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Jennifer Klein's Files
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Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
America's Vital Interest in
62
Global Health
AMERICA'S
VITAL
INTEREST
IN
GLOBAL
HEALTH
-
02/05/96 MON 28 FAX 617 565 4260
PUBLIC HEALTH REPORTS
001
Larry Gostin 202-662-9409
How addressed? Where it goes?
cover nore - Judeth Areen, Pat. King
Public Health Reports
rgn
OURNAL OF THE U.S. PUBLIC HEALTH'S ER VICE
Public Health Reports:
Room 1875
JFK Federal Building
Boston, MA 02203
617 565-1440
617 565-4260 (fax)
<[email protected]>
5 February 1996
To: Carol Rasco and Jennifer Klein
by telefax: 202 456-2878 11 pages
From: Anthony Robbins, MD, Editor
Subject: Parental Schooling and Children's Health, an article to appear this
week in Public Health Reports.
Sara Rosenbaum suggested that I fax you two this article that will appear this
week in Public Health Reports, the journal of the US Public Health Service.
Sara and I thought that both the President and the First Lady would be
interested in these results.
If you need more information or I can help in any way, please let me know.
Tony
02/05/96 MON 16 30 FAX 617 565 4260
PUBLIC HEALTH REPORTS
002
SYNOPSIS
NEARLY ONE IN every four children in the United States is
lower educational standards and the tendency of more
bom to a mother who has not finished high school, and more
advantaged women to have children later than less advan-
than one in eight is reared by such a mother during the criti-
taged women.
cal preschool period. Large-scale studies show that the health
The education system and community organizations must
and welfare of children are linked to the education level of
provide young people who are not doing well in school with
their parents, with parent education often being a stronger
positive alternatives to low-education, high-risk parenthood.
predictor of child well-being than family income, single par-
Health care providers should be proactive, teaching parents
enthood, or family size. Higher parent education levels make
with few resources how best to promote their children's
it more likely that children will receive adequate medical care
growth and development. The changing global economy
and that their daily environments will be protected and
makes it more important than ever that current and future
responsive to their needs. Average parent education levels
generations of children be reared by parents who have ade-
have risen over the last 30 years, but progress has slowed
quate skills and training to be competent members of society
because of high rates of immigration from countries with
and effective and responsible parents.
Parental Schooling
PHOTO BY RICK FALCO © 1995/BLACK STAR
34: Public Health Reports
lanira
/February
Volume, 111
02/05/96 MON 16:32 FAX 617 565 4260
PUBLIC HEALTH REPORTS
003
Children at Risk
Nicholas Zill, PhD
immunization, there have been resurgences in measles,
whooping cough, and other infectious diseases. No progress
has been made over the last decade in reducing the number
espite heartening advances in some areas
of low-birthweight babies or the proportion born to moth-
D
of child health over the last three
ers who did not receive timely prenatal care¹.
decades, there has been a troubling lack
What is the greatest obstacle to improving the health
of progress or even retrogression in other
status of children in the United States? Some would say it is
areas. Death rates for infants and young
persistent and increasing economic inequality in American
children have declined dramatically, but
society, which brings with it high rates of child poverty and
those for teenagers and young adults are almost the same as
less than adequate health care for many youngsters². Some
they were 30 years ago. Youthful deaths due to homicide
would cite family breakdown, noting the million and a half
and suicide have been increasing. Childhood diseases that
children whose lives are affected by parental separation and
were common in the 1950s and 1960s-diphtheria, Ger-
divorce each year and the 1.2 million who are born each year
man measles, mumps, polio-have been eradicated or
to unmarried mothers3-6. Others would point to the detri-
greatly reduced in frequency, but because of inadequate
mental effects on children of environmental pollution⁷ or of
& Children's Health
PHOTO BY RICK FALCO © 1995/BLACK STAR
January/Feb uary
plume III
ch Reports
35
02/05/96 MON 16:34 FAX 617 565 4260
PUBLIC HEALTH REPORTS
004
Children at Risk
the interconnected epidemics of drug
abuse, violence, and AIDSᵃ.9. Still oth-
Figure 1. Percentage of births within each ethnic group that are to
ers would mention the need for further
mothers with less than 12 years of schooling, U.S., 1993.
advances in basic biomedical knowl-
edge, especially regarding the genetic
Mexican
origins of many childhood disorders.
Central American
Puerto Rican
The Demographics
American Indian
Black
All of these claims have merit. But
U.S. TOTAL
there is another childhood risk factor-
Hawalian
one that has received far less public
Cuban
attention than any of those mentioned
Chinese
above-that may be a greater threat to
White non-Hispanic
children's health and well-being. That
Filipino
factor is the substantial minority of U.S.
Japanese
children who are born to or raised by
parents with low levels of formal educa-
tion. In 1993, 23.3% of all births in the
0
10
20
30
40
50
60
70
Percent
U.S. were to mothers who had less than
12 years of schooling¹⁰. Some of these
Source: Ventura, S.J., " al.; Advance report of final natality statistics, 1993. Monthly Vital Statistics Report
mothers go on to finish high school or
44: Tables 10-11 (1995).
get GEDs by the time their infants are
Twenty-three percent of all births in the United States in 1993 were to mothers with
ready to start school. Nonetheless, in
less than 12 years of schooling. The proportion of children born to these mothers
1993, 13% of all 4-year-old preschoolers
varies greatly across ethnic groups, with the highest rates found among Hispanic
in the U.S. were being cared for by
groups. Many Hispanic parents are recent immigrants from countries where educa-
mothers who had not finished high
tional opportunities are more limited than in this country.
school or earned equivalency di-
plomas¹¹. Thus, nearly one in every four children in the U.S.
Ethnic differences. Birth certificate data show that the
is born to a mother who has not finished high school, and
proportion of children born to mothers with low levels of
more than one in eight is reared by such a mother during
education differs greatly across ethnic subgroups of the U.S.
the critical preschool period.
population. The highest rates are found among Hispanic
Parent
education is
linked to
children's
economic
well-being,
their social
development
and emotional
well-being,
and their
physical
health.
PHOTO BY RICHARD HUTCHINGS © PHOTOEDIT
36 Public Health Reports
January/February 1996
Volume III
02/05/96 MON 16:35 FAX 617 565 4260
PUBLIC HEALTH REPORTS
005
Children at Risk
American groups (Figure 1), partly because many Hispanic
emotional well-being, and their physical health. For exam-
parents are recent immigrants from countries where educa-
ple, a recent study of a nationwide sample of 2,000 4-year-
tional opportunities are more limited than in the United
olds who had not yet attended kindergarten found 12% to
States. Overall, 53% of Hispanic women in the United
be in less than very good or excellent health. Among
States who gave birth in 1993 had less than a high school
preschoolers whose mothers had a high school diploma or
education. The percentage of births in 1993 to mothers with
more education, the proportion in less than optimal health
less than a high school education was twice as high among
was 9%, while among those whose mothers did not have a
African American women-30%-as among non-Hispanic
high school diploma or equivalency certificate, the propor-
white women-14%. Rates for the major Asian American
tion was three times greater, 28% (Figure 2). Low maternal
groups were generally lower than the national average¹⁰.
education continued to be associated with suboptimal
Although births to Hispanic women comprised 16% of
preschooler health status when additional risk factors-such
all births in the U.S. in 1993, they accounted for 38% of the
as family poverty and single parenthood-and other child
births to women with less than 12 years
of education. White non-Hispanic
women accounted for 37% of low-edu-
Figure 2. Developmental accomplishments and difficulties of 4-year-old
cation births, and black women, 20%¹⁰.
preschoolers, by mother's education, 1993
Not just teen mothers. Women who
Identifies colors
have less than a high school education
by name
when they give birth are younger, on
Recognizes
average, than more educated mothers.
most letters
But not all-or even most-are
Counts to 20
teenagers. Overall, 36% of the 916,388
or higher
births in the United States in 1993 to
Very restless.
fidgets a lot
mothers with less than 12 years of
schooling were to women in their teens.
Very short
attention span
Thirty-one percent were to women ages
Less than high school
Often has
20 to 24, and 33% were to women ages
High school or GED
cemper tantrums
25 and older. However, the majority of
Health less
births to older mothers with low levels
than very good
of education were second or higher-
order births; i.e., they were subsequent
0
20
40
60
80
100
births to women who began having
Percent
children in their teens or early 20s.
Two-thirds of first births to low-educa-
Source: Zill. N., Collins, M., West, J.. and Germino-Hauken, E.; Approaching kindergarten: A look at
preschoolers in the United States, U.S. Department of Education, National Center for Education Statistics,
tion mothers occurred in the teen
Washington, DC (1995).
years¹².
Among African American women,
Compared to preschoolers whose parents have more schooling, 4-year-olds whose
the majority of mothers with less than a
mothers have not completed high school are three times more likely to be in less
than optimal health. They are less likely to display signs of emerging literacy and
high school education-51%-were
numeracy and are more likely to exhibit short attention spans and behaviors that
teenagers. Roughly one-quarter (23%)
can create problems when children reach kindergarten and first grade.
were women ages 25 and over. Among
births to white women with less than 12 years of schooling,
and family characteristics-such as sex, race, Hispanic ori-
one-third were to teenagers and 35% were to women ages
gin, and family size-were controlled by means of multiple
25 and over¹⁰.
regression analyses¹¹.
The national study of preschoolers also found that 4-
The Link Between Parent Education and
year-olds whose mothers had not finished high school were
Child Well-Being
less likely than other 4-year-olds to display signs of emerg-
ing literacy and numeracy and more likely to exhibit short
A number of large-scale studies have found evidence
attention spans, extreme restlessness, and other behaviors
that the health and welfare of children are linked to the edu-
that can create problems when children get to kindergarten
cation level of their parents. Of the various aspects of child
or first grade (Figure 2). For example, only 33% of the chil-
development and well-being, parent education is associated
dren whose mothers had not finished high school could rec-
most closely with cognitive development and academic
ognize most letters of the alphabet, while 61% of the other
achievement. But parent education is also linked to chil-
four-year-olds could do so. Also, 38% of the children whose
dren's economic well-being, their social development and
mothers had not finished high school were reported to have
January/February 1996
Volume III
Public Health Reports 37
02/05/96 MON 16:36 FAX 617 565 4260
PUBLIC HEALTH REPORTS
006
Children at Risk
short attention spans in contrast to 21% of the other 4-year-
for those whose parents had had some college education—
olds. Again, limited maternal education was associated with
14%. Parent education was a stronger predictor of grade
lower literacy and higher problem behavior in preschoolers
repetition than poverty status, ethnicity, coming from a sin-
when other risk factors and child and family characteristics
gle-parent family, or family size¹⁴.
were controlled in multiple regression analyses¹¹.
In the National Adult Literacy Survey conducted by the
Other studies of school-aged children, have found the
National Center for Education Statistics in 1992, young
connection between parent education and child well-being
adults ages 20-29 whose parents had dropped out of high
is often stronger than the association between family
school were twice as likely-34% versus 14%-to have
income and child well-being. For example, the research
received less than a high school education themselves, com-
organization Child Trends prepared a special set of tabula-
pared to young adults whose parents did get a high school
tions from the 1976 National Survey of Children (a study of
diploma or GED (Figure 3). Young adults whose parents
2301 children ages 7 to 11) for the 1981 report of the Select
had some postsecondary schooling or a college degree were
Panel for the Promotion of Child Health¹³. For seven of
even less likely to have dropped out of high school-11%
nine well-being measures (vocabulary test score, school per-
and 4%, respectively. Adults whose parents had less than a
high school education were two
to three times more likely than
Figure 3. Educational attainment of young adults ages 20-29 by
the offspring of high school grad-
uates to score in the lowest cate-
educational attainment of their parents, U.S., 1992
gory in the tests of functional lit-
Parents' educational
eracy that were administered as
attainment:
Educational attainment of
part of the survey. Such low
Grade school only
young adults
scores meant that they lacked the
Less than high school
High school or GED
skills to function effectively as cit-
Some high school
Some college or more
izens and consumers in modern
society15.
High school or GED
Parent Education and
Some college
Children's Health
College graduate
The link between parent edu-
cation and children's health status
is at least partly explained by
0
20
40
60
80
Percent
findings that higher parent edu-
cation makes it more likely that
children will receive adequate
Source: National Center for Education Statistics: Unpublished data from the 1992 National Adult Literacy
Survey, Table 2.56P. Educational Testing Service, Princeton, NJ (1995).
medical care and that their daily
environments will be protected
Young adults whose parents were high school dropouts are twice as likely not to finish high
and responsive to their needs.
school themselves as those whose parents did get a high school diploma or GED. Young
Analyses of data from the
adults whose parents had some college education or a college degree are even less likely to
1975-76 National Health Inter-
become dropouts.
view Survey prepared by Mary
Grace Kovar showed that children
formance ratings, a practical skills index, child-reported
of better educated mothers were more likely to receive med-
misbehavior, child's feelings of rejection by parents and
ical or dental care than children of mothers with little edu-
rejection by peers, and the child's level of fears and worries),
cation, regardless of the family's income or whether the
parental education was a stronger predictor than family
child lived with a mother only. A child with a poorly edu-
income.
cated mother in a middle-income family was no more likely
Having low-education parents substantially increases
to have received medical and dental care than a child with a
the chances that a young person will experience academic
poorly educated mother in a low-income family¹³.¹⁶.
difficulties by the time he or she reaches adolescence. The
Similar results were found a decade later in the 1988
1988 National Health Interview Survey on Child Health,
National Health Interview Survey on Child Health. Thirty-
for example, found that one-third of young people ages 7 to
one percent of children of parents with less than a high
17 whose parents had not finished high school had to repeat
school education had not seen a dentist in two years, while
a grade in school. This rate was two-thirds higher than the
only 19% of children of high school graduates (including
grade repetition rate for young people whose parents had
those who had had some college) and 10% of children of
finished high school-20%-and twice as high as the rate
college graduates had not seen a dentist in two years (Figure
38 Public Health Reports
January/February 1996
Volume III
02/05/96 MON 16:37 FAX 617 565 4260
PUBLIC HEALTH REPORTS
007
Children at Risk
4). A multivariate analysis found parent education a
determinant and exerted an independent effect after income
stronger predictor of a child's receiving dental care than
and welfare and poverty status were controlled¹⁷.
income, welfare or poverty status, parents' marital situation,
family size, or race¹⁷.
Health-related aspects of the child's daily environment.
The same survey found that 19% of children whose par-
In terms of child health, parent education seems to make
ents had less than a high school education lacked a regular
the greatest difference with respect to health-related aspects
source of routine medical care, as opposed to 8% of children
of the child's daily environment. Mothers and fathers with
whose parents had more education. They were also more
higher levels of education may be more likely to practice
than twice as likely not to have a regular provider for sick
good health habits themselves and to take precautions to
care (37% versus 16%). Multivariate analyses showed that
insure that their children's surroundings are safe and sup-
family income and welfare or poverty status were significant
portive. For example, the 1988 National Survey on Child
predictors of children having no regular providers of routine
Health (NHIS-CH) found that 58% of children whose par-
care or sick care. But parent education was also a significant
ents had not completed high school lived with a smoker in
The research findings do not support the contention that parent
education level is just a surrogate for other measures of social
class or socioeconomic status.
PHOTO BY ROB NELSON © 1990/BLACK STAR
January/February 1996
Volume III
Public Health Reports 39
02/05/96 MON 16:40 FAX 617 565 4260
PUBLIC HEALTH REPORTS
008
Children at Risk
their household, compared to 49% of those whose parents
other demographic or socioeconomic characteristics of the
were high school graduates (including those who had had
family17.
some college), and 23% of those whose parents were college
Many of the health problems that affect today's children
graduates (Figure 4). Parent education was a more impor-
stem from or are exacerbated by high-risk behaviors on the
tant determinant of parental smoking than region, urban-
part of parents. Several kinds of adult behavior that can have
rural residence, welfare or poverty status, family income,
detrimental effects on the health and development of chil-
marital status, or ethnicity¹⁷.
dren have been found to be more common among high
school noncompleters than among par-
ents with more schooling. These
Figure 4. Percentage of children younger than 18 with selected
include inadequate supervision that
health risks, by parent education level, 1988
leads to unintentional child injuries¹⁸,¹⁹,
Living with adult
harsh punishment²⁰, failure to get chil-
smoker in household
dren immunized²¹, and parental alcohol
Total
or drug abuse²²,²³. Sexual activity with-
Less than high school
out consistent contraception is also
High school graduate
more common among school
Some college
dropouts24. Such unprotected sexual
College graduate
activity may be hazardous for the off-
Graduate school
spring because of the spread of sexually
Rarely or never uses
seat belt
transmitted diseases or the birth of sib-
Total
lings who are too closely spaced for the
optimal development of each²⁴.²⁵.
Less than high school
High school graduate
Some college
Implications for Public Health
College graduate
Programs for Children
Graduate school
No dental visit in
Many observers believe that low fam-
lost two years
(children ages 3-17)
ily income and lack of resources are the
key factors behind disparities in child
Total
health status across ethnic and income
Less than high school
groups. The results of the research sum-
High school graduate
Some college
marized above do not support this view.
