ED 124.281

AUTHOR-TITLE

INSTITUTIONREPORT NOPUB DATENOTE

AVAILABLE FROM

DOCUMENT RESUME

PS 008 605

Stretch, Bonnie BarretiThe Role of the Fanny in Child Developsent:,Implications for State Policies and Programs.Education Commission of the Atates, Denver, Colo.'ECS-R-57 -

Dec 7553p.; The.fifteenth report of the EducationCommission of the States. Early. Childhood ProjectEducation Commission of the States, ,300 Lincoln -

Tower, 1860 Lincoln Street, Denver, Colorado 8I201(Paper,43.50)

EDRS.PRICE MP-80.83 HC -$3.5Q flusj,ottage.'DESCRIPTORS *Child Development; Day Care Services; *Family Role;

Federal lid; Health Services; ParenthOod Education;*Policy Formation;, *Piogran Evaluation; SpecialServicet; *.slate,rograns

'IDENTIFIERS *Education Conkistion of the Statet

ABSTRACTrat report contains suggestions for state level

policy that move allay from the deficit model of intervention andtoward a policy of continuing support to all young children and theirfamilies. It includes information ,for evaluating programs and dealslargely with nmthods of program implementation in four areas of earlychildhood: (1 .education for parenthood, (2) health service, A3) d4ycare, and (4) services to families with special needs (including 1W

families with handicapped children, teenage parents, or child abusing

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parents.) (JAB)

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0s.

The AL)le of the Pamily in Ghild Development

`Implications for state 4-Policies and Programs

Vitad-1

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Early Childhood PrOlectReport No. 15

Education Commission of the StatesReport No 57

December1975

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'11111b.,

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Governor Jerry Apodaca *,New MexiccChairman

Hannih AtkinsOklahoma State Representative

Robert W. BlanchardSuperintendent of Schools.Portland, Oregon

Nikki BlankenshipEarly Childhood Bilingu I ProgramSouthwest Educational evelopmentLaboratory

Austin, Texas

HoWard BrayAcademy for Contemporary ProblemsWashington, D.C. I

oent,

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Task Force Members

Hubirt Hcmplirey IllMinnesota State Senator

Prestor,BruceOffice of Child' DeveloWashington, O.C.

Edwin Martin,Deputy Commissioner

theBureau of Education for e

Handic pedU.S, Off ce Of Education, H.E.W.

Robert . McNairGovemo of South Carolina, 1965.71

Mrs. Rey E. MillerChairmaState Ad isory Council forVocatio al Education

North Da ota

John H. Homey@ r

President EmeritusBank St t CollegeNew Yor Now York

Betty Bumpers ,Bethesda, Maryland

Benjamin CarmichaelTennessee

Barbara FinbergProgram OfficerCarnegie Corporation of New York

D. Robert GrahamFlorida- State Senator

I o-Dorothy GreggDirector of Public Relation'sCelinesirCorporation .

New York, New York

Beverly GunstVice President, Nursery School

ssociation for ChildhoodEducation International ..

rval Hanlonormer U.S. Representativel

daho

ohn B. Himelrickirictorest Virginia Interagency Councilfor Child "Qavelopment Services

*The Albert SchneiderPrinci I

St. Franc Xavier SchoolAlbuquer ue, New Mexico

Howard S bragDirectorIdaho Inst lute of Human Development

Marilyn S ithExecutive 'recto: _

National-A ciation for the

Jule SugarChief AdmAtlanta, Ge rgia

Daniel B. T ylor;Superinten enPof Publir Instruction'West Virgin a

'Jeannette tsonIDirector

Education Commis ion

vernor Arch A. Moore Jr.est Virginia

ECS Chairman, 1975.76

Wendell H. PierceExecutive Director

Omer MI

anistrative Of icer

Texas Off ic of Early ChildhoodI Develo m nt

Bur oil hiDie kir Pr hool Projet

Hl lnt unto [School of Education

t e i ate

T resaS laza , Asirci"ste Director\ / ly Ch Iiih d P °jut '

I A ors n,Resiarch t ssociatiarty Child oject

ri !pixi

Elementary/Secondary Education

E. Robert LaCrosse, DirectorEarly Childhood Project

4

Administrative

Poject

, Si rotaryd P oject ,

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The ik)le(of the GFamily

in C9hild GDevelopment:

'Implications for Mate Policies and Progranis

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The fifteenth report ofThe Education Cothmission Of the States

Early-Childhood Project

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Education Con'imissiori of the States,Denver;Colorado 80203

Wendell H. Pierce, Executive Director

December 1975

Additional copies of this report may be obtained for S3.50from the Education Commission of the States,100 Lincdln Tower,

* 1860 Lincoln Street, Denver, Colorado 80203, (303) 893.5200

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FOREWORD

This report concerns the shaping of public' policy..at the state level in support offamilies and family life. It contains broad general principles to 'guide state action aswell as suggestions for specific procedures' arid activities. It also'includes guidelines forevaluating programstO determine whether they are indeed supportive of familystructures and family living.

The, principal author of the report, Bonnie Barrett Stretch\was'a -research associatewith the early childhood project of the Education Commission of the States (ECS)until January 1975. John H. Niemeyer, presidqnt emeritus of-the Bank Street Collegeof Education and a .member of the former ECS early childhood task force, assumedresponsibility for the final editing of the manuscript. The report was guided in its

.development by the early childhood-task force, which had among its membership someof the nation's most highly qualified and specialized experts.in the area of earlychildhood.

Established in 1970, this advisory body has brought its expertise to-bear on all of themajor publications of the project, including this one, and has thereby caused these .

lications to be practical and creative, comprehensive and yet solicity_grountledin.,theory. As a result of organizational changes within ECS, the task force.Was disbandedin'October 1975.

While this report does reflect the cumulative insights of the task force, it does notnecessarily represent in every aspect the professional opinions or personal beliefs ofeach of its, members. We are-grateful for thaeffofts that each member made toproduce an accurate, substantive and comprehensive report.

The Education Commission of the States has long held a deep commitment to earlychildhood development Insofar as the early years affect the later educationaldevelopment of the individualand there can be no doubt of their overridingimportance in that regardthey form the foundation for the ultimate successes andfailures of the educational system. Because ECS is vitally concerned with the success ofthe educational endeavor, we will maintain our commitmenttoenhancing those earlyyears of development. This report is one expression of that commitment.

Wendell H. PierceExecutive Di ,rectorEduCation Commission of the States

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CONTENTS

'Foreword

1. Public Policy and the Family

II: Definition of the Family 3

.':1,11 .The Need for States to Provide Servicesto Parents With Young Children 4

Objectives for State Programs and Policies` 'for Yiiung Children and Parents

V. State Program Alternatives for Families WitheYoung Children 9

EduCatiori for Parenthood A 9

Health Services 16

Day Care rr 21

27ServicestoParents and Childreiti With SpeciaMee&

VI. Developing a Comprehensive Approach to Servicesfor,Young Children and Their Parents '44

VII. Funding Alternatives for Comprehensive State Progrg:ns 39

VIII. Recommendations 44

I. PUBLIC POLICY AND THE FAMILY

The family is the primary and most funda-mental influence in a young child's develop-ment. During the first three years of life, achild's curiosity, social and motor skills,language abilities, sense of security, self-esteem, coping ability and moral values areburgeoning, at a rate unequalled in subsequentyears. Upon the successful development ofthese physical, emotional and cognitive proc-,esses depends much of a person's later capa-bilities and achievement. The kindnd qualityof care and .guidance the, young child receivesduring this period are therefore critical. Mostof this care and guidance is usually in thehands Of the child's family.

In effect, the fatnily, acts as a system fordelivering to young children the educationaland developmental stimulation and supportthat will critically influence their later lives.Yet our increasingly complex and changingsociety only partially acknowh dges, in termsof practical support, the tance of thisfamily role. At present, servicesincluding early health screen; g, family coun-seling, educltion foi parenthood, preschool-ing, day care and homemaker and health aideservicesr-are available in only a limited innu-

. ber of communities and usually only (tofamilies on welfare or otherwise, deemedlikely to require welfare assistance in thefuture.

Clearly,_ it is not only the poor, the handi-capped or families in crisis that ,need support.There is much evidence that many parentsand children of all socioeconomic back-grounds suffer from a degree of isolationunique to our modern, mobile society. Smallfamilies and our increasingly. age-segregatedcommunitles often deny parents sufficientexperience with children or the opportunityto learn child-rearing techniques from a varie-ty of older persons. The informal supportivestrUctures of WI extended family and thestable community are being seriously eroded,and yet the society has not committed itselfto providing similar supportive structures out-side the family.

The.cost of this lack of support is measurablein public dollars as well as in human toll. Forexample, 10 to 12 percent of the childken inthis country suffer from handicapping condi-tions that require some type of specializedservice. Special education fox handicappedchildren sometimes costs as much as 2.4 times

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the cost of 'a regular education program;institutionalization costs 5 times as. much.'Yet, according/ to the report of the JointCommission on Mental Health for Children,one-third of these handicapping conditioncould be corrected or prevented by appropri-ate care in the preschool years. Until recently,however, identifying the needs of these chil-dren only wt they enter the public school

Tystem at age l6 or older often came too latefor effectiveeintervention.2

A. The Purpose of This Report

The purpose of this report is to offer helpfulsuggestions to states as to ways to movebeyond the deficit model of intervention,which provides help only after a family crisishas occurred or a child's handicap requiresspecial education programs. A coherent policyof continuing support to all young childrenand their families is needed if every child is tofulfill the potential with which he or she wasborn. The report draws on numerous exam-ples of states already moving in this direction.The largest section of the report presents arange ,of program examples and . methods ofimplementation in, four major service areaseducation for parenthood, health services, daycare and services to families with specialneedsareas directly affecting the family'schild-rearing capability.

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B. A Sensitive Area

The concept of family support services re-mains one of great sensitivity4however. Amer-ican praise for the institution of the familyhas long been accompanied by a hands-offpolicy. Attempts to support and guide thedirection of family efforts in child-rearing canquickly raise fears for tkie sanctity of hefamily. Some persons and groups feel su hefforts to be an intrusion into private li e,bordering on socialism. Others fear the under-mining of their cultural traditions and mores.

1Handicapped Children's Education Project, Financ-ing Education Programs for Handicapped Children.Regional Conference Highlights, Report No. 50 (Den-ver, Colp.: Education Commission of the States,1974).

2Joint Commission pn Mental Health of Children,Crisis in Child Mental Health: Challenge for theI 97O's (New York: Harper and Row, 1970).

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In .many.....case,s_these_ e valid fears. Anyprogram. of aid to families must thereforeclearly demonstrate Hat aim as support toparents in achieving more effectively theirown- goals for their children. The goal ofState-supPorted fUrnily, dnd child services andprograms di,scusseci this report is to increasethe cohesiveness of,the family and to encour-age its independence in its child-rearing.capacity.

