP91QD1 with HEARING
40 

we want more than anything in the world to be the ones to give 

it to them. 

I have seen both sides of what a home visiting program can accomplish, and it is so much more than life changing. It is life enhancing. So I thank you today from the bottom of my heart for your 

time and your own supportive ears. 

Thank you. 

Chairman MCDERMOTT. Thank you very much for telling your 

story to us. It is tough. 

[The prepared statement of Ms. D’Aprix follows:] 

Statement of Cheryl D’Aprix, Senior Family Support Worker, Starting 

Together Program, Canastota, New York 

Good morning Mr. Chairman and distinguished members of the committee. My 

name is Cheryl D’Aprix, and I am a Senior Family Support Worker with the 

Healthy Families America program serving Canastota, New York. It is an honor and 

a privilege to be here today to share my experience, first as a participant in the 

Healthy Families America program, and now as a home visitor for the program. 

In 1993, my husband Jeff, our 3-year-old daughter and I were presented with a 

new challenge. I received the news that we would be expecting another baby and 

could welcome him into our world in about 71⁄2 months. I very gently broke the news 

to my husband and together we sat in silence each struggling with our own fears 

and thoughts. Jeff had his mind on the already insufficient funds and how we were 

going to replace all the baby furniture we had just given away because we were convinced we were already blessed and would not have any more children. I was busy 

thinking about having to go through post partum depression with another baby. I 

had suffered with PPD for more than a year after the birth of our daughter. I had 

no clue what was happening to me but I made it through that year with the patience of my husband and kind words from my family. Now I was petrified of going 

through it again and the possibility of it worsening. I had heard the horror stories 

in the news and I prayed that I could remain well enough to take care of our children and hold things together. 

While visiting with a friend, I expressed some of my concerns and she recommended that I check into a home-visiting program that was available in our 

county through our Community Action agency. The program was called Starting Together, which is part of Healthy Families America, NY. The program partners with 

families who have children prenatal to three to five years of age. After much 

thought and a lengthy conversation with Jeff I reluctantly gave the program a call. 

I have to say that it was really scary and unnatural to invite a stranger into my 

home but after just a few minutes of meeting with our home visitor I knew that 

we had made the right decision for our family. 

During my pregnancy she would meet with me weekly and Jeff would join us 

whenever he got the chance. She listened to me and shared information with me. 

She gave me the support I needed to not only feel like a competent parent to the 

child I already had but she helped me gain the confidence I needed to talk with my 

doctor about the post partum depression. I was afraid that whichever doctor happened to be on call that day would either just dismiss my concern or tell me it’s 

normal to have the blues after a baby comes. Through the information she brought 

me I knew that it was much more than the baby blues. I was now able to get the 

help I needed and with medication and strong shoulders, I was on my way to a 

healthier life and a more secure attachment with my son. 

Once Damian was born, our home visitor brought us curriculum on the stages of 

development; books and videos on basic care and information on the community resources that helped our family stay afloat. She left information on fatherhood for 

Jeff so that he could also feel competent and strong in the vital role he played in 

our lives. Throughout the course of three years, we spent time together doing activities with the kids, setting attainable goals for my family and spending countless 

hours of just talking. We talked about everyday stresses and there were plenty of 

those. We also spent time talking about my life and what it was like growing up. 

She gave me the opportunity to tell my life story and I came to see that I too, was 

worth listening to. She laughed with me on the good days, and she let me cry on 

the bad days that were so overwhelming I could barely get one foot on the floor. 

But I put that foot on the floor because I knew she was coming to visit. It meant 

so much to me that she understood the importance of nurturing the parent as well 

as the child. 


bjneal on DSKFP91QD1 with HEARING
41 

When Damian turned three, my family graduated out of the program. Jeff was 

working 2 jobs, I was now working full time, and our daughter was honing the skill 

of bossing her baby brother around. The job I was doing was unfulfilling but it 

helped pay the bills. On our last home visit our support worker encouraged me to 

apply for an open position in the Starting Together program as a home visitor. I 

jumped at the chance. After all she had taught me, and with all the ways our family 

had benefited from the program I was excited about applying for the job. I was anxious to start lending a helping hand and a supportive ear to other parents. One of 

the greatest gifts our home visitor left with me was the belief in myself and I was 

lucky enough to have the program see my strengths as well and I was offered the 

position. 

My home visiting career started out with months of training and researching community resources so that I could be equipped to meet the diverse needs of each family. The very heart of Healthy Families America is promoting healthy parent/child 

interaction and child development. While on the floor doing an activity together we 

will also discuss life challenges such as housing, employment, accessing medical care 

or transportation. Offering referrals and brainstorming ways to remove barriers that 

the family feels may interfere with their success is a key part of our visits. As one 

recent example, I visited with a single mother with relationship challenges and insufficient income. I referred her to a child care center, which she enrolled her child 

in, enabling her to go to work. Once she had a stable income, we were able to connect her to a first-time homebuyers program, which provided her with financial education to make sure home ownership was appropriate for her. I am happy to report 

that she is still successfully employed and owns her own home. Outcomes can be 

amazing when supports are identified and goals are attainable. 

So here I am eight years and a few home visits later. I am still learning about 

the benefits and the power of preventative programs and my passion to partner with 

families is as strong as ever. I home visit with low-income families, no income families and middle class families who are now finding themselves in positions they have 

never been in before. All who have a multitude of stresses and some that just need 

another adult to talk to. Each having their own story worth listening to, each craving the opportunity to learn and grow, each deserving to be nurtured. The common 

bond with each and every one of these families (including myself) is their child. We 

all want the best for them and we want more than anything in the world, to be 

the ones to give it to them. 

But despite all the many proven benefits of home visiting, benefits that I witness 

everyday, the lack of resources in most communities limits the reach of home visiting services to the lucky few. A federal investment in evidence-based home visiting, as proposed by Chairman McDermott, Congressman Davis, and Congressman 

Platts, will ensure that more families in communities across the country are given 

the opportunity to participate in this valuable service. I urge every member of this 

committee to support an investment in evidence-based early childhood home visitation services and to move quickly and thoughtfully on legislation authorizing new 

federal funding. 

I have seen both sides of what a home visiting program can accomplish and it’s 

so much more than life changing. It’s life enhancing. I thank you from the bottom 

of my heart today for your time and your own supportive ears. 

Thank you. 

f 

Chairman MCDERMOTT. Our next witness is Sharon Sprinkle, 

who is a program manager for the Nurse Family Partnership Program. And she has been doing it for 8 years and has probably seen 

a lot. 

Ms. Sprinkle. 

STATEMENT OF SHARON SPRINKLE, NURSE CONSULTANT, 

NURSE-FAMILY PARTNERSHIP, DENVER, COLORADO 

Ms. SPRINKLE. Thank you. Good morning, Mr. Chairman, 

Ranking Member Linder, and Members of the Subcommittee. 

Thank you for the opportunity to testify on behalf of the NurseFamily Partnership program in support of evidence-based early 

childhood home visitation. 


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I am Sharon Sprinkle and I work as a nurse consultant for the 

Nurse-Family Partnership National Service Office. I have been fortunate to serve in many different capacities for Nurse-Family Partnership, as a nurse home visitor, a nurse supervisor and now as 

a nurse consultant, integrating the knowledge and skills from my 

earlier roles to help guide and support our nurses, administrators 

and agencies to successfully deliver program services. I am here in 

support of the Obama Administration’s proposed initiative to create 

a new evidence-based home visitation program for low-income families. 

I would like to thank Chairman McDermott, Congressman Davis 

and Members of the Subcommittee for their commitment to improving the health and well-being of children with dedicated funding for 

evidence-based home visitation. The Nurse-Family Partnership program model has served almost 100,000 families to date, and we 

currently have over 18,000 first-time families enrolled in 28 States. 

Our voluntary program provides home visitation services by registered nurses to low-income, first-time mothers beginning early in 

the pregnancy and continuing through the child’s second year of 

life. The children and families we serve are overwhelmingly young, 

poor and minority. Our families are at the highest risk of experiencing significant health, educational, and employment disparities 

that have lasting negative impacts on their lives and communities. 

Nurse-Family Partnership has three major goals; they are to improve pregnancy outcomes, improve child health and development, 

and improve parents’ economic self-sufficiency. Nurse-Family Partnership is an evidence-based program with multigenerational outcomes that have been demonstrated in three randomized controlled 

trials conducted in both urban and rural locations, and with Caucasians, African Americans and Hispanic families. 

A randomized controlled trial is the most rigorous research method for measuring the effectiveness of an intervention. The NurseFamily Partnership model has been tested for over 30 years with 

the ongoing research, development and evaluation activities conducted by Dr. David Olds. Evidence from one or more of these 

trials demonstrates powerful outcomes, including a 79-percent reduction in preterm deliveries of women who smoked, 56-percent reduction in emergency room visits for accidents and poisonings, 46- 

percent increase in fatherhood involvement in the household, 59- 

percent reduction in arrests of a child at age 15, and 72-percent reduction in arrests by the mother of the child at age 15. 

As the Nurse-Family Partnership model has moved from science 

to practice, great emphasis has been placed on building the necessary infrastructure to ensure quality and fidelity to the research 

model during the replication process nationwide. Independent evaluations have found that investments in the Nurse-Family Partnership model lead to significant returns to society and government. 

For example, the Pacific Institute for Research Evaluation released 

a report in March of 2009 which found a 154-percent return on 

Federal Medicaid investment over 10 years from the Nurse-Family 

Partnership model based on findings from the Memphis trial that 

showed reduced enrollment in Medicaid and food stamps. 

I would like to take this opportunity to share an experience I had 

as a nurse home visitor while working with a client named Alice 


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43 

in Greensboro, North Carolina. Alice became pregnant when she 

was 14 and was caring for her child while living in an apartment 

with six siblings and her two parents. She called me one morning 

because no one in her family could take her to her local WIC appointment—Women, Infants and Children. During the car ride, 

Alice informed me that her household had not had power for a 

week, but she didn’t seem too upset by this development. 

I knew immediately that Alice and her family needed assistance 

identifying and connecting to community resources. I called the Department of Social Services, but did not get much of a response. So 

I decided to contact the few local community nonprofits that would 

assist low-income families who are unable to pay for food and other 

vital services. Two organizations agreed to jointly cover the electric 

bill. 

When I drove Alice home, I told her that she could tell her father 

that the power would be restored the next day. Up until this point, 

in my relationship with Alice and her family, Alice’s father was not 

very engaged during my visits. After the electricity was restored to 

the house, this proud man said to me, ‘‘A lot of people say they will 

help, but you are the one that really did it.’’ 

This is one of the many stories about the impact that NurseFamily Partnership has. We can help break the cycle of poverty by 

empowering young mothers to become knowledgeable parents who 

can care for their children and guide them along a healthy life 

course. 

The Nurse-Family Partnership urges the Subcommittee to devote 

resources to assist States in implementing and expanding their 

home visitation programs to serve even more vulnerable families. 

We encourage the Committee to target taxpayer resources to the 

poorest communities that often lack the critical maternal and child 

health and social resources to ensure that the most at-risk families 

succeed. 

I would like to thank the Subcommittee for inviting me to testify. 

And I would also like to thank Chairman McDermott and Congressman Davis and Platts for their leadership on behalf of the 

Early Support for Families Act. 

Chairman MCDERMOTT. Thank you very much for your testimony. 

[The prepared statement of Ms. Sprinkle follows:] 


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Statement of Sharon Sprinkle, RN, Nurse Consultant, Nurse Family 

Partnership, Denver, Colorado 


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Chairman MCDERMOTT. I am going to start, I think, by letting 

Mr. Linder ask the first question, because I want to think a little 

bit about—you opened up so many possibilities, I am not quite sure 


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that the staff questions are quite what I want to do. So I am going 

to wait. 

Mr. LINDER. Thank you very much. I would like to ask a question of Ms. Sprinkle. 

I have seen numbers of 6,000 children are born to girls 14 and 

younger each year in this country. Is the prospective mother your 

client or is the family your client? 

Ms. SPRINKLE. The mom is the client, because when you improve parenting capacity, the child reaps the benefits. 

Mr. LINDER. The pregnant mother is the client? 

Ms. SPRINKLE. Yes. We enroll clients prenatally before they are 

28 weeks pregnant. With first-time moms there is a window of opportunity in which they are receptive to the education and are willing to make a change and are committed and motivated to make 

the change for a better life for their child. 

Mr. LINDER. The program, as proposed, is going to try and help 

450,000 people a year and I am told that there is about 1.5 million 

in the same boat. 

Who picks and chooses? Ms. Sharp? 

Ms. SHARP. Well, from our point of view as a State agency, we 

look at a number of factors, but the primary one is the capacity of 

the local community, the implementing organization, to be able, 

from their perspective using data that is available on all sorts of 

measurements, to be able to target the resources, and services to 

those most at need most able to be positively impacted. 

So, from our point of view, it is a local decision that we would 

be guiding. 

Mr. LINDER. Dr. Daro, as a scientist evaluating programs, Ms. 

Sharp said in her testimony that for every dollar spent, $3.02 is 

saved. 

How does a scientist or an examiner make that decision? 

Ms. DARO. The cost savings are determined by looking at a 

group of people who receive the service and those that didn’t receive the service generally, randomly assigned to these two conditions; and then you look at their experiences in utilizing public resources going forward. 

In the case of the Nurse-Family Partnership, they have 18, 20 

years of evidence. And what you find in the individuals who have 

received services, is less welfare utilization, less use of public 

health care dollars because there is greater employment. And that 

occurs because, as Jeanne noted, they stay in school longer and 

they complete their education. 

So it begins a cycle of investment in themselves such that the social savings can be realized down the line. 

Mr. LINDER. Mr. Chairman, I ask unanimous consent to put in 

the record the fiscal year 2010 budget conference agreement. A 

CRS memo describing on page 2 includes a provision establishing 

a deficit-neutral reserve fund for establishing or expanding home 

visitation programs. 

[The information follows:] 


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Mr. LINDER. The bill before the Committee, we are told, will 

cost about 2 billion dollars over 5 years. The proposal in the Obama 

budget would cost 9 billion dollars over 10 years in just Federal 

funds for this new program. 


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Today, the President is going to speak on urging us to pay for 

all new entitlements. So can anyone tell us how we are going to 

pay for this? 

Mr. Chairman? Mr. Davis? Do you have offsets? 

Chairman MCDERMOTT. Are you asking us or are you asking 

the witnesses? 

Mr. LINDER. I am asking you how it is going to be paid for. 

Chairman MCDERMOTT. My policy basically, Mr. Linder, is 

this: One should decide what good public policy is and once you 

have decided what good public policy is, then you decide how you 

are going to pay for it. 

I think what we are trying to do here today is determine, what 

is the best public policy. And you are correct, finding the money for 

it is going to be a real problem. 

Mr. LINDER. Dr. Brooks-Gunn, can any of the money in this 

program be used for anything else? Can it be used for drug treatment? I assume you read the proposal. Is this a mandate for just 

nurse visitations, if the State has a bigger problem in another area, 

can it be used there? 

Ms. BROOKS-GUNN. I think the State options—you guys are 

the ones that will have to decide if there is some State—— 

Mr. LINDER. Flexibility. 

Ms. BROOKS-GUNN. Flexibility, thank you. Flexibility in terms 

of how the money is spent now. 

Mr. LINDER. There isn’t now? 

Ms. BROOKS-GUNN. At the moment, most home-visiting programs, because of the cost, do not offer drug treatment, although 

people certainly try to link up their clients with what might be 

available in their community for mental health services and for 

drug treatment services. 

Mr. LINDER. Thank you. 

Thank you, Mr. Chairman. 

Chairman MCDERMOTT. My question is this, and it really 

comes off what John has said. And I read all your testimony before 

you came in; and I want you for 1 minute to think about the perfect program and what it would look like. 

Because as I look at it, you can do prevention, you can sort of 

say there is a high-risk bunch over there, let’s focus on them; or 

we can sort of, one, look for the ones like Ms. D’Aprix, who have 

had some problems and put their hand up and said, I am high 

risk—there are a lot of different ways to go at this. 

And are you looking at first-time mothers? 

If you had limited dollars, where would you put the program and 

what would it look like? I would like to hear as much as you can 

give me, so you can start anywhere. 

Anyone want to put their hand up and go on that? 

Ms. DARO. Never shy. 

I think if I were starting with some dimensions, I would certainly 

begin to look during pregnancy, begin to—and do a systematic risk 

assessment, not necessarily use demographic markers for this, because I think—as we heard from Cheryl’s testimony—using the demographic markers is going to miss a number of women that are 

facing significant challenges. 


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So it would be prenatally. Remember, these programs are all voluntary. So you need to present them in a way that is most welcoming and encouraging for families to come forward. So I would 

start with the systematic assessment at all prenatal clinics. I 

would engage OB–GYNs so they were asking a set of questions 

when women came to them and then make this service available 

to people. 

Again—I think I have outlined the parameters of what a successful program would look like, but the idea of targeting simply on demographics, I think does a great disservice to the nature of the 

problem and to the nature of our ability to really reach those families that are most challenged. 

Chairman MCDERMOTT. How would you—I will leave the question alone for a second. 

Go ahead, Dr. Gunn. 

Ms. BROOKS-GUNN. I would probably start with the first-time 

and young mothers, because I think that is a group at most risk. 

Chairman MCDERMOTT. Is your microphone on? 

Ms. BROOKS-GUNN. Yes, it is on. 

I would actually target first-time and young mothers. That is the 

group that is most at risk, and programs such as these ones that 

we are discussing today are most likely to make an impact overall 

on that group of mothers. Consequently, I like the way the bill has 

focused on that particular group of mothers. 

It doesn’t mean other families might not be at risk. But it is a 

group that on the aggregate is more at risk than probably any 

other group. 

Again, the education of the mother and the school readiness of 

the children is for both generations. My ideal program would focus 

on both generations. That is why I would love to see some experimentation in States, in terms of combining home visiting with child 

care services, and/or combining home visiting with some of the new 

approaches that are being tested right now to help moms go back 

to school or stay in school. 

Chairman MCDERMOTT. Do you know any program that has 

had any kind of positive predictive capacity to pick out child abuse 

situations before they happen? 

Ms. DARO. The Healthy Families America model has a screening 

tool that they use for assessing risk. It examines a variety of conditions such as asking if the mom used prenatal care perhaps, or if 

she is under a great deal of stress. 

When they follow these families forward, the families with the 

highest number of stresses and risks during pregnancy, by the time 

they give birth, are far more likely to show up in child abuse reporting systems. 

I will just say, to follow up on what she said, when we look at 

families reported for child abuse, we look at the proportion of the 

population of those children coming into child welfare. It is not necessarily the first-time, teen moms that show up in child welfare. It 

is the woman who is in her 20s, who is having her second or third 

child. Those were the big welfare users; those are the families in 

the child welfare system. 

You should not limit the program only to first-time parents. It 

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we missed them and there is no other option on the table to provide services. We know that a second and third child just adds to 

the stress of the family situation. 

Chairman MCDERMOTT. Ms. Sprinkle, you are out in the field. 

What would be the ideal program to deal with what you have seen? 

Ms. SPRINKLE. Chairman McDermott, I don’t think there is—— 

Chairman MCDERMOTT. Your microphone is not on. 

Ms. SPRINKLE. I don’t think—— 

Chairman MCDERMOTT. Just swallow it. 

Ms. SPRINKLE. My experience, I don’t believe that there is one 

home visitation program that fits all the needs of families. 

Programs that have been proven to be effective and have longterm impacts are where I would place my emphasis and at the 

same time recognize that there are multiple families out there who 

are not first-time parents. If you really want to make a positive impact on preventing child abuse and neglect or reducing it, you must 

catch the first-time parent and teach her what is happening with 

her body and the ways to cope with the stresses in her life and to 

put her in touch with resources to reduce some of those stressors. 

I agree with you that education is very important. Education is 

the key out of poverty in my estimation. So, if you can provide 

wraparound services or support services to those first-time moms 

and help her get connected or attached, if you will, during pregnancy, then she is less likely to be abusive to her child because she 

will understand or have been taught what to look for when she is 

stressed and how to support and nurture a child who is difficult to 

console. 

Ms. SHARP. I would like to add a note. 

I think it is important that we keep an R&D function associated 

with these programs so that we can build the pipeline of programs 

that can eventually get the research and evaluation to establish 

their effectiveness. I agree otherwise with these other commentators. 

Chairman MCDERMOTT. Thank you. 

Dr. Boustany. 

Mr. BOUSTANY. Thank you, Mr. Chairman. Listening to all of 

you and having read the testimony, I gather that programs administered by nurses seem to be more effective than programs administered by those who are not nurses. Is that correct, based on current 

literature? 

Ms. SPRINKLE. I can only share what my experience has been 

with Nurse-Family Partnership. Dr. David Olds, before doing the 

randomized clinical trials of which there were three across three 

different decades using three different ethnic groups—Caucasians 

in Elmira, New York; African Americans in Memphis; and Hispanics in Denver, Colorado. 

He did a focus group, if you will, asking potential participants or 

Members in a community who would be most trusted in terms of 

letting you into their homes, and overwhelmingly it was nurses. 

Nurses have the trust of the community and are seen as nurturing 

individuals who were there to support them and have the medical 

and scientific knowledge to support them during such a critical 

time in pregnancy. 

Mr. BOUSTANY. Do you all agree with that? 


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Ms. SHARP. I will make a quick comment, and I would just like 

to say that certainly nurse-delivered programs have been proven 

very effective. 

I will just reiterate the point in my testimony which is, many 

programs have not had the opportunity to have the same level of 

rigorous evaluation. So I think that there is some evidence still out 

on that issue. 

Mr. BOUSTANY. Thank you. 

Dr. Brooks-Gunn, did you want to comment? 

Ms. BROOKS-GUNN. Yes. 

If we can expand to other countries besides the United States, 

my read of the literature is that what is important is a professional, not necessarily a nurse. It depends on the goals of the program. 

The Nurse-Family Partnership has very specific goals, and so the 

nurse makes sense. But I think that there are demonstrations in 

the literature where social workers, educators, folks with B.A.s 

with terrific training can have some of the impacts that we want 

to see. 

My read of the literature is that the paraprofessionals—in general, those are the programs that are least likely to succeed. 

Mr. BOUSTANY. Thank you. 

Dr. Daro. 

Ms. DARO. I would just add that we don’t have to go overseas. 

There are evaluations here in the United States. New York State— 

the last time I checked, it was in this country—has had success 

with paraprofessionals. A lot of the success of the paraprofessionals, though, hinges on the quality of training they receive and 

the supervision they receive. 

So it is not sufficient to say what is the characteristic of the provider, it is the way you embrace—surround that provider with certain supports; and I think with certain support, they certainly can 

be effective. 

Mr. BOUSTANY. I gathered from reading your testimony that 

there are a number of programs that are of questionable effectiveness; others have been shown to be very effective. And it seemed 

to me that programs administered by nurses had a more proven 

track record, or at least more consistent track record. 

Would you want to comment on that? 

Ms. DARO. With the outcomes—as Jeanne noted, if the program 

is designed toward certain outcomes, such as the Nurse-Family 

Partnership, nurses may be effective, but their own randomized 

trial comparing nurses and paraprofessionals found some mixed results. 

There were actually some outcomes where the paraprofessionals 

did better by the time the child was 4—areas like maternal employment, areas like enrolling a child in an early education program. Those are important outcomes to consider when we are 

thinking about long-term potential savings. 

Mr. BOUSTANY. I know our Ranking Member talked about the 

cost and how all this would be paid for, given the current deficits. 

There was also another cost factor in all this that I don’t think has 

been discussed, particularly if we are looking at nurses. That is the 


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acute nursing shortage we have in this country and given current 

circumstances. 

So if we expand with a new entitlement program that is going 

to be heavily reliant upon nurses, then there is going to be the expense of getting more nurses available and trained to do this. I am 

not sure if that is included in the cost analysis that has been provided. 

I don’t know if you want to comment on that. 

Ms. BROOKS-GUNN. That is one reason that many of us want 

to see some experimentation with different programs. So, as an example, we have a grant pending at NIH—we will see if we get it— 

to take the nurse home visiting model and have nurses come into 

the home two or three times over the 3 years and then have folks 

with a B.A. delivering the services. The idea was to get what you 

get from a nurse home visiting program, but make it cheaper so 

that a nurse—we want to leverage it. And this is something that— 

again, as the field evolves, we have to keep looking to see what 

makes sense. 

To me and David Olds, who is going to help us with this, this 

seems like a really good bet to see if this would work. But stay 

tuned. 

Mr. BOUSTANY. One last question if you don’t mind. 

There are a lot of different programs out there, a lot of different 

funding sources. Given the variation in effectiveness, has there 

been any systematic look at some of these programs that are really 

not effective? How do we combine resources rather than create a 

whole new mandatory spending program? 

Ms. DARO. The way the legislation is crafted, which is actually 

very instructive and very useful, is to direct States toward investing in stronger and stronger program models as the legislation goes 

forward; and I think that is important. I think States themselves, 

local communities as a field, we need to be able to recognize those 

programs that are not working and then move them off the plate 

so those resources can be invested in programs that have stronger 

evidence. 

Mr. BOUSTANY. Before increasing spending again in a new 

mandatory spending program, shouldn’t we look at the current resources and try to make a more efficient use of those? 

Ms. SHARP. I would like to state, as someone responsible for administering public dollars, that we did in fact cut funding from programs in our State based on lack of performance; and I think a responsible administering entity would be looking at those—this is 

after some attempts were made to make sure they had the capacity—and build the capacity to be able to deliver programs effectively. When that became—when it became clear that was not 

going to be the case, then we were able to remove funding based 

on these performance-based contracts. 

Mr. BOUSTANY. How many programs did you eliminate? 

Ms. SHARP. A relatively small number of the total portfolio and 

in some cases it was an issue at the community level in terms of 

local capacity to continue to come up with the resources to match 

our dollars. 

But there are also just some straight-out not delivering program 

with fidelity to the model, as a matter of fact, being—straining far 


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afield and those are the kind of things that a funder or administrator would want to make sure they were looking at along with 

the data about the outcome. 

Chairman MCDERMOTT. Mr. Davis of Illinois will inquire. 

Mr. DAVIS of Illinois. Thank you very much, Mr. Chairman. 

You know, as you were making your earlier comments, I was reminded myself of the fact that you did go to medical school in Illinois; and that perhaps is one of the reasons that I was in agreement with your comments. Let me thank you for your leadership 

on this as well as a number of issues that relate to the well-being 

of children and ultimately to the well-being of our country. 

I have always believed that all of us are the sum totals of our 

experiences. I have spent at least 500 home visits with visiting 

nurses, with community health aides, with nurse practitioners, 

with individuals in training to become nurse practitioners; and I 

agree with you, Ms. Sprinkle. I don’t think that there is any one 

set of individuals who necessarily get the information or see certain 

kind of needs or can make use of those needs in such a way that 

we ultimately reduce the likelihood that children growing up or 

that their families are going to cost society more than they would 

if we provide these services to them. 

My question is, based upon each one of your experiences, who do 

you think are the people that are most likely to make use of this 

program and these services once we pass the bill, find the money, 

and get it established? Who are the people who are going to make 

use of it? 

Perhaps we will just begin with you, Ms. Sharp. 

Ms. SHARP. Okay, I will start with that. My read of the literature and understanding of the program services, one issue becomes very clear and that is the issue of engagement. If families, 

if individuals, families, moms, dads, are not brought into the program consistent with the values within the program, in other 

words, respect and honesty, all those other things that go along 

with this, then you are not going to have success in the program 

by any measure because engagement is a critical part of that and 

retention is the other side of the engagement process. So I think 

the programs, all of these programs, are challenged by those issues 

of reaching out and finding the people who would have the greatest 

benefit. 

But I do trust the local implementers of these programs to know 

their communities well enough to be able to reach deeply into the 

community to find those with the greatest need who would experience the greatest benefit. 

Mr. DAVIS of Illinois. Dr. Daro. 

Ms. DARO. You know, having done several surveys on the idea 

of the social exchange process, people are twice as likely to offer 

help as they are to ask for help. So one of the things we have to 

do with voluntary prevention programs is create a context in which 

parents are comfortable asking for help. 

So who should ask for help? I think parents that have questions 

about their own capacity to care and meet the needs of their child, 

a first-time parent that may not have the information they need or 

the knowledge available in how to nurture and support that child 

or meet just basic care conditions, families that are going through 


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some particular stress in their own lives, women that are concerned about their own safety. There is a whole constellation of 

issues that need to be brought to the table. 

But I would put the responsibility on both creating a context in 

which an offer of assistance will be receptive to someone hearing 

this and then make it broadly available. Let people know, again, 

starting at pregnancy through birth. Many of the programs that 

have been most successful in reaching high-risk families do a universal offer of assistance, a universal visit, if you say while women 

are in the hospital delivering, outlining a set of conditions, and 

again making that offer available to them. 

Mr. DAVIS of Illinois. Dr. Brooks-Gunn. 

Ms. BROOKS-GUNN. My answer is similar to Dr. Daro’s. 

Mr. DAVIS of Illinois. Ms. D’Aprix. 

Ms. D’APRIX. From a personal perspective, I don’t think there is 

a parent out there that doesn’t want to learn, that doesn’t want to 

experience someone supporting them, whether it is your first child, 

your second child. 

I visit with a family who now is on their sixth child, with two 

sets of twins under two, and really asking for support. And through 

the temp assessment we partner with every doctor’s office, every 

hospital so that we can be there and available to offer services to 

every family. 

Mr. DAVIS of Illinois. Ms. Sprinkle. 

Ms. SPRINKLE. I think the families that benefit the most from 

this type of intervention will be those families from low income, 

vulnerable populations who don’t have the advocates in place or the 

resources needed to ask for assistance or even know to ask for assistance. So increasing an awareness of services that are available 

to them in the community will make great strides in getting families the services that they need. 

Mr. DAVIS of Illinois. Thank you, Mr. Chairman. 

Chairman MCDERMOTT. Thank you. 

Mr. Roskam from Illinois. 

Mr. ROSKAM. Thank you, Mr. Chairman; and thank each of you 

for your time today. 

And, Ms. D’Aprix, thank you very much for sharing your journey. 

It is helpful, and it is insightful. 

As we are sitting here listening, I am reminded of my older 

brother who has no discernment when it comes to movies. You call 

him up. ‘‘Steve, should I go see this movie?’’ ‘‘Oh, yeah’’, he says. 

‘‘It is great. You will like it’’. You go see it, and it is not very good. 

And you call him up later and you say, ‘‘I thought you said this 

was good;’’ and he says, ‘‘well, it was entertaining.’’ He has no discernment whatsoever. 

You call my wife and say, ‘‘should I see this movie?’’ And she 

says, ‘‘no. No magic, no plot line. They ran out of money. They 

ended it too fast. Don’t waste your time.’’ 

So as I am here today, I am trying to discern, are you more like 

my brother or are you more like my wife? The question is a serious 

one. Because here you are, three of you. You all gave great testimony. Three of you sort of hit a particular theme, and I stopped 

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dentiary threshold or peer review or those sorts of themes. And 

that was you, Ms. Sharp, and you, Dr. Daro, and you, Ms. Sprinkle. 

Implicit in your testimony when you use an evidence-based argument is that there are programs that you have looked at in this 

environment where you have said, ‘‘That is a loser. We are not 

going to do that.’’ 

You mentioned a minute ago, Ms. Sharp, that there was a program or some kind of de minimis program—I am putting words in 

your mouth a little bit—but some that stuff because of a local 

match you kind of waived off on. But I guess, Dr. Daro or Ms. 

Sprinkle, are there programs that you have looked at in this arena 

and you just said, ‘‘This is not going to cut it?’’ I will get to you, 

because I sense you have got something to say. 

Ms. DARO. There certainly are. I think there are programs that 

are not well conceived. They are going to accomplish everything in 

the world with the family. What are these programs offering? They 

claim they can accomplish these broad outcomes with three home 

visits. That is a no-brainer for me. It is not going to happen. 

So I think you can look at the internal consistency of a program, 

their logic model, I think; and then you look at outcomes. If time 

and time again they can only engage a handful of the people they 

want to bring into the program, they only retain people for a fraction of the time they want to keep them, I think that kind of ongoing data management should begin to tell you this program needs 

to go back and retool. It is not ready for prime time. 

And there are, unfortunately, a number of programs that just 

crop up. We call them homegrown programs. They are not attached 

to any of the national models. They just exist because somebody 

thinks it is a great idea. 

I think in this environment we can’t fund everybody’s great idea. 

We need to be able to pull the plug. 

Mr. ROSKAM. Thank you. 

Ms. Sprinkle. 

Ms. SPRINKLE. I am supportive of programs that will improve 

lives of families in general, particularly low-income minority families, because we know that they are at risk for the worst outcomes 

in terms of economics and health. 

Most certainly you want to put your resources where you are 

going to get the greatest benefit, those programs that have a data 

tracking system, that look at client characteristics, that look at the 

quality of the home, that look at content and have a curriculum or 

protocol with the desire and intent to make a positive impact outcome. 

Mr. ROSKAM. I don’t want to cut you short. I want to refocus 

you on this question. Have programs come across your desk that 

are home visitation programs that have those characteristics that 

you have looked at and you said, ‘‘ we are not going to do that?’’ 

Or have you liked every home visitation program that you have 

heard about? 

Ms. SPRINKLE. My experience has been exclusively with Nurse 

Family Partnership. 

Mr. ROSKAM. Thank you. 

Ms. Sharp. 


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Ms. SHARP. I did want to get back to your question about being 

more like your brother or your wife. 

Mr. ROSKAM. Choose well. 

Ms. SHARP. And I guess think of me as your sister-in-law. 

Mr. ROSKAM. Fair enough. 

Ms. SHARP. Yes, we have definitely come across programs that 

we did not find the evidence persuasive as to their effectiveness, 

and we did not include them on the list of those that we would 

fund. And we are committed to reviewing the literature and new 

evidence as it comes along, but clearly there are some programs 

that may even do harm. 

Mr. ROSKAM. One quick final word. Ms. Sprinkle, you mentioned that, in that example of the 14-year-old that you gave, that 

there were people that the family had reached out to that weren’t 

willing to help. And I guess part of the concern that some of us 

have is how do we direct programs that are actually getting toward 

that particular need? So implicit in that is that some program is 

failing this family, right? A well-intentioned, good program is failing this family. I am going to share with you one quick quote, and 

it is from President Obama’s inaugural speech. 

He said, ‘‘The question we ask today is not whether government 

is too big or too small but whether it works. And where the answer 

is no, programs will end.’’ 

In closing, our challenge, in light of the President who tells us 

that we are broke, is how do you properly allocate resources? How 

do we all properly allocate resources so that those families that 

really need the help are helped and that there is not a great deal 

of waste? I think that is what Dr. Boustany was driving at, taking 

a step back, looking at the totality of these programs and trying 

to move forward where there is a great deal of consensus. 

I think my time has expired. 

Chairman MCDERMOTT. Since we have good experts here, I 

thought we would go a second round, if anybody would like to. 

Mr. Davis. 

Mr. DAVIS of Illinois. Thank you very much, Mr. Chairman. I 

had a couple of additional questions. 

I guess part of my experiences have been that I am old enough 

to remember when a lot of things didn’t really exist. Physician assistants, I happen to have been a Member of the new career section 

of the American Public Health Association when many of the ancillary groups who now provide certain kinds of services did not exist. 