College graduate
Observed
Nor do the research findings support
Graduate school
Adjusted
the contention that parent education
level is just a surrogate for other mea-
0
20
40
60
80
sures of social class or socioeconomic
Percent
status. To be sure, parents who lack a
high school education are less likely to
Source: Colro, M.J., Zill, N., and Bloom, B.; Health of our nation's children; United States, 1988 (DHHS
be steadily employed than those with
Pub. No. 95-1519), Hyattsville, MD (December 1994).
higher educational attainments and,
Nearly 60% of children whose parents did not finish high school have an adult smoker
when employed, earn substantially
in their household. Half rarely or never use seatbelts when riding in a car, and nearly
lower wages and have fewer benefits.
a third have not been to the dentist in two years or more. Children of more edu-
But parent education has been found to
cated parents are more likely to have healthful daily environments and adequate
health care. This is true even when family income and other related factors are
have an independent effect on the qual-
controlled (adjusted percentages).
ity of children's daily environment and
on their medical care and health status
after income, welfare and poverty status,
Another finding of the 1988 NHIS-CH was that the
race and ethnicity, and marital status are controlled.
use of seatbelts or child restraints varied substantially by
These findings indicate that it is not just a lack of finan-
parent education level (Figure 4). The proportion of chil-
cial resources, or ethnic discrimination, that are at work in
dren who rarely or never wore seatbelts was 51% among
impeding progress and producing group differences in chil-
those whose parents had not completed high school, 32%
dren's health status. Rather, they suggest that lack of knowl-
among those whose parents were high school graduates
edge and unhealthful parental attitudes and behavior pat-
(including those with some college), and 17% among those
terns, among other factors, are contributing to the elevated
whose parents were college graduates. Again, parent educa-
rates' of childhood illness and injury that are observed
tion was a more important determinant of seatbelt use than
among young people from disadvantaged groups and areas.
40 Public Health Reports
January/February 1996
Volume III
02/05/96 MON 16:41 FAX 617 565 4260
PUBLIC HEALTH REPORTS
009
Children at Risk
PHOTO BY MARK RICHARDS c /PHOTOEDIT
Acknowledging this is not "blaming the victim" but recog-
nantly those with low test scores and grades, who are disen-
nizing a reality that must be changed if children's health is
gaged from school or in active conflict with parents, teach-
to be improved.
ers, or school authorities²⁷.²⁸. As journalist Hedrick Smith
Part of the reason why parent education is often a better
has stated, in most American high schools there are two
predictor than family income of medical care use and chil-
tracks, the track to college and the track to nowhere²⁹. Most
dren's health status is that public programs such as Medic-
school-age parents are on the track to nowhere. Improving
aid, food stamps, and WIC have succeeded in making med-
both curricular and extracurricular programs for the so-
ical care and adequate nutrition available to most young
called "forgotten half" of students, namely those who are
people from low-income families. Poverty in the United
not college bound, is not only essential for strengthening the
States for the most part is not like poverty in Bangladesh or
future labor force and making the U.S. more competitive in
Ethiopia; à total lack of medical care and extreme malnutri-
the global economy. It is also likely to reduce the number of
tion are thankfully quite rare in this country, although,
babies born to low-education parents³⁰,³¹.
unfortunately, not unheard of. If child health and nutrition
programs were to be abolished or severely curtailed, the rel-
Continued schooling for low-education parents. Even if
ative importance of economic and educational factors as
vigorous preventive efforts are mounted, significant, though
determinants of ill health in children might well be
hopefully reduced, numbers of children will be born in the
altered²⁶.
forsecable future to teenagers and adults who have not com-
pleted high school. These parents should of course have
Providing alternative pathways. Girls and boys who
opportunities to obtain more education, either immediately
become parents while they are still of school age are not a
after the birth of their children or later. But women and
random subset of all young people, or even of young people
men with less than a high school education are far less likely
from disadvantaged backgrounds. Rather, they are predomi-
to get additional job-related training or other forms of adult
January/February 1996
Volume III
Public Health Reports
41
02/05/96
MON
16
43
FAX
617
565
4260
PUBLIC HEALTH REPORTS
010
Children at Risk
education than those who have completed high school or
to 35 years. Disadvantaged groups will contribute more than
attended college³².
their proportionate share to the child population. This dis-
New approaches to raising the functional literacy levels
parity in the intergenerational interval exists within virtually
of adults with limited education are called for, especially
all ethnic segments of the population³⁸. Thus postponing
approaches that tie instruction to the real-life challenges
parenting continues to be a choice of the economically well
and demands that these adults are facing every day. It makes
off, regardless of ethnicity.
little sense simply to offer more of the same to individuals
Our rapidly changing economy is affording less and less
who have not done well in regular school and often hate
in the way of gainful employment opportunities to young
school. There is a growing body of evidence from welfare-
women and men with low skills and limited educational
to-work evaluation studies that first getting a welfare
attainments³. From the standpoint of economic rationality,
mother into a job and then providing basic skills education
these changing conditions should be making it less likely
or job-related training works better than the reverse
that these adults will become parents; it is getting harder
sequence³³. It also seems logical to blend basic skills educa-
and harder for them to support a family. Ironically, though,
tion with instruction in childrearing for new parents who
the changing economy is probably making it more likely
have a lot to learn in both areas³⁴. Unfortunately, demon-
that young adults with low skills will become parents
stration programs that have provided comprehensive educa-
because they have so few attractive alternatives to parent-
tion and social services to disadvantaged young mothers and
hood as a way of gaining some measure of adult status and
their children have thus far produced only modest
societal respect.
results³⁵,³⁶.
The rapid and profound changes occurring in the global
Education programs for school-age mothers and fathers
economy may make it harder to change both the lives of
must be designed to function in ways that do not inadver-
children born to parents with less than a high school degree
tently condone or even encourage parenthood. It is not
and the likelihood that at-risk individuals choose parent-
helpful to deterrence efforts for school systems to offer little
hood over education. The education system and community
to those who are doing the right thing (in this case, not hav-
organizations must provide young people who are not doing
ing sex or at least not getting pregnant) and then to lavish
well in school with positive alternatives to low-education,
special attention and services on those who have gone astray.
high-risk parenthood. Health care providers should be
Continuing education for low-education parents should
proactive, teaching parents with few resources how best to
come with some stipulations, one of them being that the
promote their children's growth and development by struc-
people involved are taking specific steps to avoid getting
turing a healthier and more suitable home environment,
pregnant (or making someone pregnant) again.
obtaining immunizations and other preventive care, and
using sick care services appropriately. The changing global
Progress Made; Progress Yet to Be Made
economy makes it all the more important that current and
future generations of children be given the best possible
Striking changes have occurred in the United States
chance to develop in healthy and productive ways. That
over the last half century as the average years of schooling
means, first of all, being reared by mothers and fathers who
rose among all young adults. During the last 30 years, edu-
have adequate skills and training to be competent members
cational expectations and opportunities have increased,
of modern society and effective and responsible parents.
especially for girls and young women, for both men and
women from minority groups, and for those from low-
Dr. Zill is Vice President and Director of the Child and
income families. However, the pace of progress has been
Family Study Area at Westat, Inc., in Rockville, MD, and a
slower in the last decade than in prior decades¹⁷.
member of the National Committee on Vital and Health
The current high rates of legal and illegal immigration
Statistics.
from less developed countries with lower educational stan-
dards is one of the factors that statistically increases the
Tearsheet requests to Nicholas Zill, PhD, Westat, Inc., 1650 Research
number of births attributable to mothers with less than a
Boulevard, Rockville, MD 20850; tel. 301-294-4470; fax 301-294-
high school diploma.
3992; e-mail <[email protected]>.
Another societal change is the increased tendency of
women who are performing well academically and have
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January/February 1996
Volume 111
Public Health Reports 43
National Association of
Children's Hospitals
and Related Institutions
NACHRI April 24, 1997
Ms. Pauline Abernathy
Office of The First Lady
The White House
Washington, DC 20500
Dear Pauline:
Just a short note to thank you again for your assistance in the Prescription for
Reading event and the early childhood development conference.
I hope you were pleased with both events and the complimentary news
coverage. We certainly thought both initiatives were a huge success, and I
greatly appreciated your efforts to include us.
One way we are promoting both early reading and the importance of
supporting young children is through the enclosed publication, Healthy
Children in Healthy Families, being released this week. It features successful
parent and family support programs operating nationwide at children's
hospitals, including Reach Out and Read (see page 17). This publication may
be helpful to you in identifying sites or programs that Mrs. Clinton or other
administration officials might want to visit in their travels or highlight in
speeches.
Please let us know if there are other ways NACHRI can be of assistance. We
look forward to continuing to work with you. And again, thank you for all your
assistance and support to date.
Sincerely,
Lisa M. Tate
Vice President, Public Affairs
Enclosure
P.S. Would it be possible to get the invitation list, with addresses, from the child
development conference? We'd like to distribute this publication to those leaders.
401 Wvthe Street, Alexandria, VA 22314
(703) 684-1355 Fax (703) 684-1589
Healthy
children in
healthy families
Improving child health by
supporting parents
NACHRI
National Association:of
Children's Hospitals
and Related Institutions
Published by
National Association of Children's Hospitals and Related Institutions
401 Wythe Street, Alexandria, Virginia 22314
ph: 703/684-1355
fax: 703/684-1589
Copies of this publication are available from NACHRI for $10 (includes
shipping and handling).
This document may be reprinted in part or entirely with acknowledgment
to the National Association of Children's Hospitals and Related
Institutions, Healthy Children in Healthy Families.
National Association of
LAWRENCE A. McANDREWS, FACHE
Children's Hospitals
President & Chief Executive Officer
and Related Institutions
NACHRI
April 1997
Dear Colleague:
In recognition of Child Abuse Prevention Month, NACHRI is pleased to release Healthy
Children in Healthy Families: Improving Child Health by Supporting Parents.
There has been unprecedented attention paid recently to the importance of the early years of
life and how experiences during this period-both good and bad-have a decisive and
lasting effect on a child's later development. We also know the critical role that parents play
in this process.
The programs outlined in this report espouse the recommendations of the seminal 1994
Carnegie Corporation report, Starting Points: Meeting the Needs of Our Youngest Children, which
stressed that when men and women are prepared for the opportunities and responsibilities of
parenthood, they are more likely to provide the care and create the conditions that promote
healthy child development. Specifically, this report profiles programs that:
Expand education about parenthood in health care settings, schools and communities,
including programs that reach out to employed parents and adolescent parents, as well as
those that educate young people before they become parents.
Offer home visiting services to disadvantaged families, including programs that work
with poor, drug-affected, and other highly vulnerable families.
Create family and child centers to provide services and support to families, including
programs that offer integrated health, educational and social services.
Few jobs are more vital to the well-being of children and society as a whole than being a
parent; yet few jobs are undertaken with so little solid information and training. Much of the
parent training in years past was conducted informally among large extended families and
close-knit communities, however these resources are no longer within the reach of many
Americans. As health care providers and advocates for children and families, we can and
should fill this void.
I hope this report inspires you to develop parent support and training programs or improve
upon your existing efforts. My best wishes for all your health promotion efforts in 1997.
Sincerely,
Laurence Oa. andrews
Lawrence A. McAndrews
401 Wythe Street, Alexandria, VA 22314
(703) 684-1355 Fax (703) 684-1589
Contents
Facts about America's children and families
1
Expanding education about parenthood in health care
settings, schools and communities
M.A.L.E.S.-Detroit, Michigan
7
Young Fathers Program-Columbus, Ohio
9
The Parenting Place-Pittsburgh, Pennsylvania
11
Parent Warmline-Minneapolis, Minnesota
13
Partners With Parents-Milwaukee, Wisconsin
15
Reach Out and Read
17
Young Moms Program-Johnson City, Tennessee
19
Offering home visiting services to disadvantaged
families
Healthy Families America
25
Healthy Connections-Boston, Massachusetts
29
Parent Aide Program-San Diego, California
31
Family Network-Boston, Massachusetts
33
H.I.P.P.Y.-Little Rock, Arkansas
35
Creating family and child centers to provide services
and support to families
Family Care Connection-Pittsburgh, Pennsylvania
39
The Parenting Center-New Orleans, Louisiana
43
Decker Family Development Center-Akron, Ohio
47
Resources
51
iii
Facts about
America's children
and families
Facts about America's children
and families
More than half of all infants and toddlers (56 percent) have mothers in
the workforce full or part time.
Nearly a third of infants and toddlers in two-parent families (31
percent) have parents who both work full time at paying jobs.
In a recent Commonwealth Fund survey, more than half of all parents
report that they would like to spend more time with their children.
Employed parents feel this tension most strongly; eight out of 10 parents
who work full time wish for more time with their children.
A national insurance research survey estimated that in 1992 American
businesses and their employees paid $5.6 billion through their health
benefits for unhealthy birth outcomes of mothers and infants.
Each year, teenage girls give birth to nearly 500,000 babies. Today 3.3
million children live with adolescent mothers.
One in four infants and toddlers under the age of three-nearly 3
million children-lives in a family with an income below the federal
poverty level.
The United States now leads the world in fatherless households. In
1960, 17 percent of American children lived apart from their fathers; in
1996 the figure was 40 percent.
There were an estimated 2.8 million cases of child abuse and neglect
reported in the United States in 1993, up from 1.4 million cases in 1986.
Almost 60 percent of the pregnancies in the United States are
unintentional, either mistimed or unwanted altogether.
Children born to mothers who have less than 12 years of education
have a fourfold increased risk of mental retardation.
For every $1 spent on prevention, $2 are saved in costs associated with
treating and managing the consequences of child abuse and neglect.
Healthy Children in Healthy Families
3
Expanding education
about parenthood in
health care settings,
schools and communities
M.A.L.E.S.-Men Are Living
Examples of Strength
Abstract
Contact information
M.A.L.E.S. is a school-based curriculum designed to teach 12- to 14-year-
old boys the responsibilities of fatherhood and reduce the future
M.A.L.E.S.-Men Are Living
Examples of Strength
incidence of child abuse and neglect. The program was founded at Spain
Children's Hospital of Michigan
Middle School in Detroit. Since the school population is primarily African
3901 Beaubien Boulevard
American, a culturally sensitive approach was developed for
Detroit, MI 48201-2196
implementing the curriculum.
Contact:
History
David Allasio, M.S.W.
In Detroit, as in most U.S. cities, there are few educational programs to
Child Protection Team Coordinator
prepare boys for responsible parenting, according to a recent Michigan
(313) 993-7106
conference on fatherhood. Most child abuse is perpetrated by men, and
many children with social and emotional problems reside in families with
uninvolved fathers. In response, the Children's Hospital of Michigan
developed the M.A.L.E.S. curriculum to inform boys about the realities of
fatherhood before they become sexually active.
Target population
The program is geared to seventh and eighth grade African-American
boys at a middle school adjacent to the hospital.
Program design and features
The 16-week curriculum is presented in 50-minute sessions to groups of
15 to 20 boys who are selected by their teachers. The M.A.L.E.S. program
coordinator recruits professional men-all of whom are actively involved
with their children-to present on various subjects (see box). The
teaching approach is highly interactive and the subject matter is
presented through group exercises, role play, music and video. The
format encourages the presenters to serve as role models to these young
men.
Community partner
Detroit Public Schools
Budget and funding sources
The salary of the part-time program coordinator and related
administrative expenses (approximately $800) are included in the hospital
social work department budget.
Evaluation and outcomes
The boys are given a pre- and post-program test. Among the six groups that
have completed the curriculum, results indicate improved understanding of the
Healthy Children in Healthy Families
7
Subject matter
subject matter. Both teachers and students report a high
regard for the program.
The image of fathers in society
Definition of male strength
Lessons learned and advice to others
Male and female sexuality
Present the curriculum in a manner that appreciates the
Relationships
socio-cultural characteristics of the group to gain
Goal setting
credibility and acceptance of the program among the
Planning for responsible fatherhood
students.
Developmental needs of small children
Child abuse prevention/non-violent discipline
Next steps
Financial needs of children
Pursue grant funding to expand the program to other
Spirituality and fatherhood
Detroit middle schools.
Develop a program for seventh and eighth grade
girls on the role of the father and how adult parents
can support each other.
Replicability
The program is replicable at children's hospitals or other organizations
that work closely with schools. The M.A.L.E.S. program materials are
available upon request.
8
Healthy Children in Healthy Families
Young Fathers Program
Abstract
Contact information
The Young Fathers Program is a case management and educational
program that promotes fathers' early and consistent involvement in their
Young Fathers Program
Children's Hospital
children's lives.
700 Children's Drive
Columbus, OH 43205
History
For many years, the Children's Hospital of Columbus has offered clinical
Contact:
and educational services to teen mothers and their children. In response
Charles Campbell, MSW, LSW
to the growing body of literature showing negative outcomes for children
Program Coordinator
with uninvolved fathers-namely school failure, persistent poverty and
(614) 722-2452
increased likelihood of incarceration-the hospital proposed a program
to address the needs of young fathers and promote responsible
parenting. This program was launched in 1995.
Target population
The program is open to fathers age 15 to 24 residing in Columbus, with
priority given to fathers whose infants are cared for in the hospital's teen
parent clinic and home visiting program.
Program design and features
Through a combination of individual counseling, peer support groups
and case management, the program offers the following services:
Positive role modeling
Educational and employment assistance
Child development and parenting education
Relationship and family guidance
Life skills training
Sexual responsibility instruction and family planning services
Referrals to substance abuse treatment services
Community partners
Columbus Private Industry Council and temporary employment
agencies, for job training and employment assistance
Columbus Public School's teen parent program, area hospitals and
prenatal clinics, for client recruitment
Columbus Council on Alcoholism, for substance abuse treatment
Franklin County Child Support Enforcement Agency, for paternity
establishment
Budget and funding sources
The program is funded through a $50,000 grant from the Columbus
Foundation. Program expenses include salaries for the coordinator and
Healthy Children in Healthy Families
9
Objectives for participants
secretary, staff and client transportation costs and
related program expenses.
To provide financial and emotional support for their
children
Evaluation and outcomes
To play a visible role in their children's lives
In the past year, participating fathers have
To establish official paternity
demonstrated improved financial support for their
To complete education and/or vocational training
children and parenting knowledge, and more regular
To secure employment
visitation with their children. More than two-thirds of
To prevent repeat pregnancies
participating fathers are involved in school, vocational
training or work and there have been no reported
subsequent pregnancies.
Lessons learned and advice to others
Don't expect instant receptivity. This is not an easy population to
engage and establishing trust can take considerable time because these
young men are often skeptical of programs offering assistance.
Don't limit your program to a young age group. If your funding source
permits, make your program available to older fathers as well.