C. Other Polidy Conside tions

While the emphasis o`f this report is onspecific state-level actions to make better useof programs and policies that already exist,there are many important issues relating tothe family and its needS in ,child- rearing thatlie beyond these paraMeters. For example,states need to review j the ways in whichunemployment, welfare and housing practicesaffect family cohesion! and viability. Theyneed to examine laws and policies that influ-ence business and industry practices affectingthe family. And they should consider acontinuing process to analyze the impact of"government and othei- institutions on thequality of family life.3

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Although these latter questions are beyondthe scope of the main body of this report,they must form part of the background forany discussion of state policies toward youngchildren and their families.

?The family in the .American social system hasresponded and adapted to the demands ofbusiness and industry and to the Changingpressures and expectations of the larger socie-ty. This, adaptability is, of course, an impor-tant source i of vitality in the family's func-tioning on behalf of its members: It is equallytrue, hoWever, that the demands for adapt-ability can be so great that critical familyfunctions are seriously impaired. The needtoday is for, conscious and consistent policiesthat will help strengthen the family,,as well asgive the family a new priority in stateplanning. However, in no way does this reportintend to suggest that the state shouids'assuniethe major responsibility for the raising ofchildren. That responsibility belongs properlyand practiedllyto the family.

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3Testimony by Edward Zigler, former director of theU.S. Office of Child Development and Urie Bronfen-brenner, professor, Corfiell University, before theU.S. Senate Subcommittee on Children and Youthhearings on "American Families: Trends and Pres-sures,' September 24.26, 1975. (Washington, D.C.:U.S. Government Printing Office).

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DEFINITION OF THE FAMI

Families in America take many forms. Thenuclear family of a married man and woman,and their offspring is only one of manydifferent arrangements. There remain varia-tions of the extended family that may includegrandparents, .other relatives and -close sup-portive friends. On the other hand, the highmobility of sour society has left many familiesisolated and without sufficient support. ,In-creased rates of diyorce and the increasingnumbers of unmarried mothers rearing theirchildren have created unprecedented numbersof single-parent families. More fathers arereceiving custody of the children in divorcecases. More mothers are working. More coup-les are Jiving together and bearing childrenwithout being,legally.married.

Even federal agencies cannot agree on adefinitif,n of the family. The U.S. Bureau ofCensus defines the family as two or -morepersons related by blood, marriage. or adop-tion, who reside together. The Family Assis-4tance Plan includes in its definition all rela-tives living in the home with children. Thefood stamp program is addressed to house-holds, which .may include unrelated as well asrelated persons.

Family arrangements are increasingly varied.Each form has its own strengths and weak-nesses, and each is capable, under favorable

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circumstances, of providing a cohesive, warm,supportive environment for the healthy devel-opment of children.

Since this report deals with child-rearingaspects of the family, the term "family" willbe used here to refer to any adult arrange-.ment that has as one of its functions thenurturing of an infant or a young child. By theSame token, the term "patent" refers to anyadult who hag assumed responsibility for thephysical, psychological, emotional and educa-tional-nurture, as well as proper protection, ofa child. Often this is the biological mother;sometimes it is the father, a grandmother, an ".

aunt or other relative. Its could, be a so-calledfictive relativsomeone personally close. tothe child .but unrelated biologically or legally.

0,The close relationship of the married couplenurturing their own biological offspring isdeeply engrained in our traditions, and thefamily thus constituted continues to be ourbasic social unit. Such ,road definitions offamily and parent as those suggested abovemust be taken seriously however, for they arenecessary for an understanding of our chang-ing and varied Society. The' aim of stateprograms must be to help families build ontheir strengths, not to penalize them for theirweaknesses or their unconventionality.

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III. THE NEED FOR STATES TO PROVIDE SERVIFOR PARENTS WITH YOUNG CHILDREN'

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Two assumptions have pervaded Americanattittldes toward families and child-rearing:

(1).that the ability to raise children wisely is anatural talent possessed by most parents and(2) that child-rearing is always a joyful,positive experience. Partly as .a result. of thesebeliefs, no coherent policy of .continuousfamily service has been devetoped in thiscountry. Yet there is, growing evidence thatneither of these assumptions is entirely true.While raising children is one of the mostrewarding of human experiences; with manyjoyful moments, it is also one of the mostdemanding.

Data gathered during the last two decadesindicate that, for most couples, child-rearingis a seriously stressful experience7economid-ally, emotionally and . psychologically. Forexample; study of 46 couples done by E. E.

eMasters, professor of Social Work andociology at the University of Wisconsin,

reported a "general disenchantment with theparental role" expressed bY many of theseyoung parents after the birth of their first vi.

child. The couples were college-educated andin middle-class occupations, and most of themnot only wanted but planned. for the child.None 'were having unusual economic, psycho-

ilogical, emotional or physical difficulties. Yet18,3 percent of this group declared they had,experienced "severe crisis" in adjusting to the!effects of the newborn on their lives. "Practi-cally nothing in school or out of school got(these couples) ready to be fathers andmothershusbands and wives, yes, but notparents," declared LeMasters in the conclu-sion to his study.

The' responsibilities and skill's required in.t. caring for young children. too often take

young parents by surprise. Guiding the devel=opment of a young child from helpless infantto mature adult is a complex and unrelentingtask, and the pleasures of having children canbe overshadowed by feelings of inadequacy,insecurity concerning child-rearing methodsand lack of outside resources for advice,support, help and temporary relief from thecontinuous responsibilities of parenthood.

Furthermore, children are expensive. A recentstudy by the Commission on PopulationGrowth and the American Future estimatedthat the cost of raising one child in the U.S.E. E. Le Masters, "The Crisis in Parenthood," in

Sourcebook in Marriage and Family, Marvin B.Sussman, ed. (New York: HoughtonMifflin, 1968).

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to age 18 is $34,464.1 This figure climbs to$98,361 if one adds a college education andan estimate of the wages the mother. lost bytatting care of the child instead of h,oldingapaying job. The study concludes: "Having achild will not only mean giving up one lifestyle for another, but.also potentially givingup one standard of living for another."2

In, light of this reality, the partkpation ofmothers in the labor force has almost doub-ledfrom 22percent in 1950 to_42.percent in1970: By 1980 working mothers of preschoolchildren alone are expected to increase by .

over` 1.5 million.3

For single parents or wives of low-incomehusbands, the ability to stay at home and carefor children is a luxury not available except atthe expense of public assistance. The follow-ing table indicates the distribution of familyincome nationally as of 1969. These figuresinclude the income of working mothers. Thisis an important fact because a two-parentfamily in which the father earn$10,000 andthe mother does not work has very differentchild-rearing needs from those of a family inwhich the father earns $6,000 and the mother$4,000.

1970 Selected Statistics Related to Distributionof U.S. Family I ncome4

Total U.S. PopulationChildren 0.5

Children 5-19

203.2 million17.0 million_

(8 percent of total)58.3 million

(28 percent of total)Number of families

1969 Income

51.3 million

Percent offamilies

50 3,999 15.2S4000 5999 10.8$6000 9999-- 26.7$10,000 14,999 26.6$15,000 24,999 16.0

2Sarane Spanse Boocock, "The Status of the Childand Alternative Structures for Child Care Systems,"-speech presented at the annual meeting of theAmerican Educational Research Association, April18, 1974.

'3U.S. Senate Committee on Finance, Child Care:Data andllaterials (Washington, D.C.: U.S. Govern-ment Prihting Office, 1971).'Adapted. from Issues in the Design of a DeliverySystem for Day Cure and Child Development Servicesto Children and Theis Families, Joan M. Bergstrom,Gwen Morgan, Wheekrk College, for the Day Careand Child Development Council of America, Inc.,May 1975, p. 7.

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The stresses of cbild.rearing, ,coupled withlack of knowledge about child developmentandthe parental role, prevent 'many parentsjiom adequately meeting their children'sneeds. This situation was documented by .avariety ..of statistics compiled 'for the 1970White House Conference on Children:

One-fourth of American children suffer fromsome degree of malnutrition; 59 percent ofchildren under age 6 have substandard levels ofvitamin A; 40 percent orchildren under age 2have low values of vitamin C; and 50 percent ofchildren under 2 have insufficient iron in theirdiets.

Almost one-half The population under age 19has not t been adequately, immunized againstdiphtheria-pertussis-tetanus.Few?r than 75 per-.,..en t of persons in the same age group have beenimmunized againSt rubeola. The percentage of,children ages t through 4 who are fullyinununizcd againstpoliomyclitis has fallen froma high of 87.6 percent in 1964 to 67.7 percentin 1969.

Fifteen thousand children under age 15 dieeach year fro& accidents; another 19 millionate injured severely enough to need medicalcare. Most accidents involving childro takeplace In the imme.5

In addition, an. estimated 35 percent' ofapparently normal children display behavioraldifficulties by the age of 4.6 And, perhapsmost devastating of all, it is estimated thatmore than t'.1,000 children are victims ofserious child abuse each year.'

The prOblem for inany families is that sup-portive xesources tend to be unavailable untilfamily breakdown is complete. Then helpcomes too often in the form of crisis service,.emergency wards, police and the courts. Weknow that very young children are especiallyresponsive to preventive and corrective treat,menA and that nearly one-third of latercrippling conditions could be eliminated bytreatment in the preschool.years.

We also know that children with serioushandicaps can often learn to manage theirlives and to master tasks if help is given early.Yet the educational and medical systems do

5White House Conference on Children, Profiles ofChildren (Washington; D.C.: U.S. Government Print-ing Office, 1970). 1

6Joint Commission on Mental Health of Children,Crisis "in Child Mental Health: Challenge for the1970's (New \kirk: Harper and Row, 1970).

?Early Childhood Project, Child Abuse and 'I'Vegh;e1:. Model Legislation for the Slates. Report No 71

(Denver, Colo: Education 'Commission of the States,1975).

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not track most Of these children during thecritical period between birth and the schoolentrance age, and no other system has been

, developed sufficiently to fill this 'gap; Forexample, of the 4 to 4.5 million preschoolchildren whose mothers w.ork, only aboutthree percent have found places .in licensedday, c e homes-or centers. The majority ofchildre are left in the care of neighbors,friends or relatives; and many are left entirelyalone d ing the worli:day.8

Even ivt\ hen services for young Children areavailable, individual programs tend to, disre-gard the family.' as a unit and deal only withthe childmedically, educationally or social-lyas an isolated individual. In recent years,many public officials have recognized theneed to provide comprehensive (services tomeet the developmental needsof young chil-dren. Often, however, fundamentally soundchild development or child health' serviceshave not given full weight to the child'sfamily situation or background. The resultinglack of ,tcontinuity between -prograin andhome may prevent such programs from fullyachieving their stated objectives for the child.Moreover, placing an expert between theparent and child in order to further a child'sdevelopment can have the unintended effectsof weakening the parent's confidence in his.orher own child-rearing abilities, encouraging.abdication to the expert the responsibility forthe child.