I wanted to ask two questions. Dr. Daro, I wanted to ask you, 

we have talked a great deal about stable funding. Although I agree 

with Chairman McDermott, if we come up with good social policy, 

then we can determine how to get the money once we decided that 

it is good. But why is a stable funding stream so important in the 

development of a program like this one? 

Ms. DARO. I think when you are talking about investing in 

newborns and their parents and you are trying to do it on a scale 

large enough to impact the population-based indicators that most 

distress you, like reducing child abuse, like making sure children 

arrive at school ready to learn, families need to know that this isn’t 

a program that is going to be here today and gone tomorrow. They 

need to know that it is going to be here for them when they have 


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their first child or their second child, that they can refer their 

neighbors to it. 

And too often programs that are quite good—I mean, one of the 

problems is it is not just poor programs in the marketplace, it is 

good programs in the marketplace that have way too many families 

that they can’t possibly reach or serve. It is good programs in the 

marketplace that lose their foundation funding so they have to 

close their doors. That does a disservice to the communities, and 

that is why the stable funding is so important. 

Mr. DAVIS of Illinois. So we talk a great deal about these things 

but do them much less. I mean, I was saying that after all is said 

and done, more is generally said than done. So there is a lot of conversation, not movement to the action. 

My last question, Ms. Sprinkle. I notice that you placed a great 

deal of emphasis on low-income people. Why did you place so much 

emphasis, on low-income, disadvantaged individuals? 

Ms. SPRINKLE. Low-income, disadvantaged individuals typically 

don’t have the advocates needed to help them get the resources to 

meet their needs. 

My experience, growing up here in Washington, D.C., within 

walking distance from the Capitol here is an experience in which 

I grew up in a low-income environment; and those are the families 

that can benefit greatest from this type of service. 

Mr. DAVIS of Illinois. So you are saying that if we don’t create 

special attention for these individuals for as long as they live, as 

long as their children live, and as long as their population group 

lives, they will still be low-income, disadvantaged people? 

Ms. SPRINKLE. When families are presented a program that 

helps meet their needs, hopefully it breaks the cycle of poverty and 

has a positive multi-generational impact. 

Mr. DAVIS of Illinois. Thank you very much. 

Thank you, Mr. Chairman. 

Chairman MCDERMOTT. Dr. Boustany. 

Mr. BOUSTANY. Ms. Sprinkle, are the nurses in your programs 

RNs or LPNs or both? 

Ms. SPRINKLE. The nurses in the Nurse Family Partnership 

are registered nurses, predominantly baccalaureate prepared registered nurses. 

Mr. BOUSTANY. My son is a counselor. He does home visits. He 

finished with a master’s degree and jumped into one program, and 

it was very disorganized. A lot of people were quitting. There was 

no continuity of care with the families. He went to another one, the 

same sort of thing. Now he is doing something different in counseling, but he was very frustrated. He said, ‘‘We are not going to 

make a dent in any of this because we are not measuring outcomes 

properly.’’ 

The continuity issue is a real problem. There was just no structure to any of the programs. I was thinking, ‘‘Okay, that is two programs in my home State of Louisiana, a lot of it being funded by 

Medicaid dollars.’’ States are struggling with their budgets across 

the country. How many more of these kinds of programs are out 

there, and how do you root them out? You talked about having a 

way of doing it in your home State. But are the other States 

equipped to do this? Are they doing a good job? 


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Ms. SHARP. I guess I would just like to add that our ability to 

sort through and make these performance-based contracts work, 

along with the capacity building, goes back 20 years to our focus 

on outcome-based evaluation. We felt that, as a funder, our best 

value add for these local organizations was to help them understand how to be outcome-based and to know how to measure and 

report those results. And so that has been the key to their sustainability. 

So it is part of our learning organization way of doing business 

to sort of focus on those kind of things. And those can—while it 

sounds very specific to a reporting process, it actually is what 

builds the organizational capacity to deliver programs with effective service delivery models. 

Mr. BOUSTANY. Thank you. 

I know Senator Moynihan has talked about all this back in the 

seventies, and breaking this cycle of poverty is something I am certainly interested in. I have got a high degree of poverty in my district. I am frustrated because it seems like we throw a lot of money 

into programs, but we never weed out the bad ones, consolidate the 

good ones, and focus the resources, as my colleague, Mr. Roskam, 

was saying earlier. 

I guess I have one final question, in the spirit of Father’s Day, 

which is approaching. What share of households have the fathers 

in the picture in this? And can you talk to me about some of the 

best practices of what is happening there? 

Ms. DARO. Almost all of the models now have explicit instructions to visitors when they go in the home to engage as many as 

they can. And I think the Nurse Family Partnership does a wonderful job with fatherhood. I know Healthy Families America does 

as do many of the other programs that are out there. I mean, people recognize that dads are a big part of the picture, and they need 

to be there at the beginning, hopefully engaged in the pregnancy, 

if at all possible. 

Mr. BOUSTANY. Thank you. 

Ms. BROOKS-GUNN. The best way to do that, actually, could be 

programs that really start in the hospitals. We talk about the 

magic moment, and that is when the child is born. And you can 

often get fathers very engaged at that point whether or not they 

are in the household or they are living elsewhere. 

Ms. SPRINKLE. In my experience working in Greensboro, North 

Carolina, operating a Nurse Family Partnership program, we had 

a fatherhood component where the services were designed exclusively for the dad, to get him involved in the life of the child early 

on; and you can see the positive impacts it has on the child when 

the dad is involved, if not physically present in the home, emotionally present in the child’s life in a positive way. 

Mr. BOUSTANY. So you do make efforts to reach out when the 

dad is not in the home to make contact with him? And so that is, 

in effect, a separate visit, or at least phone calls? 

Ms. SPRINKLE. He can be included in the visit during the time 

of the home visit in Nurse Family Partnership. There are some programs that are specifically designed to serve fathers outside of that 

relationship with the mother, because they have their own needs 

and resources. 


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Chairman MCDERMOTT. If the gentleman will yield, Ms. 

D’Aprix, you are sitting there rocking your head, but you are not 

saying anything. Come on. 

Ms. D’APRIX. I am. We have a fatherhood program within the 

Starting Together Program for Madison County. When we go out 

to visit a family for the first time, we take the information about 

him; and we set up a visit for the family to meet with him. And 

that is every single family. 

Mr. BOUSTANY. What kind of outcomes are you getting with 

trying to get the father involved? Do you have some metrics on 

that? I mean, success rates? Is the trend good or bad or neutral? 

Ms. SPRINKLE. Nurse Family Partnership has been able to 

demonstrate a 46-percent increase in fatherhood involvement within the Nurse Family Partnership program. 

Ms. SHARP. I will have to get back to you on that one. 

Ms. BROOKS-GUNN. It is going to have to be anecdotal. There 

is not much in the literature about what is happening to the father 

as a function of home visiting programs. 

Mr. BOUSTANY. Should that be part of the metrics, though? 

Ms. SHARP. I mean, it goes back to my point about building the 

pipeline. Because we are funding some very exciting programs that 

are showing very strong outcomes related to father engagement, et 

cetera. But they are not at this point evidence-based programs. 

Chairman MCDERMOTT. Thank you. 

I would just close by saying in my training back in 1965, the 

Mental Health Act had passed in the U.S. Congress and the first 

mental health centers were opening across the country of Illinois, 

the money went—in every State, it went to the Governor, except 

in Illinois. Mayor Daley got a chunk of it. 

I was at the University of Illinois, and it was there where we 

started the first mental health center in the Woodlawn area south 

of the University of Chicago. It was an area that was troublesome 

to the Mayor; and he said, well, what they need is a mental health 

center. So they sent a group of us down there to start a mental 

health center in the Woodlawn area. 

And when they got together with the community, they said to 

them, what do you want this mental health center to do? And they 

said, well, it is over for us as adults, but we care about our kids. 

We want this mental health center to focus on the kids. 

And we did research for a number of years there around what 

affects school performance and how kids do and so forth. And getting the parents involved and actually going up to school and actually seeing what the kids did really was the most effective thing, 

because suddenly they knew their parents cared about what was 

going on. 

That research was done 1965, 1966, 1967, 1968. I don’t think 

there has ever been a program funded off of it. And what a struggle 

I think our Subcommittee has is to figure out which one of these 

evidence-based programs or how we should put the money out 

there so that States will look at it in that way that that is—we 

ought to take things that have already been researched and implement them and give them a solid funding base, which is really 

what Mr. Davis is talking about. We start them, stop them. And 

one gets going and looks good and then we defund it. 


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So I think that is what the Committee on both sides of the aisle 

is really looking at, it is how can we figure out where the best place 

to put the money is and actually fund things that we know have 

had positive effect. So I am thankful and we are all thankful for 

your coming here and spending the time trying to educate us and 

we will see what works out in the future. 

Thank you. The meeting is ended. 

[Whereupon, at 11:27 a.m., the Subcommittee was adjourned.] 

[Submissions for the Record follow:] 

Statement of Alice Kitchen 

My name is Alice Kitchen. I am a social worker and the Principal Investigator 

for the Team for Infants Endangered by Substance Abuse (TIES) sponsored by Children’s Mercy Hospitals and Clinics in Kansas City, Missouri. We strongly support 

passage of the Early Support for Families Act (H.R. 2667) because we too have experienced and documented the impact of home visitation on mothers, infants, and 

young children. 

TIES has been in existence for over 18 years, with most of those years having 

been funded by the Administration of Children Youth and Families Children’s Bureau Abandoned Infants Administration. TIES is an intensive in-home intervention 

program serving high risk parenting women abusing drugs and alcohol while pregnant or after delivery in the urban Kansas City, Missouri area. Our support for this 

federal legislation is based on our years of experience that adds to the body of experience and research stated in the legislation. Our experience provides evidence that 

early childhood community based in-home interventions are effective tools for not 

only reducing out of home placement and child abuse/neglect but providing skill 

building in the areas of parenting, reducing drug use, promoting physical and mental health, securing economic stability, and maintaining housing. 

The TIES evaluation was conducted by the Institute for Human Development 

(IHD) affiliated with the University of Missouri-Kansas City (an Applied Research 

and Interdisciplinary Training Center for Human Services) led by Kathryn L. Fuger, 

Ph.D. and her team. TIES has been a grant awardee for four cycles of four years 

through the U.S. Department of Health and Human Services Children’s Bureau 

Abandoned Infants Assistance Program, Grant # 90–CB–0139/04. 

Participants in the TIES Program were rated in five goal areas: (1) becoming drug 

free, (2) improving parenting, (3) accessing appropriate child health care, (4) gaining 

economic stability, and (5) maintaining adequate housing. The goal attainment for 

each of the five areas ranged from 1 (poor) to 5 (optimal) parenting outcomes. 

TIES participants were rated initially (Time period 1), at 3 months after enrollment (Time period 2), at the child’s age of 13 months (Time period 3), and at discharge (Time period 4). Participants showed gains in all five primary goal areas, 

with improvements reaching statistical significance in all areas except housing. The 

evaluation team findings include: 

• Regarding the goal of becoming drug free, women initially were below the expected outcome. They improved consistently between Time 1 and Time 3 to reach 

the expected outcome level, with a slight decline at Time 4. 

• Goal ratings on improved parenting increased from Time 1 to Time 2, and then 

remained at roughly the expected outcome level for the other time periods. 

• Regarding the goal of providing children with health care services, ratings improved from the expected level initially to better than expected for all other assessment times. The majority of participants were rated above the expected outcome 

from 3 months until discharge. 

• Regarding the goal of economic stability, only 13% of participants were at or 

above the expected outcome at intake, but significant improvement was seen in all 

analyses of change over time. Even with these gains, mean scores only rose to 2.4 

on the 5-point scale when comparing those assessed at all four time periods. 

• Goal ratings on the adequacy of housing for participating families ranged from 

very poor to very good each time period. By Time 3, some improvements in mean 

ratings occurred, but did not reach statistical significance. Of the 5 goals, it appeared that adequate housing took longer to achieve. 

The level of engagement over time was a factor in the success of goal attainment, 

as seen by these statistically significant associations: 

• Child health and housing ratings at intake were associated with the level of engagement with program staff at 3 months. 


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• The goal ratings of becoming drug-free, parenting, child health, and housing at 

3 months and at discharge were associated with the level of engagement at 3 

months. 

• Parenting and economic stability ratings were also associated with the level of 

engagement at 13 months. 

Relative caregivers tended to improve in child health care, economic stability, and 

housing as they progressed through the TIES Program and stabilized at discharge, 

suggesting they were providing a more stable, healthy environment for the children 

in their care. (E–3 Executive Summary, TIES Report to AIA, CB, DHSS, December, 

2008) 

Our experience is based on an intensive community based model using social 

workers in the role we call Family Support Specialist. The two most important ingredients that are essential for success are 1.) early intervention in the home, and 

2.) a selection of high quality experienced professional staff who are comfortable in 

the setting and have strong social work skills. 

As you can tell from the research findings, the social workers are very adept at 

establishing relationships with the mothers and using their interpersonal skills to 

draw out the strength in each mother and her family. Given the risk factors this 

population presents, this is an enormous challenge for any professional staff. Careful attention has been paid to hiring staff that are of the same ethnic population, 

have extensive experience in child welfare with our local population and have proven they are skilled and comfortable in a high risk environment. Social workers add 

value to this proven model in that their education and practicum go beyond developing skills in work with the individual, the families, and the community. Social 

workers start where the person/family is and help to empower the family members 

to develop their own strengths. Social workers also are expected to work simultaneously to change the environment and the policies that keep families from helping 

their children survive in highly toxic environments. 

Our TIES complete December 2008 evaluation is available upon request. We will 

be pleased to assist in any manner we can to support the Early Support for Families 

Act (H.R 2667). 

Witness Information: 

Alice Kitchen, LCSW, MPA 

Director of Social Work and Community Services 

Children’s Mercy Hospitals and Clinics 

f 

Statement of Children and Family Futures 

Children and Family Futures thanks you for the opportunity to submit this written statement for the record of the June 9, 2009 Hearing on Proposals to Provide 

Federal Funding for Early Childhood Home Visitation Programs held by the House 

Committee on Ways and Means Subcommittee on Income Security and Family Support. Our comments reflect the views of our own organization and do not represent 

those of any of our funders or sponsors. 

Children and Family Futures (CFF) is a non-for-profit organization based in 

Irvine, California. Our mission is to improve the lives of children and families, particularly those affected by substance use disorders. CFF consults with government 

agencies and service providers to ensure that effective services are provided to families. CFF advises Federal, State, and local government and community-based agencies, conducts research on the best ways to prevent and address the problem, and 

provides comprehensive and innovative solutions to policy makers and practitioners. 

We thank the Subcommittee for its leadership in this critical area. Home visitation is a strategy for ensuring good parenting and preventing child maltreatment, 

and as research has demonstrated, appears to show considerable promise towards 

improving the well-being of low-income families and their children. The typical 

home visitation program involves a trained worker—a nurse or sometimes a paraprofessional—who visits families in their homes and provides parent education and 

support services. Sometimes the program begins during prenatal visits, in other 

cases it begins in the hospital after a birth or with a referral of an at-risk family. 

A recent publication on State home visitation programs summarized the approach: 

Home visiting for families with young children is a longstanding strategy offering 

information, guidance, risk assessment, and parenting support interventions at 


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1K. Johnson (2009) State-based Home Visiting: Strengthening Programs through State Leadership. National Center for Children in Poverty. 3, 5 2The assumptions underlying these estimates include: 

500–600,000: This is a conservative estimate based on recent prenatal screenings in multiple 

sites, as well as prevalence studies based on screening at birth. N. Young et al., (2008) Substance-Exposed Infants: State Responses to the Problem. National Center on Substance Abuse 

and Child Welfare, Irvine, CA. A May 2009 report based on the National Household Survey on 

Drug Abuse indicated that 19% of pregnant mothers used alcohol in their first trimester of pregnancy; projecting this number to the 2007 total of births would raise the estimate of prenatal 

exposure to 820,000 annually. Substance Use among Women During Pregnancy and Following 

Childbirth, SAMHSA May 21, 2009. http://oas.samhsa.gov/2k9/135/PregWoSubUse.htm 

5% prenatally exposed identified: the 5% figure is the product of comparisons of infants reported to CPS in several jurisdictions to available data about overall prevalence of prenatal exposure [Orange County study: http://www.ochealthinfo.com/docs/public/2007–Substance-ExposeBaby.pdf; N. Young et al., op.cit. 

6 million: National Household Survey on Drug Abuse, June 2003, Children Living with Substance-Abusing or Substance-Dependent Parents, SAMHSA. http://www.oas.samhsa.gov/2k3/children/children.htm 3 Neil Guterman, (2001) Stopping Child Maltreatment Before It Starts: Emerging Horizons in 

Early Home Visitation Services, Sage Publications.115–120 4 Ibid 120. 

home. The typical ‘‘home visiting program’’ is designed to improve some combination 

of pregnancy outcomes, parenting skills and early childhood health and development, particularly for families at higher social risk . . . When funded by government, such programs generally target low-income families who face excess risks for 

infant mortality, family violence, developmental delays, disabilities, social isolation, 

unequal access to health care, environmental exposures, and other adverse conditions.1

This list of risk factors underscores an important question about home visitation 

programs: what problems do they screen for among target families and how do they 

intervene to improve outcomes in those problem areas? 

The impact and co-occurrence of substance abuse 

The impact of substance abuse on families with younger children is well-documented to have major effects on a significant number of these children and families, 

and to co-occur with other, closely linked problems, including mental illness, developmental delays, and family violence. One in eleven children—a total of six million—live in families in which one or more caretakers are alcoholic or chemically 

dependent on illicit drugs. Another group of children living with the effects of parental substance abuse are the estimated 500–600,000 infants who are born each year 

having been prenatally exposed to alcohol or illicit drugs. Only about 5% of them 

are identified at birth, and even fewer are referred to child protective services and 

removed from their families. Cumulatively, this means that nine million children 

and youth under 18 were prenatally exposed and are at risk due to that exposure 

and the co-occurring problems that accompany exposure.2

The omission of substance abuse 

But despite their emphasis upon risk factors and prevention of poor outcomes, 

many home visitation programs de-emphasize parental substance abuse and prenatal exposure far below the relative importance of these factors. Several reviews 

of home visitation programs have cited the downplaying or omission of substance 

abuse as a risk factor. One recent summary of home visitation programs as they 

affect child maltreatment has a full chapter on substance abuse, which includes a 

detailed review of how home visitation programs tend to minimize substance abuse 

as an issue in working with families. The author concludes that most home visitation programs simply list substance abuse as one of many problems in a screening 

and risk protocol and refer clients out to substance abuse programs when they selfreport.3 This source documents the importance of screening for substance use disorders in home visitation programs by citing the literature that found that substance abuse is ‘‘a strong predictor for physical abuse and neglect, tripling the risk 

for later maltreatment.’’ 

Early home visitation services have rarely reported tailored or integrative service 

protocols for home visitors working with families also contending with substance 

abuse.’’. . . Home visitation programs still face a need to augment their intervention 

strategies to effectively address the ongoing and intertwining problems of substance 

and child abuse risk. . .4

Another recent evaluation of a widely used program in California concluded: 

Moreover, substance abuse specific interventions have not been developed for use 

within this model. Indeed, when substance abuse is identified to occur, the individual is referred to a substance abuse provider in the community, or is denied from 


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5Donohue, B., Romero, V., & Hill, H. H. (2006). Treatment of co-occurring child maltreatment 

and substance abuse. Aggression and Violent Behavior, 11 (6), 626–640. 6K. Johnson op.cit, 15 A.Butz, et al. 2001. Effectiveness of a Home Intervention for Perceived 

Child Behavioral Problems and Parenting Stress in Children With In Utero Drug Exposure. Archives of Pediatrics & Adolescent Medicine 155(9): 1029–37. Eckenrode, et al. 2000. Preventing 

Child Abuse and Neglect with a Program of Nurse Home Visitation: The Limiting Effects of Domestic Violence. Journal of the American Medical Association 284(11): 1385–91. 

enrolling . . . if the substance abuser is not enrolled in a substance abuse program 

. . . Therefore, although the intervention components. . . appear promising, the investigators do not recommend its use for substance abuse issues.5

Finally, a review of home visitation outcomes concluded: 

While many program evaluations show positive effects on primary prevention by 

improving daily reading, parent communication skills, discipline strategies, and parent confidence, fewer have shown impact on maternal depression, family violence, 

and substance abuse. Some limited success was shown with highly tailored models 

for specific concerns such as substance abuse, as opposed to multi-risk families. Opportunities exist to improve the training and supervision for home visitors, as well 

as to create enhanced interventions that engage and embed more highly trained professionals from the social work, mental health, or substance abuse fields.6

How can substance abuse be addressed? 

Guterman sets forth four practice principles that would improve the capacity of 

home visitation programs to address substance abuse in greater depth. 

• ‘‘Home visitors should routinely and sensitively assess the presence and role of 

substance and/or alcohol use and abuse early in their work with families.’’ 

• When substance abuse has been identified, home visitors should work to reduce 

the risks and harm on the developing child and family. 

• ‘‘Home visitors must intensively and persistently orchestrate formal supports to 

maintain essential health, economic, and social supports’’ for substance-abusing 

mothers 

• Home visitors should work with substance-abusing parents to develop informal 

support networks to reduce both substance and child abuse risk 

Building on Guterman’s comments and other reviews of HV as they address substance abuse, there are at least five critical questions in home visitation with respect to substance abuse: 

1. As clients enter the program, is the possibility of substance abuse explored in 

depth through screening by trained staff using proven screening protocols? 

2. If services begin with prenatal visits, are adequate screening tools used and followed up with adequate interventions when substance abuse is detected? 

3. Is prenatal exposure a trigger for referring clients and establishing clients’ need 

for prevention and treatment services? 

4. Is substance abuse used as a factor to screen some clients out of the program? 

5. Do clients who are less likely to enroll or be retained in voluntary services due 

to their substance abuse problems receive adequate engagement and retention efforts that address those problems? 

What do current models do? 

In determining what current home visitation programs do to address substance 

use, we reviewed information on four models in wide use throughout the country: 

Healthy Families America (HFA), the Home Instruction for Parents of Preschool 

Youngsters (HIPPY) Program, Nurse-Family Partnership, and Parents as Teachers. 

Early Head Start and the Parent-Child Home Program are also included in some 

listings of the most frequently adopted programs but were not part of this review. 

In assessing how each of these home visitation programs seek to address substance use disorders, it is difficult to conclude how adequately the models accomplish this, since most of these models refer to substance abuse as one of a series 

of risk factors but do not provide descriptive details on how it is to be handled. Evaluations of these models are also of limited value, since substance use outcomes are 

not included routinely in most evaluations of the results of home visitation. It is also 

worth noting that sometimes these models are combined; for example, 136 Parents 

as Teachers sites are combined with HFA programs. 

Healthy Families America (HFA) 

The base model for HFA does not emphasize substance abuse; a summary of services content simply says: 


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7http://www.healthyfamiliesamerica.org /downloads/hfalimpllservicelcontent.pdf 8http://www.healthyfamiliesamerica.org /downloads/evallhfmltuftsl2005.pdf 9http://www.hippyusa.org/refId,28036/refDownload.pml 

10http://www.nursefamilypartnership.org /content/ 

index.cfm?fuseaction=showContent&contentID=4&navID=4 11http://www.parentsasteachers.org /atf/cf/%7B00812ECA–A71B–4C2C–8FF3– 

8F16A5742EEA%7D/ Research—Quality—Booklet.pdf 12 H. Chang, and M. Romero, (2008) Present, Engaged, and Accounted For: The Critical Importance of Addressing Chronic Absence in the Early Grades. National Center for Children in Poverty. N. Connors, et al. 2004. Children of Mothers with Serious Substance Abuse Problems: An 

Accumulation of Risks. American Journal of Drug and Alcohol Abuse 30(1): 85–100. http:// 

www.nccp.org/publications/publ837.html 

A single home visit may cover between 5 and 9 different topics, with a median 

of about 6 topics. Topics are grouped into broad areas such as parent-child interaction or child development.7

A fifty-eight page chapter on HFA program design mentions substance abuse 

briefly as one of many conditions that may need to be addressed. One of the state 

evaluations indicated that fewer than 1% of the clients were referred for substance 

abuse services.8

However, one of the HFA models in the District of Columbia was awarded a 

three-year Starting Early, Starting Smart (SESS) grant by the Substance Abuse and 

Mental Health Services Administration (SAMHSA) in partnership with the Casey 

Family Programs. This national partnership was designed to support the integration 

of mental health and substance abuse services into primary health care and early 

childhood settings serving children ages 0–5 years and their families/caregivers. 

This site used the SESS model to supplement the HFA base model with these special services. While outcomes of this project are not available, the project shows that 

the HFA model can be adapted to include greater attention to substance abuse 

issues. 

Home Instruction for Parents of Preschool Youngsters (HIPPY) 

The HIPPY model uses home visitors and family group sessions targeted on 

younger children to improve parent involvement and school readiness outcomes. Its 

research summary does not refer to substance abuse.9

Nurse-Family Partnership 

Under the Nurse-Family Partnership program, nurses conduct a series of home 

visits to low-income, first-time mothers, starting during pregnancy and continuing 

through the child’s second birthday. Some NFP research cites reductions in smoking, but there are few references to use of alcohol or other drugs. In one of the most 

recent evaluations of NFP, conducted by the program’s original designers, substance 

use by mothers was assessed and summarized: 

Earlier reported impacts of the Elmira program on ‘maternal behavioral problems 

due to substance abuse’ [was] . . . no longer statistically significant in the new 

analysis.10

Parents as Teachers 

Although Parents as Teachers (PAT) models emphasize equipping parents to understand child development and include developmental screening, there is no reference to prenatal exposure or substance abuse-related outcomes in the research 

summaries published by (PAT).11 However, a recently issued guide to working with 

children with special needs briefly discusses fetal alcohol effects. 

Why substance abuse must be addressed 

Because substance abuse affects developmental outcomes and school readiness 

Home visitation programs often cite school readiness as a major goal. In seeking 

to serve children and families with high risk factors, the overlapping group of children living with substance-abusing parents and those who were prenatally exposed 

are at considerably greater risk for developmental delays, behavior problems, and 

difficulties as they enter school. A recent study of children whose school attendance 

is substandard noted that parental substance abuse can be a contributing factor in 

poor attendance; 12 again, one in eleven children lives in a family where substance 

abuse is serious enough to be classified as alcoholism or chemical dependency. But 

with the exception of the above-mentioned HFA program that was linked to Starting 

Early, Starting Smart, there are few examples of home visitation models that directly address these risks. 

As the exception makes clear, that gap is not for lack of models. Home visitation 

programs that are formally linked with center-based early childhood education can 


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13 California Mental Health Services Oversight and Accountability Commission Report: Co-Occurring Disorders, March 2007. 14 ‘‘Home Visiting: Strengthening Families by Promoting Parenting Success,’’ Policy Brief No. 

23, National Human Services Assembly. November 2007. 

address the substance abuse issues by using one of the two widely recognized programs designed for linking substance abuse services and early care and education: 

Starting Early, Starting Smart or the Free to Grow model developed by the Head 

Start program. Both of these are promising approaches that should be encouraged 

further as means of improving the focus of early childhood programs on substance 

abuse effects impacting millions of children. 

Because substance abuse is intergenerational 

Because substance use disorders are inherently intergenerational, with a genetic 

component, a component that is affected by multi-generational family patterns, and 

effects of both organic and environmental exposure on children, family-centered 

home visitation must provide services to parents and children that specifically address substance use disorders. 

Because home visitation addresses other problems that co-occur with substance use 

disorders. 

To address mental illness, family stress, domestic violence, and other conditions 

that co-occur with substance use disorders as though they were each separable ignores the reality of co-occurring disorders. It is not possible to neatly separate the 

mental health and family violence portions of family risk factors from substance 

abuse. 

Approximately one half of the people who have one of these conditions—a mental 

illness or a substance abuse disorder—also have the other condition. The proportion 

of co-morbidity may be even higher in adolescent populations . . . Availability of integrated treatment for mental health and substance abuse problems is currently the 

exception rather than the rule.13

Because home visitation appears to benefit higher-risk families more than lower-risk 

ones 

The finding that ‘‘home visiting appears to carry more benefits for high-risk families than for low-risk ones’’ 14 raises the issue of which risks are being addressed. 

Combined with the finding that high—quality programs are more likely to assess 

family needs and link them with community resources, this suggests that identifying substance abuse as it affects both parents and children is a necessary component of addressing major risk factors to promote strong families and healthy child 

development. 

Identifying those parents needing treatment would also help to reduce the sizable 

gap between those needing and those receiving treatment. Based on the National 

Survey on Drug Use and Health (NSDUH) data, in 2007 of the 23.2 million persons 

over 12 who needed treatment for illicit drug or alcohol use, only 2.4 million received treatment. 

To the extent that home visitation programs have been shown to have the highest 

payoff for families with higher at-risk profiles, the families affected by co-occurring 

substance abuse, mental illness, and domestic violence-related trauma are those 

that would benefit most from home visitation programs designed to respond to these 

challenges. 

Legislative Options 

The legislation emerging from Congress can build upon these lessons drawn from 

the recent history of home visitation, in recognizing the importance of substance 

abuse as a critical risk factor. We thank Chairman McDermott for your leadership 

in this critical area through your sponsorship of the Early Support for Families Act 

of 2009 (H.R. 2667) along with Representatives Danny Davis and Todd Platts. We 

also commend Representatives Davis and Platts for their sponsorship of similar legislation, the Education Begins at Home Act of 2009 (H.R. 2205). These important 

pieces of legislation offer a significant opportunity to States and Tribes to create and 

expand early childhood home visitation programs. However as currently drafted, the 

Early Support for Families Act of 2009 (H.R. 2667) does not specifically mention nor 

speak to the issue of substance abuse. Similarly, in the Education Begins at Home 

Act of 2009 (H.R. 2205), substance abuse is mentioned only once as one of the agencies that should be collaborating with the central program organization. It is left 

out of lists of several risk factors, is left out of a list of agencies to which families 

should be referred for services, and is left out of a list of technical assistance topics. 


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To ensure that substance abuse is given appropriate attention in home visitation 

models, we offer the following recommendations on provisions that could be included 

in legislation: 

1. Require that state or local plans for home visitation programs that are developed also include the prevalence of substance abuse in a formal needs assessment 

and indicate how substance abuse agencies will be actively engaged in program design and services effectively coordinated, how the training of home visitation personnel will include training on proper risk and safety assessment techniques that 

include substance use, and include information on the program’s outcomes including 

how effective the program model has been in conducting risk assessments, the number of parents (when appropriate and necessary) referred for treatment, and the outcomes of treatment for those referred. 

2. Require that home visitation programs that begin with prenatal visits include 

a proven risk assessment and safety model that identifies substance use and links 

pregnant women with treatment services in effective agencies that are full partners 

with the home visitation programs. 

3. Require that parents with substance use disorders receive continuing care following treatment. 

4. Require that children of substance-abusing parents receive developmental 

screening and are given eligibility for intervention services in the case of developmental delays, linked with Individuals with Disabilities Education Act (IDEA) eligibility. 

5. Require that any set-asides for training and technical assistance also require 

funds to support the development and dissemination of risk and safety assessment 

protocols that at a minimum address substance abuse to expand the capacity of existing and promising home visitation models in addressing substance abuse among 

these high-risk families. 

6. Require that the Secretary of the U.S. Department of Health and Human Services in administrating this home visitation program to States and Tribes implement 

a multi-agency approach including participation by the Administration for Children 

and Families, the Substance Abuse and Mental Health Services Administration, the 

Health Resources and Services Administration, as well as any other agencies the 

Secretary determines may be appropriate to ensure a coordinated system of family 

support is implemented. 

Again, we thank the Committee for holding this important hearing and for the 

opportunity to submit this statement for the record. We look forward to working 

with you as this legislation moves forward to ensure that the promise of home visitation is realized for low-income families, and in particular, that home visitation 

strategies seek to improve the lives of families and children impacted with substance use disorders. 

f 

Statement of the Children’s Defense Fund 

The Children’s Defense Fund (CDF) appreciates the opportunity to submit written 

testimony for the record for the Hearing on Proposals to Provide Federal Funding 

for Early Childhood Home Visitation Programs held on June 9, 2009, by the Subcommittee on Income Security and Family Support. 

The Children’s Defense Fund has worked very hard for 36 years to ensure every 

child a Healthy Start, a Head Start, a Fair Start, a Safe Start, and a Moral Start 

in life and successful passage to adulthood with the help of caring families and communities. CDF seeks to provide a strong, effective and independent voice for all the 

children in America who cannot vote, lobby, or speak for themselves, but we pay 

particular attention to the needs of poor and minority children and those with disabilities. CDF encourages preventive investments in children before they get sick, 

get pregnant, drop out of school, get into trouble, suffer family breakdown, or get 

sucked into the dangerous ‘‘Cradle to Prison Pipeline.’’ 

CDF works to ensure a level playing field for every child and recognizes that for 

every minute we waste, we lose another child. Consider that a child is born into 

poverty every 33 seconds, a child is born without health insurance every 39 seconds, 

and a child is abused or neglected every 40 seconds. CDF has for decades advocated 

for improvements in child welfare policies that would help to enhance outcomes for 

vulnerable children and families across the country. 

We want to begin by thanking the Subcommittee for its bi-partisan leadership in 

the 110th Congress, which led to the enactment of the Fostering Connections to Success and Increasing Adoptions Act of 2008 (P.L. 110–351). These reforms for abused 

and neglected children in foster care, the most significant in more than a decade, 


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hold the promise of greater stability and permanence and enhanced well-being for 

tens of thousands of children and youths across the country. 

We are very pleased that you now are focusing attention on the front end of the 

child welfare system to expand opportunities to prevent problems from occurring, 

such as developmental delays, poor child health, and child abuse and neglect, all 

of which can bring children to the door of the child welfare system. The need for 

prevention has long been ignored, and the Early Support for Families Act (H.R. 

2667) represents a significant step forward in establishing and expanding home visiting programs that can reach hundreds of thousands of children. 

We applaud the efforts of both Chairman McDermott and Representative Danny 

Davis, as well as Representative Todd Platts, to highlight home visiting as an important strategy to strengthen outcomes for both children and parents. The Early 

Support for Families Act builds on both the evidence-based home visitation initiative included in President Obama’s Fiscal Year 2010 budget and on the reserve 

clauses in both the House and Senate-passed 2010 Budget Resolutions. It recognizes 

how children could positively benefit from a significant expansion of quality home 

visitation programs that improve multiple outcomes for children and families, both 

in the short term and over time. 

In our statement for the record, we want to emphasize the multiple ways that 

children and families can benefit from home visitation, describe the lack of coordinated attention to home visiting that currently exists at the federal level, and then 

highlight the most important features of the Early Support for Families Act and 

several ways it might be further strengthened. 

First-time pregnant women, parents of young children with disabilities, teen parents having a second or third child, and single fathers raising children and others 

can all benefit from different models of home visitation programs. Thousands of parents like these are looking to the Subcommittee to push forward this year an investment in quality evidence-based home visitation that can have real positive impacts 

for them and their children. 

Investments in Quality Home Visiting Programs Are Essential for Improving Outcomes for Children quality home visiting programs offer congress an opportunity to build on what we know works. 

Under the Early Support for Families Act, programs with the strongest level of 

evidence will be able to expand to reach more children and families with different 

needs, and emerging programs will also be able to prove their effectiveness with 

children and families over time. 