Use welfare reform to make the case for this service. The new federal
law will increase the demand for programs aimed at improving fathers'
financial support of their children. Establishing a Young Fathers Program
could be a hospital's proactive response to the potential negative effects
of the new welfare reform law.
Next steps
The hospital recently hired a coordinator for all community adolescent
services, including the Young Fathers program, teen parent clinic and
home visiting program, to integrate programming and fund-raising efforts.
Replicability
The program is best replicated at children's hospitals and other
institutions that offer services to teen mothers and/or have strong ties to
prenatal programs.
10 Healthy Children in Healthy Families
The Parenting Place
Abstract
Contact information
The Parenting Place is an educational program that promotes positive
discipline and effective communication skills for parents.
The Parenting Place
Children's Hospital of Pittsburgh
One Children's Place
History
3705 Fifth Avenue
In 1990 the National Center on Child Abuse and Neglect (NCCAN)
Pittsburgh, PA 15213
awarded the Children's Hospital of Pittsburgh a $70,000 grant to create an
educational program to decrease parents' physical punishment of
Contact:
children. The grant was one of nine programs that were funded
Jim Bozigar
nationwide. A $100,000 grant from the Children's Trust Fund of
Coordinator of Community Relations
Pennsylvania in 1992 expanded the program to serve 300 percent more
(412) 692-8665
parents.
Target population
The program is open to all parents in Allegheny County-the hospital's
primary service area-as well as four surrounding counties.
Program design and features
The Parenting Place uses trained community volunteers to present a
parent education curriculum developed by the hospital. Because
volunteer instructors interact with class participants in the communities in
which they live and work, parents often view the instructors as local
resources whom they may approach with questions about parenting
issues. A 12-hour volunteer training is offered twice a year.
The parenting course consists of six presentations addressing self-
esteem for children and their parents, discipline, effective listening,
communication and sibling rivalry. An optional presentation is available
on communicating with children about human sexuality and substance
abuse prevention. Program staff is also developing new curricula about
parenting teenagers and children with special health care needs.
The Parenting Place has two full-time staff members-a curriculum
development coordinator and a volunteer coordinator. In addition to their
regular duties, Parenting Place staff are frequently asked to give radio
and TV interviews on child development and parenting topics.
Community partners
To expand the reach of the program, the Parenting Place collaborates
with local libraries, schools, religious organizations, health centers,
YMCAs and work places, which serve as host sites for the classes.
Healthy Children in Healthy Families
11
Budget and funding sources
The annual budget for the program is $110,000, which is derived from
participant fees and grants from the local Presbyterian Church (which
funds child care during parenting classes), Allegheny County Children
and Youth Services, local school districts (which use federal "drug free
schools" funding) and the American Foresters Association.
Evaluation and outcomes
A pre- and post-program test measurement has indicated a statistically
significant drop in parents' use of corporal punishment as a discipline
technique. The Parenting Place has trained 140 volunteer instructors and
presented the parenting course to over 6,000 parents. The program has
been presented at more than 200 locations in Western Pennsylvania.
Lessons learned and advice to others
Always charge a fee for your parent education course. Paying even a
nominal fee will improve the likelihood that parents will remain in the
program until completion of the course.
Recognize that parents' behavioral and developmental concerns about
their children are universal. The techniques you recommend for dealing
with these concerns will not change significantly among different socio-
economic groups.
Next steps
Secure corporate underwriting for the program.
Replicate the program at area hospitals.
Replicability
Staff are available to train other children's hospitals in the use of the
Parenting Place curriculum.
12 Healthy Children in Healthy Families
Parent Warmline
Abstract
Contact information
The Parent Warmline is a telephone consultation service that provides
Parent Warmline
support, encouragement, practical advice and resource referral to parents
Children's Health Care
of young children who have questions about their child's development or
2525 Chicago Avenue South
behavior.
Minneapolis, MN 55404
History
Contact:
The Parent Warmline was created in 1987 in response to the many calls
Linnea Grey, M.S.
received by various hospital departments related to child development
Program Coordinator
issues. At that time, nurse advice lines and triage services were available
(612) 813-6160
in the Minneapolis/St. Paul area, but there was no central telephone
consultation service for behavioral and developmental concerns. Using a
model presented at the Chicago-based Family Resource Coalition, the
manager of the hospital's primary care clinic, along with a pediatrician
and a parent educator, launched the Parent Warmline program with an 18
month start-up grant from the hospital foundation.
Target population
The Parent Warmline is open to all Minnesota residents.
Program design and features
The Warmline receives calls 24 hours a day through a voice mail system.
Working from home, volunteers check the voice mail system periodically
throughout the day and respond to callers. Calls focus on a range of child
development topics. Two-thirds of callers' concerns are addressed on the
phone; one third of callers are referred to pediatricians, literature or other
community resources, such as counseling and mental health programs.
The hallmark of the Parent Warmline is its corps of volunteers, all of
whom are professionals with at least a bachelor's degree in child
development or a related field. Volunteers receive an intensive three-day
orientation and attend bimonthly continuing education seminars
thereafter. The program trains 10 to 12 new volunteers a year and has an
average volunteer base of 40. Each volunteer is asked for a minimum
commitment of one year of service, working three to four shifts per
month.
A program coordinator manages all volunteer recruitment, training
and retention activities, as well as program development and evaluation
functions. A program assistant is responsible for administrative duties.
The Warmline is consulted frequently by the local print and broadcast
media on parenting concerns. Warmline staff and volunteers also present
at health fairs, early childhood education programs and professional
training conferences.
Healthy Children in Healthy Families
13
Community partners
Area pediatricians/physicians
Counseling and parent education programs
Day care centers
Churches
Other community hospitals
Budget and funding sources
The annual budget is approximately $40,000, which covers the salaries of
a program coordinator and a program assistant, and volunteer expenses
(orientation, training, etc.). The program is fully funded by the hospital
through the Family Resources Department.
Evaluation and outcomes
In 1995 the Warmline service received 2,300 calls, averaging 19 minutes
in length, from 125 zip code zones throughout the state. A recent
telephone survey indicated that 95 percent of parents reported they were
"highly satisfied" with the program and that their conversation with the
Warmline representative relieved the immediate stress of their issue.
Objectives
Lessons learned and advice to others
Understand how volunteerism works.
To provide current and accurate information regarding
Hold regular volunteer recognition events and high
child development and behavior to parents of infants
quality in-service training with CEU credits.
and young children.
Position this service as a community resource and
To provide a link to existing community resources for
partnership-not necessarily as a marketing tool or
parents who might not otherwise have access to such
primary feeder program for the hospital.
services.
To prevent child abuse by increasing parental
Next steps
knowledge and ability to cope with normal parenting
Expand the Parent Warmline to serve non-English
concerns.
speaking clientele, particularly Hmong and Spanish-
To serve as a professional clearinghouse for
speaking families.
information relating to the health and development of
children.
Replicability
To promote awareness of Children's Health Care within
The program is highly replicable. Parent Warmline staff
the medical, mental health and lay communities.
offer training and consultation for children's hospitals
TO collaborate with area pediatricians by addressing
and other organizations.
the parenting, developmental and behavioral concerns
of their patients.
14 Healthy Children in Healthy Families
Partners with Parents
Abstract
Contact information
Partners with Parents is a workplace parent educational program for
Partners with Parents
Wisconsin employers.
Children's Hospital of Wisconsin
9000 West Wisconsin Avenue
History
P.O. Box 1997
In an effort to become more visible with the Wisconsin employer
Milwaukee, WI 53201
community, the Children's Hospital of Wisconsin's planning and education
departments developed a program to provide parenting education for
Contact:
employees of those businesses. Statistics indicating that 70 percent of
Pat Gruenwald
Wisconsin children have both parents in the work force and that over
Planning and Marketing Department
6,600 children are hospitalized in Wisconsin annually for preventable
(414) 266-6175
injuries provided compelling evidence in support of the program. In 1995
the hospital pilot tested Partners with Parents with the businesses
represented on the hospital foundation board. Shortly thereafter, the
hospital introduced the program to employers around the state.
Target population
The program is open to all Wisconsin employers.
Program design and features
Employers participating in the program receive free or low-cost services
for their employees with children. The education department designs
these items in consultation with clinical experts in the hospital. Services
include:
Workplace educational seminars-available as one-time lectures or in
series format. Conducted at the work site by the hospital's community
educator, the seminars address pertinent issues such as stress,
communication, discipline and other topics of concern to parents.
"Parenting Works" newsletter-published three times a year, featuring
general parenting articles and conversations with working parents from
Wisconsin businesses.
Health tip sheets-published quarterly in camera-ready format (suitable
for employee newsletters and payroll envelopes), featuring family health
and safety information.
Community education newsletter-published three times a year, listing
educational classes sponsored by the hospital.
Booklets and brochures-on a variety of subjects, including child day
care, discipline, drugs and alcohol, and injury prevention.
Planning department staff meet regularly with human resource
directors and small business owners around the state to promote the
program. The program is also marketed through chamber of commerce
newsletters and through outreach to Wisconsin's 17 employer coalitions
Healthy Children in Healthy Families
15
(business federations that are organized to address health care issues).
The Partners with Parents advisory board, which includes participating
employers, meets twice a year to provide feedback and direction to staff.
Budget and funding sources
The hospital funds the program's $150,000 budget, which covers
materials, travel expenses and the following staff: a program coordinator
from the planning and marketing department, clerical and public
relations support. Education staff time is assumed by that department.
Fees from materials and classes partially offset expenses.
Evaluation and outcomes
The program has been well received by employers-150 of whom now
participate at some level. On average, parents rate highly the format and
content of the workplace educational seminars. The hospital plans to
conduct a thorough evaluation of the program in the future.
Lessons learned and advice to others
Make the program a partnership between the hospital's marketing and
education departments.
Utilize talents of both departments to make the program successful.
Next steps
Work with employers to identify their most prevalent pediatric
insurance claims and design specific health education or disease
management services to address those issues. The hospital intends to
pilot test this approach with employers on the Partners with Parents
Advisory Board.
Distribute educational materials to pediatrician, OB-GYN, and family
practice offices around the state.
Develop specialized programs and materials for single mothers in
Wisconsin, 81 percent of whom are in the paid work force.
Replicability
The program is highly replicable. Partners with Parents staff are available
for consultation to other children's hospitals seeking to implement similar
programs.
16 Healthy Children in Healthy Families
Reach Out and Read
Abstract
Contact information
Reach Out and Read (ROR) is a pediatric early literacy program that
Reach Out and Read
integrates parent education on literacy development into regular
Children's Mercy Hospital,
preventive health care for children between the ages of six months and
Kansas City, MO
six years.
Hughes Spalding Children's
Hospital, Atlanta, GA
History
Children's Hospital of Michigan,
Reach Out and Read began as a collaboration between pediatricians and
Detroit, MI
early childhood educators. The program is based on the connection
Children's Health Care,
between reading and children's well-being-and is rooted in the belief
Minneapolis, MN
that illiteracy is the catalyst for other negative child health outcomes such
Rainbow Babies and Childrens
as school failure, substance abuse and teen pregnancy. Launched at
Hospital, Cleveland, OH
Boston Medical Center in 1989, the program seeks to change the culture
Children's Medical Center,
of ambulatory pediatrics by making literacy development an integral part
Tulsa, OK
of anticipatory guidance. Today, there are over 80 ROR sites across the
Children's Hospital
of Philadelphia, PA
country, including 11 at children's hospitals.
University of Virginia Children's
Medical Center,
Target population
Charlottesville, VA
The program targets socially and economically disadvantaged families,
Children's National Medical Center,
whose children are most at-risk for reading and school failure.
Washington, DC
Phoenix Children's Hospital,
Program design and features
Phoenix, AZ
The program has three basic components. In the clinic waiting room,
Children's Hospital of New Mexico,
volunteers engage children with books, reading aloud and modeling book-
Albuquerque, NM
related interactions for parents. Then in the examining room, the
pediatrician or nurse practitioner introduces an age-appropriate children's
Contact:
book into the visit, commenting on the child's response and offering
Abby Jewkes
National Program Administrator
information to the parent or guardian on how to use books to support the
Reach Out and Read National
child's healthy development. At the end of each visit, the child is given a
Training Site
new, culturally and developmentally appropriate book to take home. The
Boston Medical Center
accumulation of these books in the home encourages reading as a regular
(617) 534-5701
feature of the family's routine.
Staff for an ROR site typically includes a part-time program
coordinator and a medical consultant.
Partnerships
To support their efforts, ROR projects often collaborate with local service
organizations, such as the Junior League and Kiwanis. Many ROR sites
also work with local bookstores, which can contribute new or
overstocked books and can sponsor fund-raising events.
Healthy Children in Healthy Families
17
Budget and funding sources
ROR projects are typically supported by grants and donations. On
average, it costs $30 per child to provide books at each primary care visit
for the first five years of life. A hospital that provides books at both its
primary care and specialty clinics can expect to spend an average of
$20,000 a year on the project.
Evaluation and outcomes
An evaluation of the pilot program at Boston Medical Center in 1991
found that mothers who participated in the program were four times
more likely to read aloud to their children than were mothers from
similar socioeconomic backgrounds who had not participated in the
program.
Next steps
Expand the program to more hospitals and clinics around the country.
Create a stronger research and evaluation component for the program.
Expand the program to target new parents at the time of delivery.
Replicability
The program is replicable at any children's hospital offering ambulatory
care. A comprehensive program manual is available for prospective
Reach Out and Read sites. For more information, contact Abby Jewkes,
National Program Administrator, Reach Out and Read National Training
Site at Boston Medical Center at 617-534-5701.
18 Healthy Children in Healthy Families
Young Moms Program
Abstract
Contact information
The Young Moms Program is a prenatal education and support program
for expectant teens.
Young Moms Program
The Children's Hospital at Johnson
City Medical Center
History
400 State of Franklin Road
In 1989 a group of obstetricians, nurses, a perinatologist and concerned
Johnson City, TN 37604
individuals from various community agencies serving teens came together
in response to the growing number of young, high-risk mothers who were
Contact:
delivering in the Children's Hospital at Johnson City Medical Center's
Pam King, R.N.C., B.S.N.
maternity unit. Based on their collective experience that expectant teens
Prenatal Education Coordinator
did not receive care until late in pregnancy, and national data indicating
(423) 461-6183
that traditional channels of prenatal care and education did not reach this
population, the hospital developed the Young Moms Program.
Objectives
To improve teen pregnancy outcomes
To prevent school dropout
To prevent repeat teen pregnancies
Target population
The program is open to pregnant teens under 21 residing in the hospital's
eight-county service area.
Program design and features
The program receives referrals from area OB-GYN and family practice
physicians, local health departments, school nurses, counselors, teachers
and court systems. Each week for 18 weeks, expectant teens come to the
hospital for a "one stop" visit. They attend a prenatal education and
support class taught by hospital staff and volunteers from the community
(see box); have an opportunity to visit a social worker; and receive
referrals to community resources. They also receive nutritional counseling
and can apply for and receive WIC vouchers. At each class, moms
receive refreshments and vouchers as incentives for attendance that can
be "cashed in" at a baby store run by volunteers. They also receive a
convertible safety seat for completing the program. Each year, the
program hosts a reunion and/or holiday party for all program alumni.
Community partners
In addition to its network of referral partners, the Young Moms Program
has organized a coalition of service providers, including representatives
from city and county schools, hospitals, health departments, mental
health agencies, legal and social service departments, job training
Healthy Children in Healthy Families
19
agencies and early childhood development programs. The coalition meets
quarterly to coordinate efforts for pregnant teens and new mothers in
Johnson City and the surrounding areas.
Budget and funding sources
The annual budget for the Young Moms Program is $33,000, which
includes salaries for a program coordinator and a social worker and other
program expenses. The hospital funds the program with help from a
grant from the state to purchase child safety seats and a grant from the
March of Dimes to purchase educational supplies and snacks.
Evaluation and outcomes
To date, more than 1,000 mothers and support persons have been served.
The program has been effective in lowering the rate of low birth weight
(LBW) infants delivered by program participants. While teens nationally
give birth to 10 percent of all LBW births, only 4 percent of babies born
to mothers who participated in the program in the first three years were
LBW. The hospital's costs for providing care for these patients were
lowered significantly during the first three years of the program's
operation.
In 1992, the Young Moms Program was designated a model
adolescent service program by the Tennessee Commission on Children
and Youth. In addition, the program has received an Outstanding
Achievement Award from the National Organization for
Educational topics
Adolescent Pregnancy and Parenting and a Secretary's
Award for Excellence in Community Health Promotion
Options for pregnant teens
from the U.S. Department of Health and Human
Reducing risk factors during pregnancy
Services in 1993.
Goal setting for education and employment
Physical and emotional changes
Lessons learned and advice to others
Labor and delivery
Rely on adolescent experts to guide and administer
Father involvement
your program. Expectant teens are a very challenging
Sexually transmitted diseases
group and it takes special skills to deal with them.
Contraception
Secure strong administrative support. Staff members
Nutrition
credit the ongoing, visible support of upper
Newborn care
management for the hospital's continued funding of
Child development
the Young Moms Program.
Parenting skills
Use clients as advocates for the program with
Injury prevention
funders, community leaders and the media. They can
Coping skills/Stress management
provide the most compelling argument in support of
Self-esteem
special services for pregnant teens.
20 Healthy Children in Healthy Families
Next steps
Provide follow-up and ongoing parenting support to mothers after the
birth of their babies.
Improve the participation of fathers in the program.
Use alumni as mentors for new program participants.
Replicability
The program is replicable at children's hospitals with linkages to
maternity hospitals.
Healthy Children in Healthy Families
21
Offering home
visiting services to
disadvantaged
families
Healthy Families America
Abstract
Contact information
Healthy Families America (HFA) is a national home-visiting initiative that
seeks to ensure that all new parents, particularly those facing the greatest
Healthy Families America
Kapiolani Medical Center for
challenges, receive the education and support they need prenatally or at
Women and Children,
the time their baby is born, and continuing throughout the first years of
Honolulu, HI
life.