The present arrangerbent of independent 're-sources through hospitals, community.health,welfare services and the schools is highlyfragmented and fails for the most part todeliver _significant aid tp children and theirfamilies. Family needs are varied and interre-lated. Integrated, coordinated services ad-dressed to the family as a unit are required tomeet these needs. States should develop acomprehensive coordinated service system 'ap-plicable at state and local levels, available tofamilies from all socioeconomic strata. Exist-ing agencies and services should be examinedand new structures considered to determinehow best to establish a single-entry-accessagency through which parents can obtain thefull range of services applicable to theirindividual needs. Continuing services need to'be readily accessible to all families long befdreserious difficulties are evident. Emphasisshould be on identifying the need for assis-tance and providing such assistance earlyenough in the child's development for. opti-mum benefit, and on supporting the family asa unit.

8 U.S. Senate Committee on Finance, op. cit.

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IV, /OBJECTIVES FOR STATE POLICIES AND PROGRAMS.6FOR PARENTS AND YOUNG CHILbREN

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Services to support, parents- in' their Child--rearing tasks should lead to greater familycohesiveness and independence. In developingprograms to pursup this broad goal, a specificset of objectives should . be considered toensure that state programs-and policies con-..tribute to "strengthening the families theyserve.

-The following four objectives are suggested asan operational base for all state programadesigned to serve young chil&en and theirparents:

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1. To make it possible- for parent's to becomemore involved in the hues of their. ,children. ,

For a variety of reasons, American parentsincreasingly are less involved in the daily livesof their children. ReCent stndies of changes in,hild-rearing practices, in the 'U.S. over a24-year period reveal a decrease, especially inrecent years, in all spheres of interactionbetween parent and child. In more families,both parenti are employed outside the home,sometimes from choice, usually from econom-ic, necessity as well. But :even during theperiods when the parents are at home, only asmall proportion of that time is devoted tointeracting withtalki g, playing, loving, dis-ciplining, helpingthe children.

Such fa,ctotS as work hours, commuting,centralized schooli and the roOssionaliza-

. tin of child care have contributed to 'age' separation. Anpther factor tending to separate

parent and child is the relatively, low statusNit grailted to child rearing .and child caring.

Since 'btrr society has generally'equated statuswith finkncittl-remuneration, person who carefor ,children liave generally been considered tohave relatively low positions in society-

- women, servants and persons in "nonetoduc--tive" years such as older persons whip haveretired; Thus, one of the consequences of thewomen's liberatiOn nievaakent is that, aswomen Come. to think more highly 'of them-selves as human beings, those, who belit inequating status add pay will also be lesswilling to periOnl the tasks "in society' thatcarry less weight and prestige, including themore tedious aspects of child. caret Men have,..

not yet moved to share equally the importalt.task. of _child card The ideology concerningshared parenting does seem to be changing,but there is a large gap between the ideology 'and the societal realitieS that often make itdifficult or impossible for men to play an lenged, and there-is much evilience of change.

-- adequatf parenting role. . G 5But shared parenting should Iso be encour-

Nonetheless, children need interaction withadults, as well as other. children, in order togrow into fully developed human being's. In'the earliest yearschildrenare almost totallydependent on adults not only for health 'and'safety, but for the experiences through whichthey can grow and develop:And it is partlythrough observing, playing and working withothers older than themselves .that they devel-op their capabilities and identity.

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Care must be taken that family servicessdv"not' inadvertently have the effect of withdraw-ing parents even further from responsibilityfor their children. Such program's must bedesigned to foster the kinds of.conditions andsituations in which.parents can function poreeffectively. They must increase the parents'confidence in their child-rearing ability, notsuggest that someone else (doctor, educator,home visitor) can do it better,. One way tpaccomplish this is to ensure that parents have'opportunities. for participating in a variety ofways in all publicly supported child. programs...Parents should be able to, play an Active partboth in the planning. and administration ofprogram activities and sharing their insightswith the professionals. Those who choose? toshould have the -opportunity to help withgroups of children as volfmteers or aides.

Programs, whether in health, day care oreducation, should not be confided to centersbut should reach out in appropriatq ways toinvolve homes and neighborhoods in activitiesin behalf of the children. They should not;however, view the children's families as ad-juncts to assist the programs; the programsexist as part of_the support structure thatfamilies put together to rip them meet thecomplex task of rearing th it children.

Special attention should be given to new waysof involving fathers in programs for,parentsand children and to help them develop a moreactive responsibility for their children.dren need to 'receive care and attention frommen as Well aswomen.

Policies to support shared parenting need tobe considered seriously by states. Increasing-ly, men have too small a share in theupbringing dr children, and the whole familyloses because of this. The traditionalattitude

* toward sex, roles is largely responsible for thisAituation. This attitude is being Widely chal-

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aged through changes in business and employ-ment practices. For example, employmentlaws could be changed to permit men andwomen to hold shared jots or paired jobswith salaries, benefits and job security com-mensurate with the standard full-time job.Compulsory overtime, heavy travel schedules,frequent location transfers should be elimi-nated or reduced, whenever feasible, forparents with young children.'

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Incentives to state governments, business andindustry to troduce practices supportive offamily life fight include tax deductions,low-cost loan and matching funds for enter-,prises providing day care facilities, health care -and other_ services, as well as resources andfacilities that will increase the involvem4nt ofparents in the lives of children-in the commu-nity. By commanding. the major portion ofadult time and energy, business and industry.profoundly affect the quality of,,Americanfamily life.States should examine a variety ofways to .encourage these institutions to revisetheir policies to support family life andprovide opportunities for more adults andchildren, to come together again.

2. To, help parents understand better theprocess of child growth and development.Parenting abilities are assumed to develop..naturally as part of being human, or at least aspart of having been a member of a family. Butthe small mobile families of today do notoffer young people growing up the same

- -.opportunities for experiences with young.children, and. observing...parent_ roles as wereprovided in the larger families of two or three

--generations-ago. Only five percent of house-today Colitairran adult other than

parents. The average family h4 approximate-ly two children, compared to five in families100. years,ago,Moreover,In..1,97f) nearly one_out of every five younsters between the. agesof 14.and 17 did not live in a two,parenthome.2. ".

Parents and prospective parents need to learnmore about the process of child growth anddevelopment and the role of the fainily infurthering that development. To that end,'state educatiOn departments should examineways in whiCh family life education can beintegrated throughout the elementary andsecondary ,school curriculum. (ChapterEducation for Parenthood, pages' 1u-11, pro-aridei information on school-related parenteducation programs.i- ,

'Testimony of Uric Bronfenbrenner, before the U.S.Senate Subcommittee.on Children and Youth, Op. cit.

2Testimony of Vincent P. Barabba, Director, Bureauof the Census, hefore the U.S. Senate Subcommitteeon Children and Youth, op. cit.

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137

At the same time, all programs dealing withthe education, health and welfare of youngchildren should be required to develop com-ponents of parent education directed towardseveral ends: (1) to educate parents aboutchild development, including what behaviorto expect at certain ages and the importance.of this behavior in the child's personalitygrowth and educational prpgress; (2) to in-form parents about techniques- and 'materialsthey can use to enhance 'their daily inter-actions with their child; and (3) to helpparents become more knowledgeable about,and more involved in, the institutions affect-ing their child-including medical facilities,day care centers and preschools. The educa-tion, of .parents about_their Children should, be_an integral part of all programs and services,for younfthildreri.

3. To provide assistance that will increase thepgssibility f the fc,imily staying togetherrather than bfingseparated.In ,recent yea s' professionals in a variety offields, includi g health, ,mental health, socialwork and co ections, have begun to turnaway from lon -term institutional care towardcornmunity.ased home care as of more pbsi-tive approach to alleviating family problems.This change has come about primarily becausethe separation of v child from family 4,is atraumatic experience that often has psycho-logical side effects more disruptive than ifthe family had been left intact ..despite thedifficulties. Contributing to this danger is thefact that, by and large, child care institutions,in spite of their high cost, often are notstaffed -to-provide-children Athe positive_par-enting essential, to_ .normalormal development.It is-also true that,...until_recently, institutionssuch as foster care homes, orphanageS, hospi-tals, detention homes and jails were burdenedfar bey.Ond their capacity. A final contrib-uting factor haiTheeh-that--institutionalized-care is enormously expensive to the state.

This,,is not to say tlipt all institutional care isbeing abandoned. Clearly there will always beextreme cases where children must be sepa-rated from their parents for the sake of theirhealth or physical safety. But institutionalcare should be ,considered as only one amongseveral options and selected deliberately asthe best choice forthe individual situation.

If community-based home care is to improvea family's situation while keeping the familytogether, however, services need to be'morecarefully coordinated and more immediatelyavailable to meet a family's needs. Wilhoittsuch comprehensive support, tending a handi-capped child, an ill parent, a delinquentadolescent or an aging grandparent at home

can impose on a family a burden too heavy tobear. Crisis services such as emergency healthand social services need to be coordinatedwith long-term services such as homemakers,visiting nurses and day care.

The availability of coordinated communityservices can often mean the difference be-tween a temporary crisis and a long-termtrauma. For'example, when a parent falls ill, ahomemaker service, contacted by the hospi-tal, could make the difference between scat-tering the children. to a variety of foster caresituations and providing care in their ownhome until the crisis is past. In a long-termchronic situation, as with a'handicappedchildor a mentally _ill parent, comprehensive com-munity services can provide ongoing bare tostabiliie the situation and prevent the "revolv-ing door" experience of intermittent crisesand hospitalizations.

Such services are presently available in toofew communities. States need to considerpolicies and incentives to encourage commu-

e% nities to coordinate comprehensive services toaddress the full spectrum of needs of thefamily as a unit. These incentives couldinclude providing administrative expertise andpriority in funding, as well as other forms ofdirect and indirect aid and services, to com-munities attempting to develop such a plan.

4. To utilize the strengths of .different cultur-'ilt-;,.;and' ethnic values and different familyforrns:Basic to any state program that aims toinform and to involve parents in the educi-

_______tion_ot their children is a respect for the--culture and traditions of those-families. ACtill

socioeconomic levels in the U.S. today, there,is'a rich variety of cultures, each with its ownspecial, forms of family relationships andvalueS. Far from being viewed as a problem,

this-diversity- of cultures-and-backgroundsought to be seen as a way of enrichingapproaches to programming. One culture canlearn much from another culture's apprecia-tion of childhood, parenthood, education andfamily life. Programs adapted to these specialcultural . needs may in turn suggest othervalues or' approaches applicable to more gen-eral programs.