Home visiting is a program model and a family engagement strategy that has a 

long track record and has evolved over the years. As elaborated below, there are 

at least five national models of home visitation programs, all of which are associated 

with a national organization that has comprehensive standards that ensure high 

quality service delivery and continuous program quality improvement. They all have 

been operating in some form for at least a decade and in some cases two or three 

decades. There are also other models and approaches being used that hold promise. 

And still others that have come and gone over the years. When Rep. Roskam asked 

the hearing witnesses on June 9, if they had ever met a home visitation program 

they didn’t like, the answer for most was a resounding ‘‘yes.’’ The witnesses recognized the challenges in operating quality programs and the need to target ongoing 

federal support to programs that meet at least the basic requirements spelled out 

in the Early Support for Families Act. 

Research from the five national home visiting program models, described only 

briefly below, demonstrates that quality home visiting programs can improve outcomes for children and parents by preventing child abuse and neglect, improving 

school readiness, increasing positive parenting and parental involvement, and improving child and maternal health. The randomized controlled trial of the Nurse 

Family Partnership, one of the five models, was first conducted in 1977, more than 

30 years ago. Since then several subsequent randomized controlled trials have been 

conducted, and each of the national models has had at least one randomized controlled trial. 

Healthy Families America (HFA), a program of Prevent Child Abuse America, 

is a voluntary home visiting model designed to help expectant and new parents get 

their children off to a healthy start. The program works with participants starting 

prenatally or at birth up to the time the child reaches three to five years of age 

to promote positive parenting, enhance child health and development and prevent 

child abuse and neglect. 

• A study published in the March 2008 issue of the journal Child Abuse and Neglect indicated that Healthy Families New York (HFNY) decreased the incidence of 

child abuse and neglect during the first two years of life, and reduced the use of 


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iDuMont, et al. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early 

child abuse and neglect. Child Abuse & Neglect, 32(3), 295–315. ii Caldera, et al. (2007). Impact of a statewide home visiting program on parenting and on 

child health and development. Child Abuse & Neglect, 31(8), 829–852. Landsverk, Carrilio, et 

al. (2002). Healthy Families San Diego Clinical Trial: Technical Report. Child and Adolescent 

Services Research Center, San Diego Children’s Hospital and Health Center. iii Baker & Piotrkowski, 1996, National Council of Jewish Women Center for the Child (U.S. 

Department of Education funded study of HIPPY). ivLuckey, Dennis W., David L. Olds, Weiming Zhang, Charles Henderson, Michael Knudtson 

John Eckenrode, Harriet Kitzman, Robert Cole, and Lisa Pettitt, ‘‘Revised Analysis of 15-Year 

Outcomes in the Elmira Trial of the Nurse-Family Partnership,’’ Prevention Research Center 

for Family and Child Health, University of Colorado Department of Pediatrics, 2008. Olds, 

David L., Charles R. Henderson Jr, Robert Cole, John Eckenrode, Harriet Kitzman, Dennis 

Luckey, Lisa Pettitt, Kimberly Sidora, Pamela Morris, and Jane Powers, ‘‘Long-term Effects of 

Nurse Home Visitation on Children’s Criminal and Antisocial Behavior: 15-Year Follow-up of 

a Randomized Controlled Trial,’’ Journal of the American Medical Association, vol. 280, no. 14, 

October 14, 1998, pp. 1238–1244. Olds, David L., John Eckenrode, Charles R. Henderson Jr, 

Harriet Kitzman, Jane Powers, Robert Cole, Kimberly Sidora, Pamela Morris, Lisa M. Pettitt, 

and Dennis Luckey, ‘‘Long-term Effects of Home Visitation on Maternal Life Course and Child 

Abuse and Neglect: 15-Year Follow-up of a Randomized Trial,’’ Journal of the American Medical 

Association, August 27, 1997, vol. 278, no. 8, pp. 637–643. vOlds, David L., Harriet Kitzman, Carole Hanks, Robert Cole, Elizabeth Anson, Kimberly 

Sidora-Arcoleo, Dennis W. Luckey, Charles R. Henderson Jr, John Holmberg, Robin A. Tutt, 

Amanda J. Stevenson and Jessica Bondy. ‘‘Effects of Nurse Home Visiting on Maternal and 

Child Functioning: Age-9 Follow-up of a Randomized Trial,’’ Pediatrics, vol. 120, October 2007, 

pp. e832-e845. viZigler, E., Pfannenstiel, J.C., & Seitz, V. (2008). The Parents as Teachers Program and 

School Success: A Replication and Extension. Journal of Primary Prevention, 29, 103–120. 

aggressive and harsh parenting practices, particularly among first-time mothers 

under age 19 who were offered HFNY early in their pregnancy.i

• Two randomized control trial studies of HFA found that participation in the 

program positively impacted children’s cognitive development when measured on 

the Bayley Scales of Infant Development (which measures developmental function 

of infants and toddlers and assists in diagnosis and treatment planning for those 

with developmental delays or disabilities).ii

Home Instruction for Parents of Preschool Youngersters (HIPPY) is a voluntary home-based, family focused, parent involvement program that provides solutions that strengthen families and helps parents prepare their three-, four-, and 

five-year-old children for success in school and beyond. 

• A two-site, two-cohort longitudinal study of children’s school performance 

through second grade found that children participating in HIPPY scored higher on 

standardized achievement tests, were perceived by their teachers as being better 

prepared, and had better school attendance than those who did not receive HIPPY 

services.iii

Nurse Family Partnership (NFP) is a voluntary program that provides home 

visitation services by registered nurses to low-income first-time mothers, beginning 

early in pregnancy and continuing through the child’s second year of life. 

• In a 15-year follow-up to a randomized control trial, there were 48 percent 

fewer officially-verified child abuse and neglect reports for the families served by 

NFP as compared to the control group; and women served by NFP had experienced 

19 percent fewer subsequent births than those in the control group.iv

• In another randomized control trial, children who were served by NFP at age 

two had spent 78 percent fewer days in the hospital for injuries or ingestions compared to those in the control group.v

Parent-Child Home Program (PCHP) is a voluntary early childhood parent 

education and family support model serving families throughout pregnancy until 

their child enters kindergarten, usually at age five. It is designed to enhance child 

development and school achievement through education delivered by parent educators, who all have at least a bachelor’s degree. It combines home visiting and 

group meetings, is accessible to all families and has been adapted to fit differing 

community and family needs. 

• More than 5,700 public school children from a stratified random sample of Missouri districts and schools were examined at kindergarten entry and at the end of 

third grade. Path analysis showed that participation in PAT, together with preschool, positively impacted children’s school readiness and school achievement scores 

and also narrowed the achievement gap between children in poverty and those from 

non-poverty households.vi


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viiWagner, M., Iida, E. & Spiker, D. (2001). The multisite evaluation of the Parents as Teachers home visiting program: Three-year findings from one community. Menlo Park, CA: SRI 

International. Obtained from www.sri.com/policy/cehs/early/pat.html. viiiKnickebein, B. (2005). The Parent-Child Home Program Final Report, Center for Educational and Program Evaluation, Department of Educational and School Psychology, Indiana 

University of Pennsylvania. ixLevenstein, P., Levenstein, S., Shiminski, J. A., & Stolzberg, J. E. (1998). Long-term impact 

of a verbal interaction program for at-risk toddlers: An exploratory study of high school outcomes in a replication of the Mother-Child Home Program. Journal of Applied Developmental 

Psychology; 19, 267–285. 

• In a randomized control trial, children participating in PAT were much more 

likely to be fully immunized for their given age and were less likely to be treated 

for an injury in the previous year than children in the control group.vii

Parent-Child Home Program (PCHP) is a voluntary early literacy, school 

readiness, and parenting program serving families with two- and three-year-olds 

who are challenged by poverty, low levels of education, language and literacy barriers and other obstacles to educational success. The model uses intensive home visiting to prepare families for school success. 

• Indiana University of Pennsylvania’s independent evaluation of PCHP replications in two Pennsylvania counties indicates that positive parent behaviors increased dramatically as a result of program participation. Half of the children identified as ‘‘at risk’’ in their home environments at the start of the program were 

found to no longer be at risk at the completion of the program.viii

• A longitudinal randomized control group study of PCHP found that low-income 

children who completed two years of the program went on to graduate from high 

school at the rate of middle class children nationally, a 20 percent higher rate than 

their socio-economic peers and 30 percent higher than the control group in the community.ix

Quality home visitation programs impact children and families in multiple 

ways. 

Home visiting recognizes the uniqueness of individual children and families and 

acknowledges that a single program strategy may have different impacts on the 

same children and families over time and different impacts on children and families 

with differing needs. As demonstrated above, it is not unusual for home visiting programs to have multiple impacts on children and families perhaps most notably improved child health and development, enhanced school readiness, and the prevention 

of abuse and neglect. The five major models described above also have had an impact on parents and their parenting skills and leadership. Perhaps most significant, 

several of these models have had even greater impacts when coupled with other 

early childhood programs. 

A number of states have established multiple models of home visiting programs 

or combined program model elements to create blended programs, recognizing that 

families’ needs vary. For example, the Illinois Department of Human Services and 

the New Jersey Department of Children and Families are both beginning to use the 

Nurse Family Partnership, Healthy Families America and Parents as Teachers 

models to prevent child abuse and neglect. Such an approach allows them to reach 

families with multiple needs and gives staff helpful discretion in matching the needs 

of families with the strengths of a particular model. New York is also implementing 

the Nurse Family Partnership, Healthy Families New York, and Parents as Teachers. 

There are many other examples of states using multiple programs in different 

parts of a community or parts of a state. For example, 60 percent of Medicaid-financed births, a proxy here for low-income births, are to women who already have 

one child, ruling out a model that is limited to first-time births. Models that serve 

parents after the birth of a child are often needed to respond to the thousands of 

low-income women in our country who receive no prenatal care, yet could benefit 

from quality home visiting models with their babies. 

Home visiting programs also are intergenerational and can impact more children 

than the one who is seen as the recipient of the service. All five national models, 

for example, track both child and parent specific outcomes. Few, however, have examined the impact of such programs on the future or existing siblings of the child 

being served. It is not a stretch to think that programs like these may well impact 

the trajectory of family’s lives, foster improvements in health, safety and well-being 

over time, and can affect multiple children. 


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Home visiting programs have been proven to result in long-term benefits 

when their impact on children and families can be tracked over time 

The Nurse Family Partnership Program has longitudinal data documenting the 

fact that for every public benefit dollar invested in a local Nurse Family Partnership 

program, communities can realize more than $5.00 in return. In fact, in its very earliest study in Elmira, New York, initiated in 1977, researchers found that the community could recover the costs of the program by the time the child reached the age 

of four, and additional savings accrued after that. Data from the 15-year follow-up 

of this same study show positive effects for the nurse visited families for more than 

12 years after the visits had concluded. 

While the other models generally do not have results from longitudinal studies, 

a number do have documented outcomes for children and families, which can be 

linked to long-term cost savings related to special education, health care, and child 

welfare and criminal justice system involvement. Increased school readiness, for example, can help to prevent the need later for extra support or investments in sometimes costly special education programs. There are also data that show the benefits 

of child abuse prevention, by contrasting it with the adverse impacts of child abuse 

and neglect on later problems in adulthood—problems that result in lost opportunity 

costs and costly treatment. Similarly, increases in healthy births can help to offset 

the costs of low birth weight babies. The cost of hospitalization for a preterm or low 

birth weight baby is 25 times that of when a healthy baby is born. Children born 

at low birth weight are twice as likely to have clinically significant behavior problems, such as hyperactivity, and are 50 percent more likely to score below average 

on measures of reading and mathematics by age 17. 

Access to the funding in the Early Support for Families Act will help grantees to 

continue to assess outcomes and also offer the opportunity for additional longitudinal studies to document long-term cost savings. 

There is currently no targeted guaranteed funding stream for prevention 

in young children. 

Currently there is no targeted guaranteed funding stream for prevention in young 

children. President Obama’s evidence-based home visitation initiative and The Early 

Support for Families Act are intended to do just that to help expand the reach of 

home visiting to children and families across the country, and to continue to document their benefits to the children and families served. 

This Committee’s Promoting Safe and Stable Families Program was first established in 1993 and then given its current name in 1997. It includes some funding 

from family support and family preservation programs, but it also includes dollars 

to help children in foster care be safely reunified with their families or to be supported in adoptive families. Similarly, some funds from the Temporary Assistance 

for Needy Families Program and the Maternal and Child Health Program are also 

used for home visiting, but since both of these are fixed amount block grants, home 

visiting must compete with many other activities. There are also programs, like 

Early Head Start, where home visiting is one of a multitude of activities provided 

to participating children and families. 

New dedicated funding for home visitation will promote the coordination of this 

current patchwork of funding and enable states to assess how best to complement 

existing programs with new investments to continue to make progress in reaching 

all the children and families who can benefit from home visiting programs. Currently, the Nurse Family Partnership is in 28 states across the country, serving 

about 18,000 families. The Parents as Teachers Program is in all 50 states, but in 

some there are only a small number of programs, most often established in school 

systems. Healthy Families America is in 35 states. And both the Parent-Child Home 

Program and HIPPY are smaller with programs in 16 and 23 states respectively. 

Clearly more new programs and expanded programs that build on successful models 

are needed to reach more young children and families. 

The Early Support for Families Act Moves Toward a System of Quality Evidence-Based Home Visitation Programs 

The grant program established by the Early Support for Families Act seeks to establish in states a coordinated system of quality evidence-based home visitation programs. It is more than just another funding stream for these programs. It takes important steps toward establishment of a system of quality, evidence-based home visitation that will build on and coordinate with existing early childhood programs. It 

focuses on models with the strongest level of effectiveness, requires states to conduct 

a statewide needs assessment to describes programs already underway, who they 

are serving, how they are funded, gaps in service, and the training and technical 

assistance already in place to support the goals of home visitation. It also requires 


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federal evaluations of the effectiveness of home visitation on parent and child outcomes and on different populations. Congress must also be kept informed about the 

service models being used, the target communities and families served, and outcomes reported, as well as the cost of the program per family served. Much of this 

information, which now is generally not very accessible within or across programs, 

will be made available within and across program models so effective planning can 

be done to best serve children. 

In closing, these are three areas that we want to mention briefly that we believe 

are important to strengthen in the Early Family Support Act as it moves forward. 

• Further definition of strongest level of effectiveness. To help provide consistency and continuity for states and programs as the grant program is developed 

and implemented over time, we believe it is important for the statute to establish 

parameters to make clear what a program must do to get any funding under the 

bill and then to distinguish between models with the strongest level of effectiveness 

and others. Such parameters will also send a useful message about the standard to 

which home visiting models just getting underway will be held accountable as their 

work progresses. 

Beginning with the strongest level of effectiveness, we would like to recommend 

that the Subcommittee consider language that was developed and has been agreed 

to by members of the Steering Committee of the Home Visiting Coalition of which 

CDF is a member. It defines the ‘‘strongest level of effectiveness’’ in relation to the 

research standard for evidence-based home visitation that will distinguish those 

models that are eligible for funding from those with the strongest level of effectiveness. Over time all funded programs will aspire to reach this level of research. The 

standard developed reads: 

Evidence-based home visitation programs with the strongest level of effectiveness 

are those that have demonstrated positive outcomes for children and families consistent with the outcomes being sought (for the populations being served) when evaluated using well-designed and well-conducted rigorous evaluations, including but not 

limited to randomized controlled trials, that provide valid estimates of program impact and demonstrate replicability and generalizability to diverse communities and 

families. 

The members of the Home Visiting Coalition supporting this definition include, 

in addition to CDF, the five home visiting models described above (Healthy Families 

America/Prevent Child Abuse America, HIPPY, Nurse Family Partnership, Parents 

as Teachers and the Parent-Child Home Programs) as well as six other national organizations (Child Welfare League of America, CLASP, Fight Crime Invest in Kids, 

National Child Abuse Coalition, and Voices for America’s Children). 

• Increased coordination at all levels. The Early Support for Families Act recognizes the importance of quality evidence-based home visiting as a part of a larger 

coordinated service effort to meet the needs of young children and their families. 

In addition to supporting the expansion of home visiting models, the bill also offers 

support to ensure programs can meet the multiple needs of at risk families by connecting them to service delivery systems at multiple levels. Connections can be 

made at the federal, state and local levels; and processes should also be in place 

to link individual families to what they need. We believe that there are a number 

of ways coordination could be strengthened, and ask the Subcommittee to consider 

them. 

• At the federal level, it would be helpful to require that the Secretary of Health 

and Human Services consult with the Secretary of Education in determining what 

to require with regard to state applications for funding under the program, since 

some home visiting programs are funded through the federal Department of Education. 

• At the state level, states should be required to consult with other state agencies 

that currently support home visiting programs for young children. This would help 

ensure that the new federal support for home visitation would build on any existing 

infrastructure to strengthen services for young children and families across the 

state. Home visiting should also be coordinated in states with child care services, 

health and mental health services, income supports, early childhood development 

services, education programs, and other child and family supports. 

• At the individual model level, each model funded under this new federal program must be required to establish appropriate linkages and referrals to other community resources and supports, such as those listed above, to ensure that children 

and families will have access to all the services they need in their local communities. 


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• Further recognition of the need for multiples types of research and evaluation. 

We are pleased that the Early Support for Families Act highlights the importance 

of evaluation. It makes evaluation an eligible use of funds for grantees and sets 

aside funds for a national evaluation by the Department of Health and Human 

Services. Given that the goal of this program is to fund quality evidence-based programs, it is essential to ensure that evaluation and research to maintain fidelity to 

program models and adapt models to new populations be funded appropriately. As 

the proposal is being finalized, the funds set aside for evaluation—of all home visitation models and the new federal program itself—must be significant enough to serve 

the needs of the models in proving that they meet the strongest level of evidence 

to continue receiving funding and assess the federal monitoring of overall quality. 

The Children’s Defense Fund is supportive of the Early Support for Families Act 

and steps taken to move toward a major guaranteed investment in quality evidencebased home visiting and we look forward to working with you as the bill progresses. 

Thank you again for your leadership on behalf of vulnerable children and families. 

f 

Statement of Dan Satterberg 

Chairman McDermott and members of the subcommittee, thank you for holding 

this important hearing, and for the opportunity to submit this testimony for the 

Record. I also wish to thank Chairman McDermott, Representative Danny Davis 

and Representative Todd Platts for introducing the ‘‘Early Support for Families Act’’ 

(H.R. 2667). 

My name is Dan Satterberg, and I am the Prosecuting Attorney of King County, 

Washington. I worked in the Prosecuting Attorney’s Office for more than 20 years 

before being elected Prosecuting Attorney in 2007. 

I submit this testimony as a member of Fight Crime: Invest in Kids, an organization of over 5,000 police chiefs, sheriffs, prosecutors, other law enforcement leaders, 

and victims of violence—including 215 in Washington—who have come together to 

take a hard-nosed look at the research about what really works to keep kids from 

becoming criminals. My colleagues and I know from the front lines in the fight 

against crime—and the research—that among the most powerful weapons against 

crime are quality investments in kids that give them the right start in life. 

As a criminal justice leader, I am proud to support the ‘‘Early Support for Families Act,’’ which invests $2 billion over 5 years in guaranteed funding to establish 

and expand programs providing voluntary, quality home visiting to assist families 

with young children, and families expecting children, especially in high-need communities. These are programs that my colleagues and I in Washington State have 

advocated for, both with the Governor and in our Legislature. 

Child Abuse Leads to Later Crime and Violence 

In 2007, there were 794,000 confirmed cases of child abuse and neglect in the 

United States. In my home state of Washington, there were more than 7,000 confirmed cases of child abuse and neglect. This statistic is alarming enough on its 

own, but it cannot account for the thousands of additional cases that either go unreported or unconfirmed by overburdened State child welfare agencies. Research 

shows the true number of victims nationwide, including those never reported to authorities, may be well over 2 million. 

Child abuse and neglect killed 1,760 children nationwide in 2007. In Washington, 

there were an average of 12 deaths a year between 2002 and 2006 that stemmed 

from child abuse or neglect. 

Even though the majority of children who survive abuse or neglect do not become 

violent criminals, these children carry the emotional scars of maltreatment for life, 

and many do go on to commit violent crimes. Best available research, based on the 

confirmed cases of abuse and neglect nationwide in just one year, indicates that an 

additional 30,000 children will become violent criminals and 200 may become murderers as adults as a direct result of the abuse and neglect they endured. 

Evidence-Based Home Visiting Programs Help Reduce Child Abuse and Later Crime 

and Violence 

Fortunately, research also indicates that evidence-based home visiting programs 

can prevent abuse and neglect and reduce later crime and violence. These programs 

offer frequent, voluntary home visits by trained professionals to help new parents 

get the information, skills, and support they need to raise healthy and safe kids. 

While there are many models of home visiting, all are dedicated to helping young 


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children get a good start in life and improving outcomes for family. Research shows 

that these programs work. 

Evidence-Based Home Visiting Programs Are Sound Investments That Result in Substantial Cost Savings 

Prevent Child Abuse America estimates that child abuse and neglect cost Americans $104 billion a year. Research has demonstrated that quality, evidence-based 

home visiting programs offer significant returns for money invested. For example, 

a 2008 study by Steve Aos of the Washington State Institute for Public Policy found 

NFP produced $18,000 in net savings per family served and saved three dollars for 

every dollar invested. Other home visiting models have also demonstrated positive 

cost savings. 

I urge this Committee to make investments in high quality, evidence-based home 

visiting programs. These programs should be a priority as you work on health care 

reform. Investments made in programs with a proven ability to produce positive outcomes for children and their families will result in safer communities and cost savings. 

Current Funding Does Not Meet the Overwhelming Need 

Existing guaranteed funding streams, such as Medicaid, State CHIP, and TANF, 

as well as discretionary programs such as Healthy Start, Early Head Start, Head 

Start, Special Education, Child Welfare, Social Services, Community Services, and 

others, have not been able to provide meaningful investments in quality, evidencebased home visiting programs. We can no longer afford to wait for a patchwork of 

partial funding from multiple programs to meet the overwhelming need for these 

services. We must have dedicated, guaranteed funding for this proven-effective approach. 

Every year in the United States, over 600,000 low-income women become mothers 

for the first time. 1.5 million women who are pregnant or have a child under the 

age of two are eligible for NFP at any given time. However, due to lack of funding, 

the program is only able to serve about 20,000 mothers annually. Other home visiting programs serve an additional 400,000 families, many of whom are not in highneed communities. The result of inadequate funding is hundreds of thousands of atrisk families nationwide do not have access to quality home visiting. 

Early Support for Families Act (H.R. 2667) 

I applaud the introduction of the ‘‘Early Support for Families Act,’’ based on President Obama’s initiative in his FY 2010 proposed budget. By investing $2 billion in 

guaranteed funding over 5 years, H.R. 2667 takes a significant step forward toward 

meeting the as-yet-unmet need for quality, evidence-based home visiting programs. 

Funds will be distributed using a two-tiered approach. First-tier programs—those 

with the strongest research evidence of effectiveness—will receive the majority of 

funding. First-tier programs must adhere to clear evidence-based models of home 

visitation that have demonstrated significant positive effects on important child and 

parenting outcomes, such as reducing abuse and neglect and improving child health 

and development. A second tier of promising program models—those with some research evidence of effectiveness and adaptations of previously evaluated programs— 

will have a chance to upgrade to the first tier if they are proven to be effective 

through rigorous evaluations. 

The ‘‘Early Support for Families Act’’ also prioritizes investments in high-need 

communities. States will be required to identify and prioritize high-need communities, especially those with a high proportion of low-income families or a high incidence of child maltreatment. To receive funding, States must submit (1) the results 

of a comprehensive, statewide needs assessment; (2) a grant application describing 

the high quality programs supported by the grant, including evidence supporting the 

effectiveness of the programs; and (3) an annual progress report, including the outcomes of programs supported by the grant. 

To ensure federal funds support quality, evidence-based home visiting programs, 

this legislation provides an annual set-aside of $10 million for federal evaluation 

and technical assistance to the States. 

Conclusion 

Investments in quality, evidence-based home visiting programs work. Research 

has shown that these programs can help achieve profound reductions in child abuse 

and neglect, crime, and violence while at the same time producing significant cost 

savings for the public. The ‘‘Early Support for Families Act’’ makes an important— 

and necessary—commitment to expanding access to these programs for at-risk families. 


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We urge you to make these proven investments in kids that help them get the 

right start in life and in turn reduce later crime and violence. 

Thank you again for introducing the ‘‘Early Support for Families Act,’’ and for the 

opportunity to submit this testimony. The law enforcement leaders of Fight Crime: 

Invest in Kids look forward to working with you to achieve enactment of such legislation, through health reform this year. 

f 

Letter from David Mon 

I wanted to address the issue of Social Security beneficiaries returning to work 

and have earnings that are significant enough to reduce the monthly SSI and or 

SSDI to which they are entitled who report the work earnings in a timely manner 

but continue to receive benefits to which they are not entitled because SSA lacks 

the necessary representatives to input the reported changes. 

As a community work incentive coordinator who works with beneficiaries on a 

one-to-one basis who return to work, I advise the beneficiaries that I work with that 

reporting the earnings are the first step. It is necessary for them to carefully track, 

with my assistance, work earnings that result in a reduction of benefits, and SSDI 

monthly payments to which they are no longer entitled, and to make arrangements 

to return this money, even before SSA makes a determination that an overpayment 

has occurred. 

Advising beneficiaries on proper reporting and steps to prevent overpayments before they occur has become standard practice in the area of Work Incentive Planning and Assistance. 

Sincerely, 

David Mon 

Community Work Incentive Coordinator 

Center for the Independence of the Disabled 

San Mateo, CA 

f 

Statement of Every Child Succeeds 

Chairman McDermott, Ranking Member Linder, and members of the Subcommittee on Income 

Security and Family Support of the Committee on Ways and Means, on behalf of 

Every Child Succeeds in Southwest Ohio and Northern Kentucky, I am happy to 

submit this testimony in support of H.R. 2667, the Early Support for Families Act. 

We would like to thank the sponsors of this legislation, Representatives Jim 

McDermott (D–WA), James McGovern (D–MA), Lynn Woolsey (D–CA), Mazie 

Hirono (D–HI), Jim Cooper (D–TN), Danny Davis (D–IL), and Todd Platts (R–PA). 

Every Child Succeeds (ECS) is a voluntary home visiting program whose aim is 

to improve the health and development of at-risk children in the Cincinnati region. 

Our prevention/early intervention program is founded upon the knowledge that 

what happens in the earliest days and months of life has profound implication for 

the lifetime course of parents and children. ECS has provided home visiting services 

to nearly 16,000 families during the past ten years, with the goal of helping these 

children get off to a good start in the most critical period of their lives—prenatal 

to age 3. We and the communities we serve believe that home visiting is an effective 

and important way to support high risk families and help them succeed in parenting. 

The mission of ECS is to ensure an optimal start for children by helping families 

achieve positive health, parenting and child development outcomes. The goals of 

home visitation, as provided by ECS, are: (1) to improve pregnancy outcomes 

through nutrition education and substance use reduction, (2) to support parents in 

providing children with a safe, nurturing, and stimulating home environment, (3) 

to optimize child health and development, (4) to link families to health care and 

other needed services, and (5) to promote economic self-sufficiency. 

Public-private partnership has been at the center of our approach to financing and 

delivering services. ECS was founded by Cincinnati Children’s Hospital Medical 

Center, United Way of Greater Cincinnati and Hamilton County Community Action 

Agency/HeadStart and began operation in July, 1999. The program has thousands 

of community stakeholders and contracts with more than 30 social service and 

health agencies, and all local birth hospitals. Our board and advisors include a variety of business leaders and experts who have helped to guide our program and our 

quality improvement efforts. 


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Funding for ECS also is provided through a blend of public (50 percent) and private (50 percent) dollars. The level of private funds for ECS from the United Way 

of Greater Cincinnati has been continually increased based on outstanding performance and outcomes, as well as the demonstrated need for ECS services. Funding 

from the Temporary Assistance to Needy Families (TANF) program has been essential in the development of ECS in four counties in Southwest Ohio through the State 

‘‘Help Me Grow’’ program. Public funds are available for our three Kentucky counties to fund the state HANDS program through Medicaid and proceeds from the 

Kentucky state tobacco settlement. 

The ECS program matches at risk, first-time pregnant women or new mothers 

with infants under three months of age with a network of trained professional home 

visitors who work with them and their young children for up to 3 years. Families 

are recruited primarily through prenatal clinics or birth hospitals. Program elements include care coordination, health promotion, medical liaison, child development assessment, and goal-setting through the Individual Family Service Plan 

(IFSP). 

ECS uses two national models of home visitation, namely, Nurse-Family Partnership  (NFP) and Healthy Families America (HFA). Both NFP and HFA models, 

and research about them, have had value in improving the quality of the ECS approach. In a series of studies, Olds and colleagues have found that home visiting 

for first time mothers by nurses reduced smoking during pregnancy, decreased 

preterm birth rates for smokers, increased birth weights among adolescent mothers, 

and decreased rates of child abuse and accidental injuries in children. (Olds et al.) 

Studies of HFA inform us about how to serve a broader array of families, including 

those whose risks are identified following the birth of a baby. (Healthy Families 

America) In addition, our own ECS quality studies, evaluative research, and randomized clinical trials are guiding us to state-of-the-art, evidence-based practice. 

Mothers eligible for ECS have one or more of four risk characteristics, including; 

(1) unmarried, (2) inadequate income (up to 300% of poverty level, receipt of Medicaid, or reported concerns about finances), (3) 18 years of age, or (4) suboptimal prenatal care. Women are enrolled either during pregnancy (before 28 weeks for NFP) 

or before their child reaches 3 months of age (HFA only). Regular home visits are 

provided by social workers, child development specialists or related professionals 

(82%), trained nurses (12%), or paraprofessionals (6%). Home visits are made until 

the child reaches 2 years (NFP) or 3 years (HFA) of age, starting with weekly or 

more-frequent visits and tapering to fewer visits as the child ages. 

ECS is an evidence-based model with a comprehensive ongoing evaluation component. The ECS research and evaluation system provides ongoing data about process 

and outcomes. To date, we have achieved and can reliably report the following results. 

Infant Mortality 

¥ Infant mortality rate for ECS families is 4.7 per 1,000 live births, significantly 

below those for Ohio (7.8), Kentucky (6.9), Hamilton County (9.7) or the City of Cincinnati (17.4). (See Figure 1.) ¥ An analysis of 1,655 mothers and babies enrolled in ECS between 2000—2002 

and a comparison group of 4,995 non-participants from the same region, showed 

that non-participants were 2.5 times more likely to die in infancy, compared with 

those enrolled in ECS. 

Child Health and Development 

¥ 95% of children are developing normally in language, physical coordination, 

and social abilities. ¥ 98% of babies have a medical home ¥ 76% of children are fully immunized by age two 

Maternal Health and Well-being 

¥ Of the 33% of mothers with clinically significant levels of depression, 52% improve after 9 months in home visitation. Using a grant from the Health Foundation 

of Greater Cincinnati, ECS developed an in-home treatment for depressed mothers 

through a unique Maternal Depression Treatment Program that is currently being 

studied in randomized clinical trials through a grant from the National Institute on 

Mental Health. ¥ After 6 months in the program, 77% of mothers are in school or are working. 

¥ 80% of mothers report high levels of social support, a factor associated with 

effective parenting and maternal mental health 

¥ Of those ECS mothers who smoke during pregnancy, 94% quit or substantially 

reduce their tobacco use by the time of the baby’s birth. ECS home visitors help 

mothers decrease smoking and reduce second hand smoke in the baby’s environment 


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through the Assuring Smoke Free Homes (ASH) Project (funded by a grant from the 

Ohio Tobacco Use Prevention and Control Foundation). 

Perhaps the most important aspect of the ECS design is continuous quality improvement guided by evidence-based practice and data about our providers and clients. We believe, as described by Daro, that the quality of home visiting programs 

is based in having self-evaluation in each program and in applying what we know 

about quality. 

‘‘Greater positive impacts among a broad range of home visitation models reflect, 

in part, two trends—improved program quality and improved conceptual clarity. 

With respect to quality, the six major national home visitation models are each engaged in a series of self-evaluation efforts designed to better articulate those factors 

associated with stronger impacts and to better monitor their replication efforts’’ 

As Congress moves to adopt legislation that can support and guide home visiting 

programs across the country, we make three recommendations. 

1. Provide funding for the core work of home visiting programs. To date, 

home visiting programs—ECS included—have had to cobble together a variety of 

funding sources and keep families on waiting lists until funds become available. 

Current federal funding streams such as TANF and Medicaid are not designed to 

fund home visiting. In trying to use these existing funding streams, programs often 

must divert effort or change the structure of service delivery to families. With a 

more reliable and continuous source of federal funding, ECS and other programs can 

optimize private, as well as state and local, resources. 

2. Support outcomes-driven programs that make evidence-based decisions. 

Expand policy and operational programs that have credible evaluations and that are 

shown to work. We do not recommend relying on a tiered funding approach that 

tends to reward high performers while limiting dollars available for innovation, 

quality improvement and improved implementation among other good programs. 

3. Focus on quality, not one model. Taken together, the body of research 

knowledge about home visiting tells us that successful programs have well-trained 

staff, solid supervision, ongoing relationships with families, a design that fits the 

specific program activities to desired outcomes, and linkages to other community 

programs such as child care and health care. Ongoing data collection analysis and 

evaluation, as well as training activities, are essential to achieving desired results. 

Congress and the Obama Administration have an opportunity to provide a framework such as that used in Head Start or Community Health Centers, through which 

performance standards and program guidelines help local programs deliver quality 

services and outcomes. This could be created out of the thousands of existing programs, including 40 state-based home visiting programs in operation today. (Johnson) 

Recognize that home visiting programs target multiple outcomes. A new 

federal home visiting program should aim not only to prevent child abuse and neglect; but also aim to improve an array of outcomes that affect early childhood 


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health and development. ECS has shown that a single program can have impact on 

infant mortality, parenting skills, maternal depression, well-child visits, smoking reduction, and more. Congress should expect quality programs that provide quality 

services and data to show their results in multiple areas. 

References 

Ammerman, RT, Putnam FW, Kopke JE, Gannon TA, Short JA, Van Ginkel JB, 

Clark MJ, Carrozza MA, Spector AR. Development and implementation of a quality 

assurance infrastructure in a multisite home visitation program in Ohio and Kentucky. Journal of Prevention and Intervention in the Community. 2007; 34, 89–107; 

Ammerman RT, Putnam FW, Altaye M. Chen, Holleb L., Stevens J., Short JA & 

Van Ginkel JB. Changes in depressive symptoms in first time mothers in home visitation. Child Abuse & Neglect, 2009; 33, 127–138. 

Daro D. 2006. Home Visitation: Assessing Progress, Managing Expectations. Chicago, IL. Ounce of Prevention Fund and Chapin Hall. 

Donovan EF, Ammerman RT, Besl J, Atherton H, Khoury JC, Altaye M, Putnam 

FW and Van Ginkel JB. Intensive Home Visiting Is Associated With Decreased Risk 

of Infant Death. Pediatrics. 2007; 119:1145–1151. 

Healthy Families America Effectiveness: A comprehensive review of outcomes. 