Children's Hospital and Health
Center, San Diego, CA
History
Le Bonheur Children's Medical
Healthy Families America-an initiative of the National Committee to
Center, Memphis, TN
Prevent Child Abuse (NCPCA)-is built on 20 years of research and the
Driscoll Children's Hospital,
experience of numerous communities, beginning with the Hawaii
Corpus Christi, TX
Healthy Start program at Kapiolani Medical Center. HFA was launched in
Connecticut Children's Medical
1992 with a start-up grant from the Ronald McDonald House Charities.
Center, Hartford, CT
Currently, over 250 local HFA sites are operating in 37 states and the
Children's Hospital at the
District of Columbia. To date, nine children's hospitals are sponsors or
University of Texas Medical Branch,
Galveston, TX
co-sponsors of HFA programs in their communities.
Hughes Spalding Children's
Hospital, Atlanta, GA
Target population
Tampa Children's Hospital at
All new parents can benefit from parenting education and support
St. Joseph's, Tampa, FL
services. However, due to fiscal constraints, most HFA sites offer services
Arnold Palmer Hospital for
to those new parents facing the greatest challenges, such as poverty and
Children and Women, Orlando, FL
social isolation.
Contact:
Program design and features
Training and technical support for
All HFA sites adhere to a set of core elements that assist program planners in
HFA programs:
Anna Loftus
developing and implementing comprehensive services, while enabling the
NCPCA
program to be tailored to the community. The basic approach is as follows:
(312) 663-3520
1. Families are assessed prenatally or at the time of a child's birth to
identify those most in need of services. Program enrollment is voluntary.
Specific HFA children's hospitals
2. Visits begin weekly and gradually progress to bimonthly, monthly and
representatives:
quarterly. Families may remain in the program for up to five years.
Stacy Collins
3. Parents learn appropriate parent-child interaction, healthy infant and
NACHRI
child development and a host of other parenting and life skills, depending
(703) 684-1355
on the needs of the family. Parents work closely with the home visitor to
develop an individual family support plan outlining goals and expectations.
4. All families are linked to a medical home to assure optimal health and
development and are referred to other appropriate community services,
as necessary.
5. Services are provided by staff with limited case loads (i.e., for most
communities, no more than 15 families per home visitor).
6. Home visitors receive intensive training and on-going effective
supervision.
Healthy Children in Healthy Families
25
Community partners
HFA places a high priority on community collaboration. Children's
hospitals' HFA sites work closely with social service agencies, health
departments, other hospitals and health care providers and school systems.
Some hospitals have more integrated arrangements. For example,
Connecticut Children's Medical Center sponsors an HFA program jointly
with three community-based agencies, with each contributing staff and
other resources. Other hospitals collaborate with existing HFA sites by
offering specific services. For example, All Children's Hospital in St.
Petersburg, FL provides evaluation and treatment of children with
developmental delays in the Pinellas County Healthy Families program.
At the national level, NCPCA has developed a partnership with NACHRI
to advance the HFA model to children's hospitals across the country.
Budget and funding sources
Most hospitals' HFA programs are grant-funded, through private or public
sources, or both. Public sources include state departments of health or
social services, state Title V programs and children's trust funds. Private
sources include hospital foundations and foundations created as the result
of for-profit conversions in the health care industry (e.g., the California
Wellness Foundation). Hospitals also receive Medicaid reimbursement for
certain services.
Conversely, some hospitals have chosen to become involved in HFA as
funders. The Children's Hospital of Wisconsin provides support to nine
HFA projects in Wisconsin through its Child Abuse Prevention Fund,
which receives its funding through employee contributions and private
donations.
Evaluation and outcomes
Research over the last 20 years has consistently confirmed that providing
education and support services to parents around the time of a baby's
birth-and continuing for several months or years thereafter-significantly
reduces the risk of child abuse and contributes to positive, healthy child-
rearing practices.
Families receiving this type of intensive home visitor service also
demonstrate other positive changes, such as consistent use of preventive
health services, including immunization; increased high school completion
rates (for teen parents); higher employment rates; lower welfare use and
fewer subsequent pregnancies. Children's hospitals involved in HFA are
also evaluating specific institutional measures, such as emergency room
use and rates of pediatric subspeciality care referrals.
26 Healthy Children in Healthy Families
Next steps
Ensure that all states have a multidisciplinary task force of public and
private agency representatives working to institutionalize Healthy Families
at the state level.
Implement the HFA credentialing system for all current and future HFA
sites.
Advocate for funding to ensure a permanent nationwide infrastructure
for home visitor services.
Replicability
HFA can be tailored to any community.
Healthy Children in Healthy Families 27
Healthy Connections
Abstract
Contact information
Healthy Connections is an infant mortality reduction program, providing
intensive perinatal nursing services, with community outreach and home
Healthy Connections
Children's Hospital
visits, to families who use the hospital's primary care clinics.
300 Longwood Avenue
Boston, MA 02115
History
In reaction to the alarming infant mortality rates among African-American
Contact:
and Hispanic infants, the city of Boston in 1991 undertook an in-depth study
Constance Keefer, M.D.
of all infant deaths in the city in the preceding 24 months. Results indicated
Child Development Unit
that infant deaths occurred when the care system was fragmented, when it
(617) 355-6948
provided no outreach to at-risk families and when it offered few
opportunities for patient involvement. In response, Children's Hospital
designated $5 million for research and health service programs, including
Healthy Connections, to improve outcomes for at-risk newborns.
Target population
Each year the program serves approximately 1,000 mothers and
newborns from poor, largely minority Boston neighborhoods with high
infant mortality rates.
Program design and features
In-hospital intervention
Healthy Connections works with two Boston maternity hospitals that deliver
most of the infants receiving care at Children's primary care sites. Those
mothers who indicate they will be using Children's for primary care are
visited by a Healthy Connections perinatal nurse within 24 hours of delivery.
The in-hospital visit is a comprehensive intervention that includes
assessing family strengths regarding infant care knowledge and availability of
support networks; identifying needs, including health insurance, nutrition,
primary care for all family members, housing, transportation, mental health
and substance abuse treatment; educating families on all aspects of newborn
care and post-partum adjustment; and an interactive physical exam and
behavioral assessment of the baby.
Every mother receives a Polaroid picture of herself and her baby to place
in a booklet containing the infant's appointment record and infant care
information. The low literacy booklet, Your New Baby, was prepared by the
Healthy Connections staff and is available in Spanish, Haitian-Creole and
Vietnamese (see Resources chapter for information). An initial well-baby
appointment is scheduled and all hospital information is transmitted directly
to the primary care provider.
Healthy Children in Healthy Families
29
Community outreach
The perinatal nurse telephones the mother 48 hours after discharge to assure
the infant's health and the parents' adjustment. If a family misses its well-
baby appointments, the program's community health liaison makes a home
visit to re-establish the family's connection to primary care. The community
health liaison can assist with transportation, housing, welfare benefits and
other immediate needs of the family.
Community partners
In addition to the maternity hospitals, Healthy Connections staff work closely
with prenatal care clinics and the Visiting Nurse Association of Boston to
identify at-risk pregnant and post-partum women. With most client families
residing in public housing, the program has also established partnerships
with the Boston Housing Authority on injury prevention and health
education initiatives and the Massachusetts Union of Public Housing Tenants
to train neighborhood perinatal outreach workers.
Budget and funding sources
The program's budget of $112,000, financed by the department of pediatrics,
covers the salaries of a nurse practitioner and a registered nurse, data
management and support services, and supplies. The salaries of the
community health liaison and the medical director are funded through other
departments.
Evaluation and outcomes
The program has documented a 75 percent decrease in the rate of
emergency room visits in the first month of life (roughly $50,000 in savings
per year); a dramatic increase in the rate of kept well-baby visits at two, four,
and six months; and an increase in immunization rates. Newborn health
records are now available at virtually 100 percent of first well-baby visits and
primary care providers report increases in their efficiency and effectiveness
during first visits with the newborn and family.
Objectives
Lessons learned and advice to others
Keep good cost data on your program.
To develop secure attachment between the family and
Demonstrate the savings from reduced emergency
primary care provider
room usage and improved efficiency among the
To identify and reduce barriers to care
primary care practitioners. Such data provides evidence
To provide comprehensive, in-hospital assessments of
for continued funding of perinatal outreach programs.
mother and newborn
To provide infant care information in useable form for
Replicability
parents.
The program is replicable at children's hospitals that offer
primary care services.
30 Healthy Children in Healthy Families
Parent Aide Program
Abstract
Contact information
The Parent Aide Program is a child abuse prevention and family support
Parent Aide Program
project providing lay home visitation, parent education and peer support
Children's Hospital and Health Center
groups for young families at risk for abuse and neglect.
3020 Children's Way
San Diego, CA 92123
History
Launched in 1976, the Parent Aide Program was developed as a follow-
Contact:
up service for at-risk families discharged from the Children's Hospital and
Diana Champion
Health Center's inpatient and intensive care units. As the only hospital-
Center for Child Protection
based early response system for at-risk families in San Diego at that time,
(619) 576-5910
the Parent Aide Program quickly became a referral source for other
hospitals, pediatricians and social service providers in the area.
Target population
The program targets single, isolated parents, particularly those with
childhood histories of abuse or neglect; parents of medically fragile or
special needs children with few support systems; mothers with alcohol and
other drug use histories; and teen parents.
Program design and features
Upon entering the program, families are offered both individual and
group services, depending on their needs. Services include a 10-session
parent education course and a bimonthly mothers' support group.
Services are offered at the hospital and free, on-site child care is
provided. Families needing more intensive help are matched with a
parent aide-a trained community volunteer who works with the family
in the home to provide emotional support, good parent modeling and
help in securing community resources.
The unique feature of the Parent Aide Program is its incorporation of
volunteers into all program services. Parent aides are asked to give a one-
year commitment to the program, during which they serve an average of
six hours per week. Parent aides receive 27 hours of initial training,
weekly supervision and monthly in-service education. Volunteers also
serve as child care workers and as "special friends" (a big brother/big
sister style relationship) for children in the program. Most volunteers are
college-educated professionals under the age of 30.
Community partners
The Parent Aide Program's referral partners include area hospitals,
physicians, social service agencies and the county child protective
services system. The Parent Aide Program has also formed a partnership
with the San Diego Child Abuse Prevention Foundation to jointly sponsor
Healthy Children in Healthy Families
31
community educational programs and volunteer training workshops. The
San Diego Exchange Club/National Parent Aide Network has also
recently joined with the program to help recruit volunteers, provide
financial support and expand community parenting classes.
Budget and funding sources
The program budget is approximately $50,000, which supports a program
administrator/volunteer coordinator, a parent educator and a part-time
secretary. Revenue sources include parenting class registration fees, the
hospital's foundation, the San Diego Child Abuse Prevention Foundation
and other private sources.
Evaluation and outcomes
Mothers participating in the program have shown decreased maternal
stress and improved understanding of appropriate discipline, with a
resulting decrease in reports of child abuse.
The program was named the 490th "Point of Light" by President Bush
in 1991, and received the 1991 American Hospital Association "Program
of Excellence" award.
Lessons learned and advice to others
Start small.
Secure strong administrative support for the program.
Involve a broad cross-section of hospital staff in planning.
Collaborate with as many community agencies as possible.
Demonstrate the value you place on your volunteers
Objectives for participating families
through in-service training, quality supervision and
regular recognition events.
To reduce the level of risk for child abuse and neglect
Next steps
To increase ability to establish trusting relationships
Secure additional foundation funding-a challenging
and utilize community resources
task, given the trend in the child welfare community
To reduce children's isolation through individual and
toward staff model home visiting programs.
group services
To enhance health and lifestyle habits of family
Replicability
members
The program is replicable and specific program
To increase ability to view children as individuals with
materials, including staff and volunteer job descriptions
separate needs and feelings
and training outlines, are available on request.
To demonstrate use of age-appropriate discipline
To enhance help-seeking behavior during stressful
times
32
Healthy Children in Healthy Families
Family Network
Abstract
Contact information
Family Network is a community and home-based intervention program
for pregnant and parenting women, infants and families who are at very
Family Network
Children's Hospital
high risk for poor birth outcomes, developmental delay and child abuse
300 Longwood Avenue
and neglect.
Boston, MA 02115
History
Contact:
Boston is one of 22 cities involved in "Healthy Start," a federal grant
Francine Azzara
program for rural and urban communities with infant mortality rates 1.5
Martha Eliot Health Center
to 2.5 times the national average. The city is working to reduce the infant
(617) 971-2301
mortality rate by changing the way health care is delivered to at-risk
groups. With funding from the Boston Healthy Start Initiative, the
Children's Hospital and the Visiting Nurses Association developed a
program to serve the often invisible population of pregnant and
parenting women who do not access or appropriately utilize the health
and ancillary services available.
Target population
The program is aimed at pregnant and parenting women residing in the
service area of Children's primary care clinic-the Martha Eliot Health
Center-who have no regular source of health care.
Program design and features
The Family Network program is based on a team approach involving a
registered nurse-who coordinates the family's medical care-and a
paraprofessional family health advocate-who conducts on-going home
visits with the family, arranges for needed psychosocial and other ancillary
services, teaches parenting and nurturing skills, and, most importantly,
provides the vital link between the family and the health care system. A
mental health professional also provides support to clients in need.
Referrals are accepted on clients who are discharged from other
programs for lack of compliance and women who are hard to engage due
to multiple problems such as substance abuse, family violence and
transient living arrangements. Family health advocates also conduct
outreach in neighborhoods and at public events. A unique aspect of
Family Network is the staff's commitment to remain accessible to women
who normally reject intervention or services. Repeated and persistent
attempts to contact at-risk women results in 95 percent of them eventually
accepting help.
Services, offered in both the home and health center, include a full
range of case management and primary health care services (see box).
Clients receive on-going services based on the levels of risk and need,
during the perinatal period and up to one year after birth.
Healthy Children in Healthy Families
33
Community partners
The Family Network program relies on the Visiting Nurse Association of
Boston for skilled nursing services. Family Network staff also coordinate
services and advocacy efforts with other Boston Healthy Start grantees.
Budget and funding sources
The program's budget of $244,000 is funded through grants from the
Boston Healthy Start Initiative and the Massachusetts Department of
Public Health.
Evaluation and outcomes
Of babies born to program participants, 100 percent are immunized,
100 percent have an identified primary care provider and 64 percent
are breastfed.
The program has also improved self esteem of the mothers, birth
outcomes and compliance with care, and decreased use of the hospital
emergency room for routine care. Family Network has been selected as
a model home visiting program by the Massachusetts Department of
Public Health.
Lessons learned and advice to others
Make a long-term commitment to the program. Families with multiple
problems need continuous care to improve their lives. Moreover,
communities depending on outreach programs often lose trust in the
sponsoring institution when the program suddenly disappears for lack of
funding.
Build in adequate support and training for the staff. Staff working with
families with multiple needs are often at risk for burn out and need
regular recognition, professional supervision and quality continuing
education.
Services
Next steps
Hire an educational specialist to work with mothers
Prenatal, postpartum and pediatric nursing care
in the program to improve their literacy skills.
Health assessment and monitoring
Secure funding for a teen life center, where pregnant
Parent education
and parenting teens can receive life skills and parenting
Developmental screening
instruction.
Breast-feeding instruction and support
Conduct pregnancy prevention education with pre-
Nutrition counseling
teens.
Mental health counseling
Substance abuse services
Replicability
Subsidized housing referral
The program is replicable at children's hospitals that
offer primary care.
34
Healthy Children in Healthy Families
HIPPY-Home Instruction Program
for Preschool Youngsters
Abstract
Contact information
The Home Instruction Program for Preschool Youngsters (HIPPY) is a
HIPPY-Home Instruction
home-based early intervention program that helps parents provide
Program for Preschool Youngsters
educational enrichment for their preschool age children.
Arkansas Children's Hospital
1120 Marshall Street
History
Little Rock, AR 72202
HIPPY was developed in 1969 by a team of early childhood educators at
Hebrew University of Jerusalem in Israel. Since its inception, HIPPY has
Contact:
grown into a worldwide movement adapting a curriculum-originally
Barbara Gilky
designed for undereducated parents in Israel-to local communities on
Arkansas State HIPPY Director
five continents. Introduced in the United States in 1984, the HIPPY
(501) 320-3671
program is now used in 28 states. The Children's Hospital of Arkansas
sponsors the nation's only HIPPY State Training and Technical Assistance
Center, providing services to 30 HIPPY sites throughout the state.
Target population
The HIPPY program is designed for parents with preschool age children
(ages 3 to 5) who may not feel confident in their own abilities to teach
their children.
Program design and features
The HIPPY curriculum, presented over the course of two years, is
primarily cognitive-based, focusing on language development, problem
solving, logical thinking and sensory discrimination skills. Every other
week, paraprofessionals make home visits to role play HIPPY activities
with parents.
On alternating weeks, group meetings are held. During group
meetings, paraprofessionals and parents role play the week's activities
and an enrichment activity focusing on parenting and family life issues is
offered. Parents enrolled in the program commit to spending 15 to 20
minutes a day doing HIPPY activities with their children.
In Arkansas, HIPPY programs are sponsored by a variety of
organizations, including schools, educational cooperatives, universities,
Head Start agencies and other community-based organizations. The role
of the State Training and Technical Assistance Center based at the
hospital is to provide initial training for all new HIPPY home visitors,
sponsor in-service training and regional and statewide seminars on early
childhood issues and provide a networking forum for HIPPY
coordinators.
Healthy Children in Healthy Families
35
Community partners
HIPPY programs work closely to coordinate services with other
community agencies, including health departments, school districts,
human service departments and literacy councils.