States seeking to develop a .diversity ofprograms to meet ethnic needs will find itnecessary to involve members of those groupsin, the planning and execution of their pro-

-

48

grams, Such involvement achieves two ends:(1) it enriches the planning procesS with thespecial perspective and ideas of thoseindivid-uaLs who will be the program's recipients and(2) it facilitates the program's implementationby, helping to ensure its relevance to commu,nity needs and its acceptability NO respectto community values. .-

In addition to accommodating these ethnicand cultural considerations, state policies andprograms affecting families also need to recog-nize the different issues and problems present-ed by changing family forms. With increasingfrequency, children move from one familyform to another, The infant of a newlymarried couple may enter a single-parentstructure if the marriage breaks up. If themother needs or desire's to work, the child isconfronted with the strengths and weaknessesof a dual-work family.

Human service. ,systems intending to serveyoung children and their parents must be ableto accommodate this .diversity of familyforms. Families should not have to conformto a certain style in order to be allowed tokeep their children, nor should they have toreach a certain point of dissolution beforethey qualify for help, Services must be de-signed to, fit family needs, instead of fittingthe family to the requirements of formal,impersonal structures.

To promote the flexibility necessary to 'ad-dress the different strengths arid weaknessesofindividtial family forms, states must involvefamily and community members in establish-ing-serviee-priOrities..and_theimplententatio iiOr program's that affect them,- -Federal-pro,-grams such as Head Start and CommunityAction Projects have demonstrated that fami-ly participation in designing, operating and ,

evaluating programs has contributed greatlyto tieir inc-eers. -StateleVeragencies -shouldconsider ways to ,achieve similar involvement,at both the state and community levels, in theplanning and executionu.at their programs.State programs and ,polici, s need to ,moveaway frOm determining: "so utions" to ,prob-lems and toward the deVelo fnent of alterna-tive support structures that are responsive andeffective. Until recipients have some say inthe services and the methods of delivery,interventions in family 'life, however gentleand however beneficial, may receive resistanceand resentment.

V. SOME STATE PROGRAM OPTIONS FOR STRENGTHENINGFAMILIES WITH YOUNG CHILDREN

While most parents with young children ap-proach the child-rearing task as a profoundlyjoyful experience, many find the burdens areheavier than they imagined, often heavierthan one or two persons can successfully bearalone. The process of raising children repre-sents the opportunity for personal growth andfulfillment. It also represents- years of contin-uous responsibility facing a 'Young -couplefinancially, psychologically and emotionally.

. ,

Although society has acknowledged that achild's earliest years are critical to futuregrowth and development, it has not yet fullyrecognized the importance of providing sup-port services on an ongoing basis for parentsin their demanding task of child-rearing.States need to explore ways to expand andimprove their service capacity in four majorareas of family need:

Education for parenthood..Health services.Day care.Services' to parents and 'children with spe-cial needs.

These services have in cdmmon several impor-tant elementt. They aim to support families,not to replace them; they represent a preven-tive approach (i.e., they are not emergencyservices but ongoing services directed primar-ily at meeting- needs before they becomeproblems); they -address, needs common tomany-families, regardless of-cultural okeOnic

_-----background:orsocioeconomic.positiOne

The public demand for services in these.areashas been great, but the available programshave generally been inadequate to meet the_need-, While surveys of most states would%probably 'reveal a wide range of programs, toooften a,lack of collaboration among state andlocal agendiei and a lack of coordinatedstatewide planning prevents a state fromsystematically serving the needs of its fami-lies.

The following sections suggest a- variety ofways of providing for needs in the several'areas. For the sake of convenience and clarity,some alternative services in each area arediscussed separately. However, states shouldrecognize that these areas of need are inter-dependent and that family programs shouldaddress these needs comprehensively. Forexample, day care centers must have liaisonwith health and social services.- An early

2 f59

screening . program must be able to refer afamily to an agencya hospital, a day carecenter, a home visitor program or a familycounseling servicethat can directly serve itsneeds.

The sections below discuss in some detail theextent of need in each area and a range ofprogram approaches a 'state might contem-plate in determining its own course of action. 444-Choice of: a specific approach in a specificarea will depend.on the needs and preferencesof the families to be served and their commu-nities. In any cage,, however, it is urged thatstates recognize that planning and coordina-tion among the state departments and agen-cies providing these services will be requiredfrom the outset. Methods of implementingcomprehensive program approaches are dis-cussed in the next chapter.

EDUCATION FOR PARENTHOOD

Parenthood is a major social role for which nocredentials and no training dare required bysociety. A variety of programs need to beavailable to help parents and prospectiveparents understand better the developmentalneeds of the young child and-the complexity .

and significance of their role as parents.Information must be made available concern-.ing; 4

The social, physical; emotional and intel-_lecluatneeds of young children.

The Similarities and differences in the ,waysthat children develop.The role of the family in every child'sdevelopment.

Even more haSically, perhapsT-adolescents--need td know more about how a baby isconceived, the physical changes and demandsof pregnancy and the fundamental health andsafety requirements of caring for a newbOrn.-One out of every ten 1.7-year-old girls in thiscountry is a mother and 16 percent of thesegirls have at least two children.'

Parent education programs should be availableto at least three specific groups of persons:(1) parents with infants or young-children;(2)junior high and high school students and (3)teenage parents who may or may not still be

1Children Out of School in America; (Cambridge,Mass.: The'Children's Defense Fund, 1974).

in school. This section of this chapter dealsfirst' with programs addressed to parents andnext with school-based programs designed forjunior high and high,school students. Teenageparents represent an especially high-tisk groupand programs addressed to their special prob-lems are discussed in detail in the fourthsection of this chapter, which deals withprograms for parents and children with specialneeds.

A. Programs for Parents of Infantsand Young Children

Parent education has become a component ofan increasing number of educational, medicaland social service programs directed towardthe welfare of veiy young children. Thisemphasis recognizes the parents' role as themajor educators of their preschool childrenand offers them -new skills and knowledge tofurther the development Of their. childrenthrough their natural daily activities andrelations. In addition, Many programs_teachparents how to impart basic skills to theirchild, how to recognize early psychologicaland physical difficulties and, where necessary,how to provide remedial help for any recog-nized deficiency, supplementing professionalaid. `)

Because programs for educating parents: canbe offered in a wide range of settings and forseveral different purposes, it is not possible toestablish a single set of criteria,regarding theirqnalitY. However,. two guidelines should bekept in mind. On the one hand, programsdeveloped for parents by professionals in anyfield cannot be implemented successfullywithout serious, input by the parents whomthe program is to serve. On the other hand,

- while addressing the expressed needs of par-

identification of the various elements of theenvironment.

Parent education programs have been usefulcomponents in a variety of institutional set-tings such as schools, hospitals, clinics andday care centers. In addition, a number ofhome-based programs, primarily for- remedialpurposes, have been developed and are begin-ning to be disseniinated under the auspices ofschool systems, medical programs and stateagencies. Less formal approaches such asdrop-in centers and toy libraries have sprungup as independent projects - or 'as adjuncts tolarger programs. Two other approaches toeducation for parenthood are worthy of note:parent- implemented programs and the use ofpublic media. Moreover, there are severalmodel federal programs that offer comprehen-sive services to young children by working,through the parents and, the.home setting.

Descriptions of such programs and settings areoffered below as concrete examples of ap-proaches states might sponsor or encourage.

1. School - related parent education programs.School-related parent education programshave, long been offered under such traditional.auspices as adult education and the Parent-Teachers Association; Most of these programsprovide information on. improved housekeep,ing, better money management, preparationof more nutritional meals and sewing. Manyclasses also include some instruction in childdevelopment and child management. The ex=pectation is the same in both casesthat, withgreater knowledge, parents will be able tobetter provide for the child's physical, socialand emotional well-being. While- such: -pro --grams have had a loyal though limited follow-ing, little is known about their effect upon

ents, the programs must n-e-foat-ided-prra-firnr----7---parent-liehavie '

base of professional information and skills. Abalance must be achieved between respect forthe autonomy and private goals of the familyand the value of the professional instrumentsand knoWledge that can enhance the capabili-ties of the familyin rearing its children.

The emphasis in parenting programs shouldnot- rest on imparting information but inteaching skills. For example, it is not enoughto simply tell parents that it is better to speakto their children in full sentences; they shouldbe shown wayrof talking -and playing withthe child, criteria for selecting toys appKopri-ate to the child's age and interests, and skillsin .reading to a child or telling a story. Parentsneed to know not only that play is the child'sway of learning but also how, realistically,they can provide opportunities for explora-tion and discovery, for manipulation and for

10

,

Recently, new curricula for this ,type ofprogram have been developed that focusspecifically on improving certain skills of theparents. Mothers learn new songs and gamesto play with their children, and they learn tomake educational games and toys from inex-pensive household objects, such as countingbooks -made from magazine pictures andsorting and matching, activities using miscel -.laneous household items and an egg carton fora sorting tray. The emphasis on appliedskillsthings parents can dorather than ongeneral information appears to be effective inenhancing the interaction between parent andchild. .

a. Family-oriented 'Programs. A far moreextensive program has been developed by a'.school district in St. Cloud, Minnesota, Under

\ '

the Family Oriented Structured PreschoolActivity .program, any parent with a childbetween ages 2 and 5 may come to a centerfor a six-day orientation course of specific

`activities and materials for at-home learning.At the same time, the child is evaluated forskills in five areas. After the orientation weekthe'parent is given an activity kit designed bystaff members to enhance the child's abilitiesin any areas where he appeared weak. Enrich-ment kits are available for children whoseabilities are exceptional. Parents can returnweekly for conferences with staff membersand every six weeks for group sessions withstaff and other parents. The program is openwithout cost to parents of any social oreconomic group.2

b: 44 comprehensive approach-the BEEPprogram. An ambitious program that uses theschools as the sponsoring institution is theBrookline (MassachusettS) Early EducationProject (BEEP). A combination center-homevisitor program sponsored by the Brooklinepublic schools in conjunction With Children's

. Hospital in Boston and the Preschool Projectof the Harvard Graduate School of Education,BEEP offers a comprehensive approach todiagnostic and educational services for veryyoung children and their' parents, from theprenatal period until school entrance, Byoffering an unusual opportunity for pediatri-cians and educators to work together, BEEP

- can' provide an array of services to familiesfrom a wide range of backgrounds.