Journal of Prevention and Intervention in the Community. 2007; The evaluation of 

Healthy Families Arizona: A multisite home visitation program. Journal of Prevention and Intervention in the Community. 2007; 34(1–2):109–127; Caldera D, Burrell 

L, Rodriguez K, et al. Impact of a statewide home visiting program on parenting 

and on child health and development. Child Abuse Neglect. 2007 Aug;31(8):829–52; 

Duggan A, McFarlane E, Fuddy L, Burrell L, et al. Randomized trial of a statewide 

home visiting program: impact in preventing child abuse and neglect. Child Abuse 

Neglect. 2004; 28(6):597–622; Barnes-Boyd C, Nacion KW, and Norr KF. Evaluation 

of an interagency home visiting program to reduce postneonatal mortality in disadvantaged communities. Public Health Nursing. 1996; 13:201–8. 

Johnson K. State-based Home Visiting Programs. New York: National Center for 

Children in Poverty. 2009. Available at www.nccp.org; Johnson, K. No Place Like 

Home: State Home Visiting Policies and Programs. New York: The Commonwealth 

Fund. 2001. Available at www.cmwf.org 

Olds D, Henderson C, Tatelbaum R, Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. 

Pediatrics. 1986; 77: 16–28; Olds D, Henderson C, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics. 1986; 78:65–78; Olds DL, Henderson CR, Tatelbaum R, and Chamberlin R. Improving the life-course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health. 1988; 

78(11):1436–45; Olds D and Kitzman H. Can home visitation improve the health of 

women and children at environmental risk? Pediatrics 1990; 8–16; Olds DL, Henderson CR, Phelps C et al. Effect of Prenatal and Infancy Nurse Home Visitation on 

Government Spending. Medical Care. 1993; 5–74; Olds DL, Robinson J, Pettit L, et 

al. Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results 

of a randomized trial. Pediatrics. 2004; 114:1560–1568; Olds DL, Kitzman H, Hanks 

C, et al. Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial. Pediatrics. 2007; 120(4):e832–45. 

Sweet MA, Appelbaum MI. Is home visiting an effective strategy? A meta-analytic 

review of home visiting programs for families with young children. Child Development. 2004 Sep-Oct;75(5):1435–56; Bilukha O, Hahn RA, Crosby A, Fullilove MT, 

Liberman A, Moscicki E, Snyder S, Tuma F, Corso P, Schofield A, Briss PA; Task 

Force on Community Preventive Services. The effectiveness of early childhood home 

visitation in preventing violence: a systematic review. Am J Prev Med. 2005 

Feb;28(2 Suppl 1):11–39; Bennett C, Macdonald GM, Dennis J, Coren E, Patterson 

J, Astin M, Abbott J. 

Home-based support for disadvantaged adult mothers. Cochrane Database Syst 

Rev. 2007 Jul 18;(3):CD003759. Update in: Cochrane Database Syst Rev. 

2008;(1):CD003759; Geeraert, L., Van den Noorgate, W., Grietens, H., & Onghena, 

P. The effects of early prevention programs for families with young children at risk 

for physical child abuse and neglect: A meta-analysis. Child Maltreatment. 2004; 

9(3):277–291. 

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Statement of The Family Violence Prevention Fund 

Chairman McDermott, Ranking Member Linder and Members of the Subcommittee, thank you for the opportunity to comment on the value of home visitation programs and specifically the Early Support for Young Families Act. 

The Family Violence Prevention Fund is a national non-profit organization based 

in San Francisco. We were founded almost 30 years ago with a simple mission: to 

end violence against women and children. Like many domestic violence organizations at the time, we began by focusing on the criminalization of violent behaviors 

by men toward their wives and girlfriends. However we quickly came to focus on 

the strong link between the safety and well-being of mothers and the safety and 

well-being of their children. 

That is why we emphasize prevention and the critical need to ensure that all family members are safe and healthy. We have identified early supports for young and 

vulnerable families as an essential strategy both for preventing initial perpetration 

of violence and for early identification of children living in violent homes. Importantly, these early interventions can also mitigate the effects of the violence on children and provide support to the non-abusing parent, typically the mother, to improve her and her children’s safety and stability. 

We commend the Committee for its commitment to the safety and well-being of 

children and families and particularly for your focus on home visitation programs. 

As you well know, home visitation is one of the few documented, well-evaluated 

interventions that works to prevent child abuse and maltreatment. While there are 

several models out there—and we would support funding for multiple types of programs—the Nurse-Family Partnership model is probably the most rigorously evaluated. This intervention targets younger and lower-income pregnant women, and has 

been shown to significantly reduce reported rates of child abuse throughout childhood and into adolescence. One of the most—if not the most—significant barrier to 

the success of home visitation, however, is domestic violence. That is the focus of 

our comments. 

Domestic Violence Limits Effectiveness of Home Visitation 

While we strongly support home visitation as an effective strategy for improving 

health outcomes for children and reducing child abuse and neglect, we are convinced 

that home visitation programs must address domestic violence. The first reason is 

simply that domestic violence is so prevalent. Approximately 15.5 million children 

witness domestic violence each year in their homes. This means that almost onethird of American children cared for by married or cohabitating parents are exposed 

to domestic violence. 

The consequences of children’s exposure to domestic violence are well-documented. 

Children who witness domestic violence display a host of problematic behaviors at 

far greater rates than children not exposed to violence. These include being more 

likely to become a perpetrator of such abuse (for boys) as well as higher rates of 

violence, aggression, suicide, school failure and mental health problems. The effects 

of witnessing abuse on children may be equal to, or in some cases worse, than the 

direct experience of being abused. However, it also is important to note that many 

children who witness adult domestic violence do just fine. Often the reason is the 

child’s strong relationship with her or his mother, even if that mother is experiencing abuse, because it serves as a protective factor. Home visitation programs are 

thus critical in identifying these children, helping them be safe and cope with what 

they have witnessed, linking abused mothers to helpful community resources, and 

supporting strong relationships between mother and child. 

We also recommend that home visitation programs address domestic violence because it serves as a major—if not the major—barrier to the effectiveness of these 

programs. Research reported in the Journal of the American Medical Association in 

2000 detailed the most convincing rationale: first, about half the mothers participating in the well-known Nurse-Family partnership study experienced domestic violence; and where domestic violence did exist, the effectiveness of home visitation to 

reduce abuse and improve child outcomes diminished. Among mothers experiencing 

the higher rates of and more severe abuse, the beneficial effects of the program disappeared entirely. 

This research appears consistent with other studies that show varying impact and 

effectiveness of home visitation programs, though few have teased out as clearly the 

impact of domestic violence. Because domestic violence rates are so high and because they hinder the effectiveness of the programs, it is essential that home visitation programs tailor their interventions and provide training to staff on how to talk 

to young parents about violence and its effects on children, and how to recognize 

and respond to families already experiencing violence. 


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Home visitation programs have the ability to not only help families when domestic violence is occurring, but also to provide primary prevention of both child abuse 

and domestic violence. Healthy, non-violent relationships are fundamental to 

healthy parenting. 

Specifically, we strongly recommend that any home visiting legislation include the 

following four components: 

1. State plans and/or assessments should include information on how domestic violence will be addressed and how programs will safely and confidentially refer 

women to domestic violence services when necessary; 

2. Training and technical assistance for home visitation programs should be funded and should include: 

a. information on how to safely assess for domestic violence in the families 

being served, 

b. promotion of healthy and non-violent partnering as helpful to a child’s 

health and development, 

c. how and when to talk to men and fathers who use violence about how 

domestic violence can affect parenting and how to get help; 

3. Community-based service providers referenced should include domestic violence, fatherhood and batterers intervention programs so families are given the 

information and referrals they need; and 

4. Women living in domestic violence shelters should be eligible for services, assuming these services can be provided in a safe and confidential manner. 

Thank you for the opportunity to comment on this critical legislation. For additional information, please go to www.endabuse.org; or contact our Washington, D.C. 

office. 

f 

Statement of First 5 Alameda County Home Visitation Programs: A 

Multidisciplinary Approach 

Background 

First 5 Alameda County Every Child Counts (F5AC), funded by revenues from the 

California 1998 Proposition 10 tobacco tax, works to ensure that every child reaches 

his or her developmental potential. F5AC focuses on children and families from prenatal to age five years. 

Alameda County is the seventh most populous county in California with a population of 1,454,159 (American Community Survey Demographic Estimates, 2005– 

2007) and one of the most ethnically diverse regions in the United States. It is a 

county with sprawling urban areas as well as agricultural centers, and is as large 

as many states with over 821 square miles. 

In 2007, 125,450 children aged 0–5 years lived in Alameda County. Young Latino 

and Asian children are the fastest growing populations accounting for approximately 

33% and 25% of all births, respectively (State Department of Finance, Demographic 

Research Unit, 2007). 

Race/Ethnicity Alameda County 

Population (1) Birth Population (2) 

African American/Black 13.0% 11.0% 

Asian 24.6% 24.5% 

Caucasian/White 24.4% 22.0% 

Latino 21.4% 42.2% 

Native American 0.6% 0.2% 

Pacific Islander 0.8% ¥ 

Multiracial 3.6% ¥ 

Other/Unknown 11.7% 0.1% 

Sources: American Community Survey 2006 (1); Alameda County Public Health Department 

Vital Stats, 2007 (2) 


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Overall, in 2006, an estimated 3,149 (3.0%) of all children ages 0–5 in Alameda 

County were foreign born, and 2,483 (2.4%) were not U.S. citizens (American Community Survey, 2006). Linguistically, 43.5% of the 5+ population speak a language 

other than English at home and 19.1% speak English less than very well. Among 

these 19.1%, 45.1% speak Spanish and 42.5% speak Asian and Pacific Islander languages (American Community Survey, 2006). 

As evidenced by the data above, Alameda County needed to address a variety of 

factors in developing programs to meet the needs of a large and diverse county. 

F5AC began planning for the implementation of a voluntary home visitation strategy in 1999. F5AC explored several best practice home visitation models in existence at that time: Hawaii’s Healthy Start, Healthy Families America, The Nurse 

Family Partnership-Olds Model and Parents as Teachers. F5AC decided not to utilize one particular model, but rather embraced the best practice standards that were 

emerging by creating a set of tenets to infuse into F5AC home visitation programs 

for the prenatal to five population in Alameda County. 

FSS Tenets provides a framework for continuous quality improvements to meet 

evolving needs in targeted populations. 

1. Family-centered: acknowledges the reciprocal nature of family well-being and 

child development, and includes support to the family as a whole rather than 

restricted to child-level services. 

2. Relationship-based services: Emphasizes that the family-provider relationship is the most important tool for provider and addresses the need for staff 

to be supported to ‘‘reflect’’ on her/his responses to individual cases. 

3. Child development focused: Expects the service provider to continually observe and use opportunities to help families understand their child’s behavior 

in the context of child development; incorporates a ‘‘child find’’ strategy for 

early identification and intervention by requiring completed developmental 

screenings/assessments throughout the period of services. 

4. Appropriate caseload ratios: Maintains a case ratio of 1:20–25 per case 

manager (and 1:13 for families at risk for child abuse) to support the manageability and intensity of family support services by individual staff. 

5. Reflective supervision: Supports staff to understand the importance of reflection as a tool in their intervention work with families. Supervisor/staff relationships parallel the provider/family relationship. 

6. Multi-disciplinary approach: Emphasizes the use of a variety of professional 

disciplines to meet family needs. 

Implementing home visitation models in Alameda County also relied on key operational factors: the ability to access a large number and diverse pool of nurses to 

serve our diverse community; the cost of using PHNs to provide services; capacity 

to address language and cultural continuity for parents; the need to utilize existing 

programs; the desire to avoid investing in unsustainable programs; the capacity to 

meet diverse and multiple family risk factors. 

• Relying on the nursing supply in Alameda County severely limited the 

number and diversity of families able to receive home visits: Of the approximately 21,000 annual births in Alameda County, 7,000 were to very lowincome mothers qualifying for California’s Medicaid and Healthy Families programs; 1,504 were born low birth weight; 1,325 to teen mothers. The number 

and cost of Public Health Nurses who had both linguistic capacity and reflected 

the cultural backgrounds of our community could not possibly meet the demand 

for services. 

• The high risk nature of clients targeted by F5AC required multi-disciplinary approaches to engage difficult-to-reach families: F5AC families 

targeted to receive home visitation included pregnant and parenting teens, parents of infants discharged from the neonatal intensive care unit due to severe 

and long-term health issues at the time of birth, and children at-risk of neglect 

or abuse due to substance use, mental illness or other unstable family environments. Up to 36% of mothers experienced postpartum depression, 7% of children were exposed to substance use, and 9% of families were involved with 

Child Protective Services. Each significant risk factor necessitated immediate 

attention by a multi-disciplinary team of providers who were most able to offer 

timely support services—which were pre-requisites for maintaining a quality, 

trusting and continuous relationship between a home visitor and the family. 

• Meeting culturally and linguistically diverse needs of families necessitated an agile and culturally responsive workforce: Community organizations offered comparative advantages by staffing the programs with home 

visitors who reflected the face of the county’s community. A children’s hospital 


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and family services department of Alameda County Public Health provided a 

mix of nurses and paraprofessional community health workers who effectively 

addressed long-term health and child development issues of children discharged 

from the Neonatal Intensive Care Unit. Multi-lingual and bi-cultural specialists 

helped families navigate community resources and medical specialists critical to 

the stability and health of the families. Community-based organizations that focused on reaching teen parents worked with schools and Social Services Agency 

to help young parents remain on track with high school requirements and to 

assist in obtaining services to which they are entitled to give their children a 

healthy start. Three community-based organizations demonstrated success in offering alternative response intensive case management to families already 

known to the Child Abuse Hotline but who did not qualify for immediate investigation by Child Protective Services. 

Over the past 9 years, F5AC collected individual client level case management 

and outcomes data to support a robust accountability framework of continuous program quality assurance and impact measurement. F5AC’s home visitation models 

produced impressive outcomes. 

§ Children stayed healthy and up-to-date on preventive care: Over the last 

8 years, F5AC home visiting programs consistently reported 86–99% of children had 

health insurance; 94–98% were up-to-date with immunizations; 92–97% had an 

identified primary pediatric provider (medical home); 95–98% had all the appropriate well-child visits for age. 

§ Early identification and treatment of maternal depression: Early identification of mental health issues and referral to appropriate supports and treatment 

options provided the necessary foundation for a socially and emotionally secure parent-child relationship. F5AC implemented a county-wide standard to screen every 

at-risk parent for depression. 20–36% of mothers who received home visits screened 

positive for maternal depression. Those who screened positive for depression were 

also more likely to have children who screened ‘‘of concern’’ in at least one developmental domain. 

§ Anticipatory guidance and early screening and support for children’s 

development: Home visitors used their encounters with families to help parents 

learn what to expect as their baby grows. A county-wide strategy to promote developmental screening of every child helped identify 20–63% of children with developmental concerns. 

§ Positive breastfeeding trends: In addition to promoting bonding between parent and child, 56% of teen parents and 63% of parents of children discharged from 

the NICU breastfed or used breast milk as the primary source of nutrition for their 

babies. Of those who breastfed, over 30% did so for more than six months. 

§ Low incidence of ER visits and hospitalizations for preventable illnesses 

and intentional injuries: Less than 1% of children without chronic medical conditions visited the emergency room while fewer than 4 per 100,000 suffered intentional injuries. 

§ Teen parents stayed in school or graduated: Almost 60% of teens who received home visits remained in school or graduated from high school. 

Summary 

In implementing home-based early intervention services, First 5 Alameda County 

had to take into account the particular demographic needs and workforce issues 

within our community. A key to successful program implementation was staying 

true to F5AC family support tenets while structural and demographic changes continuously shifted in the county. We were guided by evidence-based practice, but 

above all else, needed to have the flexibility to use the evidence base tailored to the 

circumstances of the populations to be served (pregnant and parenting teens, infants 

discharged from the neonatal intensive care unit, children referred to child protective services, parents in need of family support during the transition to parenthood). 

Each one of these populations had different needs in reference to dosage, single discipline versus multidisciplinary, and type of professional providing the intervention. 

What unified our providers in the provision of home-based services was the common 

language we developed over the years, the ongoing training and support to staff, 

and continuous monitoring and quality improvement measures put in place to assure we were having an impact on families. 

f 


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Statement of Gaylord Gieseke 

I, Gaylord Gieseke, as the Interim President of Voices for Illinois Children, would 

like to submit the following in support of the Early Support for Families Act (H.R. 

2667). Voices for Illinois Children builds better lives by working across all issue 

areas to improve the lives of children of all ages. We envision Illinois as a place 

where all children have the opportunity to grow up healthy, happy, safe, loved and 

well educated. 

The importance of starting early 

‘‘One of the most valuable things I can say I learned through the home visits is 

that I am the example my children will follow; therefore, I have to take the lead.’’ i

Spoken by Monica, a teen mother participating in an Illinois home visitation program, this statement communicates the motivation and hope many mothers are able 

to find with the support of a home visitor. 

Home visiting participants come from all walks of life, but often they resemble 

the story of a 17-year-old high school student who unexpectedly became pregnant. 

Enrolling in a home visitation program, she learned about healthy nutrition and 

then chose more healthy foods for herself and her growing baby. Although the mother had a difficult birth, she and the baby bonded well—the home visitor provided 

encouragement and education about how to interact with a fussy baby during sleepless nights, and helped the mother identify signals the baby may give to indicate 

what he likes and doesn’t like. Initially unsure about how to talk to doctors or social 

workers, the mother has become an advocate for both herself and her baby, having 

observed and practiced communicating her needs effectively with the home visitor. 

Since graduation, the mother has started work as a Certified Nursing Assistant, obtained a driver’s license, and started saving for a car, which would enable her to 

begin taking courses at a nearby community college. In preparation for college, the 

home visitor is helping the mother find and fill out scholarship applications. 

With the support of a home visitor, teen parents are accessing the resources they 

need to build better lives for their children. Recognizing the importance of the parenting role and that learning begins at birth, home visitation programs around the 

country offer in-home services designed to strengthen parenting skills, assist in the 

development of a safe and nurturing home environment, and promote early learning 

for children, from the months before birth to age five. 

The importance of interventions in early childhood—including the months before 

birth—has been supported many times over by an impressive quantity of research 

on children’s brain development. Brain scans indicate that the brains of well-cared 

for babies are fundamentally different from those of neglected infants, with lasting 

implications for each child. Beginning in the 1980s and continuing to the present 

day, researchers consistently find that brain development happens in the context of 

the child’s environment and is not a stand-alone biological phenomenon.ii,iii

As a child bonds with a caregiver, builds vocabulary, plays with toys, and otherwise engages the broader world around him through his five senses, he increases 

brain activity, which in turn preserves neurons to be used in future learning. Without these experiences, or when a young child is exposed to stress without supportive 

relationships to mitigate its impact, the brain pares down neurons, creating future 

learning challenges for the neglected child.iv,v Acting in this critical window for development, early childhood interventions support the creation of an environment in 

which infants may develop a secure attachment to a responsive caregiver—science 

tells us this enhances brain development. All later interventions work with the 

brain function already established in infancy and early childhood. 

The Education Continuum: Beginning Earlier with Home Visiting Programs 

Although the continuum of education has traditionally been P–12 (kindergarten 

through high school), brain research makes it clear that age five is much too late 

to first offer educational supports to the child and family. A child’s experiences before entering kindergarten may hinder or promote her chances of successfully finishing high school and reaching college. Recognizing the need to expand the education continuum to include much, much younger ages, professionals around the 

country began developing programs, known as ‘‘Home Visiting Programs,’’ to fill the 

early childhood gap and to support parents of young children. 

For all programs, participation is entirely voluntary; program models are generally designed to include weekly or biweekly home visits, which last two to five 

years. By having nurses or paraprofessionals visit families in their homes, home visiting programs reduce the obstacles that may otherwise prevent a family from accessing services. Seven nationally recognized home visiting programs are Early 

Head Start, Healthy Families America, Nurse-Family Partnership, Parents as 

Teachers, the Parent-Child Home Program, Parents Too Soon, and Home InstrucVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00102 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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tion for Parents of Preschool Youngsters (HIPPY). HIPPY and Parents as Teachers 

are universal access programs, while the others target teen mothers, single mothers, 

low-income parents, or families with some other significant risk factor. 

Several home visiting programs are designed to engage families when children are 

at their earliest ages—during pregnancy and infancy. Home visitors provide or link 

women to prenatal care and assist the family with establishing a medical home and 

making and attending the baby’s well-being appointments. Doulas may work with 

a mother to prepare for delivery and begin breastfeeding. Furthermore, home visitors talk with parents about caring for the baby, discuss the child’s developmental 

stages, and help moms and dads develop practical and appropriate parenting skills 

and strategies. Overall, these programs emphasize the importance of family health, 

economic self-sufficiency, and parenting skills—factors that significantly affect the 

home environment and the child’s developmental foundation. 

As children reach the toddler and preschool years, home visiting programs build 

on healthy development and empower parents to be their child’s first and most important teacher. Arriving with an educational toy or book, visitors teach or model 

parent-child interactions that stimulate brain development, and they encourage parents to take advantage of preschool. Reading, talking with the child, and promoting 

age-appropriate exploration and choices contribute to the development of the child’s 

burgeoning vocabulary, self-confidence, and ability to reason. Parent involvement in 

nurturing verbal, reasoning, and social skills in the informal home environment is 

critical to preparing children to learn in the more formal school environment. These 

programs also provide parents with information about their child’s development and 

related capabilities and limitations. 

Illinois’ commitment to Home Visiting 

As a state, Illinois has long recognized the benefits associated with home visitation and has been investing in programs since 1982. On average, these programs 

serve 15,880 children each year in Illinois through the Healthy Families, Parents 

as Teachers, Parents too Soon, and Nurse Family Partnership models.vi However, 

especially in these difficult economic times, the current level of programming is not 

meeting the need for home visiting. As financial pressures increase for a family, so 

does the risk of child abuse and the need for preventive services. Including children 

receiving Medicaid assistance, Illinois currently serves only 48 percent of the 35,000 

infants born each year who are most likely to benefit developmentally and academically from home visitation.vii There are still many children and families yet to be 

served. 

However, this is also an exciting time, as Illinois has a critical opportunity to 

broaden the reach and strengthen the quality of home visiting in Illinois through 

the Strong Foundations Project. The Illinois Department of Human Services, along 

with the Department of Child and Family Services and the State Board of Education, has received a $500,000 five-year federal grant for this project. Having previously and independently funded home visiting programs, these agencies are working together and with service providers and advocacy groups to support and expand 

home visiting across the state. 

Specifically, Strong Foundations will operate under the Illinois Early Learning 

Council as a new committee—the Home Visiting Task Force. The Early Learning 

Council is charged with the coordination of services for young children, and the 

Home Visiting Task Force will coordinate resource allocation, community capacitybuilding, training, data collection, monitoring, and technical assistance across the 

three state agencies and more than 150 home visiting programs involved in the 

project. This project will support high-quality service delivery, and to this end will 

develop special trainings to help home visitors serve particularly vulnerable populations, such as those experiencing mental illness, substance abuse, domestic violence, or developmental disability. 

Research has clearly identified the importance of a nurturing family environment 

during early childhood brain development. Moreover, evaluations have affirmed the 

effectiveness of home visiting as a means to improve child and family outcomes on 

a number of health, safety, economic, academic, and social indicators. Though the 

needs are great in these economic times, the passage H.R. 2667 would demonstrate 

the national commitment to enhancing children’s well-being through a wide array 

of approaches, of which home visiting is clearly an integral part. It is critical that 

the recognition and support of home visitation is established in sound federal policy 

as our nation seeks to improve the educational and developmental outcomes for our 

nation’s children. 

If you would like additional information regarding home visiting in Illinois, please 

contact Gaylord Gieseke. 

f 


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Letter from Gladys Carrio ́n, Esq. 

Thank you for your recent legislative effort to subsidize and support evidencebased home visitation programs. The legislation, the Early Support for Families Act, 

adds Subpart 3 to Title IV–B of the Social Security Act to provide grants to states 

to establish or expand quality home visitation programs for families with young children and those expecting children. 

The National Association of Public Child Welfare Administrator’s (NAPCWA) discusses briefly in its submission for the record, that New York State currently administers an evidence-based home visitation program with positive outcomes. That 

program, the Healthy Families New York (HFNY) home visitation program has successfully provided child abuse prevention services to low-income families for many 

years. As Commissioner of the New York State Office of Children and Family Services (OCFS), I wholeheartedly agree with Congress’ decision to make home visitation 

an important part of its investment strategy for preventive services. 

The economic downturn has forced many states to reduce substantially their investment in home visitation and other prevention programs in order to preserve 

dwindling resources for mandated child welfare services. In New York State, despite 

strong evidence from a randomized controlled trial demonstrating the effectiveness 

of HFNY, the program sustained an 8% cut in SFY 2008–2009 and maintained that 

cut in SFY 2009–2010. The availability of significant federal funding for home visiting purposes will likely allow states to continue to invest in this strategy and permit more families to participate. In 2003, Healthy Families America (HFA) programs alone assessed 71,000 families and provided home visiting services to 47,500 

families across the country. 

Based on the Healthy Families America home visitation model, HFNY targets expectant parents and parents with an infant less than three months of age who have 

characteristics that place them at high risk for child abuse or neglect and live in 

vulnerable communities marked by high rates of poverty, infant mortality, and teen 

pregnancy. Specially trained paraprofessionals, who typically live in the same communities as participating families and share their language and cultural background, deliver home visitation services until the child reaches five or is enrolled 

in Head Start or kindergarten. HFNY’s home visitors provide families with support, 

education, and linkages to community services designed to address the following 

goals: 1) to prevent child abuse and neglect, 2) to enhance parenting skills and parent-child interactions, 3) to provide optimal prenatal care and promote child health 

and development, and 4) to increase parents’ self-sufficiency. Since its inception in 

1995, HFNY has provided more than 600,000 home visits to over 20,000 families. 

HFNY has been rigorously evaluated using a randomized controlled trial. The 

evaluation has reported positive program effects in terms of childbirth outcomes, 

child abuse and neglect, parenting practices, and access to health care. A study published in the January 2009 issue of the American Journal of Preventive Medicine 

showed that mothers who are enrolled in HFNY before their 31st week of pregnancy 

were only half as likely to have low birth weight babies as mothers in a control 

group. HFNY was particularly effective in reducing low birth weight among AfricanAmerican and Hispanic mothers, groups that persistently experience high levels of 

poor birth outcomes. For example, 3.1 percent of the African-American mothers in 

the HFNY group delivered low birth weight babies, compared to 10.2 percent of the 

African-American mothers assigned to the control group. In addition to the impacts 

on low birth weight, HFNY has been shown to increase access to health care, particularly among African-American and Hispanic women. A study published in the 

March 2008 issue of the journal Child Abuse and Neglect indicated that HFNY decreased the incidence of child abuse and neglect during the first two years of life, 

and reduced the use of aggressive and harsh parenting practices, particularly among 

first-time mothers under age 19 who were offered HFNY early in pregnancy. Finally, HFNY has been found to promote the use of positive parenting skills that 

support and encourage children’s cognitive and social development (Published Report/Working Paper, 2008, available at www.ocfs.state.ny.us). 

Based on the evaluation’s rigorous random assignment design and the program’s 

significant and positive effects on a range of outcomes, HFNY was designated as a 

‘‘proven program’’ by RAND’s Promising Practice Network and an effective program 

by both Child Trends and the Office of Juvenile Justice and Delinquency Prevention. In addition, the evaluation received grants from both the National Institute of 

Justice and the Doris Duke Charitable Trust Foundation to support the extension 

of the randomized trial into its seventh year. 

HFNY and other evidence-based home visiting programs that rely on paraprofessionals and those professionals other than nurses to deliver home visitation services 


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can help address the serious shortage of nurses in low-income communities and the 

under representation of minorities in the nursing field. 

I applaud Congress on their sensitivity to this issue. I urge you to consider funding this program in a manner that does not impose unfunded mandates or administrative burdens. In addition, please consider restructuring the matching and Maintenance of Effort strategies so that states may be better prepared to participate in 

this federal funding program in these times of economic distress. I look forward to 

the success of this legislation’s intent and am willing to offer my assistance to you 

in achieving this goal. 

Sincerely, 

f 

Gladys Carrio ́n, Esq. 

Statement of Healthy Families Florida 

On behalf of our network of 38 community-based service providers and the more 

than 13,000 Florida families they serve annually, Healthy Families Florida is grateful for this opportunity to provide testimony in support of federal investment in 

early childhood home visitation. 

This testimony will briefly explain the value of home visiting services to Florida 

families and how Healthy Families home visiting services are being effectively implemented in Florida to prevent child abuse and neglect in our state’s highest risk 

families before abuse ever happens. 

Federal Investment in Home Visiting to Promote Positive Parent-Child Relationships 

and Healthy Child Development Makes Sense 

Early childhood experiences, especially interaction with parents and caregivers, 

influence a child’s developing brain and provide the foundation for all future development. While stable, nurturing experiences can help children develop the resilience 

to overcome typical adversities in life, experiencing child abuse and neglect can be 

devastating to child development, often setting in motion a chain of events that has 

lifelong consequences as children grow to adulthood. In addition to increasing the 

likelihood of delinquency, criminal involvement, substance abuse and low educational achievement, child abuse and neglect has a long-term impact on physical 

and mental health. 

Research shows that the added stress low-income families face during economically depressed times causes child abuse and neglect to increase. The human and 

monetary costs of child abuse and neglect are unconscionable, especially compared 

to the low cost of effective prevention. 

Prevention services, like those offered through Healthy Families Florida and other 

evidence-based home visiting programs in Florida, support healthy child development and family stability at a fraction of the cost of providing services that intervene after abuse and neglect have occurred. 

About Healthy Families Florida 

Healthy Families Florida is a statewide, nationally accredited, voluntary home 

visiting program that is proven to prevent child abuse and neglect before it ever 

starts. The program is modeled after Healthy Families America, an evidence-based 

initiative of Prevent Child Abuse America. Healthy Families America is recognized 

by the U.S. Office of Juvenile Justice and Delinquency Prevention as an ‘‘effective 

prevention program, demonstrating empirical findings using a sound conceptual 

framework and an evaluation design of high-quality.‘‘ Healthy Families New York, 

which implements the same model, is also acknowledged as a successful and proven 

program by the Rand Corporation, a non-profit institution that addresses the challenges facing the public and private sectors around the world. 

Healthy Families Florida equips parents and other caregivers with the knowledge 

and skills they need to create stable home environments free from child abuse and 

neglect so their children can grow up healthy, safe, nurtured and ready to succeed 

in school and in life. Highly trained home visitors provide parents and other caregivers information, guidance and emotional and practical support by: 

• Modeling positive parent-child interaction to enhance their child’s development. 

• Providing education on child health and development and the importance of 

immunizations and well-baby check-ups. • Teaching about safe and unsafe sleeping environments for infants, coping with 

crying and other prevention topics. 

• Conducting child screenings for developmental delays. 


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• Connecting families to medical providers and making referrals to other community services. • Teaching how to recognize and address child safety hazards in and around the 

home, in the car, in and around water and in other environments. • Helping to develop appropriate problem-solving skills and identify positive 

ways to manage stress. • Promoting personal responsibility for their future and the future of their families by helping them to set and achieve goals, such as furthering their education and acquiring stable employment. 

Who do we serve? 

Research shows that the key to preventing child abuse and neglect is intervening 

early, during pregnancy or shortly after the birth of a baby. Healthy Families services begin during pregnancy or within three months of a baby’s birth and can last 

for up to five years depending on the unique needs of each family. Healthy Families 

uses a validated assessment tool to determine which families are experiencing a variety of difficult circumstances that place their children at high risk for abuse and 

neglect and other adverse outcomes that are preventable through intensive home 

visiting services. 

Most Healthy Families participants are low-income single parents with less than 

a high school education and little awareness of appropriate discipline options for 

their children. Participants often experienced abuse or neglect during childhood. 

Other common participant risk factors include: 

• Late or inadequate prenatal care • Multiple children under five years of age • Prior involvement with Child Protection Services • Inappropriate coping mechanisms • Current maternal depression or history of mental illness • Unrealistic expectations about child development • Limited contact with close friends and/or family • History of, or current, domestic violence or other abuse • Raised in an unstable home • History of, or current, substance abuse 

Healthy Families services are available in all of Florida’s 67 counties; in some 

throughout the entire county and in others only in targeted high-risk zip code areas. 

How do we know it works? 

Healthy Families Florida has undergone a rigorous five-year quasi-experimental 

study conducted by independent evaluators to determine whether the program 

makes a measurable difference in participants’ lives. The evaluators concluded that 

HFF has a significant impact in preventing child abuse and neglect and achieves 

positive outcomes for both parent and child: 

• Before their second birthday, children in families who received intensive HFF 

services experienced 58 percent less child abuse and neglect than children of the 

same age in families who received little or no HFF services. 

• Children whose families did not receive HFF services were nearly four times 

more likely to suffer maltreatment before their second birthday than children of the 

same age in families who completed the program. 

• Participants who completed the program were more likely to be employed within 36 months than those in the comparison group who received little or no service. 

• Mothers who participated in HFF for three or more years were significantly 

more likely to read to their children. 

• 93 percent of children participating in HFF services were fully immunized by 

age two. 

• 92 percent of mothers participating in HFF services did not have a subsequent 

pregnancy within two years. 

• 81 percent of participants who completed the program improved their education 

level, received job training or became gainfully employed while enrolled in the program (measures of increased self-sufficiency). 

HFF has sustained high performance in promoting positive outcomes for parents 

and their children since its inception in 1998. 

Why is Healthy Families So Successful? 

Key elements that contribute to Healthy Families success include: 

• Services are voluntary, which empowers families to make positive changes in 

their behaviors and the way they lead their lives. 

• Home visits are frequent and long-term. Families start out with weekly visits 

for at least six months. As families progress in establishing stable, safe and 


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nurturing environments for their children, the frequency of the visits decreases 

to bi-weekly, then monthly, then quarterly. 

• Services are available during non-traditional hours, including evenings and 

Saturdays, to accommodate families’ work and school schedules. 

• Intensive training prepares staff for their roles and responsibilities and helps 

them succeed in their work with families. 

• Quality supervision allows supervisors to review the progress of families with 

staff on a weekly basis in order to provide guidance and clinical support and 

develop the skills of the home visitors. 

• Low caseloads allow home visitors to spend the time they need to meet the individual needs of each high-risk family. 

• A strong statewide system that includes a central office that provides annual 

quality assurance visits to ensure accountability and fidelity to the Healthy 

Families program model; ongoing technical assistance and training; fiscal oversight and data management; and ongoing evaluation that identifies progress 

toward measurable outcomes and areas in need of improvement or change. 

• Strong community partnerships provide families with additional services such 

as child care, mental health counseling, substance abuse treatment and domestic violence intervention. 

Conclusion 

In closing, the value of public investments in young children and their families 

is obvious when looking at the long-term societal benefits. According to the Center 

on the Developing Child at Harvard University, ‘‘the empirical data from cost-benefit studies presents a compelling case for early public investments targeted towards 

children who are at greatest risk for failure in school, in the workplace, and in society at large.’’ Home visitation is an effective, evidence-based, and cost-efficient way 

to bring families and resources together, and help families to make choices that will 

give their children the chance to grow up healthy and ready to learn. Florida recognizes that an array of home visiting services is needed to meet the diverse needs 

of families throughout our state. We believe that HR 2667 is an important step towards ensuring that families have access to these valuable services so that all children have the opportunity to grow up in a safe, healthy, and nurturing environment. 