Budget and funding sources
Costs are approximately $1,000 to $1,500 per child each year over two
years. This estimate is based on an average of 60 families in the first year
and 120 families in the second year. Most HIPPY programs are staffed
with a full-time coordinator and one paraprofessional home visitor for
every 12 participating families. Arkansas HIPPY programs receive funding
from several private and public sources, including Title IV, Head Start,
Even Start and the Americorps Program.
Evaluation and outcomes
Extensive research in Israel shows HIPPY benefits children by improving
academic achievement and adjustment to school, reducing the need for
children to repeat grades and increasing the rate of school completion.
Parents become more involved in their children's education, develop
higher self-esteem and pursue further education for themselves. The U.S.
Department of Education is now funding the first systematic evaluation of
HIPPY in the United States. Preliminary findings of first grade teacher
ratings suggest that participating in HIPPY may have a positive effect on
children's ability to adapt to the classroom, an important component of
school success.
Next steps
The national parent organization-HIPPY USA-is committed to on-going
curriculum development integrating current research in emergent literacy
and the experience of HIPPY program providers and parents. An
advisory group consisting of academicians, practitioners, parents and
paraprofessionals has been established to support this process.
Replicability
The HIPPY program is highly replicable. HIPPY USA has produced a
start-up manual and a guide to fund-raising for prospective HIPPY sites.
For more information, contact HIPPY USA at (212) 678-3500.
36 Healthy Children in Healthy Families
Creating family and
child centers to provide
services and support
to families
Family Care Connection
Abstract
Contact information
The Family Care Connection (FCC) is a network of four neighborhood-
based drop-in centers providing primary and preventive health care,
Family Care Connection
Children's Hospital of Pittsburgh
respite care, parenting education, substance abuse treatment and other
One Children's Place
support services to at-risk families.
3705 Fifth Avenue
Pittsburgh, PA 15213
History
The Family Care Connection was established in 1989 when Children's
Contact:
Hospital of Pittsburgh received grants from the U.S. Department of Health
Cindy Graffius
and Human Services, the Howard Heinz Endowment and the Scaife
Manager, Prevention Programs
Family Foundation to establish a family support program for at-risk
(412) 692-8666
families in Allegheny county. The program was inspired by a local
pediatrician, who had worked in a neighborhood health clinic and
believed poor families needed more than traditional medical care to
ensure the healthy development of their children. Her vision led to the
development of the first "drop-in" center, offering family support services
as well as preventive health care. The model's success in improving
maternal and child health led to the opening of three other centers. This
network of community-based drop-in centers forms the Family Care
Connection program.
Target population
The Family Care Connection targets families in four communities in
Allegheny County-Rankin, Braddock, Wilkinsburg and Turtle Creek/East
Pittsburgh-which were selected for their high rates of poverty, low birth
weight and inadequate prenatal care. All families residing in these
targeted communities are eligible to participate in the FCC program. The
program serves approximately 1,000 families a year.
Goal and objectives
The goal of the FCC program is to improve the health of children and
families in low-income neighborhoods. Its objectives are:
To improve access to health care for children in poor communities.
To provide medical, mental health and social services to enhance the
health of children and families.
To enhance child development and prevent infant mortality and low
birth weight.
To prevent child abuse and neglect.
To prevent and treat parental drug abuse.
To provide emergency respite care for at risk children.
Healthy Children in Healthy Families
39
Program design and features
Each FCC project is located within a well-established community agency
that has invited the FCC to be located on-site. The host agency provides
free space and works to complement its program and staff with those of
the FCC. This collaboration with an existing agency helps to ensure that
community residents do not view the FCC program as foreign or
transient. The four centers are located at a Boys and Girls Club and other
community service agencies.
FCC staff includes a physician, site coordinators, nurses, a substance
abuse services coordinator, family support workers and lay parent
educators. The FCC also contracts for licensed substance abuse, respite
care, literacy and mental health professionals to provide services at the
drop-in centers and/or in the home.
The hallmark of the FCC program is its flexibility in providing
services. Families can choose the services they like, how often they will
participate and in many cases, whether they receive the services in their
home or at the drop-in center. The four centers are located within
walking distance of most families in the community.
Community partners
The FCC and its host agencies in each neighborhood
Services
are true partners, coordinating their work with families
and offering an array of services that would not
Services provided by the FCC
otherwise be as extensive. The FCC also works closely
Family case management
with the public health department to identify and
Nurse home visiting
provide services to pregnant women.
Pediatric primary care
Developmental assessment
Budget and funding sources
Child development and infant stimulation
The FCC's annual budget of $940,000 is funded through
Overnight respite care for children
a mix of private foundation and federal grants.
Clothing
Foundations include Alcoa, Hearst, Heinz Endowments
Transportation assistance
and the Scaife Family Foundation. Federal grant sources
Substance abuse treatment
include the Maternal and Child Health Bureau, HHS
Housing assistance
Office of Community Services and NCCAN. The
Parenting and health education
program receives third party payments for selected
Individual and group counseling
services and also has a contract with the Allegheny
County Children and Youth Services to provide home
Services provided by the host agency
visiting.
Food bank
Energy assistance
Evaluation and outcomes
Job training and literacy programs
The FCC has contributed to reductions in infant mortality
Recreational activities for older children
and low birth weight and improvements in first trimester
use of prenatal care in the communities it serves.
40 Healthy Children in Healthy Families
Lessons learned and advice to others
Hire a grant writer for your program.
Find partners with similar philosophical principles and compatible
working styles.
Hire your staff from the communities you serve.
Seek revenue streams in addition to grant funding.
Next steps
Seek third-party payment for more services.
Create designated funding streams for each FCC site.
Work to promote the FCC as a model for systemwide change in
Allegheny County.
Replicability
The program has been replicated in the state of Pennsylvania. Technical
assistance is available for other children's hospitals wanting to replicate
the program in their own service areas.
Healthy Children in Healthy Families
41
The Parenting Center
Abstract
Contact information
The Parenting Center is a primary prevention program offering support
and education to parents of children from birth through adolescence.
The Parenting Center
Children's Hospital
200 Henry Clay Avenue
History
New Orleans, LA 70118
The concept of a Parenting Center serving New Orleans families began to
take shape in 1977, when the local Junior League chapter conducted a
Contact:
community-wide needs assessment. Input from more than 60 civic,
Donna Newton, M.Ed.
religious, judicial, social service and educational leaders indicated a need
Director
for a primary prevention program focused on parent training.
(504) 896-9365
The Junior League approached Children's Hospital and together they
developed a proposal for a parenting center, funded with a 4-year
$90,000 start-up grant from the League. An advisory board, composed of
five hospital board members, five Junior League members and five
community representatives, was formed to oversee the operations of the
center. Following two years of development and preparation, the Center
was opened to the public in the summer of 1980. In 1982 the Parenting
Center became a department of the hospital and is now considered a
major component of the hospital's mission.
Objectives
To promote confidence and competence in parents.
To encourage optimal child development.
To enhance the well-being of the family as a whole.
Target population
The program is open to all parents in New Orleans and surrounding
communities.
Program design and features
The Parenting Center has attained broad public appeal because of its
emphasis on programming to address universal concerns of parents. Most
programs are conducted at the Parenting Center, which is located at the
hospital. Parents have the opportunity to become members of the Center
and receive reduced class fees, resource library privileges, a newsletter
subscription and use of the drop-in play space for parents and children
under 4.
Programs and services include:
Parent/infant/toddler program (ages up to 4), including classes, a
drop-in center, support/play groups, a resource library, on-site child
care for class participants, daily summer enrichment activities and
individual counseling.
Healthy Children in Healthy Families
43
Warmline, a volunteer-run telephone advice service for parenting
concerns.
Brown bag seminars for working parents, offering work site parenting
classes for area employers.
Evening parenting classes on discipline, child development,
communication, and age-specific topics (e.g., for parents of toddlers,
school-age children and adolescents).
Step family programs, including specialized support groups and
classes.
Separation and divorce counseling, to help parents address child
behavior and adjustment issues.
Community outreach seminars for Head Start programs, public
schools, churches and other organizations.
Public relations activities, including periodic interviews with and
articles submitted to the print and broadcast media.
Community partners
The Parenting Center has established a variety of community partnerships
for time specific and on-going projects. For example, using a grant from
the Louisiana Trust Fund in 1995, the Parenting Center joined with the
Catholic Archdiocese and the New Orleans Family Services to sponsor a
five-week parenting series on the local public television station. Examples
of on-going partnerships include the Step Family Association of Southeast
Louisiana, with whom the Parenting Center coordinates education events
and support programs; and maternity program at other hospitals, for
whose patients the Parenting Center provides specialized classes.
Guiding principles
Budget and funding sources
The Parenting Center's $200,000 annual budget is
Parents know their children best.
derived from individual membership fees, program
Parenting skills are not instinctive-but can be learned
fees, foundation support and fund-raising events, and
and developed.
general hospital funds. The budget includes the salaries
Parenting education is crucial for optimal child
of a director, an assistant director, two parent educators
development.
and support staff.
Parenting education is essential for the prevention of
child abuse and neglect.
Evaluation and outcomes
Information about child development is eagerly sought
Evaluations are conducted following each educational
by new parents.
program and periodic satisfaction surveys are
Many parents do not have access to extended family
conducted for Warmline customers. Overall, evaluations
and other traditional support systems.
indicate a high degree of satisfaction with Parenting
Center services.
44
Healthy Children in Healthy Families
Lessons learned and advice to others
Target your services to highly motivated groups, such as first time
parents, parents of pre-adolescents and step-parents. Although most
parents will find instruction helpful, the Louisiana experience
demonstrated that these particular audiences have the highest degree of
interest and are therefore a reliable revenue stream for the program.
Give your parenting education program an actual identity. The
credibility and visibility of your program will be enhanced if it is a stand-
alone project-like the Parenting Center-and not an activity of an
existing hospital department.
Next steps
Explore the possibility of marketing the Parenting Center's services to
HMOs and other insurers. The Parenting Center may be offered as part of
the hospital's package of pediatric services.
Offer more professional training. Staff plan to broaden the
effectiveness of the program by training professionals who interact
regularly with children and families, including teachers, day care staff,
youth development workers, and mental health specialists.
Explore the development of a web site on the Internet.
Work with television stations to develop public service announcements
and other programming to reach more parents.
Replicability
The program is highly replicable and Parenting Center staff are available
for consultation and technical assistance to other children's hospitals.
Healthy Children in Healthy Families
45
Decker Family Development Center
Abstract
Contact information
The Decker Family Development Center is a comprehensive program
providing predominantly low-income families with young children with a
Decker Family Development
Center
convenient "one-stop" location for social, mental health, medical and
Children's Hospital Medical Center
educational services.
of Akron
One Perkins Square
History
Akron, OH 44308
In the late 1980s health and social service providers in the Akron area
formed a coalition to explore ways to overcome the problems created for
Contact:
poor, multiple-risk families when these services are bureaucratically and
Mary Frances Ahern, L.I.S.W.
geographically scattered. The 25-member group-called the Akron-based
Program Director
Coalition for Early Intervention-set out to develop a model for the ideal
(330) 848-4264
program to provide all the services at-risk families need. According to a
community assessment, problems-such as lack of transportation for
families and lack of coordination among service providers-were
particularly acute in Barberton, an economically distressed community
with some of the highest teen-pregnancy and school-drop-out rates in
Summit County.
The coalition, led by a team of representatives from the Children's
Hospital, the University of Akron and the Barberton City Schools,
prepared a proposal for a comprehensive family service center, which
would be housed in a vacant elementary school. The coalition was
awarded a $1 million grant from the Ohio Department of Education as
part of its school drop-out prevention initiative, and the Decker Center
opened its doors to families in 1990.
Goals
To enable parents to recognize that they are the first and most
significant teachers in their children's lives.
To provide parents with the support, parenting skills and education to
help their children reach their developmental potential.
To work with children as infants, to promote their self-esteem and to
enhance the probability that they will remain in school and complete
their education.
To have all preschool children developmentally ready to enter
kindergarten.
To provide multidisciplinary services to special needs children so that
they may reach their full potential.
To provide encouragement, education, training and support services to
families, to enable them to become self-sufficient members of society.
Healthy Children in Healthy Families
47
Target population
The program is designed for parents on public assistance with children
under age 5. Decker currently serves approximately 150 parents and 200
preschool children.
Program design and features
The Center's holistic, family-centered approach provides parents and their
preschool age children with the opportunity to access medical/health,
educational and social support at a single site. Many services are offered
at the Decker Center to benefit participating parents and their preschool
children (see box).
In addition to being one of the nation's first comprehensive family
service centers, Decker is also distinct as a truly collaborative model
between a hospital (Children's), a school system (Barberton), and a
university (Akron). Representatives from the three institutions comprise
the senior management team for the Center. Each institution also
provides staff and services: Children's Hospital provides
Services
the center's director, nurse practitioner, pediatrician,
social workers and mental health personnel; the
Services for parents
University of Akron's Department of Elementary
Child care
Education provides the early learning and preschool
Parent education classes
instruction staff and evaluation services; and Barberton
Family literacy and GED classes
City Schools provides the facility crew, adult education
Case management services
and training staff and serves as the fiscal agent for the
Legal and financial assistance
program.
Public assistance determination
Mental health services
Community partners
Nutrition education
The core Decker Center partnership is augmented with
Pre-employment training
extensive programming support from 20 other
Home visitor and outreach service
community agencies, including the Barberton Health
Department, the Akron Metropolitan Housing Authority,
Services for children
the Barberton Public Library and others.
Pediatric health care
Parent/child play groups
Budget and funding sources
Infant and toddler stimulation program
The Decker Center's $1.6 million budget is supported
Head Start
primarily by grants and contracts from state and federal
Special needs preschool
sources including the Ohio Department of Education,
Developmental kindergarten
Head Start, the JOBS (Jobs Opportunity Basic Skills)
Foster grandparenting
program, and the U.S. Department of Education's "Even
Speech and hearing services
Start" (family literacy) and Adult Basic Education
Occupational therapy and physical therapy services
programs. Additional funding sources include Medicaid,
state child care contracts and foundation grants.
48
Healthy Children in Healthy Families
Evaluation and outcomes
Data from the Decker Center's first five years of operation indicate
important health and education gains. All of the children are up to date
with their immunizations; on average, children who participate in
programming grow 22 percent beyond normal (non-intervention) rates.
Children have also improved in their social and cognitive skills and fewer
Decker Center children require special education classes at the
elementary school level than do their non-intervention counterparts.
During any one year, 10 percent of the adults exit the program with a
GED and 11 percent leave with a job or move on to college or trade
school.
The Decker Center has received numerous awards in the past three
years, including an American Hospital Association NOVA award (1994), a
Barbara Bush Family Literacy Award from the Barbara Bush Foundation
(1994), a Secretary's Award for Excellence in Community Health
Promotion from U.S. Department of Health and Human Services (1995),
an Ohio Best Practice Award for Educational Partnerships (1995), and an
award from the National Center for Community Education as an
exemplary community/school partnership (1996).
Lessons learned and advice to others
Decker Center staff credit their success on a model for collaboration they
have coined "DISNI," which requires participating organizations to:
Devoid yourself of organizational territorial issues.
Increase communication.
Share authority and power.
Negotiate goals and objectives, then work toward their successful
implementation.
Have an Intense sense of shared ownership in the collaborative model
that is publicly displayed.
Next steps
Undertake a building enlargement and remodeling project that will
create more classroom and medical space.
Advance the Decker Center nationally as the prototype for family and
child services of the future.
Replicability
The Decker Center model is highly replicable. Program staff routinely
present the Decker model and results of research at professional
meetings and conferences and are available for individual consultation.
Healthy Children in Healthy Families
49
Resources
Resources
Children's hospitals' resources
Great Kids Program, developed by the Children's National Medical
Center, Washington, D.C., is a working parents' seminar designed to
teach step-by-step solutions to common parenting problems, encourage
parents to make real changes to improve the quality of family life and
help parents obtain the skills needed to raise well-adjusted children.
Parents learn essential survival tips, ways to develop their children's self-
discipline and the know-how to reduce the stress of parenting, especially
within a two career family. The slide program and script can be
presented at work sites over the course of four, one-hour sessions. To
order, contact Ellie Runion at (202) 884-2338.
Your New Baby, written and designed by the staff of the Division of
General Pediatrics at Children's Hospital, Boston, is an illustrated guide
for the care of the newborn in the first year of life. The easy-to-read
booklet, originally written for the hospital's Healthy Connections
program, was also commissioned by the Boston Healthy Start Initiative
for free distribution to community clinics in Boston. The booklet is
available in English/Spanish, English/Haitian Creole and
English/Vietnamese versions. The cost is $1.25 per copy and $1.10 per
copy for orders of 100 or more. To order, contact Joan Lowcock at (617)
355-6714.
The Family Institute at Kapiolani Medical Center for Women and
Children provides training and technical assistance for home-based family
support programs, conducted by trainers with extensive professional
experience with culturally diverse groups in the United States and
abroad. The Family Institute has also published its own parent education
curricula, which were designed for Hawaii's Healthy Start home visiting
program and are available for purchase. For information, call (808) 944-
9000.
Other resources
Healthy Steps for Young Children, sponsored by the Commonwealth
Fund, is a national initiative to help parents foster the healthy growth and
development of their very young children. With support from the
Commonwealth Fund, as well as matching funds from local donors, 15
sites across the country are participating in a national evaluation to test a
new approach to pediatric care that offers an expanded set of services,
emphasizing the role of parents in nurturing their children's physical,
Healthy Children in Healthy Families
53
emotional and intellectual development. A number of children's hospitals,
including those in Houston, Pittsburgh, Honolulu, Asheville and Los
Angeles, are participating in this program. The Healthy Steps for Young
Children Program has a home page on the World Wide Web
(www.healthysteps.org) that contains background information on the
program, provides details about current and on-going activities and links
Web users with program documents. For more information, contact the
Commonwealth Fund at (202) 606-3840.