Heavy emphasis is placed on diagnostic 'serv-ices so that no child progresses- through thepreschool years with an undetected' educa-tional or physical handicap.'-Formost parents,these services provide reassurance about theirchild's health, as well as extensive information

For parents-whose children need extra he p, a referralsystem ensures that once a handicap Ofpotential deficiency is identified, parents can ,..'locate specialized medical care and can obtainfollow -up services at once.

at the center anexplore materialsrow books, pamand videotapes oand other aspectabout other recreacal resources for yitrea.3

time with their children tobout early childhood, bor-hlets and toys; view films

child development topicsof childhood; and learn

ional, educational or ,medi-ung children in the Boston

2. Parent education in a medical setting.A medical clinic, a maternity ward in ahospital or a well-baby or sick-baby clinic isan opportune setting for making initial con-tact with a parent before, during or shortlyafter the birth of the infant. Through the useof nurses, social: workers and multimediatechnology such, as videotape .or film strips,instruction can be given regarding pregnancy,nutrition, childbirth, the importance of theparental role and the process of infant andchild development. Follow-up servicesthrough home visits can be arranged throughthe Visiting Nurses Association and, otherSocial services.

The Comprehensive Pediatric Care Center inBaltimore, for example, employs an interdis-ciplinary -staff of physician's, nurses, nursesaides, social workers, a dental assistant and acommunity health aide. A major component

ef:fthe program is the Parents' Club, whichelped to establish a morning recreation

program for neighborhood preschoolers andturned the clinic waiting room into a super-vised play center where parents and children

, can discover new toys and new ways ofplaying together and relating to each other.

Counseling services regarding child care andfamily- problems, as. well-at health care, areavailable through the clinic's professionalstaff. The Parents' Club, allows parents to

-meet-together-to .di s cuss -problems- arid-shareexperiences-and--provides- the means; for -parents to be involved in determining the kind ofhealth care they anti their children receive,4

The aim of the BEEP education program is toprovide resources for parents in their role asthe child's first teacher. The program isfounded on research that indicates that par-ents. are an underused resource who, with'training and guidance, can do much morethan expected to educate and protect thehealth :of their children.- Each family is as-signed a 'teacher on whom' it can call forinfekmation and help. There are home visitsand' scheduled seminars. Parents can drop in2For more information, contact,School District13th Avenue and 7th Street South, "8t, cloud,Minn.

O

San Francisco ,General Hospital Operates aprogram .especially for 16- to 21-year-old girls -

who are pregnant. It provides counselingabout pregnancy, nutrition, child develop-ment, birth control and family planning. Theprogram is coordinated with other city sem:.ices, such as education and social service, to

3For more informatiOn, contact Mr. Donald Pierson,Director, Brookline Early Education. Project, 40CentreSt.,.Brooklinc, Mass. 02146. _

'44 Eugene tangellotto, "Involving Parents in a Chil-dren's Clinic," Children, NoveMber-December 1971.For more information, contact ahe Baltimore City

,Health Department,. the Baltimore City Department/ of Social Services and the Greasier Baltimore Medi-.

cal Center.1711

provide a cotnprehensivel program for youngparents.

The major obstacle to providing a parenteducation program throe gh a medical settingis frequently lack of kno ledge on the part ofpediatriOans, gynecologi, is and other physi-cians about child grows and developrhent,about nutrition and abau the problems facedby new parents. Counsc ing techniques, andaffective aspects o patient care are, notstandard; componen of << medical education.Greater invOlvemen of pediatric nurses,'nurses aides and' social workers would serve toalleviate th's difficultY.5

Parent education it clayLess structured forms 'pf phe offered ;through day cshould be encouragedjo discuss the develop-ment of their child with the center profession-als and shOuld he permitted to observe orparticipcte in the 6rogiam. A day care centerkcan be used in the same way as a schoolsetting for instruction; in child deva,lopmentand methods of discipline and in the use ofspecific skills, such as songs and games toenhance parent-child interaction.

care settings.rent education canre centers. Parents

I,

4. ,Home- based programs with a remedialpurpose.Home-based parent training programs have'been in ei5tence on a small scale for a,number ,of years, usually under the auspibesof university research projects. Mhny are now-

: being replicated with favorable results by a; variety of public and private agencies,.includ-

hag family service, agencies, public healthprograms and school systems.,

The purpose of these programs is to enhancethe cognitive 'development of young childrenfrom_deprived environments by_im proving theWays, in which his ,parents talk and play withhim. Some, like the Home Visitors Program ofthe Georgia Department of Human Resources,haVe broader ,child development goals thatinclude the cognitive. The key to the successof such efforts seems to be the emphasisplaced on the parent as the child's primaryeducator and the active involvement of theparent in the education of his child.

at the High/Scope Educational ResearchFoundation in Ypsilanti, Michigan; and theMother-Child Program of the Verbal Inter-action Project in Freeport, New York.

The Tennessee Department of Public Health, in Applachian, Tennessee, has worked'closely

with DARCEE to develop and implement atraining program for teams of nurses, socialworkers and home educatois in a comprehen-sive program for families with young children.The Michigan Department of Education hasadopted the parent educat on component ofthe High/Scope preschool program to helpprepare preschool children for successful en-try into the education system. In Pittsfield,Mhssachusetts, the school ystem has incor-porated` the Verbal Interac ion Project as thefirst co'rnpOnent in an ed cational supportsystem that moves from infant educa4ion toHead Start to elementary chool and ollowTIlrough.

5. 8mczier, less structur d prog[ratroachd.\

'1 ap-

number of relatively simp e supportalt beAmarkably_usefuLto_.paren6. Drop4n

1 tenters ..wihefe a parent can chat informallyith other parents. and find out about other,FofesSiOnat services can do a great deal toase the Psense of isolation that affliotsk soany' 1

P C

mother program, which could be coupled :

ith a program like the aboVe or used alone, k

ii a toy-lending library. Here,. parents learn, 'llow to u e a game or toy or puzzle to helpt reir child develop a skill, learh a concept or;

. salve a problem. They may then take the toy,,k- °me-for-La-week-an d"-try-it-witlf--their-oirri i

children. After the course, p-arents may tend . '

tinue "to borrow toys and games from thel_ *1brt aryas _Often as they wish. __, .4,,_

I i 1

' oy 11-bra/lies may. be staffed almost exclusive-I? thy parents. With the help of a skillcuiItindergarten teacher or Head Start instriic

liarents can learn to operate sqell a prOgranifter a 'Week of, .special, traiihng and sokri0

assistance during the fir, t col)* ,of course},gequences, In addition t formCr parent' par- 4

ticipants, volunteers can be 'trained , in the \ ;

same training, program s p9r nts land ;el -ployed with equal success as ai Os,,, hprnevisitors or toy' derhonst atorsl T re us9 pfvolunteers, .of course, cal cut pro 1 dm Costs

\substantially. .1

I', 11

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il '''1,Many parent education pr( ams, 1 ,,1 i ,.,

act, try-generate hew* staff rfrom reir pa ocipa ,t,9,L ,Iparents who have I been wougl,1 til pard t i ,,education course n, witl? wo td ) ir ee s '

of additional train fng, l a n to p1

s n to1

I 1

Ater known programs of this type includethe Demonstration and Research Center forEarly Education (DARCEE) at George Pea-body College in Nashville, Thnnessel); the-Florida Parent Educator Program-at the -Uhi-2verity of Florida; the Perry Preschool Project

5 For more information, contact the San Francisco,-Oeneial Hospital and the Office, of the Superinten-dent, San Francisco Unified School District, 135Van Ness San Francisco, Calif.

. 1

other, parents the new skills they have,leartiedregarding toy making, health and safety,playing with the child and observing thechild's growth and development. Often aparent can communicate more easily withanother parent than can a teacher or otherprofessional. Parents with such interests could

I

be encouraged to recycle their knowledge bybecoming classroom aides, home visitors ortoy demonstrators. They should be paid forsuch Work, but their salaries would be onlyabout half that of professiOnals doing thesame work.

,6. Parent4mplemented programs.One model that states might, well explore forpractical suggestions or guidelines is the parent ediicat on ;program, which for years haScharacterized Many parent-cooperative nur-sery schools, pl y groups an centers Parents

-typically work, ith professi nal§ in t e class=rooms, hav me tings todisc ss Child eVelop-rhent and brin in e Perts to enha ce theiro:w,n and t e pi ofessi nals' earning. oopera-

1 five§ have ten ed toe 'dem nstiate1

(1) thatarticipati n o ers th yo g Parent f a firsthild an o por nity to kn the ise ation ofeking for one child t hohie, las w 11 as; he

opportuni y to Obse wiliat other c ildren ofthe same ge esdoi in the 6rogra and to

,learn how oth r mot erk. dual [with roblemss; ( that what i leartlec

chi rein will ibe reared; andoftenerie e often leads to parents

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An example of a parent-implemented programsponsored by a state agency is the RegionalIntervention Program (RIP) of the TennesseeState Department of Mental Health. Thepurpose of this program is to teach parentseffective techni ues for preventing or over-coming emotion 1 and behavioral problems intheir young chi) ren. Parents participate in anorientation cotirse on child, management ,taught by parents who are graduates of thRIP program. Only six staff members arprofessional, and most services are provideby parents. Since each mother pays for hetraining by guaranteeing to I work for thprogram for six months, RIP has become 1

self-perpetuating parent-impleinented systemThe program also provides 1 compreherisivsocial services that range froth routine parent-to-parent emotional support for all parents tfinding food, eldthing; housing or jobs foindividuals,who: need them. f

7. Media tlichnology.

,

States shoiijd Consider expanding the use ftelev,ision rind radio for parent educatio.Funds shod be provided to promote sho i

:public sergice announcements, repeated fr-quently, agiwellas longer_prOgrams,produc din coope tion with public television a d.radio bro dcasting and with local netwo kaffiliations.' The Children's Television

1

Wor,

shop enc6 `rages kind of use of local ti ein Iconju ction with their programs f"SeSairie treet," "The Electric Companand "Feerng Good.

the role f the \arent in child

Use,, of m jar, miedia, of course, can serve toreach a 1 ge m' fence with information. ab ut1:13

Perhaps t qually( important, the media anhelp to i part to parenting d significance ndst4us,,it rese4y lacks. To this end, pu licseryicea noun ements and filnied progr msmust_be. f thigh ; rofessionaLquality._:.i .

. i. .

filmed. t leviSion shoWs can also be use by'state and Weal parent and child programs as asuppleme t to Other teaching approaches and

!meetings.,a to 1 to promote discussion in oup

!meetings., Cable televisiori could be edextensive y to 1 broadcast more speCifi allyfocused i)rograis to individual cornrow) ties

f .