Contact Information: 

Carol McNally, Executive Director 

Healthy Families Florida 

f 

Statement of Howard S. Garval 

What could be more important than preventing child abuse and strengthening 

families? Nothing. That is why I am writing in strong support of HR 2667 The Early 

Support for Families Act and I urge passage of this important bill. 

Hawaii invented Healthy Start, an evidence-based model of home visiting for 

parents of newborns who are at various levels of risk of child abuse. Healthy Start 

led to the replication in over 35 states of similar programs under the Healthy Families America umbrella. In Hawaii we have had a longstanding partnership with 

Johns Hopkins University as the evaluator for this statewide effort. Child & Family 

Service is one of six providers in the state and also the largest provider of Healthy 

Start services. In Hawaii we added Child Development Specialists and Clinical Specialists to the team with paraprofessional family support workers because we found 

that the severity of many of the families dealing with substance abuse, mental 

health problems and domestic violence were beyond the competency of the home 

visitors. By adding these positions and providing increased training by a seventh organization here, we have strengthened the program and more recent evaluations 

have been very encouraging. For several years now we know that for families that 

stay one year or more in this voluntary program there has been a success rate of 

over 99% as defined by no report of child abuse/neglect. 50% of families stay a year 

or more and Hawaii’s results compare favorably to many programs in other states. 

For a voluntary program, 50% retention after one year is a good result. We are also 

beginning to define more clearly where the current model is especially successful; 

i.e. with anxious moms. We continue to look at ways we can make the program even 

more effective and Hawaii was recently one of only 17 states to be awarded a $2.5 

million grant by ACF to work on further improvements to the program and to share 

the results of these efforts nationally. ACF recognized all that Hawaii has done in 


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this area and wants us to share what we are learning and will learn with the rest 

of the country. 

There is a growing body of evidence from research that shows the effectiveness 

of home visiting programs to prevent child abuse. There is also abundant research 

to show the importance of early childhood experiences in future outcomes for children. The ACE (Adverse Childhood Experiences) study is one good example that actually shows that many costly and serious medical problems are more prominent in 

adults who as children suffered adverse childhood experiences like the trauma of 

child abuse. We also know the huge cost in human, social, and economic terms of 

not preventing child abuse. In this economic downturn where states are cutting back 

services, more children and families are at risk of serious negative outcomes. This 

legislation could not come at a better time for this reason, but at any time this is 

a smart and good investment in resources that will pay huge dividends in the years 

to come. It will offer hope to the youngest and most vulnerable in our communities 

and strengthen the family as the foundation for healthy child development. 

I urge you to strongly support HR 2667 The Early Support for Families Act. 

Thank you for the opportunity to submit testimony. 

With much Aloha, 

Howard S. Garval, MSW 

f 

Statement of Kansas Children’s Service League 

Kansas Children’s Service League (KCSL) thanks the Chairman and the other 

distinguished members of the U.S. House Committee on Ways and Means Subcommittee on Income Security and Family Support for this opportunity to provide 

the organization’s perspective on the need for a federal investment in early childhood home visitation. In particular, we would like to thank Chairman McDermott, 

Representative Danny Davis and Representative Todd Platts for their leadership on 

this issue, as most recently demonstrated with their introduction of the Early Support for Families Act of 2009 (HR 2667). 

Kansas Children’s Service League (KCSL) is a not-for-profit agency standing on 

116 years of tradition serving children and families throughout the state of Kansas, 

strengthened by a mission to protect and promote the well being of children. KCSL 

serves as the Kansas Chapter of Prevent Child Abuse America; is a charter member 

of the Child Welfare League of America; and has achieved national accreditation 

from the Council on Accreditation and Healthy Families America. Our collective efforts are aimed at keeping children safe, families strong and communities involved. 

Through this testimony our organization will identify the value of the Healthy Families home visitation programs in Kansas along with our full support for federal investment to enhance and expand our nation’s ability to promote healthy early childhood experiences. 

KCSL fully supports and reiterates testimony submitted by Prevent Child Abuse 

America on June 9, 2009 to the U.S. House of Representatives Committee on Ways 

and Means. In the 13 years of our Healthy Families intensive home visitation programs in Kansas, our experience tells us that this program keeps children healthy 

and free from abuse and neglect. Our results mirror those found among our sister 

programs across the nation including: 

• 96% of the children served are current on immunizations; 

• 84% of the families served have a primary medical provider; 

• 87% have smoke free homes; 

• 99% receive nutrition and physical activity information and training; and 

• 99% are free of abuse and neglect. 

This is incredible given that these families enter the program facing numerous 

(often 4 or more) risk factors heightening the potential chance of child maltreatment. 

We would like to take this opportunity to share with you the story of one of our 

families. Maria’s baby, Jennifer, was born with only one functioning kidney. Maria, 

a 22-year-old first time single parent entered our program unemployed, without stable housing and less than a high school education. Her own childhood had been 

somewhat disruptive. Maria stated that her grandmother did most of the caretaking 

because her father came and went and her mother ‘‘worked hard to put food on the 

table’’. Maria admits to being a very strong willed child and to being hit with a 

switch ‘‘or anything she could get her hands on’’ when she wouldn’t listen to her 

mother. The KCSL Healthy Families worker completed weekly home visits and developmental screens to make sure Jennifer was doing well with her physical, social 


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and emotional development. The developmental screen performed by the KCSL 

Healthy Families worker confirmed a possible delay and the family was connected 

with an area Infant/Toddler program so that she could receive home-based speech 

therapy. 

Over the 3.5 years that the family has been in the program they have met nearly 

90% (8/9) of their goals. These goals have been focused on a variety of needs including: Jennifer’s medical condition; employment; healthy relationships; stable housing; 

and parenting. Jennifer has received a clean bill of health from her medical provider 

and kidney specialist and is on target or ahead of the developmental milestones for 

her age. Maria is proud as she reviews all of her family’s progress thus far. She 

will graduate from the Healthy Families program this summer as Jennifer prepares 

to enter preschool in the fall. The smile on Maria’s face shows this pride as well 

as the knowledge that she is doing everything she can to help her child remain 

healthy and thrive. 

As you can see, the home visitation and services of Healthy Families is vital to 

the well-being of children and their families. Thank you for this opportunity to submit testimony and please accept our full support for the Early Support for Families 

Act of 2009 (HR 2667). 

f 

Statement of Kathee Richter 

I am the Child Development Director of Neighborhood House, a non-profit organization serving the Seattle/King County area in Washington State. 

Our organization is strongly in support of the Committee’s efforts to advance legislation supporting investments in evidence-based home visiting programs that enhance early learning and reduce child abuse and neglect. 

For the last four years, Neighborhood House has delivered the Parent-Child Home 

Program (PCHP) to 80 immigrant and refugee families a year with strong outcomes 

for both the parents and the children ages 2 and 3 who are the program participants. PCHP is one of the major national home visiting programs. Substantial research exists supporting its ability to improve school performance, lower high school 

dropout rates and improve high school graduation rates. 

We employ paraprofessional home visitors who are bilingual or multilingual and 

from the cultures of the families served. I do not believe we would have been able 

to engage or effectively serve these families if our staff did not speak their language 

or was not from the same culture. 

Overview of Neighborhood House 

The mission of Neighborhood House is to help diverse communities of people with limited resources attain their goals for self-sufficiency, financial independence, health and community building. 

From our earliest beginnings serving Jewish immigrants in the 1900s to our work 

today with people from numerous countries and cultures, Neighborhood House has 

helped generations of families fulfill the promise of America—an education for their 

children, self-sufficiency for their families and a meaningful place in a caring community. 

Our case workers, teachers, volunteers and tutors (many of whom are bilingual 

or multilingual) work in neighborhoods across King County. We provide tutoring, 

citizenship classes, early learning programs, job training, case management, community health programs and transportation to more than 11,000 low-income people 

each year. 

Selection of Neighborhood House for Funding from Business Partnership 

for Early Learning 

Neighborhood House was selected in a competitive request for proposal in 2005 

to receive a grant from the Business Partnership for Early Learning (BPEL). BPEL 

is a group of business and philanthropic leaders in King County investing in closing 

the school achievement gap for those children most likely to arrive at kindergarten 

with a ‘‘preparedness gap’’ they may never be able to overcome and for those parents 

are the most isolated. 

Neighborhood House was selected because BPEL knew from public school data 

that a sizable proportion of the students with low school success and graduation 

rates are those who are English Language Learners and whose families live in poverty. Neighborhood House has a success track record of serving immigrant and refugee families from all over the world in its family support and early learning programs. 


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Overview of the Parent-Child Home Program 

The Parent-Child Home Program is a research-based school readiness home visiting program for 2- to 3-year-olds and their parents. Paraprofessionals provide 

home visits twice weekly over a two-year period and bring gifts of books and educational toys. The home visitors provide parent coaching by modeling behaviors that 

stimulate early learning and help the parents experience the intrinsic rewards of 

seeing their child enjoy learning. 

Description of Families Served with PCHP 

• None of the 160 families a year that we serve have English as their home language. 

• As many as 75 percent of parents have limited literacy levels and cannot easily 

read English or their home language. 

• Among the more than a dozen languages spoken by the families are Vietnamese, Chinese, Cambodian, Cham, Spanish, Somali, Amharic, Oromo, and 

Tigrinya. 

• Almost 90 percent of our families have an annual income of $25,000 or less; 40 

percent have an income of $10,000 or less. 

• Many parents are unfamiliar with the notion of children as young as age 2 

being able to learn or engage with books. 

Description of our Staff for the Parent-Child Home Program 

We have two Program Coordinators who hire, train and supervise the home visitors. One coordinator has a Bachelor of Arts degree and speaks Tigrinya, Tigre, Amharic, Arabic and English. The other coordinator was a medical doctor in Cambodia 

and has a Masters Degree in social work and population leadership on reproductive 

and child health programs. She speaks Cambodian/Khmer, Thai, Lao, French and 

some Vietnamese. We employ 9 home visitors. Their ethnicity and the languages 

they speak are as follows: Mexican (Spanish), Somali (Somali), Cambodian (Khmer), 

Vietnamese (Vietnamese, Cham), Ethiopian (Amharic, Tigrinya, Oromo, Afari, Arabic) 

The Success of Parents and Children in Our Parent-Child Home Program 

In each of the four years we have delivered the Parent-Child Home Program, both 

the children ages 2 and 3 and their parents have achieved, based on a third-party 

outcome evaluation, statistically significant increases from baseline to end of Year 

1 and from end of Year 1 to end of Year 2 on all items observed by coordinators. 

Parents reported an increased understanding of their role in helping prepare their 

child for school, increased parenting skills and a greater commitment to participate 

in the education of their child. Children increased their use of behaviors that are 

beneficial for school readiness, including social skills, learning skills, and pre-literacy skills. 

We have achieved a 90 percent or higher retention rate over the two-year program. Families only leave the program if they move out of our service area or for 

another reason that precludes them from continuing. 

Our programs were certified by The Parent-Child Home Program’s national office 

in 2008 as meeting all requirements of its replication agreement and implementing 

those components with fidelity and quality. 

We also believe PCHP helps prevent child abuse and neglect, as it builds the protective factors in both parents and children that are known to prevent child abuse 

and neglect. We know that positive parent-child interaction, one of the key outcomes 

of PCHP, is a critical factor in the prevention of child abuse. However, we do not 

have the capacity or resources to track reduction in child abuse and neglect for our 

families who receive PCHP services. 

Factors Influencing Our Successful Implementation of PCHP 

We consider it absolutely essential to employ home visitors who share the language and cultural backgrounds of the families they visit. This is required because: 

• Facilitates communication with families for recruitment, enrollment and service coordination. 

• Home visitors are able to quickly establish trust and relationships with families. 

• Home visitors are accepted and considered to be trusted, credible sources of information about parenting and child development. 

• Home visitors understand and are able to effectively talk with parents regarding beliefs about parenting and child development shaped by cultural background and experience. 


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• Supports parents who may not be strong readers in feeling competent and confident to share books with their children by modeling techniques such as ‘‘picture reading’’ (telling a story through description of pictures instead of reading 

verbatim from a book). Parents are then more likely to share books with their 

children on their own. • Supports parents’ belief in their children’s ability to learn, so parents are more 

likely to become invested in their role as ‘‘first teacher’’ and help their child 

prepare for school. • Facilitates communication and understanding regarding how fathers might be 

involved in sharing books and toys with children, even if this is not a traditional parenting role. 

Each home visitor receives 16 hours of initial training and a minimum of two 

hours of supervision each week. In addition, home visitors attend local classes and 

workshops in early learning and receive extensive coaching and problem-solving 

support from the Program Coordinators. 

Community Need to Continue and Expand Parent-Child Home Program 

We are contacted regularly and asked to serve additional families both within our 

service area and outside it. We currently do not have the resources to serve any 

more families. 

We believe there are hundreds of families just in the Seattle/King County area 

who would greatly benefit from participation in PCHP. 

We know that about 45 percent of Washington State children ages 0 to 5 are at 

home with their parents and another 21 percent are cared for by relatives, friends 

and neighbors. This means that about two-thirds of young children statewide are 

largely overlooked and underserved by investments in child care centers and 

preschools. Many of those children will not be ready for school if we do not go where 

the children are and engage their parents in ways that are effective and culturally 

appropriate. 

Conclusion 

Thank you for the opportunity to provide you with information on the success of 

our replication of the Parent-Child Home Program, using paraprofessionals who 

speak the languages and are from the cultures of the diverse immigrant and refugee 

families we serve. 

We believe these home visiting programs, and other evidence-based programs, are 

essential to giving all young children a fair chance to succeed in school and life. In 

turn, they make our communities stronger and reduce the cost of bad outcomes for 

our children. 

Kathee Richter 

Child Development Director, Neighborhood House 

Seattle, Washington 

f 

Statement of Lenette Azzi-Lessing, Ph.D. 

Dear Congressman McDermott and Subcommittee Members: 

I am writing to provide testimony on proposals to provide federal funding for early 

childhood home visitation programs. Last week, the subcommittee heard testimony 

on the Administration’s plan to target $8.6 billion—over the next 10 years—for 

home-visiting programs for disadvantaged families with young children. Early childhood advocates strongly support this policy direction, given the damaging impact 

that poverty has on children’s long-term ability to learn and succeed in school and 

in life. 

In recent years, home visiting programs for poor families have won the backing 

of political leaders on both sides of the aisle as well as that of business leaders and 

economists. Much of this support stems from expectations that these programs will 

reduce the likelihood that poor children will fail in school, become delinquent or 

need welfare. Economic analyses indicating that home visiting programs can deliver 

an excellent return on investment by shrinking public expenditures for juvenile justice and welfare programs have caught the attention of members of Congress as well 

as of President Obama, who, as a candidate, pledged to extend these services to 

570,000 families a year. 

The President deserves high praise for allocating substantial resources to improve 

the life chances of young children in poverty. However, not all home-visiting programs are alike and it is critical that these new funds are targeted towards strategies that hold the greatest promise. Much of the return on investment argument is 


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based on the results of a study conducted 30 years ago, in which nurses provided 

home-visits to a relatively small group of first-time mothers living in rural parts of 

Elmira, New York. This program, known as Nurse Family Partnership (NFP), utilizes nurses to support and educate new mothers during their pregnancy and 

throughout their child’s first two years of life. Babies born to NFP-participating 

mothers in Elmira were healthier at birth, and their families were on welfare for 

substantially shorter periods of time than families not enrolled in the program. 

What set NFP apart from other home visiting programs was its rigorous evaluation, in which families were randomly assigned to participate in NFP or to be in 

a control group. Similar to procedures used by the FDA for testing new medications, 

this type of evaluation is considered the gold standard for measuring program effectiveness. The compelling results from the Elmira program, along its the stringent 

evaluation methods won support for NFP as a ‘‘proven’’ program that is now a 

frontrunner for expansion with the new federal funding. 

Receiving far less attention are the results of two subsequent tests of NFP that 

were conducted in the 1990’s with larger groups of poor women and their babies in 

the inner cities of Memphis and Denver. Many of the benefits experienced by the 

Elmira participants faded or disappeared altogether for the families in these two 

studies. The diminished outcomes in later evaluations of NFP point to the pitfalls 

inherent in attempting to apply a one-size-fits all model of intervention to an increasingly diverse array of families. It is likely that the families in the Memphis 

and Denver studies were more vulnerable than those in Elmira, due to high crime 

rates and other stresses of inner-city life and the shrinking safety-net that culminated in the mid 1990’s with the passage of welfare reform. NFP’s capacity to 

help was probably outstripped by the multiple challenges facing these more contemporary families. 

More-recent evaluations of home-visiting programs provide critical information 

about was does and doesn’t work in intervening with today’s vulnerable families. 

Programs that combine group learning opportunities for infants and toddlers—like 

those offered in the best childcare centers—with home visits to educate and support 

parents, appear to hold the most promise for improving poor children’s learning 

abilities. Moreover, home visiting programs that offer a flexible range of services 

that can be customized to meet the unique needs of each family served are often 

most effective. In order to significantly improve the prospects of disadvantaged children, however, interventions must get at the root cause of their plight, which is poverty. This means providing poor parents with education and job training as well as 

subsidizing their childcare and health care costs as they work their way up from 

low-paying, entry-level jobs. 

Developed 15 years ago by the nation’s top experts in child development, the federal Early Head Start program incorporates many of these recent findings. This program aims to help poor infants and toddlers reach their full learning potential while 

assisting their parents with employment, housing, mental health and a range of 

other needs. Like NFP, Early Head Start utilizes nurses, but the program also 

draws upon the expertise of early childhood educators, social workers and mental 

health specialists to offer a more comprehensive array of services. 

Early Head Start has the capacity to provide a customized mix of home visits and 

services delivered to children in daycare centers—making the program accessible to 

working families. Moreover, the program works with families that have more than 

one child and can be adapted to serve infants and toddlers with disabilities as well 

as those placed in foster care—children at particularly high risk for poor outcomes. 

Evaluation of Early Head Start—utilizing methods as rigorous as those used by 

NFP—is currently underway in 17 sites across the country and results are encouraging. Participating children are showing improvements in mental and emotional 

development; these gains are especially strong for children receiving a combination 

of home and center-based services. 

Dollars allocated to home-visiting in the proposed federal spending plan should 

go towards expanding Early Head Start and for rigorously evaluating other comprehensive but smaller-scale approaches operating in a number of communities. 

Currently funded at $1 billion year, Early Head Start serves only about 3% of the 

low-income infants and toddlers who are eligible for the program. The stimulus 

package allocates an additional $1.1 billion that will double the number of children 

participating in Early Head Start; but reaching only 6% of the youngest, poorest and 

most vulnerable children in America is an anemic example of change we can believe 

in. 

Members of the Committee must recognize the complex and recalcitrant nature 

of the factors that threaten the future prospects of disadvantaged, young children— 

factors made worse by the current recession. These children need and deserve the 


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most promising interventions we have: those that are proven to work under the extraordinarily challenging conditions confronting poor families today. 

Lenette Azzi-Lessing, Ph.D., is on the faculty of the School of Social Work and 

Family Studies at Wheelock College, Boston. She has 25 years experience in developing, operating and evaluating programs for disadvantaged, young children and 

their families and is currently writing a book on strategies for eliminating childhood 

poverty in the United States. She can be reached at lalessing@wheelock.edu. 

f 

Statement of Marcia Slagle 

In 1998 the Anderson County Health Council received a three-year demonstration 

grant from Covenant Health to implement Healthy Start of Anderson County. In 

1995 and 1998 Anderson County did not qualify for funding from the Division of 

Maternal and Child Health (Tennessee Dept of Health) because money was directed 

to areas with the lowest income and highest minority population. Although Anderson County’s average income looks high (due to Oak Ridge), many areas of the county reflect the surrounding area’s isolation, poverty of income and opportunity. 

Healthy Start of Anderson County is credentialed by Healthy Families America, 

the parent organization. The goals are set by the national organization and are as 

follows: 

• promote positive parenting 

• encourage and improve child health and development 

• prevent and/or reduce child abuse and neglect. 

These goals are met by providing in-home education for the parents. The weekly 

visits involve teaching age-appropriate curriculum for the baby, mentoring of good 

parenting skills, monitoring the baby’s growth and development, and providing referrals for community resources. Parents at greater risk to use inappropriate childrearing techniques are those who lack basic resources, support and information 

about effective child-rearing and have limited educational and work experiences. 

When children from these families grow up, they are at increased risk to develop 

serious problems with truancy, drug abuse, delinquency or mental illness. The positive outcomes of prevention programs, with even relatively small reductions in the 

rate of child maltreatment, demonstrate that prevention can be cost-effective. 

Most of the investments in prevention, particularly as they apply to investments in 

families with young children, are likely to have ‘‘payback curves’’ that extend over 

a long period of time, with much of the savings occurring when the child reaches 

a healthy, productive and nonviolent adulthood. 

Research shows that about 25,000 children are abused or neglected every year in 

Tennessee. The Department of Children’s Services recently stated that ‘‘every foster 

child in state’s custody costs the state $50,000 a year.’’ A recent news article stated 

that Tennessee taxpayers pay approximately $850,000,000 yearly in costs related to 

child abuse. There is legislation before Congress now called ‘‘Education Begins at 

Home Act’’ (s.503). The bill would provide $500 million in federal funds over three 

years to establish and/or expand home visitation programs in all 50 states. Anderson County has had a program like this for 10 years and that program is Healthy 

Start! 

The Healthy Start advocacy committee was formed in 2007. This committee has 

helped introduce the residents of Anderson County to the important work of Healthy 

Starts. A ‘‘Blue Ribbon Campaign’’ in April was held in conjunction with Prevent 

Child Abuse Awareness Month. Proclamations from the County Commission as well 

as local city governments designated April as prevent child abuse awareness month. 

There were two social events held (one in Clinton and one in Oak Ridge) to spread 

awareness of Healthy Start. The committee has completed a letter campaign to raise 

funds. The committee also saw a need to hire a part-time grant writer to help secure 

more funding. The grant writer searches for foundations and other funding sources 

to apply for monies. The League of Women Voters continues to be our advocate to 

the local and state leaders to find new funds. In October 2006, we began a collaboration with the Oak Ridge Unitarian Church congregation to provide volunteers to assist with our families. The members of this congregation have supported us this 

past year with transportation needs, hauling furniture, and meeting emergency financial needs of our families as they arise. 

On December 5, 2007, the Centers for Disease Control reported that ‘‘for the first 

time in 14 years, the number of teenagers having babies in the United States rose.’’ 

It was also stated that one reason for the teen birth rate rise might be partly a result of not reaching hard-to-reach teens. Many programs addressing teen pregnancy 


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1 National Research Council and Institute of Medicine, From Neurons to Neighborhoods: The 

Science of Early Childhood Development. Jack Shonkoff and Deborah A. Phillips, eds. Washington, DC: National Academy Press, 2000. 2 Ayana Douglas-Hall and Michelle Chau. Basic Facts about Low-Income Children: Birth to 

Age 3. National Center for Children in Poverty, 2008, http://www.nccp.org. 3 National Research Council and Institute of Medicine, From Neurons to Neighborhoods. 4 Ibid. 

had been eliminated because teen pregnancy and teen births had lessened consistently since 1991. Healthy Start had to eliminate the job of the Family Support 

worker serving the rural parts of Anderson County because of cuts in funding in 

2005. All of the participants served in the rural areas prior to 2005 were teenagers 

(ages 14–19). One of the goals for Healthy Start in 2009 is to hire a Family Support 

worker to serve the first-time parents in the rural parts of the county again. 

Description of Agency: 

The Anderson County Health Council was chartered as a private non-profit agency in 1968 for the purpose of promoting and assuring the highest level of health obtainable for every resident of Anderson County. 501(c)(3) status was received November 29, 1972. The volunteer Board of Directors consists of twenty-seven residents (nine residing in Oak Ridge), who serve on different committees which give 

focus and determine the direction of the Health Council’s efforts. The Anderson 

County Health Council receives funding from United Way of Anderson County; private, state and federal grants; local governments; and private donations. 

Services Offered: 

To qualify for the Healthy Start program a family must be a first time parent, 

meet the risk assessment that documents need for the program, and be a resident 

of Anderson County. Services include, but are not limited to: educational and supportive home visits; developmental testing of babies; group support meetings; parent 

and baby transportation to health and social services; used maternity and children’s 

clothing; emergency formula, diapers and food; lending library of baby equipment 

and car seats; monthly age-appropriate children’s books; referrals to community 

services; and staff attendance at birth of baby when appropriate. 

f 

June 9, 2009 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to submit the following written testimony to the Subcommittee on 

Income Security and Family Support on behalf of ZERO TO THREE. My name is 

Matthew Melmed and for the last 14 years, I have been the Executive Director of 

ZERO TO THREE, a national non-profit organization that has worked to advance 

the healthy development of America’s infants and toddlers for over 30 years. I would 

like to start by thanking the Subcommittee for its interest in examining the issue 

of early childhood home visiting programs and for providing me the opportunity to 

address the interaction between these programs and other policies and programs 

that focus on infants and toddlers. 

Any new parent will likely tell you that parenting is the most rewarding and the 

most difficult job they have ever had. Especially during the first years of their 

child’s life, parents play the most active and influential role in their baby’s healthy 

development, and it can be challenging to do so without support from others.1 Unfortunately, many parents face obstacles—such as those caused by stress, geographic and social isolation, and poverty—that impact their ability to fully support 

their baby’s development during these critical years. 

Almost half (43 percent) of all infants and toddlers live in low-income families 

(below 200% of the federal poverty level), and 21 percent live in poor families (below 

100% of the federal poverty level).2 One of the most consistent associations in developmental science is that between economic hardship and compromised child development.3 Infants and toddlers in low-income families are at greater risk than infants 

and toddlers in middle-to high-income families for a variety of poor outcomes and 

vulnerabilities that can jeopardize their development and readiness for school, including learning disabilities, behavior problems, mental retardation, developmental 

delays, and health impairments.4

Fortunately, intervening early in the life of a child at risk for poor development 

can help minimize the impacts of these risks. While you are focusing today on a specific method of delivering services, I urge you to think in terms of developing a comprehensive system of services that provide a prenatal through pre-kindergarten continuum and place home visitation squarely in that context rather than establishing 


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5 Elizabeth DiLauro, Reaching Families Where They Live: Supporting Parents and Child Development through Home Visiting. Washington, DC: ZERO TO THREE, 2009. 6 U.S. Department of Health and Human Services, Administration for Children and Families, 

Research to Practice: Early Head Start Home-Based Services. U.S. Department of Health and 

Human Services, 2003, http://www.acf.hhs.gov. 7 Ibid., fn. 3. 

it as an isolated program. Such a system would ensure that the critical needs of 

vulnerable infants and toddlers—regardless of the setting in which they might be 

reached—are included in early childhood planning. That system would help parents 

and early childhood professionals promote healthy development across all domains. 

Services in this system should support parents in forging bonds with their children 

since developing strong attachments provides the needed foundation for a child to 

explore and learn as well as to regulate their emotions as they interact with others 

(social and emotional development). Such services should also help parents and babies engage in play, reading, and other activities that foster early language skills 

(cognitive development) and they should promote good nutrition and attention to 

well-child care (physical development). 

Supporting Parents and Child Development through Home Visiting 

Voluntary home visiting programs tailor services to meet the needs of individual 

families, and they offer information, guidance, and support directly in the home environment. While home visiting programs, such as Healthy Families America, the 

Nurse-Family Partnership, the Parent-Child Home Program, and Parents as Teachers, share similar overall goals of enhancing child well-being and family health, they 

vary in their program structure, specific intended outcomes, content of services, and 

target populations. Program models also vary in the intensity of services delivered, 

with the duration and frequency of services varying based on the child’s and family’s 

needs and risks. 

A growing body of research demonstrates that home visiting programs that serve 

infants and toddlers can be an effective method of delivering family support and 

child development services, particularly when services are part of a comprehensive 

and coordinated system of high quality, affordable early care and education, health 

and mental health, and family support services for families prenatally through prekindergarten. Research has shown that high quality home visiting programs serving 

infants and toddlers can increase children’s school readiness, improve child health 

and development, reduce child abuse and neglect, and enhance parents’ abilities to 

support their children’s overall development.5 The benefits of home visiting, however, vary across families and programs. What works for some families and in some 

program models will not necessarily achieve the same success for other families and 

other program models. 

Home Visiting within a Comprehensive Early Childhood Program: The Early Head 

Start Example 

Comprehensive programs serving families with young children may incorporate a 

strong home-based component even though they are not described as home visiting 

programs; one such model is Early Head Start (EHS). EHS programs can use a 

home-based approach, a center-based approach, or a combination of the two. The 

Early Head Start evaluation results for home-based programs showed that, when 

compared to a control group, parents in the programs demonstrated more positive 

impacts with regard to providing more stimulating environments, gaining a greater 

knowledge of child development, and reporting less parental stress. Children in the 

program showed stronger vocabulary development at age 24 months compared with 

control group children, were more engaged with their parents during play at this 

age, and, in programs that fully implemented the Head Start Program Performance 

Standards, showed positive impacts on child cognitive and language development at 

age 36 months.6

It is important to note, however, that other approaches to supporting parenting 

and early childhood development can have a positive impact as well. Center-based 

programs, by themselves, have proven to have impacts on child cognitive development at both 24 and 36 months of age, as well as on other child and parenting outcomes, but without a consistent pattern.7 On the other hand, Early Head Start programs using a mixed approach, a combination of center- and home-based approaches, showed strong impacts at both 24 and 36 months for parenting and child 


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8 U.S. Department of Health and Human Services, Administration for Children and Families, 

Early Head Start Benefits Children and Families. U.S. Department of Health and Human Services, 2002, http://www.acf.hhs.gov. 9 National Center for Children in Poverty, United States Early Childhood Profile. National 

Center for Children in Poverty, 2007, www.nccp.org. 

outcomes. In fact, the national evaluation found the strongest pattern of impacts on 

children and families in mixed-approach programs.8

One issue that surfaced in the examination of Early Head Start when services are 

delivered through the home is that families with more risk factors (e.g. teen parents, parents with depressive symptoms, parents with high school diplomas) tended 

to have visits that spent more time on parent-development needs with less time 

aimed at child-focused activities. More time spent on child-focused activities was associated with better outcomes in the areas of cognitive and language development 

and increased parental ability to support development. This finding underscores the 

idea that program models must be prepared to tailor services such that the needs 

of children and parents are carefully balanced. Programs that are serving families 

with high needs require staff who are capable of addressing such needs while also 

being able to maintain a strong focus on the child and the parent-child relationship. 

It is also quite possible that these children might benefit from center-based services 

to further enhance development and support families. 

Translating Research into Practice: Recommendations for a New Home Visiting Initiative 

ZERO TO THREE is pleased to see that the Administration and Members of Congress have continued to shine a spotlight on high quality home visiting initiatives. 

As stated earlier, home visiting is an important way to deliver services within a prenatal-to five-system of early childhood development. In considering legislation to 

promote a two-tiered mandatory funding approach to creating and expanding home 

visiting programs in the states, we recommend that the Subcommittee take into account the following recommendations based on the science of early childhood development: 

1. Integrate home visiting programs into a broader state early childhood system 

and infrastructure, and emphasize coordination among home visiting programs. As 

policymakers work to expand access and improve home visiting services for young 

children and their families, they should ensure that services are not established in 

isolation, but are integrated into a broader state early childhood system that incorporates a strategy to reach all vulnerable young children in a coordinated way. Such 

a system should reach children in a variety of settings and include professional development, training, and technical assistance for providers; data collection; program 

standards; and quality assurance and improvement efforts. Thirty-two states are 

currently operating a statewide home visiting program, yet only 18 states link these 

home visiting programs to other supports for early childhood development at the 

state level.9 Representatives of home visiting programs should work with other such 

programs within the state and participate in community and statewide collaborative 

groups to improve the coordination of services for young children and their families 

across agencies and programs, particularly since some programs have been known 

to work better for families with certain risk factors. 

Federal legislation establishing state home visiting programs should ensure that 

such linkages occur by requiring that they be part of the planning and implementation efforts of the State Advisory Councils on Early Childhood Education and Care, 

created by the Improving Head Start for School Readiness Act of 2007, as well as 

other state-specific early childhood oversight boards. Governors should appoint 

home visiting representatives to the Councils. The Councils are tasked with, among 

other things, conducting a periodic statewide needs assessment concerning the quality and availability of early childhood education and development programs; identifying opportunities for, and barriers to, collaboration and coordination among federally-funded and state-funded child development, child care, and early childhood education programs and services; and developing recommendations for increasing the 

overall participation of children in existing early childhood education programs. 

Given their role in coordinating and planning state-level activities for very young 

children, home visiting representatives are a logical fit with the Councils’ activities. 

2. Develop a continuum of care for young children and their families by coordinating home visiting efforts with other child development services in the community. 

No one single home visiting program, by itself, is a silver bullet for all children, all 

families, and all communities. Connecting home visiting efforts, particularly those 

focused on children’s well-being and healthy development, with other child and family services at the community level will help to ensure that young children and parVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00116 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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10Deborah Daro, Home Visitation: Assessing Progress, Managing Expectations. Ounce of Prevention Fund and Chapin Hall Center for Children, 2006, www.chapinhall.org. 11Kay Johnson, State-based Home Visiting: Strengthening Programs through State Leadership. New York, NY: National Center for Children in Poverty, 2009. 

ents have the comprehensive support they need. In instances when parents and children have needs that are not addressed by the home visiting program in which they 

are enrolled, they should be linked to other resources available in their community, 

such as high quality child care programs and comprehensive early childhood programs such as Early Head Start, early intervention programs, health assistance programs, and mental health services. 

3. Ensure that all home visiting initiatives incorporate known elements of effectiveness and use a model appropriate to the needs of the targeted population. There is 

growing consensus on a list of key elements of effective home visiting models that 

are most likely to achieve outcomes for young children and their families. This list 

includes: 

• solid internal consistency that links specific program elements to specific outcomes; • well-trained and competent staff; • high quality supervision that includes observation of the provider and participant; • solid organizational capacity; linkages to other community resources and supports; and • consistent implementation of program components.10

Policymakers should ensure that a new home visiting initiative incorporates these 

key elements focused on effective design and implementation to ensure high quality 

and effective service delivery. Additionally, as services are expanded within states, 

policymakers should ensure that program models are implemented with families 

that exhibit characteristics similar to those for whom the program has been tested. 

Not all families will need the same level or intensity of services. In a review of 

state-based home visiting initiatives, 31 states operating 55 programs reported 

using different approaches for different families, providing more intensive services 

to families with greater risks and needs.11 We must ensure that the most at-risk 

families receive the most intense supports available, while ensuring appropriate 

services for those with fewer risks for poor developmental outcomes. 

4. Support rigorous, ongoing evaluation and continuous improvement efforts for 

home visiting programs. Program evaluation allows home visitors, supervisors, 

funders, families, and policymakers to know whether a program is being implemented as designed and how closely it is meeting objectives. This information can 

be used to continually refine and improve service delivery for young children and 

their families, as well as provide an evidence-based rationale for the expansion of 

home visiting programs. We know, based on research, that many programs and 

models have made a difference in the lives of those most at-risk. We need to continue to build on this research and provide adequate funding to allow promising 

models and strategies the chance to conduct more rigorous research. We must keep 

in mind, however, that not all programs can be delivered under the ideal situations 

in which rigorous evaluations are conducted. Not all populations will look identical 

to those for whom evaluation data was collected and expansion efforts should allow 

for innovation in serving harder to reach populations, including families living in 

rural areas or those who are homeless. When financing home visiting programs, policymakers should ensure that adequate time and funding are included for thorough 

evaluation of existing programs as well as sufficient funding to incentivize the development, expansion, and evaluation of demonstration projects for harder to reach 

families. 