Parents as Teachers (PAT) is an award-winning early childhood parent
education program for parents of children up to age 5. The PAT program
is based on the belief that experiences in the beginning years of a child's
life are critical for laying the foundation for school success and that
parents are their children's first and most influential teachers. PAT offers
families regularly scheduled personal visits by certified parent educators
who provide information on the child's development and ways to
encourage learning, group meetings with other parents and periodic
screening for early detection of developmental problems. The PAT
initiative has spread to 47 states and five foreign countries. In St. Louis,
Missouri, a parent educator from the local PAT program meets regularly
with NICU staff from Cardinal Glennon and St. Louis Children's Hospital
to identify families who might benefit from the program. For information
about Parents as Teachers, or to inquire about PAT programs in your state
or community, contact Kate Ball at the Parents as Teachers National
Center at (314) 432-4330.
National Center for Family Literacy (NCFL) is a training and research
organization that seeks to break the inter-generational cycle of under-
education and poverty by improving parents' basic skills and attitudes
toward education, their parenting skills and their children's pre-literacy
and school readiness skills. NCFL has an extensive publication list and
offers a wide array of workshops and technical assistance. For
information, contact NCFL at (502) 584-1133.
54
Healthy Children in Healthy Families
The mission of NACHRI is to promote the health and well-being of
children and their families through support of children's hospitals and
health systems that are committed to excellence in providing health care
to children. It does so through education, research, health promotion and
advocacy.
As part of its recently expanded mission, NACHRI builds public support
for improving children's health, education, safety and security and works
in alliance with others in the health care profession and the public to
advance an accessible and medically appropriate continuum of care for
children.
National Association of
Children's Hospitals
and Related Institutions
401 Wythe Street
NACHRI Alexandria, VA 22314
April 1997
cc: Ten K.
Nicole R
RAND
return)
James A. Thomson
President and Chief Executive Officer
1700 Main Street
May 9, 1997
PO Box 2138
Santa Monica
California
The Honorable Elena Kagan
Deputy Assistant to the President
90407 2138
for Domestic Policy
The White House
Washington DC 20500
310 451 6936
Dear Ms. Kagan:
Fax 310 451 6972
Many of the nation's most daunting problems concern the segment of our population that
carries our greatest hopes for the future-our children.
Board of Trustees
The quandaries cut across class and economic lines. Poverty may be the most massive-it
Paul H. Neill
is jolting to realize that one of every five American children lives below that line-but middle
Chairman
class parents also face tough challenges these days. All of us worry about the threats of
G. G. Michelson
drugs, violence, teenage pregnancy and sexually-transmitted diseases. All of us struggle
Vice Chairman
to give our children and grandchildren access to good schools, decent day care and quality
Peter S. Bing
health services.
Harold Brown
Frank C. Carlucci
James C. Gaither
RAND has been working on these very issues for over a quarter of a century, always in the
Christopher B. Galvin
same fact-based, nonpartisan vein and always with the goal of identifying policies that can
Pedro Jose Greer, Jr.
succeed. This timely edition of RAND Research Review describes some of our recent
Walter J. Humann
projects and findings. It appears just as welfare reform is taking effect, as a child health care
Bruce Karatz
bill is being debated, and as the other issues noted above remain in the headlines. I trust it
Ann McLaughlin
Lloyd N. Morrisett
will enrich your own efforts to improve the lives of our young people.
Ronald L. Olson
Patricia Salas Pineda
Sincerely,
Condoleezza Rice
Donald H. Rumsfeld
Kenneth I. Shine
Jerry 1. Speyer
James A. Thomson
Jo thonson
Paul A. Volcker
Albert D. Wheelon
JAT.sm
James Q. Wilson
Charles 1. Zwick
Enclosure
President's Council
Paul Baran
Richard C. Barker
Peter S. Bing
Frank C. Carlucci
Robert Clements
Peter M. Flanigan
Caryl P. Haskins
Rita E Hauser
Bruce Karatz
Richard S. Leghorn
Kenneth Lipper
Paul F. Oreffice
Donald H Rumsfeld
Eleanor B. Sheldon
James A. Thomson
Richard B. Wolf
RAND
RESEARCH REVIEW
Spring 1997
Focus on Children
Volume XXI, Number 1
'We are in desperate need to learn about what works'
-Douglas Nelson, Annie E. Casey Foundation
Preschool Years: As the Twig Is Bent
Day care, and its effects on child development, is shap-
This is true regardless of welfare reform, of course. Bad
ing up to be one of the most crucial and emotionally
day care can harm the development of any child.
charged issues of welfare reform. If the reforms work as
Research has shown that children benefit when care-
intended, many more mothers who now stay home with
givers are trained and the ratio of staff to children is
their children will be joining the workforce.
high. But high-quality care is expensive, and states will
have less money to subsidize day care as block grants
Recent research on brain development provides dra-
replace the more generous federal entitlements that
matic proof of the importance of a nurturing, secure and
were swept away in the tidal wave of welfare reform.
stimulating environment in the first three years of life. If
mothers are out working, however, the quality of child
In deciding how to invest their smaller share of federal
care provided by others will largely determine how well
funds, states may wish to emulate already established
the children fare. To care for their children, many
programs specifically aimed at helping the development
mothers will rely on relatives and friends, some of whom
of young children. The most notable of these models is
will be loving and attentive and some of whom will not.
Head Start.
Also, the strain on the day-care system is a matter of
grave concern to child-development and child-care
experts. A recent study found that 40 percent of day-
care centers for infants and toddlers gave less than the
minimal standard of care. Problems ranged from safety
hazards to unresponsive caregivers to a lack of toys.
Another newly published study finds that child care for
the working poor in California can cost up to 90 percent
of a parent's minimum-wage income. And the system-
Head Start-for poor kids, a
much-needed leg up in a highly
competitive world.
even before the effects of the reforms are felt-is unable
to meet much of the state's need, particularly for the
care of infants.
The challenge for state governments, which now have
the lion's share of responsibility for day-care programs,
Ron Chapple/FPG
is to oversee and subsidize child care in such a way as to
increase the likelihood of good outcomes for children.
High-quality day care. A crucial difference.
"Americans want to help poor children without subsidizing their parents,
and that's tough." A children's advocate.
Difference? Does Head Start Make a
Children and Welfare: Investing in What Works
Head
n the ideological wars now raging over the impact of welfare reform on poor children, it is
easy to forget that risks to young people in our society know no class or economic
boundaries. Violence, drugs, teenage pregnancy and sexually transmitted diseases are
problems that haunt the dreams of middle-class and poor parents alike. So, too, are
mundane, but no less troubling, issues of access for their offspring to health care, good
equal advantaged so 1964, they Head footing can start peers. with of school poor their skills, Begun matching aims children on more social in an to
schools and high-quality day care.
No matter how parties to the debate see the problems-as systemic or essentially confined
to the poor-there is no doubt that a large segment of America's children are in trouble.
Consider these statistics: 21 percent of U.S. children currently live in poverty. That's a 46
crown regarded grams, and the as Start the has jewel long in been the
percent increase since 1975, and higher overall than any comparable rate in another West-
em country or in Japan. Our children have neither the financially stable families of Japan,
where only 1 percent of births occur out of wedlock, nor the abundant state support that is
provided in Europe. Many children are simply falling through holes in the safety net.
year-olds 1993, 622,000 an support. Bout 3- to 5-
Reported and confirmed cases of child abuse and neglect are increasing rapidly-from
cost of $2.2 billion a served year.
700,000 substantiated cases in 1990 to 850,000 just two years later-and though some of
the rise is due to more stringent reporting requirements, it is still an alarming statistic. For
The Head many past evaluations
Start, of
children between 5 and 15, homicide rates have tripled and suicide rates have quadrupled
since 1950.
upbeat of the the
Such trends have disturbing implications for the nation's future health and prosperity, and
they raise an inescapable question: What investments must we make in these children as
they grow to adulthood to prepare them to be parents, to work productively, and to share in
mainstream aspirations?
school ered dren's scores Gains after a appear health, attendance troubling cognitive to have and uncov- issue. test chil- on
Social policy research has a vital role to play in guiding the vast changes that are now
under way as Congress and the Clinton administration seek to cut welfare spending by $54
billion over seven years. But assessing the patchwork quilt of state and national programs
directed at children presents an immense challenge for researchers, even without the
some fade-out that program critics a few a effect scam, years. to label disappear arguing has This the led
sweeping changes welfare reform will introduce. Since so many policies are changing at
once-all with potential effects on employment, childbearing and family incomes-figuring
it has little, if
out which questions to ask may be as difficult as finding the answers. And the swirling
long-run children. benefit any, for
political currents over race, economics and values-for example, cutting property taxes ver-
sus investing in schools-make determinations of "success" or "failure" highly subjective.
study reexamines the
A recent RAND/UCLA
"We are in desperate need to learn about what works," said Douglas Nelson, executive
director of the Annie E. Casey Foundation, a Baltimore-based philanthropy known for its
program's effective-
generous support of research on children's issues.
ness using a large
national database and
In such a climate, RAND can make a uniquely valuable contribution because of its long tra-
rigorous methodolo-
dition of empirical, bipartisan research on domestic social issues-or, put less formally, a
gy. Researchers Janet
reputation for sticking to the facts and staying clear of politics. Examining what RAND
researchers have already learned-in relatively calm waters-about
the effects on children of current programs and policies will help to
establish a baseline from which to gauge the impact of the reforms.
It will also take us a considerable distance toward answering ques-
IN THIS ISSUE
tions about what works and what doesn't. In this issue of the RAND
Research Review, we survey the results of some of those studies.
Preschool Years: As the Twig Is Bent /
The Editor
Problems/ Adolescence: 8 Forgotten Age, Forgotten
Children's Health: Is Insurance a Panacea? /6
Additional Publications / 14
Helping Children in a Downsizing World /
RAND Research Review
Currie, a RAND con-
fit less than others remains. Perhaps the answers lie
sultant, and Duncan
elsewhere-in the quality of the programs they attend,
Thomas, a RAND staff
in the families and neighborhoods they live in, or in the
economist, provide some
schools they subsequently attend. As important as those
new and useful insights.
questions are, they will go unanswered until better,
more richly detailed data become available.
Head Start has positive
and persistent effects on the
cognitive achievement of
How Do Parents Choose?
children in the program. Their
performance on vocabulary, read-
Obviously, day care is not solely a problem for the poor;
ing and math tests is significantly
it is a matter of vital concern to working parents no mat-
better than that of brothers and sisters who
ter where they stand on the economic ladder.
stay home, and it is also better than that of chil-
A study led by RAND economist Arleen Leibowitz sheds
dren who attend other preschool programs.
some light on how working parents choose among vari-
Unlike previous studies of Head Start that have
ous child-care options. The findings have important
demonstrated the fading of gains on test scores, the
implications for crafting government policies that affect
RAND/UCLA analysis distinguishes children by race
not only day care but schooling generally.
and ethnicity. It shows that, for white children, the
positive effects on test scores persist well into adoles-
Parents have three basic day-care choices-care at
cence. Further, Head Start attendance lowers their
home, care in someone else's home (family day-care),
chances of having to repeat a grade in elementary
and center-based care. Parents who are making choices
school.
may weigh many features of child care that have little or
nothing to do with its quality for the child. They may
African American children who complete a Head Start
care about the cost of care, about its reliability, about
program also have large and significant test score
location, or about the hours that care is available. Thus,
gains-on a par with their white schoolmates. But the
the more that can be learned about the role these con-
gains are quickly lost. Moreover, for them, par-
siderations play in the child-care choices parents make,
ticipation in the program has no effect on the
the more sensibly government subsidies can be tailored.
probability of grade repetition.
The research team learned that parents who value the
Regardless of race, children attending Head Start or
educational components of child care choose center-
other preschools benefit from greater access to
based care, while parents for whom hours, location, and
preventive health services than children who do not
cost of care are important choose care at home. Choice
attend. Immunization rates are higher, for example.
of family day-care increased if parents thought it was
However, there is no measurable effect of Head Start
on longer-run indicators of health and nutritional
status, such as child height-to-age measures.
In a subsequent analysis, Currie and Thomas found
that Head Start participation also resulted in large
gains for Hispanic children. Compared with their
stay-at-home siblings, Hispanic children in Head
Start programs were able to narrow the test-score gap
with white children by at least one-quarter and close
the gap in the probability of having to repeat a grade
by two-thirds.
But just as there are differences between whites and
African Americans, so there is variation in how well sub-
groups of Hispanic children fare. For example, children
of Puerto Rican mothers reap little benefit from Head
Ron Chapple/FPG
Start, even if the mothers are American-born, but the
gains of children of Mexican mothers, whether born
A nurturing, secure and stimulating environment.
here or in Mexico, are substantial and persistent.
In sum, these studies show that for white children and
important that the child know the caregiver. Several key
for most Hispanics, Head Start is a true success story,
determinants (such as mother's education) affect
giving poor kids a much-needed leg up in a highly com-
choices, primarily by increasing the importance that
petitive world. But the puzzle of why some groups bene-
parents place on the various characteristics of care.
Spring 1997
3
Policy Signposts
Child Care Act of 1989 in the staffing, training, compen-
sation and funding of the CDCs were implemented in
What is more, the study found that tax breaks for child
typically thorough military fashion. The centers under-
care stimulate parents to choose day-care centers over
go four rigorous, unannounced inspections a year,
other types of care. This is probably a consequence of
which result in Department of Defense (DoD) certifica-
how tax credits have been structured-the Internal Rev-
tion if successfully completed.
enue Service will usually allow the credit if children are
in day-care centers or in licensed day-care homes but
Congress also required at least 50 centers to be accredit-
balks at allowing the credit for less formal arrangements
ed in accordance with the standards of a "national
with relatives or friends in which the child-care provider
accrediting body" for early childhood programs. The 50
does not report the payments to the IRS.
accredited centers were to serve as a demonstration
program from which other nonaccredited centers could
Many studies have shown that day-care centers with
learn about best practices.
appropriate educational programs and trained staff pro-
mote child development in positive ways. Thus, Lei-
bowitz and her colleagues suggest, it might be a good
Explicit Guidance for Staff
idea if government policies encourage care in such cen-
Congress provided funds for an evaluation to determine
ters so that children will get an optimal amount of edu-
whether accreditation, in addition to DoD certification,
cation during their preschool years. But the recently
was worth the additional cost and effort. RAND under-
enacted Child Care and Developmental Block Grant
took this evaluation. The scope of the analysis was lim-
does not promote center care over other types of child
ited to examining the accreditation process itself,
care; 75 percent of the funds authorized under this act
exploring its perceived impact on staff and children, and
will go to direct subsidies to poor families for child-care
assessing the added value of accreditation over DoD
services from all types of providers, not only those that
certification. The important question of whether
enhance children's development.
accreditation produces better child outcomes could be
On the other hand, given the current tax system's bias
addressed only indirectly.
against home day care, the block-grant approach may
Nonetheless, Congress's provision for an evaluation was
not be bad policy. We really won't know, say the
unprecedented. In the larger society, accreditation is
researchers, until we answer the question of whether
entirely voluntary (only a minuscule 4 percent of state-
subsidies tied to the use of developmental care are
licensed centers are accredited), and there has never
preferable to those that subsidize care of the parents'
choice, regardless of what that choice might be.
The answer has direct implications for debate on other
public policies, such as vouchers for schooling, which
would enable parents to send children to any school
they choose. Additional research on how parents struc-
ture their decisions about the care and education of
their children would help us understand the issues and
form policies more clearly.
Can We Learn from
the Military?
At first glance, the military seems an odd place to look
for insights into day-care issues, but first impressions
Ron Chapple/FPG
can be misleading. The military operates a vast child-
care enterprise, with spaces for more than 162,000
A critical shortage: Day care for the very young.
preschool-age children in 831 child-development cen-
ters (CDCs) and in 9,810 family child-care homes
been a national study of its effects on child develop-
around the world. The CDCs offer centralized day care
ment. While not definitive, the RAND analysis sheds
at lower cost than is available in the civilian sector and
important light on that issue.
provide care not offered there. In each family care
home, a trained military spouse is authorized to care for
Project leader Gail L. Zellman, a research psychologist at
up to six children in her (or his) government quarters.
RAND, and Anne S. Johansen, a RAND consultant and
health policy analyst with the European Union Commis-
Responding to a push from Congress, the military has
sion in Luxembourg, found that accreditation comple-
worked hard to improve the quality and availability of its
ments and expands the benefits of military certification
day-care services. Changes required by the Military
in important ways.
4
RAND Research Review
cited higher staff morale, better-defined goals, and high-
"Does Head The American Economic Review, charge). pp.
Start Make a Difference?" Janet Vol. Currie 85, No. and 3, 1995, Duncan
er-quality programs among the chief benefits.
Given the small add-on costs of accreditation and the
Thomas, 361-364 (RAND reprint, RP-440, no Children? Janet charge. Currie and Duncan
substantial apparent benefits, the researchers conclude,
universal accreditation of military day-care centers is a
Does 1996, 40 pp., no to
Child-Care Characteristics Choice Journal of Care," of
desirable and achievable goal.
"The Anne Importance S. Johansen, Family, of Arleen Vol. Leibowitz, 53, No. and 3, August Linda J. 1996, Waite, pp. 759-772
Are there lessons in the military's experience for the
the
larger society?
Marriage (RAND reprint, and the RP-582, Effects no charge). Child
Zellman believes there are: "The military certification
Examining Development S. Johansen, Center and Jeannette Van $7.50.
process closely parallels state licensing procedures for
civilian day-care centers. Both are mainly concerned
Anne 1994, 46 pp., ISBN 0-8330-1598-2,
with functional requirements-what is needed in the
way of space and staff-and with health and safety
issues. We found these to be necessary, but not suffi-
cient, conditions for high-quality day-care programs
that emphasize child development. Our study con-
To gain accreditation, CDCs must meet the standards
vinced the military that accreditation brought extra ben-
set by the National Association for the Education of
efits that justified the additional cost. There is every
Young Children (NAEYC), the only national organization
reason to assume these benefits would carry over to
with the authority to grant accreditation for early child-
civilian day care."
hood programs.