8. Modehederal programs.Seyeral f deral programs address compr hensive servi es to poverty-level parents who havchildren nder age 3, the usual enrollme agefoil Head Start programs. In contrast to eadStart, these programs concentrate on rea hingthe child 'through, not outside of, the p entsand the 'borne setting. Among the ostprominent of these programs are th fol-kAying:

1

:s

a. Parent and child centers provide a vari-ety of 'programs designed to stimulate thedevelopment of infants and toddlers fromvery deprived environments, along with arange of services to parents, especially moth-ers. These services include health care forparents and "children, social services, day care,parent education prograins, family manage-ment classes, job skills and opportunities forparents to participate as staff assistants andon policy advisory committees. Home visitorprograms-are directed toward improving child-rearing practices by providing information,detnonstrating activities and giving temporaryrelief!from isolation and loneliness.

b. The child and family resource programprovides integrated delivery of services tochildten and families on an individualizedbasis,', using existing I-'ead Start programs as anuclOs and ekpanding services to additional-families through a system of formal andinformal` linkages to community resources.Services cover the sa e range as Head Starthealth, nutrition, m ntal health, educationand Social welfare'--b t are available to fami-lies with children fro the prenatal period to8 yeArb of age.

c.IfIdirre Start' has been described as help-ing parents do, or learn to do, the ,same kindof things for their children, in their ownhomes, that Head Start staff'do for childrenattending Head Starf Centers. The pro-grams__,rely principally on ,home visitors who visitparents on a weekly basis, themmaterials and ideas for playing with andteaching their ehildr n.

,Tplyision programs like "Sesame Street" and"Captain Kangaroo' as well as ,pareriit- meet-ing; help suppleme it the work of tl 'e homevisitor,.

As in Head Start{ Home Start d al,vs oncomprehensive community resource in, thehealth, education and social service. ai-eas andhelps parents learn to find and tre theseresources.

These federal progr ms lie entirely mitside thestate service syste s, of course, but hke HeadStart' before the they provide enormousamounts of reseal' h and evaluation data, aswill as working odels of technimechanisms for e hancing the pareiniproviding for th education andtheir children.

B.1 Programs for A oloscents

Pograms to prepare adolescents i for theirriles as parents seem to,fall naturally into the

. 1I

ties andts' roleselfare of

2 0,

-public school program, although such pro-grams may also be sponsored by civic organ-izations such as the Boy Scouts, Boy's Clubsof America; 44-1, Girl Scouts and neighbor-hood and community- centers. Since schoolsare the major institution serving all children,they have the opportunity to design programsto bring teenagers together with young chil-dren forthe'maual benefit of both.

Consideratioh should be given to the age levelat which such experiences are provided. Inlight of high dropout rates at the senior highschool level, as well as increasing rates ofpregnancy among senior high -school, girls,such offerings 'might best be made available atthe juniors high levelPrograms that serve thisage group can provide concomitant benefits 'to the students at a critical point in their own,developinent. By studying the behavior ofyoung children, adolescents can gain insightsinto their own behavior at the point of theiroCyn "identity crisis." .o

There are also advantages in providing coursesat the senior high level, however: As studentsprogress from adolescents to young ad-tiltsasthey enter those years in which family life istypiCally established-.--such courses Can have a'very high, degree of relevance to individual

_studentS and can also serve to minimize orreduce dropout rates as-students achieve abetter :understanding of the responsibilitiesassociated with parenthood and the demandsthat may soon be made upon them.

1. Integration with-S-chooLcurricula.If such programs are to attractiT.Widezange ofStudents and provide them with effectiVe-----.child Care experiences, careful considerationmust be given to their design and plaCementin the curricular structure. Those 'programsthat Currently exist are .generally consideredto be the ,domain of the .home economics-deparinieni, because of the specialized train-ing of their staff in child development. Pres-ent ptograms; however, reach only a smallfr4tion of those who will eventually needpdrenthood education.

'Most of these programs fail to ptovide stu-dent's any actual experience with ,the youhgchildren they are ostensibly learning about.The 'programs usually are confined to..oneinstructional department within the highschobl, rather than reaching out, to the re-sources of the entire school system.

This is not to say that there are no homeecoi omics departments operating. excellentprograms. For example, the Texas Depart-ment of Education offers a broad4based,

e-part program in homemaking education,.

14 -

comprised of classroom courses in familyliving and child development, work-studyopportunities as child -care aides and pre-employment laboratory training in child de-velopment. All threef aspects provide experi-ences working. with young children; all three(but especially the work-study program) at-tract relatively large numbers of boysaboutone-third of the total homemaking enroll-ment. Although based in an existing instruc-tional department, the Texas homemakingprogram reaches' out to other ,departmentsand to the community as resources.

Not all 'departnients are so flexible, however.The assignment of parenting programs to anysingle professional domain needs careful ex-amination. Possibly more effective programscould be afforded through the combinedefforts of a number of departments. Manydisciplines have a contribution to make to theclear understanding of thp changing nature ofthe family and the impact of the modernworld on child-rearing practices.. t

Cooperation is required not only amongdepartments within the high school but alsoamong the various age divisions as well.Secondary school efforts should be articu-lated with elementary 'education and adulteducation, thus at least partially relieving theage, segregation that s6 restricts youngpeople's lives. The :contributions of commu-nity agencies and individuals with particularprofessional competence should be incorpo-rated into a 'team effort. ,Pediatricians, den-tists, mental health nurses and parents couldbe extensively involved i in the planning andimplementation of such programs.

It is this kind of broad-based 'cooperation thatthe U.S. Office of EduCation and the Officeof Child Development-ere-hoping to:encour-

-age- throughtheir joint effort in dveIopingprograms across the country in "Educationfor Parenthood." Three major projects makeup this program: (1) deyelopment and discern-,ination of a model curriculum for secondarySchool students, called "Exploring Child-hpod "; (2) .a, survey ,,and report on otherparenthood education curriculums and mater -''hits now, being used in; schools; and (3) grantsto several,nationaL vpluntary youth-servingorganizations o promote parenthood educa-tion programs'among young people in com-munities throughout the nation.

"Ekploring Childhood" i k designed as a one-year elective cburse for teenage boys and girls,adaptable toi the needs ofNadolescents ofvaried cultural backgrounds. The\curriculumcombines clissroom study with field-site ex-perience in child_ care settings. Teachers

15

guides, teacher training materials and 'a manu-al for school administrators interested instarting an "Exploring Childhood" program intheir districts will be made available.

2. Suggested approaches.No single approach to parenthood educationcan suit the concerns or resources of everycommunity. However, states wishing to revisethe home economics or family living curricu-lum at the junior high and high school levelsshould consider the usefulness of the follow-ing approaches to providing students withpreparation for parenthood:

a. Providing field experience with youngchildren. This must be considered a centralfactor in any program seeking to move be-yond the traditional homemaking or familyliving classrooni course. Some high schoolshave established and operated child develop-ment laboratories within their own buildings.Others have joined forces with nearby kinder-gartens or formed. cooperative agreementswith child care centers. The students canparticipate in the laboratory or center two orthree days a.week. On other days, they attendcourses in child development, parenting- orfamily living and learn to integrate theirclassroom learning with their actual experi-ences with young chiIdren.

The Montgomery County public school sys-tem in Maryland has instituted a year-longcourse at the senior high level that providesfor student involvement in child developmentlaboratories located in each of the system'shigh schools. Lab experience includes plan:ning, .observation;, research and interactionwith very young children. In addition toproviding training for parenthood, studentsreceive occupational training in child care.,:This typeoftlaboratoryleirtning is_provided,__`on a rotating basis, Co severalstudents each year.

Child centers, located within or near the highschool, can proVide opportunities for studentsin a variety of classes. Cooking classes may .

take responsibility for , planning nutritivemeals and get practical experience in thepreparation and serving *of food. Businessstudents might participate in the center'sadministrative .operation. Muth of the basiccenter. equipment, frdm furniture to blocks,might, be made An the shop -courses. Thedramtr, music and arts departments could eachoffer their particular talents.

b. Using, films- and -other -media. Films,film strips and audio cassettes enable theinstructor to bring case studies into theclassroom that might be difficult to observe in

- -41;

4,4

their natural setting. Videotapes of the stu-dents working in the center can provide animportant dimension to the classroomcritique.

c. Pthiiiding work-study programs, inwhich junior and senior high school studentswork4Part-time in Head Start, day care centersand other programs for children are now quitecommon. States -that wish to encourageschool programs that contribute to prepara-tion for ,parenthood should first ascertainwhat is already being done at the ideal schoollevel. Once information becomes available, astate might well bring together the educatorswho have already been involved in order tomake plans for wider utilization of effectivecurriculum related to field experience. .

d Providing career preparation. Theseprograms require more intensive and moresupervised on -the job training, with relatedclassroom instruction. The aim is to providestudents with marketable skills in addition tothe general training in child development,child care and parenting.

While the above listing does provide examplesof possible options for the consideration of,state departments of education, it cannot beemphasized strongly enough that? any ap-proach or combination of approaches must becoordinoted with ,the programs of other de-partments and agencies. An incoherent "layer-ing on" .of new programs, in addition to beingneedlessly expensive, cannot result in thetargeting of scarce resources to meet the mosturgent unm,et needs of children and families.

HEALTH SERVICES

A-Neglected.Sector -t-

Children's health care, unlike public educa-tion, ,is not a generally accepted public func- .tion. Only 20 percent of the costs, of child-health care services in this country are paidfor by state" and local -government, and only19 percent by the federal government (pri-marily through 65 federal' health and

programs for disadvantaged children).Nonpublic monies, such as out-of-pocket ex-penses or insurance plans, pay for the remain- 1ing 70 percent of child 'health care services.To a large extent there are no statewidemandates, no uniform standards for carequality, no repOrting and no informationgathering requirements. I

'Sheldon H. White, et al., Federal Programs forYoung. ,Children: Review and Recommendations,Volume III, a publication of the Huron Institute andthe U.S Department of Health, Education and

16

22

The basic difficulty in providing sufficientpublic support for child health lies in the cilialnature of this country's medical system. Onthe one hand is the private system; in whiChthe physician-is paid direCtly by the,,patient orhis insurer. This system serves the, middle- andupper-socioeconomic classes and is by far themost prevalent and powerful. On the otherhand is a growing public system, in which feesare paid from public revenue. The two sys-tems operate side by side; sometimes usingthe same professionals, but coming togetheralmost exclusively in large teaching centersand 'hospitals.

Neither the public nor the private 'system isentirely satisfactory'. The public system isuneven in quality, faili to reach large numbersof -Children and generally does, not offer"comprehensive care to the individual. Theprivate system, while capable. of deliveringexcellent care to those who can find and payfor it, is expensive, inefficient and unevenlydistributed, }-

-Easy access to health care ,, is particularlyimportant in the case of children, who-havefrequent infections in the early years andwho, as a minimal preventive measure, shouldsee a physician and a dentist at least once ayear. The preventive approach , that is soeffective in detecting and remedying. child-hood health problems requires that healthservice's. be readily available. Without suchaccessibility, familes tend to seek medicalhelp only on an emergency basis.

Even for %families who can afford healthinsurance, coverage kir children is far fromadequate. The largest gap in insurance cover-age is for preventive and - out - patient care. Yetthe-- American-- -Academy -of- -Pediatric'sesti--rnaterth-dr90-0-efefirof child health care isdelivered in an, out-patient setting and thatabout half is for health maintenance (such asinoculations and checkups) and not acuteillness.