Conclusion 

All young children should be given the opportunity to succeed in school and in 

life just as all parents should receive the support they need to nurture their children’s development. While vulnerable children may have greater challenges to overcome, we should not assume that those challenges can only be addressed with services later in life. Instead, we should invest in a continuum of programs, starting 

from the prenatal period forward, when our investment can have the biggest payoff 

and help prevent problems or delays that become more costly to address as they 

grow older. 

Home visiting is an important strategy in providing services to at-risk infants, 

toddlers, and their families. By investing in programs proven to be effective, and 

integrating those successful programs into a broad range of services that touch the 


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lives of infants, toddlers and their families, we can make great strides in early childhood development and education and lay the foundation for later school success. 

Thank you for your time and for your commitment to our nation’s infants, toddlers and their families. 

WITNESS INFORMATION 

Name: Matthew Melmed 

Title: Executive Director 

Organization: ZERO TO THREE: National Center for Infants, Toddlers and Families 

Washington, DC 

References 

f 

Statement of Nancy Ashley 

I am the Project Director of the Business Partnership for Early Learning (BPEL). 

BPEL is a group of business and philanthropic leaders in King County, Washington 

State that is investing in a home visiting program to close the school achievement 

gap for those children in isolated families that are most likely to arrive at kindergarten with a ‘‘preparedness gap’’ they may never be able to overcome. 

Overview of the Business Partnership for Early Learning 

The Business Partnership for Early Learning is a group of 20 Seattle area businesses that together have invested $4 million into a five year early learning program that is reaching 400 two and three year old disadvantaged Seattle children. 

Among our major investors are the Bill & Melinda Gates Foundation, The Boeing 

Company, Safeco Corporation, Group Health Cooperative, The Seattle Foundation, 

and United Way of King County. 

Why the Business Partnership for Early Learning is Investing in Early 

Learning 

BPEL believe s that investments in early learning have a very high rate of return, 

and can simultaneously help kids and raise workplace productivity. Before investing, the founders of BPEL carefully researched the return on investments in early 

learning and concluded that for them and for the state, it offers the highest return 

of any social investment. 

Why the Business Partnership for Early Learning is Investing in the Parent-Child Program Home Visiting Model 

BPEL investors wanted to demonstrate that an effective intervention could be 

found that would reduce the achievement gap for vulnerable children by identifying 

young children from the most hard-to-reach families and providing the parents with 

the tools, motivation and confidence to get their children ready for school. 

They selected the Parent-Child Home Program because it was designed for highrisk families and it targets the intervention to the parent-child dyad. All home visits 

must take place with the parent and the child together. 

PCHP serves families challenged by poverty, low levels of education, language and 

literacy barriers and other obstacles to educational success. Many of them are isolated both physically and mentally by poverty, lack of transportation, and parental 

stress. 

In addition, the Parent-Child Home Program had 40 years of research and evaluation behind it that confirmed the program’s long-term impact on children who complete the program. The PCHP curriculum is designed to engage parents in nonthreatening, playful activities on a predictable schedule with a trusted, friendly 

Home Visitor. The Program’s approach is both research-based and research-validated: it is an early intervention model, it focuses on early literacy both within a 

social-emotional and cognitive/language development context, and it emphasizes 

both the parental bond and parental responsibility. 

BPEL Project Demonstrates that Home Visiting is a Powerful Strategy for 

School and Life Success 

BPEL provides grants to two nonprofit organizations in King County to deliver 

the Parent-Child Home Program to 160 families a year. The program reaches lowincome families speaking over 15 languages, and brings gifts of books and toys to 

the homes to model how parents can guide their children’s development. A large 

proportion of the families are immigrants and refugees who are unfamiliar with the 

concept that children can learn before they go to school and who do not understand 


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1Panel on Research on Child Abuse and Neglect, Commission on Behavioral and Social 

Sciences and Education, National Research Council (1993). Understanding child abuse and neglect. Washington, D.C.: National Academy Press. 

the role of the parent in preparing a child for school. Many families have no books 

or educational toys in their homes. 

Both nonprofit agencies employ paraprofessional home visitors who speak the languages and reflect the cultures of the families they serve. 

Evaluation of BPEL’s project has concluded that diverse families and children (1) 

can be effectively reached in their homes, (2) the parents can be coached to become 

the child’s first and ongoing teacher, and (3) the children can make substantial cognitive and pre-literacy gains. 

Specific results are shown on the following page, for parents and children who 

completed the two-year program in 2008. 

Expanded Home Visiting Efforts Needed in King County 

Participants in BPEL know that growth in the skill level of our work force has 

declined and that a greater percentage of the future workforce will come from minority populations where levels of educational attainment are lower. These trends 

can be reversed by investing early in the lives of children from those populations, 

via agencies that are trusted and respected by their diverse communities. Research 

indicates that improving the quality of the parenting environment of young disadvantaged children will bring the most powerful results. 

Many families who would benefit greatly from effective home visiting programs 

are not being reached. We have very little state funding to support home visiting, 

as almost all early learning funds now are devoted to the one-third of children who 

are in preschools or licensed child care centers. 

Conclusion 

The Business Partnership for Early Learning is strongly in support of the Committee’s efforts to advance legislation supporting investments in evidence-based 

home visiting programs that enhance early learning and reduce child abuse and neglect. 

BPEL believes that evidence-based home visiting programs are essential to giving 

all young children a fair chance to succeed in school and life, so they can provide 

us with the skilled workforce we need in this global economy. 

Nancy Ashley 

Program Director, Business Partnership for Early Learning 

Seattle, Washington 

f 

Statement of The National Child Abuse Coalition 

The National Child Abuse Coalition, representing a collaboration of national organizations committed to strengthening the federal response to the protection of children and the prevention of child abuse and neglect, supports the introduction of 

H.R. 2667, the Early Support for Families Act, legislation to provide home visitation 

services with mandatory funding available to promote an array of research- and evidence-based home visitation models that enable communities to provide the most 

appropriate services suited to the families needing them. We applaud the leadership 

taken by Chairman Jim McDermott with Representatives Danny Davis and Todd 

Platts to carry forward the initiative proposed by President Obama to create the 

first dedicated federal funding stream for the establishment and expansion of voluntary home visitation programs for low-income parents with young children. 

The most effective strategy for preventing child maltreatment before it occurs is 

to provide new parents with education and support. Home visitation has long been 

identified as an approach that works to prevent the abuse and neglect of children. 

In 1991, the U.S. Advisory Board on Child Abuse and Neglect recommended as the 

highlight of its report, Creating Caring Communities, the establishment of universal 

voluntary home visitor services.1 More than a decade later, the same conclusion was 

drawn by the Centers for Disease Control (CDC) Task Force on Community Preventive Services. Its 2003 report evaluating the effectiveness of strategies for preventing child maltreatment ‘‘recommends early childhood home visitation for preVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00119 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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2 Hahn, Robert A., Ph.D., First Reports Evaluating the Effectiveness of Strategies for Preventing Violence: Early Childhood Home Visitation, Morbidity and Mortality Weekly Report, 

Centers for Disease Control and Prevention (Atlanta, GA, October 3, 2003 / 52(RR14);1–9. 3 U.S. Department of Health and Human Services, Administration on Children, Youth and 

Families. Child Maltreatment 2007 (Washington, DC: U.S. Government Printing Office, 2009). 

U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2007 (Washington, DC: U.S. Government Printing Office, 2009). 

vention of child abuse and neglect in families at risk for maltreatment, including 

disadvantaged populations and families with low-birth weight infants.’’ 2

Voluntary home visitation is an effective and cost-efficient way to ensure that all 

children have the opportunity to grow up healthy, safe, ready to learn and able to 

become productive members of society. Investing in this research-proven approach 

now will mean savings down the road in costs associated with health, education, 

child maltreatment and criminal justice. The McDermott-Davis-Platts bill would 

support rigorously evaluated programs that utilize nurses, social workers, other professionals and paraprofessionals to visit families, especially lower-income families, 

on a voluntary basis. We look forward to adding our collective voice to support this 

initiative as it moves toward enactment in Congress. 

An Imperative for Prevention 

According to the most recent data released in April this year by the U.S. Department of Health and Human Services (HHS),3 over 3 million referrals of possible 

child abuse and neglect cases were made to state child protective services (CPS) 

agencies in the United States in 2007. Close to 2 million of those referrals were accepted by CPS for an investigation or assessment, resulting in some 800,000 children found to be victims of child abuse and neglect. 

Almost one-quarter of those child victims had a history of prior victimization. The 

HHS report says: ‘‘For many victims, the efforts of the CPS system have not been 

successful in preventing subsequent victimization.’’ Indeed, over one-third (37.9 percent) of child victims reported to CPS in 2007 received no services following a substantiated report of maltreatment. The lack of available services, a gap desperately 

in need of attention, leaves children at risk of harm. 

The youngest children continue to suffer the highest rate of victimization. Infants 

from birth to 1 year of age are the most vulnerable victims of abuse and neglect 

at the rate of 21.9 per 1,000 children of the same age group, representing 12 percent 

of all abuse and neglect victims. Nearly 32 percent (31.9%) of all victims of maltreatment were younger than 4 years old. 

Fatalities due to child maltreatment remain high. An estimated 1,760 children 

died in 2007 as a result of abuse or neglect, up from 1,530 in 2006 and 1,460 in 

2005. The rate of child fatalities was 2.35 deaths per 100,000 children, compared 

to a rate of 2.05 deaths per 100,000 children in 2006 and 1.96 in 2005. Again, the 

most endangered are the youngest: more than 40 percent (42.2 percent) of all fatalities were children younger than 1 year and three-quarters of children who were 

killed (75.7 percent) were younger than 4 years of age. 

The incidence of child abuse and neglect is beyond the capacity of our current system of protective and treatment services to be of much help. Our system of treating 

abused and neglected children and offering some help to troubled families after the 

harm has been done is clearly overworked and inadequate to the task. Prevention 

is an imperative and an investment in home visiting services can focus our resources on preventing child abuse from happening in the first place. 

Home visiting programs are often targeted to serve specific groups in a community: families with low-income; young parents; first-time mothers; children at risk 

for abuse or neglect; or low birth weight, premature, disabled, or developmentally 

compromised infants—those children who are most at risk of serious harm, as 

shown by the annual HHS data on child maltreatment reports. 

Home visiting educates families and brings them up-to-date information about 

health, child development, parenting, literacy and school readiness, educational and 

work opportunities, and connects them to critical community services. 

A Cost-Effective Strategy 

Voluntary early childhood home visitation programs offer training to parents designed to enhance the well-being and development of young children by providing 

information on prenatal and infant care, child health and development, parental 

support and training, and referral to other community services, such as day care, 

respite care, and parent support groups. Home visits are conducted by nurses, social 

workers, other professionals or paraprofessionals. 

A growing body of research has found strong evidence that early childhood home 

visitation programs are effective in reducing the incidence of child abuse and neVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00120 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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4Felitti, VJ, Anda, RF, Nordenberg, D, Williamson, DF, Spitz, AM, Edwards, V, Koss, MP, 

& Marks, JS. (1998). The relationship of adult health status to childhood abuse and household 

dysfunction. American Journal of Preventive Medicine, 14, 245–258. 5 C.S. Widom & M.A. Ames (1994). Criminal Consequences of Childhood Sexual Victimization. 

Child Abuse and Neglect. Washington, DC: National Institute of Justice. 6S.R. Morgan (1976). The Battered Child in the Classroom. Journal of Pediatric Psychology. 

7Wang, CT, & Holton, J (2007). Total estimated cost of child abuse and neglect in the United 

States. Chicago, IL: Prevent Child Abuse America. 

glect, and in improving child health and development, parenting skills, and school 

readiness. While a majority of states currently provide early childhood home visitation services to a relatively small number of families, the challenge has been to take 

this proven effective prevention approach to scale. The enactment of the legislation 

proposed here can help to move toward that goal. 

Investing in evidence-based early childhood home visitation is a cost-effective way 

to address a range of issues impacting healthy child development and later success 

in life at annual costs generally averaging $1,500 to $4,000 per family served, depending upon the type of home visiting service offered. The variation in program 

costs depends on such factors as differences in the cost of living in the communities 

being served, the frequency of home visits required for a family, the inclusion of 

evaluation costs in the calculation, and the staffing requirements of the program. 

This modest investment leads to improved outcomes for children and families and 

long-term cost savings related to special education, child welfare, health care, criminal justice, and additional social services. The consequences of child abuse and neglect often continue well into adulthood with life-long effects. Research shows a 

strong correlation between child abuse and neglect and debilitating and chronic 

health consequences, mental health illness, and drug dependency.4 Studies have 

demonstrated the link between childhood victimization and delinquency, criminal 

behavior.5 Research has shown that abused and neglected children are more likely 

to suffer poor prospects for success in school.6

Home visiting programs link families to health care resources and focus on 

healthy outcomes. Through a strong emphasis on prenatal care significant costs associated with pre-term births, and developmental disabilities are reduced. Linking 

families to consistent primary care and immunizations means reduced emergency 

room costs and reduction in chronic illness. 

Current child welfare expenditures are heavily skewed toward spending on foster 

care and adoption subsidies. For every federal dollar spent on out-of-home care, the 

federal government spends just fifteen cents on prevention and child protection. Implementing proven, effective strategies to prevent child abuse and neglect can save 

on the high cost of doing nothing until intervention later is inevitable. According 

to a study conducted by Prevent Child Abuse America,7 the direct costs of child maltreatment for foster care services, hospitalization, mental health treatment, and law 

enforcement amount to more than $33 billion annually. Indirect costs of over $70 

billion include expenditures related to chronic health problems, special education, 

and the criminal justice system as well as loss of productivity—for an expenditure 

of close to $104 billion per year. 

Home visitation programs provide the supports necessary for families to meet the 

needs of their children, to address risk factors for abuse and neglect and educate 

parents to improve their skills while seeking support and guidance. Addressing 

some of the characteristics of parents who are at risk of abusing their children, we 

see that home visitors are there to confront a symptom before it becomes a crisis. 

While no single factor accounts for abusive behavior by parents, in combination, 

these features of troubled families are more likely to create greater risk for harm 

to children. 

• Social isolation: the lack of social supports, the isolation from a community and 

effective support systems, the lack of a social network to set good examples of parenting. The home visitor reduces a family’s sense of isolation through regular visits 

that draw new parents into a sense of community and belonging. 

• Unprepared parents: new mothers and fathers with unrealistic expectations 

about their children and little knowledge about normal child development. The 

home visitor builds parenting skills and works to create better bonds between parents and their children. 

• Characteristics of the child: a premature low birth-weight child, a mentally or 

physically disabled child, or an ill child difficult to nurture, all present difficulties 

to parents coping with a new baby. The home visitor arranges primary medical care, 

so that infants get to the pediatrician for checkups and immunizations. 

• Personal stress and economic difficulties: parents with low self-esteem who are 

vulnerable to stress, parents addicted to alcohol or drugs, families hit by unemployVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00121 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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8Wagner, M.M. & Clayton, S.L. (1999). The Parents as Teachers Program: Results from Two 

Demonstrations. The Future of Children: Home Visiting: Recent Program Evaluations, 9(1), 91– 

115. 9Mitchell-Herzfeld et al. (2005). Evaluation of Healthy Families New York: First year program impacts. Office of Children and Family Services. 10 Berkenes, J.P. (2001), HOPES Healthy Families Iowa FY 2001 Services Report; Klagholz 

& Associates (2000), Healthy Families Montgomery Evaluation Report Year IV; Greene et al. 

(2001), Evaluation Findings of the Healthy Families New York Home Visiting Program; Katzev, 

A., Pratt, C. & McGuigan, W. (2001), Oregon Healthy Start 1999–2000, Status Report. 11Williams, Stern & Associates (2005). Healthy Families Florida Evaluation Report, January 

1, 1999–December 31, 2003. 12Galano & Huntington (1999). Evaluation of the Hampton, Virginia Healthy Families Partnership 1992–1998. Center for Public Policy Research, The Thomas Jefferson Program in Public 

Policy, The College of William and Mary, Williamsburg, VA. Galano et al. (2000). Developing 

and Sustaining a Successful Community Prevention Initiative: The Hampton Healthy Families 

Partnership. Journal of Primary Prevention, 21(4), 495–509.; Mitchell-Herzfeld et al. (2005). 

ment or inadequate housing. The home visitor assures that all families have full access to community agencies that can support families coping with problems and 

stresses. 

Research Supports Positive Outcomes 

Numerous researchers have documented the positive impact of home visitation 

programs on child development, parenting practices, and parent-child relationships. 

The results from a variety of randomized control trials, quasi-experimental evaluations, and implementation studies have shown positive effects in the reduction in 

child maltreatment, improved parenting practices, birth outcomes, and health care. 

Here is a sample. 

• In a randomized control trial, adolescent mothers who received case management services and home visitors were significantly less likely to be subjected to child 

abuse investigations than control group mothers who received neither.8

• A large, randomized control trial found less physical and psychological abuse 

for parents receiving home visitation services than control parents at one year.9

• Families who received home visiting services were found to be more likely to 

have health insurance and a medical home, to seek prenatal and well-child care, 

and to get their children immunized.10 Another study showed that 93% of participating families, children were fully immunized by age two compared to the statewide average of 77%.11

• Babies of parents enrolled prenatally in home visitation services have shown 

fewer birth complications in one randomized control trial and higher birth weights 

in another randomized control trial.12

By providing critically important prevention services to families with young children, home visiting programs make a real difference in families’ lives. We commend 

the sponsors of H.R. 2667 for their leadership in moving forward with ensuring significant support to home visiting programs in service to children and families across 

the country. 

Member Organizations: Alliance for Children and Families, American Academy of 

Pediatrics, American Bar Association, American Humane Association, American Professional Society on the Abuse of Children, American Psychological Association, 

American Public Human Services Association, Association of University Centers on 

Disabilities, CHILD Inc., Child Welfare League of America, Children and Family Futures, Children’s Defense Fund, Every Child Matters Education Fund, Family Violence Prevention Fund, First Focus, First Star, National Alliance of Children’s Trust 

and Prevention Funds, National Association of Children’s Hospitals, National Association of Counsel for Children, National Association of Social Workers, National 

Center for Child Traumatic Stress, National Center for State Courts, National CASA 

Association, National Education Association, National Exchange Club Foundation, 

National Network to End Domestic Violence, National Organization of Sisters of 

Color Ending Sexual Assault, National PTA, National Respite Coalition, Parents 

Anonymous, Prevent Child Abuse America, Stop It Now!, Voices for America’s Children 

f 


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1Stella U. Ogunwole, We the People: American Indians and Alaska Natives in the United 

States, p. 5 (U.S. Census Bureau, February 2006). Available at: http://www.census.gov/population/www/socdemo/race/censr-28.pdf 2 Id. at 15. 

3 Id. 

4 Id. at 12 (finding that more than 25% of American Indian and Native Alaskan people lived 

in poverty, compared to 12.7% of the U.S. population as a whole). 

Statement of the National Indian Child Welfare Association 

Portland, Oregon 

Association on American Indian Affairs 

Rockville, Maryland 

National Congress of American Indians 

Washington, DC 

Submitted to the House Ways and Means Subcommittee on 

Income Security and Family Support 

Regarding H.R. 2667, the Early Support for Families Act 

June 23, 2009 

The National Indian Child Welfare Association, the Association on American Indian Affairs and the National Congress of American Indians jointly submit this 

statement in support of H.R. 2667, the Early Support for Families Act. The voluntary early childhood home visitation programs envisioned by the bill would be an 

important component in building community-based programs whose goal is to help 

keep families intact and strong. We are delighted to see that the provisions of H.R. 

2667 have been included in the House Democratic draft health care reform proposal. 

We appreciate that the bill would provide a guaranteed stream of funding for 

early childhood home visitation programs and would allocate three percent of funds 

for distribution to tribes. The funds would be distributed via formula to tribes who 

submit eligible applications, similar to the distribution of the Social Security Act’s 

Title IV–B (Child Welfare) funds. Some tribes—primarily very small tribes—do not 

apply for IV–B funds because the amount would be so miniscule as to not make the 

application feasible. In those instances the funds are re-allocated among tribes that 

have submitted eligible applications. H.R. 2667 provides for reallocation of unused 

state funds among states; similarly, unused tribal funds should be reallocated 

among eligible tribes. The bill is not clear on this point, and we ask for an amendment that would make it clear that unused tribal funds would be reallocated among 

eligible tribes. 

We also strongly support the provision that authorizes the Secretary, except for 

the application process and eligible use of funds, to modify requirements for tribes. 

This provision represents a good faith effort to try to make the program really work 

for tribal governments who by and large do not have the sources of revenue or economy of scale that states possess. We point out that tribes do not have access to the 

Title XX Social Services Block Grant which states use largely for child welfare purposes. Tribes also receive very little funding under the Child Abuse Prevention and 

Treatment Act, sharing a one percent allocation with migrant programs under one 

discretionary grant program. And not all tribes receive Title IV–B funds, either because the funding is not available to them or the amounts are so small that it 

makes administration of the program unfeasible. 

The voluntary home visitation assistance that would be provided in H.R. 2667 is 

to be geared toward low income families with young children and toward areas 

which are especially at risk for child maltreatment. Indian Country has a young 

population and suffers from the problems attendant with high rates of unemployment and poverty. 

Services geared toward children are particularly important in Native American 

communities, which are younger, on average, than the general population. Statistics 

from the 2000 census confirm that nearly 33 percent of the American Indian and 

Alaskan Native population is below the age of eighteen, compared to a national average of 26 percent.1 Furthermore, the median age of American Indians who live 

on reservations is 25, while the median age of the same population who live elsewhere is 35.2 Similar figures hold true of the Alaska Native demographic.3

Funds directed to programs in Indian Country not only target a population that 

is younger than average, but also target a population that is relatively poorer. 

American Indians and Alaskan Natives are twice as likely to live in poverty as 

members of the general population.4 Children within that population are also more 

likely to face other problems. According to the Administration on Children, Youth 


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5 Administration on Children, Youth and Families, Child Maltreatment Study 2007, p. 25. 

and Families, roughly 14.2 out of every 1000 American Indian or Alaska Native children are victimized or maltreated.5

The funds this bill would make available could be used to establish new programs, 

to strengthen current home visitation programs, or to utilize existing programs. 

There is a major health home visitation program in Indian Country—the Community Health Representative (CHR) program. The program does not provide the services envisioned under H.R. 2667, but is an example of a successful home visitation 

program operating throughout Indian Country. The CHR programs are funded and 

overseen by the Indian Health Service, pursuant to the Indian Health Care Improvement Act (as amended, Public Law 100–713, dated November 23, 1988). This 

program trains community members as health paraprofessionals and provides funding to deliver health services through integrated home visitation programs. These 

services are culturally competent and community-based and offer a model that can 

be helpful in the context of providing in-home services to young children and their 

families as envisioned in this legislation. 

The CHR program illustrates how service providers that value human interaction 

and supportive relationships may yield better results than traditional delivery 

methods. These home visitation programs include a broad range of services, from 

patient care and case management to health education and transportation. Paraprofessionals trained under the CHR program also engage in injury prevention activities and educate patients about best health practices. Though not targeted specifically for children, these programs are proven models that advance self-determination and deliver healthcare services to underserved households who often live 

in very rural, geographically isolated areas where health services in general are not 

always easily accessible. They also raise community awareness of ongoing health 

issues in tribal communities and the steps that are being taken to address them. 

Whether used as a model on which to create a home visitation program or an initial 

foundation from which to build, the success of the CHR program is clear evidence 

that home visitation programs targeting children will be effective in tribal communities. 

While the CHR program holds promise for home visitation programs envisioned 

in H.R. 2667, the legislation specifically identifies the need to use evidence-based 

models, especially those with the strongest evidence of effectiveness. Because research dollars and projects often do not reach Indian Country it would be helpful 

to add a provision that directs the Secretary of DHHS to collaborate and consult 

with tribes and tribal organizations that have experience in this area. They could 

evaluate the inclusion of tribal populations in current home visitation models, assess the ability to adapt existing mainstream models for implementation in tribal 

communities, identify tribal home visitation programs that are working well in Indian Country, and develop recommendations on how to strengthen the development 

and dissemination of tribal home visitation models. Such a provision would help advance the purposes of the bill and ensure that tribal home visitation programs benefit from evidence-based approaches too. 

The home visitation programs envisioned in this bill would benefit American Indian and Alaska Native children and the young family households in which they are 

being raised. As a source of services and education, these programs are tools that 

Native families can use to improve well-being, help prevent child abuse and neglect 

and advance their children’s development. 

We thank Chairman McDermott and the Members of this Subcommittee for their 

active interest in the welfare of children, and look forward to working with you on 

this and related legislation. And we thank you once again for the enactment last 

year of the Fostering Connections to Success Act (PL 110–351) which brought long 

overdue eligibility for tribal governments to administer the Title IV–E Foster Care 

and Adoption Assistance programs. 

If you have questions or comments regarding this testimony, please contact NICWA 

Government Affairs Director, David Simmons at desimmons@nicwa.org or AAIA Executive Director, Jack Trope at jt.aaia@verizon.net. 

f 

Statement of Oneta Templeton McMann 

My name is Oneta Templeton McMann and I am a social work manager in a regional pediatric center. In that capacity, I oversee the operation of two home based 

intervention programs for families with a pregnant women and/or young child. I 

support H.R. 2667 Early Support for Families Act because I see first hand the value 


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of early involvement with families of young children in supporting that parenting 

relationship and thereby expanding the range of opportunities for the children. 

We work with low income, urban families who are struggling to meet their everyday needs; and who, without support, cannot focus on the early parenting and development of newborns and infants. While they possess amazing strengths, those resources must often be directed to keeping the rent paid, the utilities on and food 

enough for all to eat. Without assistance, it is difficult to concentrate on the maternal-infant dyad, building attachment and stimulating cognitive and emotional development. Well child check ups and developmental assessment often give way to survival issues in the families’ priorities. The social work and other staff who partner 

with families in their homes can enhance these parenting relationships and teach 

and model how to incorporate child development strategies into their usual routines. 

While the families with whom we work are financially and environmentally 

stressed, they desire the same positive outcomes for their children and themselves 

as parents that all families desire. With information, modeling, and support families 

can learn to engage in behaviors that promote safety, stability, and stimulation in 

the caregiving relationship. Even when, by necessity, there are disruptions—housing 

instability, community violence, multiple caregivers, parental stress—parents can 

build skills that increase their own parenting capacity, enhance their young child’s 

development, and begin to make the positive parenting role integral to the family’s 

functioning. 

It’s not quick and easy work and cannot be successful in a vacuum. Quality community child care is needed for infants and young children, for many single mothers—and married ones—must work to support their families even when their children are very young. Quality early childhood and pre-kindergarten services are imperative, ones that will link families to their school systems and provide a smooth 

transition to school. As necessary as those services are, the relationships that are 

built in the home at birth and before will be paramount. 

Many times, in our experience, the role models parents have are not adequate. 

They may have been parented largely by older siblings, in multiple extended family 

households, with their own parents compromised by poverty or challenged by mental 

health, substance abuse or other disabling conditions. Some have spent years of 

childhood in foster care, residential placements or other alternative care. To interrupt multi-generational poverty, child abuse, neglectful or absent parenting longterm, intensive work in the home is needed by professionals trained to partner with 

parents to help meet their own emotional and other needs in order to teach them 

how to meet their children’s. 

For parents whose custody of their children has been disrupted by incarceration, 

family violence, foster care, substance abuse or mental illness, these services are 

particularly important and necessary. The parent must feel absence of judgment, 

recognition of their own strengths, willingness to hear them and an intentional desire to partner from the home visiting professional. This is not simply a matter of 

providing information and education. The relationship established enables the parent to assimilate new information, try out new skills, provide honest feedback about 

their attempts and to be offered encouragement to try again when attempts do not 

go well. In a home-based partnership, parents are supported in their own eco-system, recognizing their interpersonal networks, their community values, the barriers 

they must address and the strengths and resources they possess. They are not 

viewed simply as parents, but as individuals within a family system who have many 

roles and responsibilities. And services are provided to address multiple areas in 

their lives so that they can improve the outcomes for their children. 

When I was a first (and second!) time mom, I benefited greatly from the information, support, and demonstration of behaviors to promote my child’s development 

that I received from the parent educator from my local school district. It reduced 

my anxiety, increased my confidence and enhanced my competence as my child’s 

first teacher. In addition to that monthly visit, however, I had access to financial 

resources, paid time off from my employment, support of a spouse and other extended family members and the benefit of living in a safe, affordable home. Many 

of the families our programs see do not have any of those, and the intensity of the 

intervention they need is much greater. 

The two programs I manage are a HRSA Healthy Start subcontract for both 

English speaking and Spanish speaking families and a program formerly supported 

by the Children’s Bureau Abandoned Infants Assistance program for families affected by alcohol and other drug abuse and/or HIV. The families served face multiple challenges and often live in very high risk situations. Home-based contact with 

the family must be frequent, and a comprehensive array of services is needed. Caseloads must be small to build that intense, positive partnership and individualize 

services to each family’s situation. Physical and mental health care, basic needs, hisVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00125 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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tories of family or community violence, housing, and economic stability must all be 

addressed in order for parents to reach their potential in promoting their infants’ 

development. 

So, while this early intervention with high risk families in not without significant 

cost, it is an excellent investment in getting children ready for success in school, 

building stronger families to support ongoing accomplishments, and helping replace 

unhealthy family patterns with positive parenting whose benefits will extend well 

into the future. 

We have research findings available for each of the programs noted here that we 

would be happy to provide for review. We are anxious to help support this legislation in any way possible. Thank you. 

Witness Information: 

Oneta Templeton McMann, LCSW 

Social Work and Community Services Department 

Children’s Mercy Hospitals and Clinics 

f 

Testimony of the Ounce of Prevention Fund 

The Ounce of Prevention Fund applauds the Committee’s progress in achieving 

the vision laid out for young children and families by President Obama. The Ounce 

of Prevention Fund is highly encouraged by this progress, specifically by H.R. 2667, 

the Early Support for Families Act, which would commit a substantial investment 

to home visiting programs in the states. The Ounce of Prevention Fund is committed to advocating for, designing and providing high quality early childhood programs. We believe that high quality programs, including home visiting programs, 

can and do make a real and sustained difference in the lives of vulnerable children 

and families. In order to ensure that this legislation creates a high quality system 

of home visiting programs that meet the needs of the full range of at-risk infants, 

toddlers, and their families, we offer the following comments and suggestions. 

The legislation should include a definition for what constitutes the ‘‘strongest evidence of effectiveness.’’ We recommend the following language, developed by the National Home Visiting Coalition, be adopted in statute to define the ‘‘strongest evidence of effectiveness: 

Have demonstrated significant positive outcomes for children and families consistent with the outcomes being sought (for the populations being served) when evaluated using well-designed and well-conducted rigorous evaluations, including but not 

limited to randomized controlled trials, that provide valid estimates of program impact and demonstrate replicability and generalizability to diverse communities and 

families.’’ 

Again, we are highly encouraged by and supportive of this important legislation 

that would help our most vulnerable children get a chance for a better start in life. 

Please feel free to contact me should you have any questions or need additional information. 

f 

Statement of Parents as Teachers 

Chairman McDermott, Ranking Member Linder, and members of the Subcommittee: 

The National Center for Parents as Teachers appreciates the opportunity to submit written testimony on H.R. 2667, the Early Support for Families Act. We strongly support the framework put forth in the bill: to establish a mandatory federal 

funding stream to support evidence based home visitation programs. We are grateful to Chairman McDermott, Representatives Davis and Platts for sponsoring this 

important legislation. 

Parents as Teachers Background 

Parents as Teachers is an evidence-based, voluntary parent education and family 

support program designed to increase child development and school readiness during the crucial early years of life. Established as a Missouri pilot program in 1981 

to serve 380 families, Parents as Teachers has grown exponentially since that time. 

Through programs operating in every state, Parents as Teachers currently serves 

more than 330,000 children nationally. Since its inception, Parents as Teachers has 

helped millions of American families by providing specialized home visitation services using our research-based curriculum. 


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iDrazen, S., & Haust, M. (1995). The effects of the Parents and Children Together (PACT) 

program on school achievement. Binghamton, NY.; Drazen, S. & Haust, M. (1996). Lasting academic gains from an early home visitation program. Paper presented at the annual meeting of 

the American Psychological Association, August 1996. iiZigler, E., Pfannenstiel, J.C., & Seitz, V. (2008). The Parents as Teachers Program and 

School Success: A Replication and Extension. Journal of Primary Prevention, 29, 103–120. 

The Parents as Teachers curriculum is based on brain development and neuroscience research. The program model consists of four service delivery components: 

personal home visits by a certified parent educator; parent group meetings about 

early childhood development and parenting; developmental, health, vision and hearing screenings for young children; and connections to community networks and resources. 

Parents as Teachers programs serve families with children from before birth up 

to kindergarten-entry age. Our programs deliver services to families of all configurations, including single parents, teen parents, two-parent families, grandparents raising grandchildren, and foster parents. The families we serve deal with a range of 

challenging life circumstances such as poverty, military service, low literacy levels, 

substance abuse, mental health issues, incarceration, English language challenges, 

and unemployment. We work with families regardless of whether they are in their 

first trimester with their first child or are raising multiple children, for example, 

such as a mother in Southeast Missouri with nine children from four different fathers. Three of her children under 5 participate in Parents as Teachers. Because the 

needs of the families we serve vary greatly, the intensity of our services also varies—from a minimum of monthly visits to as frequently as weekly visits. 

Reflecting the rich diversity of the families we serve, the Parents as Teachers 

home visitors (parent educators) also come from varied backgrounds. Our programs 

employ people with backgrounds ranging from early childhood education and social 

work to nursing. In addition, some programs hire experienced paraprofessionals who 

bring invaluable linkages to a local cultural community or language skills that are 

essential to successfully connect with non-English speaking families. Prior to serving families, every parent educator must complete a week-long in-depth training on 

the Parents as Teachers Born to Learn curriculum, demonstrating an understanding of the material with a daily assessment. Within three to six months of this 

initial training, each parent educator goes through an additional day-long follow up 

training to monitor implementation progress and answer any questions. 

Additionally we are expanding our training through distance learning applications 

to further increase our ongoing connection with parent educators in the field. 

Program Implementation 

Parents as Teachers programs thrive in a variety of local settings including school 

districts, Head Start programs, human service agencies, health departments, mental 

health agencies, family resource centers, child care centers and local United Way 

agencies. In some communities the Parents as Teachers program operates as a 

stand-alone entity, but the more common approach is for Parents as Teachers services to be woven into an organization as a core family service delivery component. 

We take pride in the adaptability of our model while maintaining a commitment to 

model fidelity as evidenced by our quality standards. 

Beyond our partnerships with host organizations, we also collaborate with other 

home visiting programs such as Healthy Families America, HIPPY, Parent Child 

Home, Nurse Family Partnership and other programs operating in individual states. 

These local partnerships enhance the services provided to families and further 

strengthen the continuum of care available to families in a particular community. 