The NAEYC requirements for day-care centers, like
those maintained by the military, cover space, equip-
Accreditation takes a big step
ment and safety needs, group size, staff-to-child ratio,
caregiver training and the like. However, the associa-
toward assuring high-quality,
tion goes well beyond these largely functional measures
developmentally sound day care.
to provide explicit guidance for caregiver-child interac-
tions-qualities that are closely associated with gains in
a child's cognitive development, language skills and
social development.
The message for states seems clear: Licensing ensures
For example, the standards specify that staff express
only that day-care centers meet minimal standards of
affection and respect through holding and talking with
structure, health and safety; accreditation takes a big
children, that they speak to children in a friendly and
step toward assuring high-quality, developmentally
positive manner, that the children be encouraged to
sound programs.
express their feelings, and that staff encourage coopera-
tive behavior and use positive guidance techniques to
However, accreditation in the civilian world would be
cope with negative emotions. The NAEYC also stresses
far more costly than the same process in the military.
the need to provide continuity of care and minimize the
And that creates a dilemma. Anything that increases the
shuffling of children among classrooms and caregivers.
cost of day care to parents-be it the developmental
enrichment of programs or more stringent state regula-
It is this emphasis on qualitative issues and appropriate
tions-may discourage poor women from enrolling their
educational programs that most distinguishes accredita-
children. This, in turn, may affect their ability and will-
tion from military certification. Although certification
ingness to work. Thus, two worthy goals-getting
standards are extensive and rigorous, they basically con-
women off welfare and into jobs and providing develop-
stitute a checklist for meeting DoD regulations and
mentally sound programs for their offspring-are in
ensuring overall compliance with the mandates of the
danger of canceling each other out.
legislation. Certification is, in fact, much like state
licensing procedures in its focus on health, fire and safe-
Zellman suggests a possible solution: The new federal
ty issues.
block grant for child care and development includes a
"set aside" to improve care. This might be used to sup-
Zellman and Johansen find ample evidence that accred-
port accreditation efforts, thus lowering the cost to par-
itation provides a range of additional benefits over the
ents. But she adds that as long as parents do not insist
DoD certification process alone. Nearly everyone
on or understand the importance of high-quality pro-
involved in the process judged the effect of accreditation
grams, day-care centers will have only weak incentives
to be overwhelmingly positive. Seventy-five percent
to seek accreditation.
Spring 1997
5
Children's Health:
S Insurance a Panacea?
Children's health is another front-burner issue in the
received by children covered by Medicaid, by private
welfare reform debate. Turning up the flame is concern
health insurance, and those with no insurance coverage
over the millions of children who lack health insurance.
at all.
The United States spends about $7 billion a year, or 12.6
Insurance Effects Differ by Race
percent of the Medicaid budget, on health care for poor
children. Since the introduction of Medicaid in 1965,
"If high rates of sickness and death are solely the result
this investment has paid off in lower infant mortality
of an inability to pay for care," they write, "we would
rates and increases in hospitalization rates and doctor
expect to find that Medicaid coverage has the same
visits for poor children. Despite these advances, howev-
effect on the use of care as private insurance coverage,
er, America's children remain in poor health relative to
and that white and African American children with simi-
those in other industrialized countries.
lar insurance coverage have similar rates of use."
At 10 per 1,000, the infant mortality rate in the United
States is still the highest in the developed world. Com-
pared with Canadian children, American kids are sicker,
with 28 percent more disability days and 44 percent
more bed days. Mortality rates of American children are
also much higher than in Canada-14 percent higher for
infants and 8 percent higher for children one to four
years of age. There are also dramatic racial differences
in health and the use of health care services. The infant
mortality rate among African Americans is double that
among whites and, in some states, rivals the mortality
rates of developing countries. All of this suggests that
poor children in this country, particularly poor black
children, are not receiving the same quantity or quality
of health care as children in other wealthy countries.
Mark Harmel/FPG
Many concerned observers blame this disparity on the
Despite the advances, a poor health report.
rising number of children who are not covered by insur-
ance-in 1995, 9.8 million children, almost 14 percent of
Instead they found that private health insurance and
children under 18, were uninsured for the entire year,
Medicaid are not interchangeable in their effects on the
medical care of children, and that racial differences in
the use of care persist regardless of family income and
type of insurance coverage. Based on two measures of
Poor children, especially poor black
care-routine checkups and visits to the doctor for ill-
ness-the researchers found that
children, are not getting the same
Medicaid-covered children in general are more likely
quantity or quality of care as
to have routine preventive checkups than children
children in other wealthy nations.
with private insurance or no insurance at all.
However, white children covered by Medicaid get
more attention from the health care system-both
more routine checkups and more doctor visits for
illness-than children of other races, even if those
according to the U.S. Bureau of the Census. President
children are covered by private insurance.
Clinton is reported to be considering a $750-million-a-
year program to help extend insurance to "gap kids."
For black children, neither Medicaid nor private
insurance coverage is associated with an increase in
But would extending medical coverage to all children
the number of visits to the doctor for illness.
solve the problem? The RAND/UCLA research team of
Moreover, black children with private insurance are
Currie and Thomas investigated the issue. Using a large
no more likely to have routine checkups than
national database, they compared the medical care
children without coverage.
6
RAND Research Review
These differences in levels of care of black children
Poor Children and HMOs
and white children persist across income levels. That
is, regardless of type of insurance coverage or lack of
Recently, Congress has been pondering legislation that
it, poor black children see a doctor less often than
would channel poor people on Medicaid into HMOs as a
poor white children, and middle-class black children
way of curbing costs without creating new health care
less often than middle-class white children.
barriers for the poor.
If lack of insurance is not the culprit in the unequal care
But a big question mark hovers over how HMOs achieve
of black children, what is? The researchers' data could
their vaunted efficiencies. Do they hold down costs by
not help them answer that question, but drawing on evi-
eliminating only unnecessary care or do they scrimp on
dence from other studies, they suggest an alternative
needed care as well, cutting services indiscriminately?
explanation: Because of residential segregation, black
The answer is particularly important as it affects poor
children may lack access to providers of quality care.
children, one of the largest and most vulnerable seg-
Studies have found that areas with a large residential
ments of the population.
concentration of Medicaid patients have fewer doctors
willing to serve them. In addition, doctors with a high
To find out, economist Leibowitz and her colleagues
share of black patients may provide lower-quality care.
examined how medical care obtained by children in one
Black children are twice as likely as white children to
HMO differed from that obtained from traditional physi-
cians in fee-for-service practice.
The results of the study were encouraging: Children in
both the fee-for-service and prepaid (HMO) plan had
Coverage is not, in itself, a
roughly the same number of routine doctor checkups,
but children in the HMO had significantly fewer visits
guarantee that the children who
for illness.
most need care will get it.
This does not mean that children in the HMO were get-
ting too little care, the researchers said. On the contrary;
because the reduction in acute care visits was concen-
trated in a particular group-children with no health
receive care in a clinic or emergency room rather than
problems at the start of the experiment-it suggests that
from a private provider, health maintenance organiza-
the HMO is doing a good job of targeting resources on
tion (HMO), or group practice.
kids with the greatest health care needs rather than
merely rationing services across the board.
Other factors not bearing on racial differences help to
explain why the poor need more than insurance cover-
age as their passport to the health care system. Many
states limit the services available to Medicaid patients;
for instance, in 1986, Texas did not cover clinic services,
Connecticut did not cover emergency services and New
Public Insurance, Private Insurance Duncan
Hampshire restricted Medicaid patients to 12 outpatient
"Medical Care Differences for Children: in Utilization," Janet Vol. Currie, 30, No. and 1, Winter
visits per year. Finally, bureaucratic delays may pose a
and Racial Journal of Human Resources, charge).
Thomas, The reprint, RP-397, no
significant barrier to timely care-the average delay in
processing Medicaid applications is four weeks.
1995, pp. Care: Arleen Comparison Leibowitz, A.
of a Medicaid and No. Kimberly 6, June
The message of this study is that expanding health
insurance coverage is likely to yield substantial benefits
in terms of improved health for children. But expanding
Medicaid is not, in itself, the solution that will assure
Jane McGuigan, 1994, Funding previous Mauldon, pp. 899-904 American for article Joan the the (RAND L. studies Journal was reprint, provided of P. described Public Sloan RP-353, Health, by Foundation, the no in Vol. charge). this National 84, and Institute the the
Science Office
that those who most need health care will get it. 1
Foundation, The Robert of
of Child the Health Johnson Foundation, Governors Care Financing
Wood Administration, and the National
Association.
I Other RAND studies bear on the question of expanding Medicaid
coverage for poor children and their mothers. See the bibliogra-
phy in this issue, pp. 14-15, for studies by Currie and Gruber and
by Halfon et al.
Spring 1997
7
A desperate need to be 'cool'
Adolescence: Forgotten Age, Forgotten
Problems
Adolescence is a forgotten age, its problems largely
A Disturbing Portrait
ignored in the clamor for attention to competing societal
concerns. So argues Phyllis Ellickson, a senior RAND
In a recent report, Ellickson and colleagues Maria Elena
analyst who has devoted much of her career to the study
Lara, Cathy D. Sherbourne and Bonnie Zima unveil a dis-
of young people in the years between childhood
turbing portrait of the adolescent condition.
and maturity.
Adolescents start out in good health relative to the rest of
"Perhaps that is because adolescents are so often per-
the population: Expected deaths for 10- and 11-year-
ceived as troubled kids or troublemakers," she observes,
olds are lower than those for any other age. As adoles-
"unlike younger children for whom it is easy to get a
cents grow older, however, their risk of dying increases;
sympathetic hearing."
the mortality rate for 15- to 19-year-olds is three times
that for 10- to 14-year-olds. These differences reflect the
A worry to their parents and teachers, teenagers are often
fact that more older adolescents engage in high-risk
touchy, obsessed with the approval of their peers, and
behavior and are the victims of violence.
seemingly indifferent-or
Seventy-five percent of all
downright hostile-to the
adolescent deaths are due
views and values of adults.
to three causes: uninten-
Ellickson's research has
tional injuries (particularly
shown that even good stu-
from automobile accidents),
dents from financially
homicide and suicide. Each
secure homes can go off
is more likely to occur
track when they reach
among older adolescents.
junior high school.
Each is also linked to various
Ellickson, a social policy
risk-taking activities, such as
analyst, finds the years
drug use or drinking and
between 12 and 18 are an
driving, or to negative emo-
"extremely vulnerable" time
tional states, such as depres-
in the lives of young people.
sion or conduct disorders, or
to some combination of
"They desperately want the
these.
approval of their friends, to
Diane Baldwin/RAND
Other threats to the health of
be perceived as 'cool,' and
American adolescents arise
they will do dangerous and
from what scholars are call-
just plain dumb things to
ing the "new morbidity." By
gain that status." Unfortu-
The new morbidity. Twenty percent of high school seniors smoke;
this they mean illness associ-
nately, temptations to
about 30 percent are binge drinkers.
ated with drug use (including
drink, take drugs and en-
alcohol and cigarettes), vio-
gage in precocious sex arise long before adolescents
lent behavior, unsafe sexual activity, and mental disor-
have developed skills to cope with the forces that are
ders. Such problems often go together: Drug use
whipsawing them. Violent behavior and emotional
raises the risk of unsafe sexual behavior, teens with men-
problems, such as depression, which may be the precur-
tal health problems often use drugs, and teens who use
sor of a lifelong disability, may worsen during this period
drugs are often violent or have mental health problems.
as well.
More than one-fifth of the nation's high school seniors
It may seem odd to think of adolescence as a major pub-
smoke every day, and about 30 percent are binge
lic health issue, but that is exactly how Ellickson sees it.
drinkers-practices that put them at risk of developing
"I believe that adolescent health encompasses far more
long-term addictions to tobacco and alcohol.
than the absence of physical disease or disability. It
includes mental and social, as well as physical, well-
Over half of the nation's high schoolers are sexually
being."
active, but few use condoms consistently. As a result,
8
RAND Research Review
about one million teenage girls become pregnant each
Against this backdrop of rising need and limited access,
year and the risk of contracting AIDS or other sexually
Ellickson worries that too little is known about the effec-
transmitted diseases (STDs) is rising. In addition, about
tiveness of intervention programs. Evaluations of drug
one in five adolescents suffers from a diagnosable men-
treatment programs have largely ignored adolescents;
tal disorder, which can develop into life-threatening
they have also focused on such substances as heroin,
problems or severely impede the young person's ability
which few adolescents use. Moreover, studies of mental
to negotiate the shoals that separate adolescence from
adulthood.
Young people from all ethnic and demographic groups
are prey to the new morbidity, but its consequences are
particularly severe for teenagers who lack the resources
to get help. About one-third of poor and near-poor ado-
lescents have neither Medicaid nor private health insur-
ance coverage. A surprisingly large portion of
middle-income teenagers also lack coverage-almost 30
percent of uninsured adolescents live in families with
incomes 200 percent or more above poverty levels.
The ABCDs of Sex
Diane Baldwin/RAND
Access to medical help for teenagers is further restricted
by limitations on coverage (particularly for preventive
and mental health services), by payment policies that
Before trouble with the law closes down their horizons.
promote expensive hospitalization over less costly com-
munity- or family-based treatment, and by adolescent
health services for teenagers have been plagued by
concerns about confidentiality. The frequent failure of
methodological flaws that make it difficult to identify
physicians to identify emotional and behavioral prob-
program-induced gains.
lems in adolescents, plus the adolescents' own failure
"We still lack solid evidence about what treatment
and that of their parents to seek help, are also factors.
regimes work, how long the effects last, and which prob-
Doctors also need to be more aggressive in discussing
lems and which adolescents are helped," she says.
sexual matters with teenagers. A RAND survey of 2,000
high school students found that about half of the physi-
Drugs and Other Risky Business
cians who treat these adolescents do not discuss sex and
Studies by Ellickson and others have found that school-
sexual risk prevention with them. This is the case even
based prevention programs can curb drug use in middle
though professional medical organizations uniformly
school. The programs are more effective at delaying or
urge such counseling and an overwhelming majority of
reducing cigarette and marijuana use than drinking;
the young people say they would find such discussions
they also work better for nonusers and experimenters
helpful.
than for committed users. Once the lessons stop, how-
As Dr. Catherine D. DeAngelis, editor of the Archives of
ever, program effects begin to wear off. Thus discontin-
Pediatric and Adolescent Medicine, puts it, "Discussing
uing these programs in high school is a big mistake.
the B's (birds and bees) with adolescents was never easy
"We need to keep these programs going after kids make
for physicians or parents. Now that we've added the A's
the transition to high school," Ellickson argues. "Each
(AIDS), C's (condoms) and D's (diseases of sexual trans-
year that we hold off initiation buys kids more time to
mission), it's even more challenging and important."
get some life experience under their belt. And if they do
experiment later on, they are much less likely to become
Too Little Known
addicted or to mess up their lives because of drug use.
To overcome these barriers to care, a number of systems
The name of the game in prevention is delay, delay,
that specialize in adolescent health have sprung up
delay."
across the country. Comprehensive health care centers
Programs aimed at reducing sexual activity and teenage
that provide multiple services at a single site ("one-stop
pregnancy have modest influence, she acknowledges,
shopping") have been the most thoroughly studied.
but those that provide condoms and foster their use
While they appear to be an effective strategy for reach-
may be more successful at curbing both pregnancy rates
ing poor teenagers and for getting them needed care,
and the spread of STDs.
the researchers observe, not much is known about their
effect on improving adolescent health over the long
The relatively modest results of treatment and preven-
term.
tion efforts should come as no surprise. Ellickson
Spring 1997
9
blames them, in part, on the complex nature of the
Better training in adolescent medicine, including how to
problems and on the blurring of cause and effect. Drug
communicate with teenagers, would go a long way
and alcohol use are linked to risky driving, death by
toward improving health professionals' ability to identi-
accident, violence, suicide and unsafe sex, while poor
fy and cope with mental disorders, sexually at-risk teens,
mental health and violent behavior may be either the
and drug abuse. Being able to see the doctor in a friend-
cause or the consequence of drug use. Added to that are
ly and familiar setting (teen clinics, school-linked health
influences on teenagers as diverse as belief in their own
invincibility, difficulties at school, societal and parental
attitudes that condone high-risk behavior, family prob-
lems and genetic vulnerability.
Children can't be protected forever,
Risk factors that are bound up with family dynamics,
but there are things society can, and
community and social norms, or school experience are
should, do to help them through the
difficult to modify, Ellickson notes. Certainly, sorting
out these tangled influences is beyond the province of
high school years.
clinics, community-based centers) clearly helps teens
talk more freely about personal matters, respond more
positively to the doctor and feel more satisfied with the
quality of care they receive.
If they lack the insurance coverage to get through the
door, however, few teens will benefit from greater pro-
fessionalism and more coordinated services. Although
removing cost barriers to care is not a panacea, expand-
ed insurance coverage is an important piece of the
Diane Baldwin/RAND
mosaic. Ellickson recommends that current efforts to
reform the health care system should aim at both reduc-
ing the number of uninsured and underinsured adoles-
cents and providing a basic floor of preventive and
Temperature-taking the newfangled way. Base programs in schools,
mental health services for this group.
because that's where the kids are.
"I'm not arguing that children can be protected forever.
health care providers, who see adolescents only when
They can't. But there are things we as a society can and
they happen to show up in their office or clinic.
should do to help them through the high school years,"
Ellickson contends, "before their horizons close down
That is why viewing the new morbidity as a public
and mistakes like pregnancy or trouble with the law cut
health problem is important, she maintains. Only then
them off from a good job or college."
can the door be opened to coordinated prevention and
treatment efforts that involve families, schools, commu-
nity agencies, and the media, as well as health profes-
sionals.