A further problem preventing ,optimal childhealth care is the failure of the pediatricprofession to address the total context of thegrowth and de/elopment of children. Theprofession has focused on physical growth ofthe child and some specific diseases. Knowl-edge from the fields of social and psychologi-cal development, nutrition, behavioralpsychology; learning theory and child-rearingpractices is usually not taught to medicalstudents r_pediatricians Doctors and, teach-ers come from completely separate profes-

Wedare (Washington, D.C.: U.S. Government Printing Office, 1973)., *

as

sionalt. backgrounds; hospitals and schoolsrarely interact directly. In this professionaldichotomy, the children and their parentsand, of course, societyare the losers.

B. General Guidelines for Stateso

Child health services should, be part of anystate-level planning for children's services. Inexamining what steps to take to ensureadequate health care for children, statesshould consider the following four ,Ants asgeneral guidelines:

Greater priority in the health care systemneeds to be given to preventive and ambula-tory care, services particularly appropriate tochildren.

Health problems particularly affecting chil-dren, such as congenital difficulties, and handi-caps, environmental dangers (accidents, leadpaint poisoning, sanitation) and malnutritionand hunger, need to be assigned a higherpriority within the medical community.

Public funding for child health servicesshould be expanded to be more commensu-rate with need. While -funds remain inade-quate, states might well consider using lim-ited funds to,, offer incentives for the im-provement of the ways in, which private,local dOvery systems use federal funds.

Health services should be available to chil-dren,who are in group day care centers andfamily day care systems, as well as to childrenwho are at honie.

C. Major Existing Public Prdgramsfor, Child Health ,

Most public health services administered bythe states are federally supported programsdire ctedsp e c popula-tions that consistently experience the highestrates of infant and Maternal mortality andchildhoOd illness. The following is a briefdescription of federally funded programs di-rected to specific needs of young children andtheir parents.

1. Maternal and Infant Care.This program, originally funded under Title Vof the Social Security Act, operates 60projects across the country. It provides pre-natal care and postnatal care through theinfant's first year in areas with concentrationsof lovv-income families. Its goals are to reducethe incidence of infant and maternal mortal-ity and of mental retardation and otherhandicapping conditions associated withchild-bearing.

Although not all projects haVe had equalsuccess, the impact of the program has been

2317

generally acclaimed. In 1971 the federalMaternal. and Child Health. Service reported:"In the seven years before the initiation ofM & I projects ,in 1964, the infant mortalityrate in the U.S. fell only from 26.0 to 25.2per thousand; in the seven years after, the ratefell from 25.2 to .19.8. For nonwhites, thecomparable rates were 43.7 to 41.5 and 41.5to 31.4 respectively."

Unfortunately the reach of maternal andinfant care projects has been very limited,serving approximately only 129,000 mothersand 043,000 infants per year. In addition, only33 of the 60 projects are located in stateswith the highest infant mortality rates.2

2. Nutrition.There are 12 federal programs devoted exclu-sively to nutrition or food distribution, all ofthem administered by the U.S. Department ofAgriculture...By far, the two largest programsare Direct Food Distribution and FoodStamps, neither of which is directed _specifi-cally at children's needs.

The most important nutnt on, program di-rected specifically at pregna t women, lactat-ing mothers and infants and children up toage 4 is WIC, the Supplemental Food Programfor Women, Infants, and Children. The WICprogram provides foodvsuch as.orangejuice,iron-fortified milk .and cereals, eggs; cheeseand canned fruits high in vitamin C. These arediStributed through local agencies, usually viathe state health department, to low-incomefamilies with ;Attritional needs.

In addition, the Special Milk' prograin, plusthe nutritional components of maternal andinfant_care..projectsrand-state7-materrialTriachild health services, attempt to reach infantsand toddlers up to age 2, but with onlyminimal success. At present, food stampsprobably serve the needs of more of thesechildren than most other programs.

3. Early and Periodic Screening, Diagnosisand Treatment (EPSDT).Possibly the most important new program inchild health care is the EPSDT program, amajor effort to provide preventive and correc-tive health care services directed specificallyat children, defined as "Medicaid-eligible indi-viduals under 21 years of age." It is adminis-tered at the federal level by the Social anRehabilitation Service of the Department ofHealth, Education and. Welfare. States areresponsible for local planning and imPlemen-tati on .

'EPSDT has been hailedas a model for2 Ibid., Volume

developing a total care package for all chil-dren, not just the poor. It is clearly animportant step toward making medical care alegal right in this country, since implementa-tion is required by law.

The purposes of EPSDT are to provide amechanism for entry into the health careSystem for children from needy families, tostimulate the use of existing health careservices and to make services available toyoung people before health problems becomeChronic and expensive to treat, and beforeirreversible damage occurs.

0

Since the program's inception in 1967, hdw-ever, the states have been extremely slow inimplementing EPSDT programs, partly be-cause of the extensive planning required ofstates if the program is to be implemented. Ofthe 13 million eligible children, less than 4percent have received benefits. In 1972, Con-gress set financial penalties for states not incompliance with the law by fiscal year 1975.The penalty mandates a reduction of thefederal share of Aid to Families with Depen-dent Children (AFDC) matching funds by onepercent. Obviously, Ilig penalty will have.varying impact, ranging from as much as $10million for the largest states to $20,000 forthe smaller.3

f

During 1973, the states increased.their imple-mentation of EPSDT substantially. In the firstquarter of 1973 only 13 states reported fullyimplemented programs. By the end of 1973,the number had grown to 23. Nonetheless, amajority of states continue to experienceproblems in implententation_According-to-

-the-DepartmeiitOTT-lealth, Edudation andWelfare, these problems fall, basically into thefollowing categories:

In some areas the states are having diffi-culty enlisting provider participation.Many states lack adequate dental resourcesfor diagnosis and treatment.Organizing services for the 6- to '20-year-olds is proving far more difficult than forchildren up to age 5.Information efforts A in many states areminimal

4.1

or ineffective, resulting in poorrecipient participation.Some states are experiencing problems inreporting on nurnbers of individualsscreened.Most states are experiencing problems inreporting number of individuals treated.Follow-up and case management to assure

3EarlY and Periodic Screening, Diagnosis and Treat-ment, conference proceedings (Washington, D.C.:Human Services Institute for Children and Families,1974),

that individuals rec eive treatment is a prob-lem in many states, primarily because ofstaff shortages.

Methods of implementation vary significantlyamong the states. A prime example of asuccessful program is in Maryland, where theState Department of Health and Mental Hy-giene relies heavily on interagency coopera-tion, local health departments dnd publichealth nurses. Conceptually, the program isbased on the notion of family...centered con-tinuity of care. Implementation began withservice providers in each county. The combi-nation of EPSDT and general local healthservice funds enables the local health depart-ments to offer services to all, not simplythose eligible for Medicaid. Central to theprogram's success was the fact that themedical community 'and. public interest

wereere enlisted early in the planning.The most serious difficulties have been inbuilding effective outreach and arranging sup-port services, such as education, from otheragencies. It has been suggested that Abetteroutreach services might be achieved throughthe participation of private-sector and volun-teer groups. ---

. %.

In Michigan, the Department of Social Serv-ices contracted with the Department of,PublicHealth,'Bureau of Maternal and Child Health,to develop and administer the EPSDT pro-gram. The screening -program has become aliiik in completing a state system of compre-hensive services for mothers and children. Thehealth department (state, districkandres onsible.-Tor-screenihralid-for diagnosticand preventive services. The social servicesdepartment provides outreach, notifies pa-

. tients of their -aiai-T-m -Itments and follows upon treatment plans and broken appointmerits:_Response was report9d to be enthtisiastic,with 60 percent df the patients keeping theirinitial appointments. Of the several thousandscreened, about half were referredfor furtherdiagnosis or treatment. The Michigan StateBureau of Materrial and Child Health hasdeveloped, a manual on screening clinics foruse by physicians, nurses and allied health,personnel, as well as a data system_forevaluating the program:-

In Vermont and Maine the state Medicaidagencies have contracted with local physiciansto meet the EPSDT requirement. The Cabo-rado program is.also built around the privatephysician, with referral to. the State: HealthDepartment for hearing tests and to the

, Colorado Dental Service Corporation for den-tal services. The state also has a contract withthe Colorado Handicapped Children's pro-.

24 grams to provide further diagnosis and care.

18

(1

,

D. New ApproaChes

1. Comprehensive family-oriented health ero-grams. 0

There is growing awareness that preventivehealth services for children require attentionto the family as a unit. Initiatives towardexpanded family health programs have been

.under way for many years in both the publicand private sectors. Prepaid group practice

, organizations, such as the Kaiser-Permanentesystem established more than a decade ago inCalifornia and the Health Insurance Plan(HIP) in New York, provide the prototype fora variety of recent federal projects.

Health Maintenance Organizations (HMOs),the generil term for such prepaid plans, offerpatients all medical and hospitalization serv-ices they require in return for a monthly orannual uniform per-capita fee. The emphasisis on primary care, preventive services andefficiency of operation. Advantages ascribedto HMOs are lower health costs for a familyand less frequent use of hospitalization.andsurgery. In addition, such a contractual rela-Aidnship between providers and patients ishelping to establish a, basis for legal rights tohealth care.

A variety of federal ,programs. has developedon 'this model. One of the ,earliest was theNeighborhood Health Center (NHC) programinitiated under the antipoverty program. Cen-'ters were specifically located to serve low-

' income persons and eligibility._was_usuallylimited to:the1 7'The NHC program continues but is not beingexpanded. Federal interest has shifted toother models such as the Family HealthCenters; which aim to enroll a representativemix of income groups. It is expected thatcapitation fees (on a sliding scale) and insur-

. ance reimbursements will ,eventually Jnakethese centers nearly self-sufficient. There isless emphasis on free'services to the very poorand little community, participation.

A bill passed by Congress in December 1973aims to further the development of a varietyof Health Maintenance Organizations. The billoverrides laws in 20 states that in effect

`prohibit 'HMOs. The bill authorized $325million over five years for grants, contracts.and loan guarantees to help HMOs start up.Perhaps the bill's most, important provision%requires every employer with workers coveredby minimum wage Irlws to let any employeeuse his firm's health insurance contribution tojoin an HMO instead of staying in thecompany plan.44 More.information about Ifeighborhood Health' Cen-ters, Family Health Cehters and. Health Maintenance

4

2519.