Parents as Teachers Research Outcomes 

Parents as Teachers has a long history of independent evaluations demonstrating 

positive outcomes for young children and their families. More than two dozen research reports have been completed that show the Parents as Teachers model produces positive outcomes in terms of school readiness, prevention of child abuse and 

neglect, parental involvement, school success and child health. Included among 

these studies are four randomized control trials and five studies that have been published in peer reviewed journals. A sampling of these research results show that: 

• Parents as Teachers children showed better school readiness at the start of kindergarten, higher reading and math readiness at the end of kindergarten, higher 

kindergarten grades, and fewer remedial education placements in first grade.i

• Participation in Parents as Teachers helps to close the achievement gap between children living in poverty and those from non-poverty households.ii


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iiiWagner, M.M. & Clayton, S.L. (1999). The Parents as Teachers Program: Results from Two 

Demonstrations. The Future of Children: Home Visiting: Recent Program Evaluations, 9(1), 91– 

115. ivPfannenstiel, J., Lambson, T., & Yarnell, V. (1991). Second wave study of the Parents as 

Teachers program. Overland Park, KS: Research & Training Associates. vWagner, M., Iida, E. & Spiker, D. (2001). The multisite evaluation of the Parents as Teachers 

home visiting program: Three-year findings from one community. Menlo Park, CA: SRI International. vi Albritton, S., Klotz, J., & Roberson, T. (2004) The effects of participating in a Parents as 

Teachers program on parental involvement in the learning process at school and in the home. 

E–Journal of Teaching and Learning in Diverse Settings, 1(2), 108–208. http://www.subr.edu/coeducation/ejournal/Albritton%20et%20al.Article.htm. 

• In a randomized trial, adolescent mothers who received case management and 

Parents as Teachers were significantly less likely to be subjected to child abuse investigations than control group mothers who received neither case management nor 

Parents as Teachers.iii

• In another randomized trial, adolescent mothers in an urban community who 

participated in Parents as Teachers scored lower on a child maltreatment precursor 

scale than mothers in the control group. These adolescent mothers showed greater 

improvement in knowledge of discipline, showed more positive involvement with 

children, and organized their home environment in a way more conducive to child 

development.iv

• Children participating in Parents as Teachers were much more likely to be fully 

immunized for their given age, and were less likely to be treated for an injury in 

the previous year.v

• PAT parents were more involved in children’s school activities and engaged 

their children more in home learning activities, especially literacy-related activities.vi

Parents as Teachers embraces research and evaluation of our model not only to 

document effectiveness, but also as the basis for quality improvement. We are particularly supportive of the commitment to research and evaluation included in H.R. 

2667. This set-aside evaluation funding will allow Parents as Teachers, and other 

home visiting programs, to use these evaluation results as an integral part of our 

continuous quality improvement process to enhance our curriculum and training to 

ensure that our materials remain up-to-date and meet the changing needs of the 

families we serve. 

Defining Evidence Based Home Visitation Programs 

Parents as Teachers recognizes the importance of investing public funds in proven, ‘‘evidence-based’’ home visiting programs. However, at present there is no widely 

agreed upon definition of evidence-based home visitation programs in scholarly 

writings, statutes, and regulations. 

Some strong advocates argue that the optimal definition of evidence-based programs should require multiple randomized control trials. While the Parents as 

Teachers research portfolio includes studies that use randomized control designs (as 

described in the previous section of this statement), we believe a definition that relies exclusively on this single approach is potentially counterproductive and can dissuade program innovation. A number of notable scholars, including Dr. Deborah 

Daro who testified before the Subcommittee on June 9th to discuss H.R. 2667, argue 

that while randomized control trials provide insight into a program’s impact on participants under ideal circumstances, this approach does not provide critical information about real world applications in diverse environments. 

We believe the overall quality of home visiting services would improve and associated outcomes for children and families would increase if programs were encouraged 

to select research methodologies designed to measure the outcomes their programs 

were intended to achieve. In addition to randomized control trials, programs could 

also utilize research studies that use quasi experimental designs, including regression discontinuity design which compares two groups separated by a cut-off point 

(such as child’s birthday to enroll in Kindergarten), and the interrupted time series 

method which compares trends in pre-implementation achievement data to post-implementation achievement data. 

Standard of Evidence in H.R. 2667 

Although H.R. 2667 includes language that establishes priority funding for home 

visitation programs with the ‘‘strongest evidence’’ [section (f)(2)], the bill does not 

provide a definition or criteria for what constitutes this strongest level of evidence. 

As a result, we conclude that the administering federal agency will be responsible 

for developing this critically important definition or criteria that will have overVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00128 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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arching implications for implementation of this new federal home visitation program. We therefore encourage Congress to adopt the following definition of programs with the ‘‘strongest evidence’’: 

Have demonstrated significant positive outcomes for children and families consistent with the outcomes being sought (for the populations being served) when evaluated using well-designed and well-conducted rigorous evaluations, including but not 

limited to randomized controlled trials, that provide valid estimates of program impact and demonstrate replicability and generalizability to diverse communities and 

families. 

We believe that this definition provides a rigorous standard that would ensure 

that only proven home visitation programs would be eligible to receive the funds 

outlined in this section. At the same time, this definition would allow states to develop home visitation implementation plans that incorporate one or a combination 

of evidence-based programs that can best meet the needs of families in their state 

and build on existing service infrastructures at the state and local level. 

Conclusion 

We congratulate the Committee for scheduling the hearing on this important proposal and for advancing the Administration’s home visiting initiative in Congress. 

The National Center for Parents as Teachers, along with our programs across the 

country, are enthusiastic about the prospect of a dedicated federal mandatory funding stream of mandatory funds that will allow us to provide quality home visitation 

services to more families and stand ready to work with Congress and the Administration to make this new program a become a reality. 

f 

Statement of Prevent Child Abuse America 

Prevent Child Abuse America and its network of 47 state chapters and over 400 

Healthy Families America program sites thanks the Chairman and the other distinguished members of the U.S. House Committee on Ways and Means Subcommittee 

on Income Security and Family Support for this opportunity to provide the organization’s perspective on the need for a federal investment in early childhood home visitation. In particular, we would like to thank Chairman McDermott, and Representatives Danny Davis and Todd Platts for their leadership on this issue, as most recently demonstrated with their introduction of the Early Support for Families Act 

of 2009 (HR 2667). 

Through this testimony our organization will identify the value of home visiting 

and the positive outcomes that a federal investment will achieve to enhance our nation’s ability to promote healthy early childhood experiences. 

About Prevent Child Abuse America 

Prevent Child Abuse America was founded in 1972 and is the first organization 

in the United States whose sole mission is ‘‘to prevent the abuse and neglect of our 

nation’s children.’’ We undertake our mission by advocating for the full range of 

services needed to promote healthy child development and provide parents with the 

information they need to be the caring and effective parents they want to be. Based 

in Chicago, the National Office and our networks manage over 375 different locally 

based strategies to meet the mission of the organization, including 2,900 home visitation workers, supervisors and program managers who oversee and implement 

Healthy Families America, a voluntary home visitation service. 

The Importance of Fostering Healthy Child Development 

When we invest in healthy child development, we are investing in community and 

economic development, as flourishing children become the foundation of a thriving 

society. Healthy child development starts a chain of events that follow a child into 

adulthood. Unfortunately, children are sometimes exposed to extreme and sustained 

stress like child abuse and neglect, which can be devastating to a child’s development. This toxic stress damages the developing brain and adversely affects an individual’s learning and behavior, as well as increases susceptibility to physical and 

mental illness. 

Research shows a strong correlation between child abuse and neglect and debilitating and chronic health consequences. The Adverse Childhood Experiences Study 

(ACE), conducted by the CDC in collaboration with Kaiser Permanente’s Health Appraisal Clinic in San Diego, found that individuals who experienced child maltreatment were more likely to engage in risky behavior, such as smoking, substance 

abuse and sexual promiscuity, and to suffer from adverse health effects such as obesity and certain chronic diseases. Over 17,000 adults participated in the ACE study, 


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1Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, et al. Relationship of 

Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. 

American Journal of Preventive Medicine 1998;14(4):245–58. 2Springer, K.W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term Physical and Mental 

Health Consequences of Childhood Physical Abuse: Results from a Large Population-based Sample of Men and Women. Child Abuse & Neglect, 31, 517–530. 3 (1) Wang, CT, & Holton, J (2007). Total estimated cost of child abuse and neglect in the 

United States. Chicago, IL: Prevent Child Abuse America. http://www.preventchildabuse.org/ 

aboutlus/medialreleases/pcaalpewleconomiclimpactlstudylfinal.pdf. 4Study designs include 8 randomized control trials and 8 comparison group studies. More information on the studies can be found in the Healthy Families America Table of Evaluations 

at ** www.healthyfamiliesamerica.org/research/index.shtml. 

making it the largest investigation examining the links between child maltreatment 

and later-life health and well-being ever conducted.1 The ACE findings are supported by numerous studies, including a recent population-based survey that collected data from over 2,000 middle-aged men and women in Wisconsin. This study 

found that adults who experienced abuse or neglect during childhood are more likely 

to suffer from negative health consequences as adults including asthma, bronchitis, 

and high blood pressure.2

As ACE and similar studies demonstrate, getting prevention right early is less 

costly to the nation, and to individuals, than trying to fix things later. Prevent Child 

Abuse America estimates that implementing effective policies and strategies to prevent child abuse and neglect can save taxpayers $104 billion per year. The cost of 

not doing so includes more than $33 billion in direct costs for foster care services, 

hospitalization, mental health treatment, and law enforcement. Indirect costs of 

over $70 billion include loss of productivity, as well as expenditures related to 

chronic health problems, special education, and the criminal justice system.3 An 

international study by the United Nations Children’s Fund (UNICEF, February 

2007) placed the United States next to last on child well-being, among the 21 

wealthiest nations in the world. Although only one indicator of child well-being, 

rates of child abuse and neglect are ultimately tied to a nation’s investment in its 

children. 

This is where an investment in home visitation, as contemplated by HR 2667, provides the country with a great opportunity to enhance child development, support 

communities, reduce child abuse and neglect, and ultimately have a profound impact on the health and productivity of future generations. 

Role of Early Childhood Home Visitation 

All expectant parents and parents of newborns have common questions about 

their child’s development. Early childhood home visitation provides a voluntary and 

direct service in which highly trained home visitors can help parents understand, 

recognize and promote age appropriate developmental activities for children; meet 

the emotional and practical needs of their families; and improve parents’ capacity 

to raise successful children. 

Research has shown that voluntary home visitation is an effective and cost-efficient strategy for supporting new parents and connecting them to helpful community resources. Quality early childhood home visitation programs lead to proven, 

positive outcomes for children and families, including improved child health and development, improved parenting practices, improved school readiness, and reductions 

in child abuse and neglect. 

Healthy Families America 

Healthy Families America is Prevent Child Abuse America’s nationally recognized, signature home visitation program. Through Healthy Families America, wellrespected, extensively trained assessment workers and home visitors provide valuable guidance, information and support to help parents be the best parents they can 

be. Healthy Families America focuses on three equally important goals to: 1) promote positive parenting; 2) encourage child health and development; and 3) prevent 

child abuse and neglect. 

A review of 34 studies in 25 states, involving over 230 Healthy Families America 

programs allows us to say with confidence and conviction that the benefits of 

Healthy Families America are proven, significant, and impact a wide range of child 

and family outcomes.4 In particular, Healthy Families America: 

Improves Parenting Attitudes. Healthy Families America families show positive 

changes in their perspectives on parenting roles and responsibilities. 

Increases Knowledge of Child Development. Healthy Families America parents 

learn about infant care and development; including child care, nutrition, and effective positive discipline. 


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5 Eunju Lee, PhD, Susan D. Mitchell-Herzfeld, MA, Ann A. Lowenfels, MPH, Rose Greene, 

MA, Vajeera Dorabawila, PhD, Kimberly A. DuMont, PhD (2009). Reducing Low Birth Weight 

Through Home Visitation: A Randomized Controlled Trial. American Journal of Preventive Medicine, 36, 2,154–160. 6 Rogowski, J. (1998). Cost-effectiveness of Care for Very Low Birth Weight Infants. PEDIATRICS Vol. 102 No. 1 July 1998, pp. 35–43. 7Gomby, D. (2005). Home Visitation in 2005: Outcomes for Children and Parents. Invest in 

Kids Working Paper No. 7. Committee for Economic Development: Invest in Kids Working 

Group. Available at www.ced.org/projects/kids.shtml. 8Stebbins, Helene, & Knitzer, Jane (2007). State Early Childhood Policies: Improving the 

Odds. NY: National Center for Children in Poverty. 

Supports a Quality Home Environment. Healthy Families America parents read 

to their children at early ages, provide appropriate learning materials, and are more 

involved in their child’s activities, all factors associated with positive child development. 

Promotes Positive Parent-Child Interaction. Healthy Families America parents 

demonstrate better communication with, and responsiveness to, their children. This 

interaction is an important factor in social and emotional readiness to enter school. 

Improves Family Health. Healthy Families America improves parents’ access to 

medical services, leading to high rates of well-baby visits and high immunization 

rates, and helps increase breast feeding, which is linked to many benefits for both 

babies and moms. Healthy Families America has also been found to significantly reduce low birthweight deliveries.5 By one estimate, each normal birth that occurs in- stead of a very low birthweight birth saves $59,700 in the first year of care.6

Prevents Child Abuse and Neglect. Healthy Families America has a significant 

impact on preventing child maltreatment, particularly demonstrated in recent randomized control trials. 

In addition to our stewardship of Healthy Families America, Prevent Child Abuse 

America partners with other effective home visiting models working in communities 

across the country to create nurturing environments for children. Our national home 

visiting partners include Home Instruction for Parents of Preschool Youngsters 

(HIPPY USA), the Nurse-Family Partnership, The Parent-Child Home Program, and 

Parents as Teachers. 

Together, we have accepted the responsibility to improve the home visitation field. 

Together, we share research findings and best practices, and together, we work toward common goals, and create areas for cross-program cooperation and learning 

that strengthens the home visit field as a whole, as well as enhances individual programs. At the local level, Healthy Families programs partner with other home visiting models to reach a broader population of families, to ensure that families are 

receiving the home visiting service model best suited to their needs, and to maximize limited resources. 

The Need for Reliable Funding and a Coordinated Approach 

Despite the many proven benefits of home visitation, home visitation services 

across the country struggle with unreliable and unsustainable funding. The current 

patchwork of funding results in a home visitation system that serves only a small 

percentage of families. By one estimate, approximately 400,000 children and families participate in home visitation services each year.7 A report by the National Center for Children in Poverty estimates 42% of young children (more than 10 million 

children in 2005) experience one or more risk factors associated with poor health 

and educational outcomes, and 10% (nearly 2.4 million children) experience three 

or more risk factors.8

The Early Support for Families Act (HR 2667) will address the home visiting 

funding crisis by establishing a new federal mandatory grant program dedicated 

solely to home visitation. HR 2667 authorizes $2 billion over 5 years in grants to 

states to provide evidence-based home visitation services to support families with 

young children and families expecting children. The legislation empowers states to 

fund home visitation services that best suit the needs of their communities, while 

putting important parameters in place to assure quality of services. Programs funded through the new grant must: 

• Adhere to clear evidence-based models of home visitation that have demonstrated significant positive effects on program-determined outcomes; 

• Employ well-trained and competent staff with high quality supervision; 

• Show strong organizational capacity to implement a program; and 

• Establish appropriate linkages to other community resources. 

The flexibility the legislation provides to states is supported by a compelling body 

of research demonstrating the effectiveness of a range of evidence-based models emVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00131 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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ploying a diverse and highly skilled workforce. For example, Healthy Families 

America has documented success, as outlined above, utilizing home visitors who are 

selected based on their personal characteristics, such as the ability to establish a 

trusting relationship, and their educational and experiential background in child 

health and development, child maltreatment, and parenting. HFA home visitors 

typically live in the same communities as participating families and share their language and cultural background. 

The legislation also requires that a state conduct a needs assessment prior to receiving funding to assess the reach and scope of existing early childhood home visitation efforts and identify gaps in services. States would have to provide an annual 

report on their progress in implementing the program. The report would include important indicators to help assess the state’s effectiveness in implementing the program, including the annual cost per family, the outcomes experienced by recipients, 

the training and technical assistance being provided to programs, and the methods 

to determine whether a program is being implemented as designed. 

Recommendations 

HR 2667 sets a strong foundation for a new home visiting program, however opportunities do exist to further strengthen the grant program authorized by the bill. 

Ensuring Quality 

The legislation stipulates that states should prioritize funding home visiting programs that adhere to models with the strongest evidence. States may also direct 

some funding to home visiting programs utilizing models that have not yet achieved 

the strongest level of evidence. We recommend adding more specificity to: 

1. The standards that all programs must meet to qualify for funding; and 

2. The standards that programs must meet to be given priority for funding. 

We are concerned that the overall quality of the services being provided cannot 

be assured without setting standards that all programs must meet. We believe that 

all programs funded under this grant should be home visiting programs that adopt 

and demonstrate fidelity to a clear model that: 

1. Is research-based; 

2. Is grounded in empirically based knowledge related to home visiting and child 

health or child development; 

3. Is linked to program-determined outcomes; 

4. Has comprehensive home visitation program standards, including standardized 

training, ongoing professional development; and high quality supervision; and 

5. Has been in existence for at least three consecutive years prior to the program 

being funded under the Act. 

In addition to meeting the criteria above, we recommend that home visiting models achieve the following research standard in order to be considered a program with 

‘‘the strongest evidence of effectiveness:’’ 

[the model must] Have demonstrated significant positive outcomes for children and 

families consistent with the outcomes being sought (for the populations being served) 

when evaluated using well-designed and well-conducted rigorous evaluations, including but not limited to randomized controlled trials, that provide valid estimates of 

program impact and demonstrate replicability and generalizability to diverse communities and families. 

Improving Coordination 

Home visitation services are most effective when they are linked to other services 

for children and families operating in the state, and when there is coordination 

amongst the various home visiting services provided in the state. We recommend 

strengthening language to ensure greater coordination among the various models of 

early childhood home visitation and between the home visiting programs and the 

broader child-serving community. This can be done by: 

1. Adding an assurance that the state has consulted with all of the state agencies 

that currently support home visiting programs with young children. 

2. Adding criteria that the state develop a plan for coordinating and collaborating 

in the delivery of home visitation services with child care services, health and 

mental health services, income supports, early childhood development services, 

education agencies, and other related services. This might include, where applicable, collaborations with an early childhood coordinating body instituted for 

the purpose of coordinating services and supports for young children and parents. 


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Taking this approach to implementation will lead to a more efficient use of resources and a greater assurance that families are receiving the most appropriate 

and effective home visiting services to meet their needs. This model allows for a 

clear outcome driven national public policy that promotes consistent results and allows states to manage the services in accordance with their specific existing service 

delivery systems, on-going best practices and existing public-private partnerships. 

Conclusion 

Home visitation is an effective, evidence-based, and cost-efficient way to bring 

families and resources together, and help families to make choices that will give 

their children the chance to grow up healthy and ready to learn. While no one piece 

of legislation can prevent child abuse and neglect, we believe that HR 2667 is an 

important step towards ensuring that all children have the opportunity to grow up 

in a safe, healthy, and nurturing environment. The new funding proposed in HR 

2667 does not represent an expenditure, but rather an investment in our children 

and families, and in our future. We look forward to working with members of this 

Subcommittee in moving HR 2667 towards enactment. 

Contact Information: 

James M. Hmurovich, President & CEO, Prevent Child Abuse America 

Bridget Gavaghan, Senior Director of Public Policy, Prevent Child Abuse America 

f 

Statement of Robin Roberts 

To the Honorable Members of the House Ways and Means Committee, 

I am submitting a statement for record concerning the Early Support for Families 

Act. I am so very pleased that the important role parents play in their child’s learning and development is being recognized and supported through this legislation. I 

am the state leader for North Carolina Parents as Teachers Network. Last year we 

served approximately 10,000 children, birth to age five, through supporting parents 

as their child’s first and most influential teacher. This legislation will allow us to 

serve even more families in need of support, thus ensuring North Carolina’s children have the best possible start in life. 

While I support this legislation, there is a concern that I would like to express. 

In the current legislation the language limits the types of family support services 

that will be available to families. I would ask you to consider the following: 

• Incorporate the definition of ‘‘evidence-based’’ proposed by the National Home 

Visiting Coalition. 

Have demonstrated significant positive outcomes for children and families consistent with the outcomes being sought (for the populations being served) when evaluated using well-designed and well-conducted rigorous evaluations, including but not 

limited to randomized controlled trials, that provide valid estimates of program impact and demonstrate replicability and generalizability to diverse communities and 

families. 

Members of the national home visiting coalition steering committee include: Children’s Defense Fund, Child Welfare League of America, Center for Law and Social 

Policy, Fight Crime Invest in Kids, National Child Abuse Coalition, HIPPY USA, 

Parent-Child Home Program, Prevent Child Abuse America/Healthy Families America, Voices for America’s Children and the National Center for Parents as Teachers. 

• Understand that effective home visitors come from a range of backgrounds, including nurses, social workers, and early childhood educators. 

• Build on existing state and local home visiting infrastructures as the federal 

government develops implementation plans for this new initiative. 

• Recognize the range of evidence-based home visiting programs, including Parents as Teachers, that have a long history of providing effective services to diverse families across the country. 

Research has shown that Parents as Teachers programs produce measurable outcomes in a range of areas including school readiness, prevention of abuse and neglect, parental involvement, later school success and child health. The Early Support for Families Act will allow programs such as Parents as Teachers to ensure 

the well-being of our children and will lay the critical foundation for success in 


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1Outcomes from Nurse-Family Partnership include a 48% reduction in child abuse and neglect, 56% reduction in emergency room visits for accidents and poisonings, and a 67% reduction 

in behavioral and intellectual problems for the child at age six. Nurse-Family Partnership. Overview. June 2008. http://www.nursefamilypartnership.org/resources/files/PDF/FactlSheets/ 

NFPlOverview.pdf; Nurse-Family Partnership. Benefits and Costs: A Program with Proven and 

Measurable Results. June 2008. http://www.nursefamilypartnership.org/resources/files/PDF/ 

FactlSheets/NFPlBenefits&Cost.pdf. 2L. Karoly, R. Kilburn & J. Cannon. Early Childhood Interventions: Proven Results, Future 

Promise. (Rand Corporation 2005). 3These communities are Bedford-Stuyvesant, Brownsville, Bushwick, and East New York in 

Brooklyn; East Harlem and Central Harlem in Manhattan; and the South Bronx. 

school and life learning. Thank you for supporting this important piece of legislation 

and your priorities on families and the earliest years for all of our children. 

Sincerely, 

Robin Roberts 

f 

Statement of Stephanie Gendell 

My name is Stephanie Gendell and I am the Associate Executive Director of Policy and Public Affairs at Citizens’ Committee for Children of New York, Inc. (CCC). 

CCC was founded by Eleanor Roosevelt 65 years ago to be a non-profit, independent, 

multi-issue child advocacy organization that blends civic activism and fact-based advocacy. CCC’s mission remains ensuring New York’s children are healthy, housed, 

educated and safe. We are grateful to Congressmen McDermott and Rangel and the 

members of the Subcommittee on Income Security and Family Support of the House 

Ways and Means Committee for holding a hearing on federal funding for early childhood home visiting programs and we appreciate having the opportunity to submit 

testimony. 

We strongly support the Committee’s efforts to secure federal funding for home 

visiting programs, support the McDermott-Davis Early Support for Families Act, 

and agree that it is logical to discuss home visiting programs in the context of 

health care reform. 

Throughout the country, and specifically in New York, it is widely recognized, as 

well as proven, that home visiting programs are cost-effective interventions that 

help to produce good outcomes for children. Specifically, these programs have been 

shown to reduce child abuse and neglect, language delays, emergency room visits 

for accidents and poisonings, arrests of children, and behavioral and intellectual 

problems for children.1 The Rand Corporation has found that there is a $34,148 net 

benefit per family served by Nurse-Family Partnership, equaling a $5.70 return on 

every dollar invested.2 While New York’s typical home visiting programs, such as 

Healthy Families New York and Nurse-Family Partnership, cost approximately 

$4000-$7000 per family, in New York juvenile detention costs $200,000 per child per 

year; foster care costs an average of $36,000 per child per year; and special education costs an average of $22,000 per child per year. Not only are home visiting 

programs cost-effective, but they help produce the outcomes that America’s children 

deserve—to be healthy, housed, educated and safe. 

Both New York State and New York City have been innovative in their approaches to developing home visiting programs and funding streams for these programs, but continued progress has been stymied by budget shortfalls and budget uncertainties. 

The types of programs currently available in New York are varied and differ in 

their intensity, scope and duration. These programs range from 1–2 visits by health 

workers, to three years of visits by nurses or social workers that often begin during 

pregnancy, to Early Head Start programs. While the scope, duration, intensity and 

eligibility differ, all of theses programs have produced improved outcomes for the 

children. 

As part of New York City’s Center on Economic Opportunity (CEO) initiative to 

reduce poverty, the City developed a ‘‘universal’’ newborn home visiting model. In 

7 high risk communities 3 in the City, all new mothers are offered 1–2 visits by a 

health worker. Approximately 15,000 such home visits are conducted each year. 

While the program is voluntary, over half of mothers agree to participate after they 

are either contacted in the hospital upon giving birth or soon afterwards by phone 

or mail. During the home visit the health worker provides information on 

breastfeeding, SIDS/safe sleeping, attachment, smoking cessation and health insurance; screens for potential health or social problems (e.g. post-partum depression, 


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housing instability or domestic violence); and assesses the home environment for 

hazards such as lead paint, missing window guards, or missing smoke/carbon monoxide detectors. In addition, if the family needs a crib, the home visitor will arrange 

for a free crib. 

While this newborn home visiting program is meeting the needs of many families, 

the City is currently unable to provide these services in Queens or Staten Island. 

CCC has long advocated for this program to be truly universal and serve any new 

mother in any of the City’s 52 community districts, but without federal funds it is 

unlikely that the City could support this in the near future. 

New York City, like other counties, has also been paying for more long-term and 

intensive home visiting programs such as Healthy Families and Nurse-Family Partnership. Many of these programs throughout the state are paid for through a state 

matching program whereby the counties pay 35% and the state pays 65%. Due to 

state budget deficits this match has been reduced to 33.7% for the past two state 

fiscal years. In this past budget cycle, the Governor proposed eliminating the state’s 

matching funds for these programs, but luckily the Adopted Budget restored these 

funds. Furthermore, State and City legislatures have identified home visiting programs as cost-effective and proven interventions that improve outcomes for children 

and families so annually they support these community-based programs through 

legislative additions that are therefore in jeopardy during each year’s budget cycle. 

For example, in just the past year, Healthy Families New York has received a 2% 

cut followed by a 6% cut and then threatened with a 25% cut that was ultimately 

not implemented. 

While New York State and New York City elected and appointed officials understand the value of home visiting programs, the budget deficits and negotiations create uncertainty and instability for the community based organizations and agencies 

that provide these invaluable services. Federal support for these programs, such as 

the federal match proposed in the Early Support for Families Act, would bring stability to programs that already exist and enable states and localities to expand the 

services to additional high-needs communities and families. 

In addition to the financial assistance created by a federal investment in home 

visiting programs, the federal commitment will have an invaluable impact on the 

credibility of this cost-effective, proven intervention and thus lead to an extensive 

expansion of home visiting programs—this would undoubtedly improve outcomes for 

the next generation of New Yorkers and Americans. 

Thank you for this opportunity to submit testimony on federal funding for early 

childhood home visiting programs. We look forward to working with Congress and 

the Obama Administration on ensuring all of America’s children are healthy, 

housed, educated and safe. 

f 

Statement of The National Conference of State Legislatures 

The National Conference of State Legislatures (NCSL) applauds your commitment 

to federal funding for early childhood home visitation programs designed to enhance 

the well-being and development of young children. Such programs are particularly 

important during the economic downturn, when they can help mitigate some of the 

consequences of parental stress and lack of resources by supporting parents and 

monitoring the health, safety and development in children’s critical early years. 

NCSL has long supported home visiting programs as a means of improving child 

well-being during their crucial early years. Many years of research demonstrate that 

such programs positively impact childhood development, promote child well-being, 

strengthen the family unit and significantly reduce the incidence of child abuse and 

neglect. 

States have adopted a variety of innovative ways to reach these outcomes. Recognizing this, NCSL believes that federal action in this area should recognize this diversity of approaches and support all types of programs that have proven effectiveness. 


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1 ‘‘A Policy Primer: Quality Pre-Kindergarten,’’ Trust for Early Education, Fall 2004. 

Working together on this critical issue, and maintaining state flexibility in tailoring their home visitation programs to meet local needs, we can move forward to 

improve the lives of America’s children. 

Sincerely, 

Representative Ruth Kagi 

Washington 

Chair, NCSL Human Services and Welfare Committee. 

f 

Statement of The Parent-Child Home Program, Inc. 

The Parent-Child Home Program and its network of 150 community-based sites 

across the country thanks the Chairman and the other distinguished members of 

the U.S. House Committee on Ways and Means Subcommittee on Income Security 

and Family Support for this opportunity to provide testimony on the importance of 

a federal investment in early childhood home visitation. We would like to thank 

Chairman McDermott, and Representatives Danny Davis and Todd Platts for their 

leadership on this issue and for introducing the Early Support for Families Act of 

2009 (HR 2667). 

Through this testimony, The Parent-Child Home Program will highlight the value 

of home visiting for low-income, at-risk families and how a federal investment in 

home visitation services will promote healthy early childhood experiences and enhanced school readiness opportunities for families in need across the country. 

As a nation, we will never achieve our goal of ‘‘No Child Left Behind’’ until we 

have successfully ensured that ‘‘No Child Starts Behind’’. Today, too many families 

in the United States do not receive the early support they need to ensure that their 

children have appropriate and healthy early childhood experiences that will enable 

them to enter school ready to be successful students, Today, too many children enter 

school unprepared both ‘‘academically’’ and social-emotionally. Much of this lack of 

preparation can be ameliorated simply by providing parents the support they need 

to supply their children with a language and literacy-rich environment that includes 

high quality and quantity parent-child interaction. Too many students enter school 

never having seen or held a book, without the basic literacy, language, or social 

emotional skills they need to participate successfully in the classroom. As a result 

their teachers in pre-kindergarten and/or kindergarten have to slow or stop the curriculum they had planned, to help these children catch up. Unfortunately, the data 

shows us that most children who start behind will never catch up. Children who 

do not know their letters when they enter kindergarten are behind in reading at 

the end of kindergarten, at the end of first grade, and are still having trouble reading at the end of fourth grade.1

We also know that preschool is not the sole solution to this lack of readiness. Children arrive in pre-kindergarten not ready just as in the past they arrived in kindergarten not ready. Children are more likely to be ready at any age when they have 

a family that knows what it needs to do to help them get ready. All families want 

their children to be successful, to do well in school and life, but many families do 

not know how to prepare their children for success. If you are not educated yourself, 

did not grow up in the American education system, do not have access to early childhood and parenting support services and/or do not have the means to purchase 

books and educational toys, you may benefit from guidance to help you prepare your 

child for a successful future. You may need support to provide a healthy developmentally appropriate environment to raise your children in and to develop the skills 

to support your child’s growth and development. The Early Support for Families Act 

(H.R. 2667) is designed to do just that by ensuring that families receive the supports 

they need to encourage their children’s healthily development, and prepare their 

children to enter school ready to be successful students and to go on to graduate 

from high school. 

Each of the evidence-based home visiting programs that would be supported by 

this legislation provide services to families that enable them to achieve the outcomes 

outlined in the bill, including prevention of child maltreatment, healthy child development, school readiness and connection to community services. Among the different 

evidence-based home visiting models, different programs may be more focused on 

particular outcomes or a particular target population, and for this reason the ability 

to implement a number of evidence-based programs to meet the needs of their diverse populations is vital to the success of a national home visiting policy. 


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The Parent-Child Home Program is a research-based, research-validated early literacy, school readiness, and parenting education home visiting program developed 

in 1965. For over 40 years, the Program has been serving families challenged by 

poverty, limited education, language and literacy barriers, and other obstacles to 

school readiness and educational success. The Parent-Child Home Program currently serves over 6,500 families through more than 150 local sites in 14 states. 

Many more families could be served in each of these communities, as all of our sites 

have waiting lists at least equal to the number of families they are currently serving. And many more families remain in need of these services in communities across 

the country that have not been able to develop funding streams for this critical early 

childhood support service. 

The Parent-Child Home Program works with a broad range of families whose children are at risk of not receiving the early childhood supports they need to enter 

school prepared to be successful: teen parent families, single parent families, homeless families, immigrant, refugee, and non-native English-speaking families, and 

grandparents raising grandchildren. Working with parents and children in their 

own homes helps families create language-rich home environments and lays the 

foundation for school readiness and parental involvement as parents prepare their 

children to enter school. Parents are able to continue to build their children’s language, literacy, and social-emotional skills after the Program finishes and their children enter school ready to succeed. The Program erases the ‘‘preparation gap’’ and 

prevents the ‘‘achievement gap.’’ 

The funding that would be provided by the Early Support for Families Act is critical to ensuring that quality evidence-based home visiting programs are able to 

reach families in need of services and enable children to enter school ready to be 

successful students. The families reached by home visiting are families that are isolated by poverty and other obstacles. They are not accessing center-based early 

childhood or school readiness services, including the library, play groups, parenting 

workshops, and/or other community-based supports. They do not have transportation or access to transportation to get to these services; the services are not open 

or available when the parents are available to attend; they have language or literacy barriers; and/or they have no money to pay for programs. 

We appreciate this opportunity to provide you with some specific background information on The Parent-Child Home Program to highlight the extent of its evaluation and validation and the depth of the Program’s experience working with high 

needs families across the country. For over 40 years, we have been utilizing home 

visiting to improve outcomes for children and their parents, in particular preparing 

young children and their families to enter school ready to be successful. As a result, 

four decades of research and evaluation demonstrates that Parent-Child Home Program participants in communities throughout the country enter school ready to 

learn and go on to succeed in school. In fact, peer-reviewed research demonstrates 

that program participants go on to graduate from high school at the rates of middleclass children nationally, a 20% higher graduation rate than their socio-economic 

peers nationally and a 30% higher rate than the control group in the study. From 

the first day of school, Program participants perform as well or better than their 

classmates regardless of income level. This research, published in peer-reviewed 

journals, demonstrates not only the immediate, but also the very long-term impacts 

of home visiting. 

Not only do child participants perform better in school, but their parents also become actively involved in their education, as noted by principals and teachers at the 

schools they attend. In addition, the parents go on to make changes in their own 

lives as well, obtaining their GEDs, returning to school, and improving their employment situations. At least 30% of our Home Visitors across the country are parents who were in the Program as parents; for many of them, this is an entry into 

the workforce. All of these changes have significant ramifications for their children’s 

futures. The Parent-Child Home Program proves that when programs are available 

to support parents and children from an early age, delivering services in a way that 

is accessible and meaningful to them, we can ensure that economically and educationally disadvantaged families are able to support their children’s healthy development and prepare their children to enter school ready to be successful. These families will never experience the achievement gap and will attain high levels of academic success. 