Forgotten Ages, Adolescents' Donald
"Rather than fostering hospitalization as the dominant
Health, Sherbourne, Phyllis and L. 1993, 55
strategy for treating teenagers with mental health or
pp., ISBN: 0-8330-1409-9, $13.00. RAND.
substance abuse problems," she says, "we need to pro-
mote community-based or school-linked systems of
care that recognize the interrelatedness of many adoles-
This Aboutsexication Betwerand study was funded by and and Physicians Mark David A. E.
cent problems."
Robert M. Bell, Laura P. Petersen, Adolescent Medicine,
Schuster, Kanouse, Vol. 150. No. Archives 9, September of Pediatrics 1996, and pp. 906-913 (RAND
Including schools in a coordinated program is particu-
larly important, she adds. Schools are where most chil-
reprint, This work RP-569, was supported no charge). by The American Robert Wood Foundation Johnson for
dren can be found and where problems can be
identified before they become critical. Moreover, some
Clinical AIDS Research, Scholars the Program, Agency the for Health Care Policy and
school environments exacerbate emerging problems,
Research, and RAND.
whereas others provide countervailing mores or rewards
for productive behavior. Hence, efforts to modify school
practices and norms may help curb high-risk behavior.
10
RAND Research Review
I e ping Chi dren in a Downsizing World
"The challenge is to take the array of forces at our dispos-
students-and rapidly, in the case of minorities. From
al and put them to work in a downsizing environment-
about 1975 to 1990, the average math and reading scores
to actually change welfare systems for the better, not just
of students 13 to 17 years old increased 3 percentage
hack away at benefits and services. In short, we must
points for white students, 11 points for Hispanic stu-
learn how to do more with less."
dents and 19 points for African American students. A
-Nick Bollman,
major part of the explanation is improvements in the
James Irvine Foundation, to researchers at a RAND
family environment, notably, smaller family size and a
conference on the new federalism, May 1996.
dramatic increase in the education levels of African
American mothers.
That imperative-to do more with less-has led RAND
to look not only at massive welfare programs like Aid to
New efforts are planned or under way in other areas:
Families with Dependent Children, but beyond them at
studies of programs that seek to improve parenting skills
a broad array of other less famous (and less studied)
by involving inner-city parents in their children's
efforts. The search has been for programs and strategies
schooling; studies of the role of grandparents as the
that not only help children but that may have outsized
"second line of defense" in protecting and caring for
payoffs for the dollars invested. These include investi-
their grandchildren; and a large-scale investigation of
gating novel or overlooked approaches to the problems
every aspect of neighborhoods that may be important in
of children and exploring
the lives of children-from
untapped resources in
schools, churches, libraries,
neighborhoods, communi-
recreational programs, clin-
ties and the family itself.
ics and hospitals to the
social, economic and cultur-
Among many other child-
al characteristics of neigh-
focused projects, in recent
borhood interactions. (Also
years RAND has carried out
see the box accompanying
major, scientifically rigor-
this article for an account of
ous studies of the effective-
RAND's involvement in the
ness of school-based drug
"Early Childhood Public
prevention programs and of
Engagement Campaign.")
the influence of the family
on children's school perfor-
Diane Baldwin/RAND
Perhaps the most promising
mance.
news comes from a recent
study of strategies aimed at
A multi-site drug preven-
keeping high-risk youth out
tion experiment funded by
Grandparents as the 'second line of defense.'
of trouble with the law. A
the Conrad N. Hilton Foun-
RAND research team found
dation proved successful in curbing marijuana and
intriguing evidence that crime might be reduced more
tobacco use among seventh and eighth graders. The
cost-effectively by these strategies than by the longer
two-year program yielded positive effects in highly
prison sentences that are currently in vogue.
diverse environments, including urban, suburban, and
rural communities and in schools with both high and
Dollar for dollar, the analysts found, programs using
low minority attendance. After the lessons ended, how-
financial and other incentives to induce disadvantaged
ever, the benefits of the program eroded, suggesting the
high school students to graduate avert five times as
need for continued prevention efforts during high
many serious crimes as the stiffer prison terms stipulat-
school. Reinforcing the anti-drug message in high
ed by California's "three-strikes" law. Programs that
school via "booster" programs could further delay for
provide parental training and therapy for families whose
many the initial use of these substances, the researchers
children have shown aggressive behavior in their early
said. And that would be no small victory: Children can-
school years avert almost three times as many serious
not be protected forever, but postponing initiation until
crimes.
after high school buys them time to develop more
mature judgment and skills in resisting the multifarious
RAND's earlier study of the effects of the three-strikes
pressures to use drugs.
law found that full implementation will produce a 21
percent overall reduction in crime at a cost to the state
The student achievement study found that, contrary to
of an additional $5.5 billion per year in spending on the
mainstream opinion, student test scores are rising for all
criminal justice system, notably for prison operation
Spring 1997
11
Directed by Greenwood, the team analyzed numerous
pilot programs employing four different approaches.
Many child-related studies under way
Multidisciplinary Efforts a Hallmark of
Home visits by child care professionals beginning
before birth and extending through the first two years
RAND Programs
of childhood, followed by four years of day care.
RAND is conducting many more studies concerned with
the health and well-being of children than can be reported
Training for parents and therapy for families with
here. The work draws on the expertise of researchers in
young children who have shown aggressive behavior
the fields of social policy, sociology, economics, demogra-
in school.
phy, statistics, criminal justice, education, medicine,
health care policy, health care finance and school finance.
Four years of cash and other incentives to induce dis-
Research is carried out in four programs, which cooperate
advantaged high school students to graduate.
in cross-disciplinary efforts. The programs and individuals
to contact for additional information are listed below.
Monitoring and supervising high-school-age youth
who have exhibited delinquent behavior.
The Labor and Population Program
Lynn Karoly, Director
A preliminary assessment of these programs found that
home visits reduce crime by 50 percent; parent training,
Telephone: 310-393-0411, ext. 7359
by 60 percent; graduation incentives, by 70 percent; and
Web address: http://www.rand.org/
delinquent programs, by 10 to 20 percent.
organization/drd/labor/
The Criminal Justice Program
Large-scale, multimillion-dollar
Peter W. Greenwood, Director
Telephone: 310-393-0411, ext. 6321
demonstrations of these promising
Web address: http://www.rand.org/
programs 'would be an investment
centers/icj/
worth the cost.'
The Health Program
Robert H. Brook, Director
For information on adolescents' health, contact
However, in the "real world" these benefits can be
expected to decrease. The RAND team subtracted a per-
Phyllis Ellickson
centage for relatively new and untested programs and
Telephone: 310-393-0411, ext. 7638
another percentage for the decay of effects over time.
Web address: http://www.rand.org/
Another factor is how well the programs target the pop-
organization/drd/health/
ulation most likely to eventually commit crime. Not sur-
prisingly, the later the intervention-such as with
The Institute on Education and Training
graduation incentives and programs aimed at delin-
Roger Benjamin, Director
quents-the better the targeting.
For information, contact
Kathleen Shizuru
Telephone: 310-393-0411, ext. 6684
Diverting Children from a Life of Crime: Measuring C. Peter Costs Rydell, and
Web address: http://www.rand.org/
centers/iet/
Benefits, and James Peter Chiesa, W. $15.00. The entirety 1996, 82 on pp., the ISBN:
and construction. The new work indicates that a combi-
0-8330-2383-7, World The "Drug Test," research Wide Prevention Phyllis Web is L. summarized Ellickson 1990. in Junior and in High: Robert a one-page A M. Multi-Site Bell, brief, Science, RB-4010. Longitudinal Vol. 247, of a
nation of graduation incentives and parent training
could achieve a similar amount of crime reduction for
pp. "Preventing 1299-1305, Adolescent Drug Use: Ellickson, Long-Term Robert Results M. Bell, and
less than $1 billion.
Junior High Program," American Phyllis Journal L. of Public Health, charge). Vol. 83,
"None of this suggests that incarceration is the wrong
approach," emphasize authors Peter W. Greenwood,
Kimberly No. The Conrad 6, studies 1993, McGuigan, N. Hilton pp. described 856-861 Foundation, In (RAND this article the RAND. reprint, Lilly were RP-208, Endowment supported no Inc., by the the
Karyn E. Model, C. Peter Rydell and James Chiesa. The
James Irvine Foundation, and
point, they explain, is that policies that allocate huge
sums to imprison career criminals and little for targeted
efforts to discourage such careers are "lopsided."
12
RAND Research Review
Weighing all the factors, the analysts estimated the
a much broader basis. However, their analysis showed
number of serious crimes prevented per million dollars
that the cost-effectiveness advantage of the best of these
spent for each program. The options with the most
programs will hold up even if further study reveals
immediate crime-reduction effects appear to be parent
somewhat weaker program results than those reported
training and graduation incentives.
here.
Greenwood and his colleagues are cautious about their
Large-scale, multimillion-dollar demonstrations of
findings, pointing out the need for better data about the
these promising programs "would be an investment
results of such programs when they are implemented on
worth the cost," the authors conclude.
High-Voltage Media Campaign
the strength and implications of that evidence.
RAND's task is to define and quantify-in highly
to Spotlight Importance of First
specific terms-the potential benefits of early child-
Three Years of Life
hood interventions to children, to their parents and
to society at large.
RAND Analyzing Benefits, Costs of Early
A team of researchers, led by Peter W. Greenwood
Childhood Programs
and Lynn A. Karoly, will first review the many studies
that have documented the impact of these pro-
An unprecedented and sustained media blitz by
grams. Using computer models and other analytic
prominent entertainers, national media experts,
tools, they will then pull together the findings to
leading foundations and experts on early childhood
show the specific nature of the expected benefits;
has been launched to focus public attention on the
the magnitude in dollar, or other, terms; and the
importance of the first three years of life and on
time stream of each benefit (whether it comes early
what families and communities can do to enhance
or later in life). This synthesis will be published in a
children's healthy development during these years.
form that is both understandable to a lay audience
and supportable by science.
The "Early Childhood Public Engagement Cam-
paign" plans to go beyond a media call for action,
The following are examples of potential benefits of
however. A sustained
early childhood programs:
push, over many
For the child: improved health, educational
months and in many
venues, is under way
attainment, enhanced cognitive growth, avoidance
of substance abuse and other antisocial behavior;
to foster and promote
and in adulthood, increased income
child-focused pro-
grams at every level of
For parents (because many programs target them):
government-from
enhanced job success, greater educational attain-
Washington, to state
ment, better mental health, improved marital sta-
capitols to city halls.
bility, fertility control, and avoidance of substance
The effectiveness of
dependence and child abuse
the campaign will
For the community and society: increased
depend in large part
economic participation by parents and the conse-
Diane
on its ability to show
quent boosts to tax receipts, lower welfare costs,
the public concrete
increased public safety, lower costs to the justice
evidence regarding the importance of the first three
system, and reduced expenditures on a wide range
years of life for the individual child and its family,
of public programs, such as special education,
the implications of these early years of development
foster care and children's protective services.
for the larger community, and the capacity of pub-
lic- and private-sector programs to turn this devel-
An interim report will be available by the end of
opment in a positive direction.
April, in time for the campaign kickoff-an hour-
long, ABC Prime Time Special on the first three years
With funding from the California Wellness Founda-
of life, being produced and directed by Rob Reiner.
tion, RAND will analyze existing evidence in these
Some of RAND's findings will be highlighted in the
three areas and provide an objective assessment of
program.
Spring 1997
13
Additional Publications
Day Care and Head Start
Medicaid Fee Policy," American Economic Review,
Vol. 85, No. 2, May 1995, pp. 106-111.
Hao, Lingxin, and Arleen Leibowitz, Public Policies,
Private Support and Single Mothers' Schooling, Work,
Currie, Janet, and Jonathan Gruber, "Saving Babies: The
and Child Care, RAND/DRU-853-NICHD, 1994, 41 pp.,
Efficacy and Cost of Recent Changes in the
no charge.
Medicaid Eligibility of Pregnant Women," Journal of
Political Economy, Vol. 104, No. 6, December 1996,
Hotz, V. Joseph, and Rebecca Kilburn, Regulating Child
pp. 1263-1296.
Care: The Effects of State Regulations on Child Care
Demand and Its Cost, RAND/DRU-956, 1995, 65 pp., no
Halfon, Neal, David L. Wood, R. Burciaga Valdez,
charge.
Margaret Pereyra, and Naihua Duan, "Medicaid
Enrollment and Health Services Access by Latino
Johansen, Anne S., Arleen Leibowitz, and Linda J. Waite,
Children in Inner-City Los Angeles," Journal of the
Parents' Demand for Child Care, RAND/
American Medical Association, Vol. 277, No. 8,
DRU-741-NICHD, 1994, 41 pp., no charge.
February 26, 1997, pp. 636-641.
Kilburn, M. Rebecca, and Lingxin Hao, "The Impact of
Wood, David, Cathy Donald Sherbourne, Neal Halfon,
Federal and State Policy Changes on Child Care in
M. Belinda Tucker, Vilma Ortiz, Julie Shea Hamlin,
California," The New Fiscal Federalism and the Social
Naihua Duan, Rebecca M. Mazel, Mark Grabowsky,
Safety Net, James Hosek and Robert Levine, eds.,
Philip Brunell, and Howard Freeman, "Factors Related
RAND/CF-123-RC, 1996, 200 pp., ISBN: 0-8330-2411-6,
to Immunization Status Among Inner-City Latino and
$15.00.
African-American Preschoolers," Pediatrics, Vol. 96,
No. 2, August 1995, pp. 295-301.
Zellman, Gail L., Anne S. Johansen, and Lisa S. Meredith,
Improving the Delivery of Military Child Care: An
Analysis of Current Operations and New Approaches,
Adolescent Health
RAND/R-4145-FMP, 1992, 83 pp., ISBN 0-8330-1242-8,
$7.50.
Ellickson, Phyllis L., "Helping Urban Teenagers Avoid
High-Risk Behavior," Urban America: Policy Choices for
Los Angeles and the Nation, James B. Steinberg, David W.
Child Health and Insurance
Lyon, and Mary E. Vaiana, eds., RAND/MR-100-RC,
1992, pp. 105-126, ISBN: 0-8330-1281-9, $20.00.
Currie, Janet, Do Children of Immigrants Make
Differential Use of Public Health Insurance? RAND/
Ellickson, Phyllis L., and
DRU-1461-RC, 1996, 60 pp., no charge.
Ron D. Hays, "Ante-
cedents of Drinking Among
Currie, Janet, "Socio-Economic Status and Child Health:
Young Adolescents with Differ-
Does Public Health Insurance Narrow the Gap?"
ent Alcohol Use Histories," Journal of
Scandinavian Journal of Economics, Vol. 97,
Studies on Alcohol, Vol. 52, No. 5, 1991,
No. 4, 1995, pp. 603-620.
pp. 398-408 (RAND/N-3424-CHF, $4.00).
Currie, Janet, and Jonathan Gruber, "Health Insurance
Ellickson, Phyllis L., Ron D. Hays, and Robert
Eligibility, Utilization of Medical Care and Child Health,"
M. Bell, "Stepping Through the Drug Use
Quarterly Journal of Economics, May 1996,
Sequence: Longitudinal Scalogram Analysis of
pp. 431-464.
Initiation and Regular Use," Journal of Abnor-
mal Psychology, Vol. 101, No 3, 1992, pp.
Currie, Janet, and Jonathan Gruber, "Physician
441-451 (RAND reprint, RP-159, no charge).
Payments and Infant Mortality: Evidence from
14
RAND Research Review
Ellickson, Phyllis L., Kimberly A. McGuigan, Virgil
David E. Kanouse, "The Sexual Practices of Adolescent
Adams, Robert M. Bell, and Ron D. Hays, "Teenagers
Virgins: Genital Sexual Activities of High School Stu-
and Alcohol Misuse in the United States: By Any
dents Who Have Never Had Vaginal Intercourse," Amer-
Definition, It's a Big Problem," Addiction, Vol. 91,
ican Journal of Public Health, Vol. 86, No. 11, November
No. 10, 1996, pp. 1489-1503 (RAND reprint, RP-600,
1996, pp. 1570-1576 (RAND reprint, RP-601, no charge).
no charge).
Hays, Ron D., and Phyllis L. Ellickson, "Associations
Family and Community Interventions
Between Drug Use and Deviant Behavior in Teen-
agers," Addictive Behaviors, Vol. 21,
Ellickson, Phyllis L., and Robert M. Bell, Prospects for
No. 3, 1996, pp. 291-302
Preventing Drug Use Among Young Adolescents,
(RAND reprint, RP-533, no
RAND/R-3896-CHF, 1990, 64 pp., ISBN: 0-8330-1047-6,
charge).
$7.50.
Schuster, Mark A.,
Greenwood, Peter W., C. Peter Rydell, Allan F. Abra-
Robert M. Bell, and
hamse, Jonathan P. Caulkins, James R. Chiesa, Karyn E.
Model, and Stephen P. Klein, Three Strikes and You're
Out: Estimated Benefits and Costs of California's New
Mandatory-Sentencing Law, RAND/MR-509-RC, 1994,
87 pp., ISBN: 0-8330-1597-4, $13.00.
Grissmer, David W., Sheila Nataraj Kirby, Mark Berends,
and Stephanie Williamson, Student Achievement
and the Changing American Family, RAND/
MR-488-LE, 1994, 131 pp., ISBN: 0-8330-1616-4,
$15.00.
Hao, Lingxin, "Poverty, Public Assistance,
and Children in Intact and Single-Mother
Families," Journal of Family and Economic Issues,
Vol. 16, No. 2/3, 1995, pp. 181-205 (RAND reprint,
RP-489, no charge).
Reports of research from RAND's covered Distribution in this issue Services, CA 90407-2138. may be 1700 Main To
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available URL:
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Spring 1997
15
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