The Program’s primary goal is to ensure that all parents have the opportunity to 

be their children’s first and most important teacher and to prepare their children 

to enter school ready to succeed. The Program’s hallmark is its combination of intensiveness and light touch. Each family receives two home visits a week from a 

trained home visitor from their community who models verbal interaction and learning through reading and play. The families receive a carefully-chosen book or eduVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00137 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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2 Bruce Fuller, Sharon L. Kagan, Gretchen L. Caspary, and Christiane A. Gauthier, ‘‘Welfare 

Reform and Child Care Options for Low Income Families,’’ The Future of Children: Children and 

Welfare Reform 12.1 (2002): 97–119. 3 Jeanne Brooks-Gunn, ‘‘Do You Believe in Magic? What We Can Expect From Early Childhood Intervention,’’ Social Policy Report: Giving Child and Youth Development Knowledge Away 

17.1 (2003): 3–14. 4 Brooks-Gunn 3–14. 

5Lev Vygotsky, Mind in Society: The Development of Higher Psychological Processes (Cambridge: MIT Press, 1978). 

cational toy each week so that they may continue quality play and interaction between home visits and long after they have completed the Program. Often the books 

are the first books in the home, not just the first children’s books, and the toys are 

the first puzzles, games or blocks that the child has ever experienced. The materials 

are the tools the parents use to work with their children. The materials ensure that 

when these children enter pre-kindergarten or kindergarten they have experience 

with the materials that teachers expect all children to know. 

Most importantly, the Program is fun for families, demonstrating for parents both 

the joy and the educational value of reading, playing, and talking with their children. Children’s language and early literacy skills progress rapidly, and parents find 

an enormous sense of satisfaction in the progress that comes from their work with 

their children. This combination of fun and the dramatic changes families see in 

their children are the reason that on average 85% of the families who start in the 

Program complete the 2 years. The majority of families who do not complete the 

Program fail to do so because they move to a community where it is not available. 

We know The Parent-Child Home Program is successful because of the changes 

we see in the families and the success the children have when they enter school. 

We also know it is successful because of the positive responses from the local community sponsors, including school districts, family resource centers, community 

health clinics, and many community-based organizations, and from the way the Program is continuing to expand across the country. We see that home visiting is a 

service delivery method that is able to reach families whose children would otherwise show up in pre-K or kindergarten never having held a book, been read a story, 

engaged in a conversation, been encouraged to use their imagination, played a game 

that involves taking turns, or put together a puzzle. 

We also know from over 40 years of practice in the field accompanied by extensive 

research and evaluation that home visiting is a critical and effective way to reach 

immigrant and non-native English-speaking families and ensuring that they have 

access to all the tools they need to ensure their children’s healthy development and 

future success. We have also seen the value of utilizing home visitors who are a language and cultural match for families, and, in making these matches, how welltrained and well-supervised paraprofessional home visitors can be very effective and 

vital to reaching certain difficult to access communities. 

Immigrant and refugee families with young children often do not access early 

childhood or family supports available in the communities where they live.2 In addition, because of language and cultural barriers, they often do not utilize community 

institutions like public libraries, public schools, or community centers. They are not 

familiar with the options for early childhood education for their children and often 

miss accessing center-based programming because they are unaware that it is available or that their children are eligible. Even if they are aware of programs, families 

may not trust the institutions, might not approach them because of language barriers, and may prefer that their children be cared for at home by parents or extended family. These families are often very isolated, particularly from the educational system that their children will soon be entering, and from what they and 

their children need to know before they enter school. Home visiting is an ideal way 

to reach these families as it meets them where they are most comfortable, in their 

own homes, can provide services in their own language and can adjust to their literacy levels. It also can be the most effective service for impacting the home environment in ways that will not only benefit the children’s development and preparation for school but also will support them as they continue on with their education.3

Home visiting as a service delivery method is particularly effective with high risk, 

socially and linguistically isolated families.4 In The Parent-Child Home Program 

model, the Home Visitor’s role is specifically focused on demonstrating ways that 

parents/primary caregivers can use the curricular ‘‘tool’’ of a children’s book or educational toy to interact with their young child to build language and early literacy 

skills. The goal of the home visits is to increase verbal interaction between parent 

and child, as both a cornerstone of early literacy 5 and a way to support and 

strengthen the attachment between parent and child. This approach helps to mitigate potential child abuse/neglect by increasing protective factors in the home, supVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00138 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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6Phyllis Levenstein, Susan Levenstein, and Dianne Oliver, ‘‘First Grade School Readiness of 

Former Child Participants in a South Carolina Replication of the Parent-Child Home Program,’’ 

Journal of Applied Developmental Psychology 23 (2002): 331–353. 

porting the children’s social-emotional growth through appropriate parent-child 

verbal interaction, and preparing children for school success.6 Other outcomes, such 

as the parent pursuing their own educational goals or improving their employment 

or housing situations, often occur as a result of these intensive visits. The Program 

also plays a critical role in connecting families to other programs and support systems as requested by the participating parent, such as referrals for evaluation for 

possible early childhood developmental delays, or connections to GED or ESL programs for adult family members. Local Program sites form partnerships with public 

libraries, introducing families to library services and resources. 

Many Parent-Child Home Program sites have been able to hire home visitors from 

the communities they are serving who speak the languages of the families they are 

serving and come from the same, or similar, cultures. These multi-cultural staffs 

work best when they work as a team, on an ongoing basis, under supervision, sharing their own cultures and helping each other understand the cultural nuances that 

make a difference to the families they are serving. Often the site coordinator or supervisor can best train her staff by seeking guidance and cultural knowledge from 

the home visitors s/he is supervising. Utilizing techniques of reflective supervision 

and relationship-based practice, this information and expertise-sharing can be facilitated over time. 

Matching families and home visitors based on language and/or culture is critical 

to successful outcomes with high-risk families. A language/cultural match of home 

visitor to family helps to overcome the cultural barriers often encountered when 

working with immigrant families. The language match allows home visitors to fully 

understand and communicate with family members. The cultural match enables 

home visitors to understand nuances of behavior and address them, when needed, 

from a common viewpoint. 

VOICES FROM THE FIELD—‘‘In our program, all our home visitors are familiar 

with the cultures they are serving. If somebody else was doing the home visits, I 

could imagine some conflicts—we understand the language and the priorities and 

choices our families have. We know to take things slow and understand that if the 

parents never went to school, they don’t know what sort of help and support to offer 

their children.’’ (Saadia Hamid, Parent-Child Home Program Coordinator, Seattle, 

WA) 

The issue of trust is especially important when providing a home visitor to an immigrant or refugee family, particularly if the family has experienced the trauma of 

political betrayal or war in their home country, or is still going through a period 

of adjustment in a new community in the U.S. The ability to communicate and demonstrate understanding of these issues regarding family history and adjustment is 

key to establishing a foundation of trust. The home visitor must be well-trained and 

well-supervised in home visit strategies, early childhood development, parenting, appropriate expectations, and boundary issues; however, it is the home visitor’s ability 

to communicate with the family, to understand the cultural nuances of the family’s 

behavior and attitudes toward parenting, and to connect with the parent/caregiver 

in a mature, warm, and non-judgmental way, that provides the foundation for trust, 

growth, and change. 

We would just like to share with you a brief anecdote demonstrating the longterm impact of home visiting on the families, and in particular an immigrant family. 

We have been fortunate to have followed program participants through high school 

graduation and beyond and have many wonderful examples of the Program’s impact 

on children’s lives. The long-term success of the Program is clearly depicted by an 

interview that was conducted recently with a program graduate from a New York 

Parent-Child Home Program site, which has been implementing the Program for 

over 35 years. The son of immigrants from Columbia, he noted that of the forty native Spanish-speaking students in his grade, only three went on to college. He observes that all these children went through the same schools, the only difference 

was The Parent-Child Home Program. He says it got him on the right track early; 

he entered school ready to learn and has soared ever since. He still has vivid memories of how confident he felt when he started kindergarten, how the books and toys 

were familiar and how he was the only native-Spanish-speaking child in his class 

who knew the words to London Bridge is Falling Down. For him, the Program was 

a critical bridge to the rest of his education and for his mother it was empowering. 

She went back to school herself, and he noted she regularly would call his teachers 

to tell them to give him more homework because what they had given him was too 

easy. This young man is now a corporate lawyer in New York City, and he is the 


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first Program graduate to serve on The Parent-Child Home Program’s national 

board of directors. His story is both extraordinary and typical of the kinds of success 

parents and children can achieve when home visiting is available to reach them 

where they are most comfortable and help them build the language, literacy, and 

social-emotional skills they need to be successful. 

The Early Support for Families Act (H.R. 2667) will ensure that many more families in need receive home visiting services by establishing a new mandatory federal 

grant program dedicated solely to home visitation. H.R. 2667 authorizes $2 billion 

over 5 years in grants to states to provide evidence-based home visitation services 

to support families with young children and families expecting children. The legislation empowers states to fund those home visitation services that best suit the needs 

of their communities, while putting in place important parameters to assure that 

families receive high quality services. Programs funded through H.R. 2667 must: 

• Adhere to clear evidence-based models of home visitation that have demonstrated significant positive effects on program-determined outcomes; 

• Employ well-trained and competent staff with high quality supervision; 

• Show strong organizational capacity to implement a program; and 

• Establish appropriate linkages to other community resources. 

We strongly support the flexibility the legislation provides to states to select the 

combination of home visiting services most suited to its needs. This flexibility is 

supported by a compelling body of research demonstrating the effectiveness of a 

range of evidence-based models employing a diverse and highly skilled workforce. 

As noted above, The Parent-Child Home Program has documented successful outcomes utilizing home visitors who are selected based on their personal characteristics, such as the ability to establish a trusting relationship, and their educational 

and experiential background in early childhood development and parenting education. Parent-Child Home Program home visitors typically live and/or have previously worked in the same communities as Program families and share the language and cultural background of the families with whom they are working. In addition, The Parent-Child Home Program works with families when their children are 

16-months to 4 years; often reaching families who were not able to access other 

home visiting services or picking up with the literacy, language and school readiness 

focus as other home visiting services are ending. 

Recommendations 

The Early Support for Families Act of 2009, H.R. 2667, establishes a strong foundation for a new home visiting program. We do, however, believe that there are opportunities to further strengthen the grant program authorized by the bill. The legislation calls for states to prioritize home visiting programs that adhere to models 

with the strongest evidence, but also allows states to direct some funding to home 

visiting programs that utilize models that have not yet achieved the strongest level 

of evidence. We support adding more specificity to both the standards that all programs must meet to qualify for funding; and the standards that ‘‘evidence-based’’ 

programs must meet to be given priority for funding. 

In order to ensure the overall quality of the services being provided, we believe 

that legislation should establish standards that all programs must meet. All programs funded under this grant should be home visiting programs that have been 

in existence for at least three consecutive years prior to being funded under the Act, 

and are: 

• Research-based; 

• Grounded in empirically based knowledge related to home visiting and child 

health or child development; 

• Linked to program-determined outcomes; and 

• Serving families based upon comprehensive home visitation program standards, 

including standardized training, ongoing professional development; and high quality 

supervision. 

In addition to meeting the criteria listed above, we recommend that home visiting 

models achieve the following research standard in order to be considered programs 

with ‘‘the strongest evidence of effectiveness:’’ 

[the model must] Have demonstrated significant positive outcomes for children and 

families consistent with the outcomes being sought (for the populations being served) 

when evaluated using well-designed and well-conducted rigorous evaluations, including but not limited to randomized controlled trials, that provide valid estimates of 

program impact and demonstrate replicability and generalizability to diverse communities and families. 


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We are pleased to be part of a national coalition of national home visiting organizations and advocates for early childhood and family support services that have 

been working together for a number of years to achieve federal home visiting legislation and are pleased to support The Early Support for Families Act. 

Thank you for holding this hearing and for introducing The Early Support for 

Families Act which will provide funding to support vital services for children and 

families who would otherwise miss their opportunities to experience healthy development and quality parent-child interaction and to enter school prepared and ready 

to be successful. Thank you for your support for ensuring that all parents struggling 

to help their children succeed receive the support they need to bring parent-child 

interaction, a supportive home environment, healthy development, and the joys of 

reading, playing, learning, and school success into their children’s lives. Providing 

families with high quality, research-validated home visiting services is a critical 

component of successful school readiness, early childhood education, and parent support efforts. It is truly a cost-effective way to ensure that all children and their parents have the opportunity to be successful. 

Thank you for the opportunity to submit testimony. 

The Parent-Child Home Program 

Contact: 

Sarah E. Walzer 

Executive Director 

The Parent-Child Home Program, Inc. 

Garden City, NY 

f 

Statement of The Pew Center on the States 

Pew Center on the States appreciates the opportunity to submit written testimony 

in support of quality, evidence-based home visiting programs. We fully support 

President Obama’s budget recommendation to help states implement, expand and 

establish quality voluntary home visiting models, and commend this Subcommittee 

for convening a panel of experts in order to raise awareness of the major issues surrounding home visitation. Pew would like to recognize Chairman McDermott and 

Representatives Davis (IL), and Platts (PA) for their continued leadership on this 

very important strategy that can help ensure that new and expectant families are 

given the tools that they need to become healthy, productive citizens. 

HIGH-LEVEL OVERVIEW 

Strong families create strong communities. Federal guidance and support can help 

lead, refine and focus state efforts so that state and federal investments in home 

visiting have measurable, positive outcomes. In this testimony we outline recommended principles for establishing a federal evidence-based home visiting policy, 

including: 

1. Rigorous research findings should guide federal home visiting resource allocation. 

2. Federal guidance and federal funding are critical to strengthen and expand evidence-based state home visiting programs. 

3. States should have flexibility to utilize public health insurance as part of home 

visiting finance strategy. 

Below are a description of Pew’s home visiting initiative and federal policy recommendations. 

BACKGROUND: 

The Pew Center on the States Home Visiting Campaign 

Responsible and responsive parenting is not just good for children, it’s good for 

society. Recent research has proven the common sense notion that experiences in 

early childhood—good or bad, starting even before a baby is born—can last a lifetime. Families who create a nurturing, safe and healthy environment endow their 

children with protective factors that set them on a path toward lifelong success. 

Public investments that help strengthen new and expectant families yield long-term 

benefits by eliminating need for costly remedial services associated with poor childhood development. 

The Pew Charitable Trusts applies the power of knowledge to solve today’s most 

challenging problems. The Pew Center on the States, a division of the Pew Charitable Trusts, advances effective policy approaches to critical issues facing states by 

raising issue awareness and advancing effective policy solutions through research, 


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iMiddlebrooks JS and Audage NC ‘‘The Effects of Childhood Stress on Health Across the Lifespan.’’ Centers for Disease Control and Prevention, National Center for Injury Prevention and 

Control (2008). ii National Scientific Council on the Developing Child. ‘‘Excessive Stress Disrupts the Architecture of the Developing Brain. Working Paper No. 3’’ (2005) http://www.developingchild.net/pubs/ 

wp/StresslDisruptslArchitecturelDevelopinglBrain.pdf. (Accessed June 17, 2009). iii Hoffman, S, ‘‘By the Numbers: The Public Costs of Teen Childbearing’’ (2006). National 

Campaign to Prevent Teen and Unplanned Pregnancy. Available online at: http:// 

www.thenationalcampaign.org/resources/reports.aspx#costs. ivLewit, EM., et al, ‘‘The Direct Cost of Low Birth Weight,’’ The Future of Children, 5 (1), 

(1995). http://www.futureofchildren.org/information2826/informationlshow.htm?doclid=79879 

(Accessed June 17, 2009). 

advocacy and technical assistance. Pew’s home visiting campaign, led by Project Director John Schlitt, was created to provide states with an in-depth, data-driven look 

into the urgent need to expand access to quality, evidence-based home visiting programs for new and expectant low-income families. 

In January 2009, Pew launched a national campaign to increase low-income families’ access to quality, proven home visiting programs. This five-year effort includes 

a dual focus on research and advocacy. 

Home Visiting Research Agenda 

In partnership with the Doris Duke Charitable Foundation, we will consider and 

commission research to help policymakers answer critical questions about the ever 

expanding home visiting evidence base. This research will include a 50-state report 

of home visiting policies, programs and funding to be published in 2010 as a baseline for marking states’ progress, and to provide policymakers with an in-depth, 

data-driven look into the urgent need to expand access to quality, research-based 

home visiting programs to low-income families. 

State Policy Advocacy Campaigns 

Simultaneously, Pew will engage in advocacy campaigns in 4–6 states to encourage public investment in proven home visiting services that help low-income parents 

fulfill their role as their child’s first and best teacher. We will prioritize our work 

in states that have committed to assuring expansion of quality home visiting programs to all eligible low-income families. 

The Case for Home Visiting 

Policymakers and other leaders across the country should be concerned about the 

widespread, resonating effects of negative experiences, maltreatment, and neglect in 

childhood. A 2008 report from the Centers for Disease Control and Prevention 

(CDC) states that intense, repeated negative experiences can disrupt early brain development to the point of permanently impairing the nervous and immune systems 

and, in extreme cases, cause the child to develop a smaller brain.i Similarly, researchers from the National Scientific Council on the Developing Child at Harvard 

University have shown that when a child is exposed to intense stress early in life— 

due to abuse, neglect or prolonged lack of nurturing—high levels of hormones produced in the brain can lead to increased chances for cognitive and emotional deficits.ii

Federal, state and local leaders are challenged with addressing the social and financial effects of maltreatment and negative childhood experiences. As they seek to 

build a healthy, productive citizenry, our leaders are increasingly aware of the growing costs of bad outcomes for adolescents and adults—in criminal justice, health 

care, foster care and more—and of the direct relationship between interventions in 

the earliest stages of life and children’s chances of becoming successful adults. 

Child maltreatment and neglect is a serious issue that warrants public attention. 

Both men and women who reported experiencing multiple types of abuse during 

early childhood were more likely to be a part of unintended pregnancies before the 

age of twenty. Children born to teenage mothers have higher health care costs and 

are more likely to become part of the foster care and juvenile justice systems. A report by the National Campaign to Prevent Teen Pregnancy, authored by the chairman of the economics department at the University of Delaware, showed that the 

taxpayers’ tab for teen childbearing in 2006 alone was calculated at over $9 billion.iii

Children born at low birth weight and without health insurance experience dramatically poorer health as adults, a result that is likely to generate significant costs in 

terms of medical care and lower productivity.iv

Low birth weight, child abuse and neglect, school failure and incarceration are 

devastating to families, put a tremendous strain on state budgets and are often preventable. A preponderance of evidence supports the fact that an ounce of prevention 

may be worth much more than a pound of cure. Early intervention is absolutely necVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00142 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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vSee, for example, Sweet, MA and Appelbaum, M ‘‘Is home visiting an effective strategy? A 

meta-analytic review of home visiting programs for families with young children.’’ Child Development 75(5):1435–1456, (2005).; U.S. Department of Health and Human Services. Youth Violence: A Report of the Surgeon General. Washington, DC: Department of Health and Human 

Services, (2001).; Kendrick D, et al. ‘‘Does home visiting improve parenting and the quality of 

the home environment? A systematic review and meta-analysis.’’ Archives of Disease in Childhood, 82(6):443–451. (2000). viKaroly, Lynn A., et al. Investing in Our Children: What We Know and Don’t Know about 

the Costs and Benefits of Early Childhood Interventions. (Santa Monica, CA: RAND, 1998). 

essary if we want to ensure the health, stability, and vitality of our children, our 

families, our communities and our nation. 

Quality, Evidence-Based Home Visiting Works 

Quality evidence-based home visiting programs offer families a social support network that—when properly implemented and matched to family need—can dramatically decrease negative outcomes. Pairing new and expectant families with trained 

professionals to provide parenting information, resources and support during pregnancy and throughout their child’s first three years serves to strengthen parentchild relationships, increase early language and literacy skills and reduce child 

abuse and neglect—significant outcomes that can help ease the strain on state budgets.v Economists have calculated a pay-off of up to $5.70 on each dollar invested in 

the Nurse Family Partnership, a high-quality home visitation program serving atrisk families.vi

That said, not all home visiting efforts are created equal: research shows that 

poorly designed and inconsistently implemented programs will not offer the same 

return on a state’s investment, nor necessarily result in positive outcomes for families. The most significant cost-savings from home visiting occur when low-income 

families are served by proven programs that employ well-trained professional home 

visiting staff. 

DETAILED RECOMMENDATIONS 

Pew believes that public investments in social capital should be backed by strong 

evidence—that is, programs should show evidence of effectiveness supported with 

rigorous, well designed evaluations of program implementation and outcomes. 

Particularly in difficult economic times, when stress on families and state budgets 

is heightened, states can benefit greatly from federal leadership and support in creating and implementing effective home visiting programs. States need support in 

order to set quality standards for home visiting programs, monitor and assess program fidelity and track program resources and outcomes. 

While states will choose to implement home visiting models that best fit their individual needs, they face several universal challenges in attempting to identify and 

support quality, evidence-based home visiting programs. Such challenges provide an 

opportune moment for federal leadership in setting standards for public investment 

in home visiting. 

To determine what warrants substantial public investment in large-scale implementation or program replication, Pew supports prioritized funding to programs 

that have demonstrated positive outcomes with randomized controlled trial or rigorous quasi-experimental design with equivalent comparison groups. While programs with the strongest evidence are best positioned for scaled-up implementation, 

additional support is needed to help promising programs meet the high evidentiary 

standard necessary for large-scale investments. 

The state of Washington, for example, uses evidentiary standards to prioritize 

funding allocations for home visiting programs. The state adopted criteria for assessing home visiting evaluation research on child abuse and neglect prevention outcomes and then established three levels: best, good and promising. This evidencebased approach allows the state to: 

• Prioritize program funding to programs proven to yield the highest return on 

investment; 

• Support research for promising programs with a sound theoretical basis but 

lower evidentiary standards to determine program efficacy; and 

• Continuously monitor programs for quality improvement. 

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

1. Rigorous research findings should guide federal home visiting resource allocation. 


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• Only high-quality, evidence-based home visiting programs will garner significant cost-savings in the future, as well as an improved quality of life for our children. 

• Federal policy should support states in implementing evidence-based programs. 

• Federal policy should establish standards for state evaluations to rigorously assess home visiting child and family outcomes that document program impacts. 

• Priority should be given to models that meet the highest evidentiary standards 

and ensure fidelity in implementation. 

• Federal and state policy should support rigorous evaluation of promising programs that may not fully meet the standard of evidence needed to warrant largescale investments. 

2. Federal guidance and federal funding are critical to strengthen and expand 

state home visiting programs. 

• The federal government should provide states with financial support to 

strengthen and expand effective home visiting. 

• States should be supported in their critical role of ensuring that communities 

implement evidence-based home visiting programs with fidelity. Specifically, federal 

funding should support state infrastructure for: 1) the coordination of home visiting 

policies and resources across state public health, child welfare, and early education 

programming for new and expectant parents; 2) evaluation and monitoring of quality and outcome performance measures; 3) program implementation support; and 4) 

home visiting staff training. 

• A significant secondary outcome of a federal home visiting initiative should be 

to influence the quality of all home visiting services across the states, whether federally funded or not. States can establish uniform quality standards and performance measures for all home visiting programs such as well tested parent education 

curricula, target populations, core process and outcome data elements, staff qualifications, service duration and frequency, training, intake and referral. 

3. States should have flexibility to utilize public health insurance as part of home 

visiting finance strategy. 

• Public health insurance for low-income families should cover home visiting services to help new and expectant families appropriately access medical, mental health 

and dental services, monitor the health and wellbeing of mom and baby, and identify early any potential developmental delays. As federal policymakers look toward 

healthcare reform and modernization, they should include Medicaid and SCHIP provisions that support home visitation as a preventive program. 

Conclusion 

Voluntary evidence-based home visiting programs are proven to strengthen parent-child relationships, increase early language and literacy skills and reduce child 

abuse and neglect—positive outcomes that can help ease the strain on state budgets. 

Pew’s Home Visiting Initiative will advance nonpartisan, pragmatic state policy 

solutions in home visiting. We would be pleased to serve as a resource to your committee as this issue moves forward. We sincerely thank the Subcommittee for the 

opportunity to submit testimony in full support of federal funding for quality voluntary evidence-based home visiting programs. 

f 

Statement of Voices for America’s Children 

Chairman McDermott, Ranking Member Linder and all members of the subcommittee, Voices for America’s Children thanks you for the opportunity to submit 

comments for the June 9th hearing examining proposals to provide federal funding 

for early childhood home visitation programs. This hearing, and the associated legislation, continues the subcommittee’s efforts to ensure that all children are safe, free 

from harm, healthy and able to thrive in their homes and communities. 

Voices for America’s Children (Voices) is a national child advocacy organization 

committed to speaking up for the lives of children at all levels of government. Comprised of 60 multi-issue member organizations across 45 states the Voices network 

seeks the promotion of effective public policies that improve the lives of children at 

the local, state and national level. It is the vision for Voices that all public policies 

must further the positive and healthy development of all children. 

To achieve this vision requires: 

• Equity and Diversity: All children achieve their full potential in a society that 

closes opportunity gaps and recognizes, and values, diversity; 


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1 U.S. Department of Health and Human Services, U.S. Advisory Board on Child Abuse and 

Neglect (1991). Creating caring communities: Blueprint for an effective federal policy for child 

abuse and neglect. Washington, DC: U.S. Government Printing Office. 

• Health: All children receive affordable, comprehensive, high-quality health 

care; 

• School Readiness: All children, and their parents, receive the services and 

supports to enable them to start school prepared for success; 

• School Success: All children have an equal opportunity to attend an adequately and equitably financed public school meeting rigorous academic standards 

aligned with the needs of the 21st Century workforce; 

• Safety: All children are safe in their homes and communities from all forms 

of abuse, neglect, exploitation and violence, avoid risky behaviors, and contribute to 

community well-being; and 

• Economic Stability: All children live in families that can provide for their 

needs and make investment in their future. 

The opportunity of home visiting, and of the Early Support for Families Act, is 

a strong avenue to assist in achieving this vision. 

Voices applauds the efforts of Chairman McDermott, along with committee member Danny Davis and Representative Todd Russell Platts in crafting legislation that 

advances with President Obama’s announced commitment to reach 450,000 families 

with evidence-based home visitation services within the next decade when fully implemented. Representatives Davis and Platts should also be acknowledged for their 

continued efforts and commitment in previous congressional sessions championing 

the Education Begins At Home Act—the precursor to the Early Support for Families 

Act. This bipartisan effort, along with Senators Kit Bond, Patty Murray and former 

Senator Hillary Rodham Clinton served as the galvanizing forces for this new opportunity. 

Voices for America’s Children (Voices) salutes Chairman McDermott, and other 

committee members, for maintaining their commitment in noting that ‘‘more needs 

to be done’’ following the passage of the Fostering Connections to Success and Increasing Adoptions Act (P.L. 110–351) that is now providing permanency options for 

thousands of children currently in foster care. The legislation now pending before 

the subcommittee, The Early Support for Families Act (H.R. 2667) seeks to improve 

the lives of children and families before they are in harm’s way, and allow for optimal development of health and early learning. Voices enthusiastically supports the 

offered legislation for the opportunity of mandatory funding for the establishment, 

or expansion, of high quality evidence-based home visitation programs that will 

make lasting impacts on children, families and communities. 

As the Congress continues efforts to fulfill the president’s goal of ensuring that 

every child enters school ready to succeed, effective home visiting must be a part 

of this picture, though must not be the only component. These supports must be provided in conjunction, and coordination with Head Start and Early Head Start, the 

Child Care Development Block Grant, and high quality Pre-K opportunities for children, and assurances must be made that these programs are funded at levels to dramatically increase outreach and service delivery. 

Home visiting services provided in isolation will not achieve the goal of ensuring 

that every child has a safe start in life and enters school ready to learn. 

Voluntary home visiting provides early education and support to families where 

they are—in their homes and communities—in a non-threatening environment allowing for optimal outcomes. The growth of home visiting services over the past two 

decades is driven through a solid evidence base, and community focus, as an effective early-intervention strategy to enhance child well-being. The president’s initiative, and the offered legislation, begins to follow through on recommendations initially developed by the United States Advisory Board on Child Abuse and Neglect 

in 1991 calling for voluntary, universal home visiting for every family in the country. As part of their findings, the Advisory Board noted that ‘‘no other single intervention has the promise of home visitation.’’ 1

As the Congress undertakes health reform this year, Voices urges all members to 

make children paramount in this debate while acknowledging that child maltreatment is a major public health concern. The Adverse Childhood Experiences Study 

(ACES), with 17,000 participating adults, finds that adults with exposure to adverse 

childhood experiences including abuse, physical or emotional neglect, or household 

dysfunction, are more likely to have negative health outcomes as adults. These outcomes include greater likelihood of alcoholism and illicit drug use, risk for intimate 


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2Felitti, V.J., Anda, R.F., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventative 

Medicine, 14 (4); 245–58. 3 Hahn, R.A. (2003). First reports evaluating the effectiveness of strategies for preventing violence: Early childhood home visitation. Morbidity and Mortality Weekly Report. 52(RR14);1–9. 

Atlanta, GA: Centers for Disease Control and Prevention. 4Middlebrooks, J.S., Audage, N.C., The effects of childhood stress on health across the lifespan. 

Atlanta, GA. Centers for Disease Control and Prevention, National Center for Injury Prevention 

and Control. 5Daro, D. (2009). Home visitation: The cornerstone of effective early intervention. Public testimony provided to the U.S. House Ways and Means Subcommittee on Income Security and Family Support on proposals to provide federal funding for early childhood home visitation programs. June 9, 2009. 6 Ibid. 

7 Administration for Children and Families (2003). Research to practice: Early head start 

home-based services. Washington, DC: Department of Health and Human Services; New York 

University Study on School Readiness of Parent-Child Home Program Participants (2003); Coleman, M., Rowland, B., & Hutchins, B., (1997) Parents-As-Teachers: Policy implications for early 

school intervention. Paper presented at the 1997 annual meeting of the National Council of Family Relations, Crystal City, VA, Nov. 1997. 8 Hevesi, A.G., (2001). Building foundations: Supporting parental involvement in a child’s first 

years. Report from the New York Office of the Comptroller; Lazar, I., Darlington, R., Murray, 

H., et al. (1982). Lasting effects of early education: A report from the consortium for longitudinal 

studies. Monographs of the Society for Research in Child Development, 47, 2/3; Pfannenstiel, J., 

Lambson, T., & Yaarnell, V. (1991). Second wave of the parents as teachers program. Overland 

Park, KS: Research and Training Associates. 9Mitchel-Herzfeld, S., Izzo, C., Green, R., Lee, E. & Lowenfels, A. (2005). Evaluation of 

healthy families New York: First year program impacts. Albany, NY: Office of Child and Family 

Services, Bureau of Evaluation and Research and the Center for Human Services Research, University of Albany. 10 Eunju, L., Mitchell-Herzfeld, S., Lowenfels, A.A., Green, R., et al. (2009). Reducing low birth 

weight through home visitation: A randomized controlled trial. American Journal of Preventative 

Medicine, 36, (2), 154–160; Rogowski, J. (1998). Cost-effectiveness of care for very low birth 

weight infants. PEDIATRICS, 102, 1, 35–43. 11 Hevesi, A.G., (2001). Building foundations: Supporting parental involvement in a child’s 

first years. Report from the New York Office of the Comptroller; Bartik, T.J., (2008). The economic developments of early childhood. Partnership for America’s Economic Success: Washington, DC. 12Wang, C.T. and Holton, J. (2007). Total estimated costs of child abuse and neglect in the 

United States. Chicago, IL: Prevent Child Abuse America. 

partner violence, sexual promiscuity, smoking, suicide attempts and unintended 

pregnancies.2

Investing in home visiting was also recommended by the United States Centers 

for Disease Control and Prevention (CDC) Task Force on Community Prevention 

Services as an effective strategy to combat child maltreatment.3 Just last year, the 

CDC’s National Center for Injury Prevention and Control cited home visiting as an 

effective strategy for the prevention of adverse childhood experiences.4

The evidence surrounding the effectiveness of home visiting services continues to 

grow since the initial Advisory Board report was released in 1991. Analysis of home 

visiting programs have shown less occurrence of child maltreatment, family engagement in positive parenting practices for optimal child development, and stable, nurturing environments for children.5

Longitudinal studies of programs also demonstrate a reduction in later adverse 

experiences for children including juvenile crime delinquency and substance abuse 

use, as well as improvements in school performance and increased graduation 

rates.6 Other studies show that participating children demonstrate improved early 

literacy, language development, problem solving, social awareness and competence, 

and basic skill development.7

Home visiting services also demonstrate cost savings across a number of social 

factors. Significant savings are found through reduced Medicaid expenditures, reduction in the need for special education services,8 stronger birth outcomes 9 and reduction in low birth-weight babies,10 and substantial increased work potential.11

Analysis from Prevent Child Abuse America estimates that the combined direct 

and indirect costs of child maltreatment alone exceed $104 billion each year. This 

includes more than $33 billion in direct costs associated with foster care, hospitalization, mental health services and law enforcement. Another $70 billion is 

spent each year for indirect costs including the loss of work productivity, chronic 

health problems, special education, and involvement within the criminal justice system.12 For every federal dollar spent for children in out of home care, a meager 15 

cents of federal supports is focused on child maltreatment prevention and protection. With the current federal child welfare financing system providing little in opVerDate Nov 24 2008 10:45 Dec 28, 2009 Jkt 052502 PO 00000 Frm 00146 Fmt 6633 Sfmt 6621 C:\SAVES\BJ\52502.XXX JEFF PsN: 52502

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portunities to provide primary prevention activities, and with greater supports only 

available only after a child is removed, the opportunity for states to access the proposed supports included within the Early Support for Families Act will serve as the 

greatest mandatory investment in child abuse prevention services in federal history. 

Voices supports provisions within the Early Support for Families Act that will 

provide up to $2 billion of mandatory funding when fully implemented. These funds, 

to be administered through the creation of a new Title IV–B, Subpart 3, would provide state-based grants for the expansion, or establishment of evidence-based home 

visitation programs following the completion of a statewide needs assessment. 

As efforts to adopt the legislation advance through Congress, potentially as part 

of the health reform debate, Voices hopes that the funding for programs determined 

to meet the ‘‘strongest evidence of effectiveness’’ are determined through those programs who have continued to demonstrate significant positive outcomes for children 

and families that are consistent with the outcomes being sought as measured 

through findings of well-designed rigorous evaluations. In order to maintain the development of high-quality programs, Voices also hopes that those programs seeking 

federal supports meet, at a minimum, core requirements related to prenatal health 

or positive child healthy development, promote appropriate social emotional development, enhance school readiness and academic success, increase family stability or 

economic stability, lead to reductions in child maltreatment or involvement within 

the juvenile justice system, or other demonstrated outcomes that improves a child’s 

well-being. 

These programs should also ensure that ongoing, organized training and professional development is provided for employees, and that the models themselves are 

continually seeking to improve program delivery. 

To achieve the president’s commitment of promoting to the highest available 

standard for the programs involved, Voices also hopes that efforts are made that 

allow continued training and technical assistance are available via the Department 

of Health and Human Services to assist states in their implementation efforts. 

Voices also seeks a set aside of federal monies to assist states in their ongoing program development and evaluation of funded programs. 

On behalf of child advocates across the county, and the children and families we 

speak for, Voices again applauds the efforts to date to establish a new federal program dedicated for high quality home visitation programs with associated mandatory funding. Voices looks forward to working with the committee, and all members 

of congress, to ensure adoption of this critically important legislation. Please let us 

know if we may be of any assistance in this endeavor. 

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Prepared Fight Crime 


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Prepared Sharon Sprinkle 


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