4

These new dir ctions can be 'seen as movesaway from "tlfare medicine"' toward com-prehensive b filth care for all. While theevidence is lunclear as to whether such ap-proaches improve the health of their consum-ers more than any other form of care, thereare indicatjons that Neighborhood and FamilyHealth Centers and HMOs are more accept-able form's.of ciraUtilization patterns appear'to hi'vei changed, including less 'emergencyroom care, fewer hospitalizatiqns and moreuse of Primary physicians. One major reviewof evaluations of prepaid group practice,presented to the American Public HealthAssociation, reports findings 'particularly rele-vant !to maternal and child health care. Pre-paid; group practice, the report states, tends toincrease use of preventive health services"'(general checkups, prenatal and postnatalcare), increase readiness to seek-care (i.e., lessdelay), reduce substantially the disparity be-tween high- and low-socioeconomic groups inthe use of services, increase use of specialistsfor children and childbirth and decrease pre-mature birth rates and rates of prenatalMortality.

2. New personnel. to ease manpower prob-lems.The new emphasis on preventive and earlytreatment services and on universal medicalcoverage creates a demand' for more anddifferent kinds of medical 'Personnel. Expand-ed use of middle-level profeskonals, can makehealth careoiccessible to more_people. at less-

-cost: 'Many" revised their laws topermit responsibilities formerly reseved todoctors to be handled by professionW vyithother types of training. The following: newmedical positions.have developed in' recentyears:

.

a. ,Health aides. Most Jhealth aides areamembers of the- community where the healthcenter is located, and are usually trained onthe job. Depending oivthe program, they mayassist in administering screening tests, followup on broken apppintments and make homevisits to patients. Aides sometimes help par-ents find housing and employment and other-wise act as advocates, or they may monitorand update immunization records, administerscreening' tests or act as family planningadvisors.

b. Physician assistants. In the state OfWashington, a program for employing dis-charged medical corpsmen as physicils assis-tants in civilian life has proved highly success-ful. The MEDEX program provides threeOrganizations.I.s_avallable from-the-Bureau of Coln-munity Health Services, Health Service Administra-tion, U.S. Department of Health, Education andWelfare. zs.

I

40

months training atmedical schools' then placesex-corpsmen in a ode -year training programwith general practitioners, most of whom arein rural areas. Almost all of the MEDEXs stayOn after the training period and continue to ,work with the general practitioners, theirformer 'teacners, turned employers. This type.,,,pf program, now being replicated across thecountry, is particularly appropriAte tor ruralarea where. medical help, is difficult torobtain.

c. Pediatric nurse practitioners. The Amer-loan Nurses Association and the AmericanAcademy of Pediatrics have issued joint guide- -,lines for the preparation of the ,"pediatricnurse associate," a relatively new effort 'Itpermit nurses to assume a large portion of thetasks traditionally performed by pediatricians.There. are three chief models. The Denvermodel,' developed by physicians at the Univer-sity of Colorado Medical Center (who aregenerally acknowledged as the originators offormer pediatric nurse associate training pro-grams) includes a package, complete withinstruction sheets; that can be replicatedthroughout the country. Registered nurses inDenver can become pediatric nurse practition-ers by participating in a continuous four -

'month training program.

The Boston modet-s'Opemted by MassachusettsGeneral Hospital, differs only slightly fromthe program in Denver. Rather than recruitinga class of nurses for a four -month course, theBoston group seeks nursebr who are alreadyemployed and trains them on a part-time basiswhile they remain on their jobt. They maycome to Boston for one or two days a week.The total course lists four months. Althoughsome pediatric nurse associates work in pri-

g vats offices, the majority are public healthnurses rho utilize their additional training tofunctidh ,reAatively independently in commu-nity settings*, particularly rural areas andurban poverty areas where there is a shortageof physicians.

. -The Rochester Model, spolisored by the Uni-versity ofl Rochester School of Medicine,offers a four-month training program to bringnutses out of retirement to provide a portionof well-childicare in privaite pediatric practice.Thera is a- large poOl, of inactive nurses(estimated at 300,000) who might be inter-ested in such re-employment. These nursesoffer unique advantages to pediatric work, asthey are likely to be long -term community

embers and parents themselves.

St e laws are changing rapidly_ to respond tothelnew nursing concepts, For example, Wash-ington's legislature revised its Nurse PracticeAct' to allow nurses to - expand in areas,stfdiagnosis and treatment. Idaho amended la

Nurse Practice Act to include "acts of medicaldiagnosis, or prescription, of therapeutic orcorrective measures.1" South Dakota amendedits practice act to extend the role of the nursein child health screerling,i)rograms.,.

,d. The chile' -health associate. This pro-gram, also conceived at the University ofColorado Medical Center, prepares an individ-ual who is not, a doctor of medicine to giveextensive, health cue, including some diagno-sis and treatment, to both sick and wellchildren. The three-year training program isoffered to individuals who have completedtwo years of undergraduate work at anyaccredited institution' of higher education. Itincludes two yearS of preprofessiondl training, .

plus orie year of internship. The ColoradoChild Health Associate Lava regulates thepractice of child health asgociates', defining Fl

their trainj,eg, function, .activities and degreeof required supervision. Still unique in 1975.'the law permits associates to write. prescri-

, ptions for certain drugs approied by' theboard of examiners -The drugs-such as immu-nologic agents, antihistaminics, antidiarrhealagents and hematinics, as well as diagnostidagents to deterMine the presence vaxiocsdiseaseiinclude the,, Vast majority-13T those

'used in the ambulatory practice of pediatrids.

3. Coordination bet(veen public and privatehealth care.States need to initiate or refinatt; coordinatedreferral system so that publid "and 'privateresources are fully utilized in a system inteL.grated with other child development services:Health services inmost states are administeredin fragmented fashion by any number-ofagencies. Medicaidby far the largest sourceof federal, fundsis administered 'by statewelfare departments. SchOO1 health. programsare under the aegis of state education depart...,ments. Other federal programs, such as Ma-

(!ternat And Infant Care, Neighborhood Healthbentere and' Head Start, may bypass state ,administration altogether, rendering coordina -'tion,next to impossiple

At present, most statewide programs areA providedihrough Medfcaid. As in other areas

of child ,services, states must commit theili-selves to moving beyond the welfare model inhealth care,. One step toward achieving dom;prehensive care for all' children could be astate plen developed with the active plititicipa-tion of persons from various medical profes-sions and' their state iprofessional organ-izations,

Specialists in child development, possiblyrecruited from the statets universities 'or per-haps an innovative children's kospital, could

2 6, also be involved in the planning. The inclusion

20

'V

of such educators would open communicationlines betWeen the health and education prosfessions so that child health services could bemore truly child oriented and would helpdevelop a program of preventive health educa-

.tion for parents as well as children-.

`Ideally, a statewide health plaa would be onecomponent of a comprehensive state plan for'children's services, This was the case in WestVirginia, where the Division of Medu' andChild Health, in the state health department;was assigned to develop plans to expandexisting 'health services for the state's EarlyChildhood Development Project. The planCalled for comprehensive service to motherand"child from thl. prenatal period until thechild - reaches -age 5 and -utilized-such diversefacilities as five existing general hospitals, six

-diagnostic and treatment centers providingoutpatient services, pediatric clinics and pri-vate physicians and dentists. To these were'added, mobile unit clinics, home visits bypediatric health nurses, vaccination and nutri,Lion programs and the staters programs forcrippled children:

Other states have developed differen*proaches to health care delivery. In ,Oregop,the Department of Human Resources bringstogether the health and welfare departmentsand several smaller agencies to provide theseservices with more efficient administrationand greater IfiSibility. In the state of Washing-ton, a major reorganizationin 1971 and 1972placed the maternal and child health andcrippled children's services in an Adult andChild Health Section, which also includeschronic disease, family planning and dentaland nutrition services. A n..w California lawauthorizes the state health department toapprove:experimental pilot projects sponsoredby nonprofit, educational institutions or non-profit community,hospitals or clinics to devel-op new kinds and combinations of health caredelivery systems. .

In Massachusetts, the Comprehensive He*althAgency is assigned the responsibility forhealth-bervices plamittrgz-The Office for Chd-,dren operates a hot line Service called Help forChildren. Anyone needing health- services or

7 child welfare services can call this number anda regional interdepartmental team' then decides

' If there is no service available, or if the team'disagrees, 'the office purchases the' service.Thus, the child chits not have to wait.

.'Slates might "also,

,

'consider bringing togetherthrough -their planning efforts grivate.practi-tioners of Medicine, dentistry, optometry andpsychology (individual ..or grOup)L school

21

health.programs; local clinics run by hospitals,medical schools and other agencies; mentalhealth associations; regional' or local visitingnurse associations; voluntary agencies (e.g.,Catholic, Protestant and Jewish welfare asso-ciations);°Lions-and-other-service clubsTlocal-or regional associations for the blind or theprevention. of blindness and associations forretarded Children, cerebral paliy, tuberculosisand other special diseases.

privateThe situation for loth public andhealth care in _this country is extremely fluidand will probably continue to be so for thenext several years. States can take advantageof changes in'both sectors to promote a morerational articulation between the systems ofcare.. 'In so doing, they can develop a:higherlevel of services and74hrough the use of thesliding fee scale and prepayment models ofFamily Health Centers and other forms ofHMOs, prOvide better services to all citizens,regardless of socioeconomic status.

DAY CARE

A. The Situation and Ned

The demand for child care in the UnitedStates is eno ous and increasing rapidly.Between, 195 and 1970 the participation ofwomen in t e labor force increased from 33to 43 per nt. During the same period,however, th part ipation of mothers in 'thelabor force a most doubledfrom 22 percentin 1950 to 42 percent in 1970. By 1980,working mothers of preschool children aloneare expected to increase by over 1.5 million.'Today, between 4 and 4.5 million preschoolchildren (under age 6) have mothers whowork, and only about ? percent of thesechildren are in licensed day care homes orcenters.! Even though the number, of placesin licensed facilities has risen rapidly in thepast five yeargfrom 250,000, to700,000the total picture has not improved.While the 450,000 were added, the number of,children under age 6 whose Mothers arewoilung mcreased by 800;61073--

Furthermore, for the age groups under 6,most of the out-of-home care is for children

A,

U.P,Seaste Committee op inslieq). Child Care:'Date and Materials (Washington, DX.: U.S. Govern-ment Printing Office, 1971').

2White House Conference on Children; "Forum, onChild Care," Report- to the President (Washington,D.C.: U.S. Government PrintincOffico, 1970).

Further information is available from the U.S.Senate Subcommittee on Children and Youth, Sena-tor Walter F. Mondale, Chairman.

a

between the ages of 3 and 6; very little isprovided for children younger than 3. Yet,families in need of day care-as ,well as.theOther types of support dealt with in this. report-frequently need this assistance v as

. much' for the earliest years as for the years. starting with age 3. Infants (several monthito

11/2 years) need a great deal of 'care, beinglargely 'or totally, dependent upon adults forstimulation and social contact, as well as forphySiCal health and well-being. Toddlers (11/2to 3 years) require somewhat less physicalcare but are still dependent on a maternalfigure for stimulation, emotional and physicalsupport and protection.

Still another serious need is for mote ade-quate. care for school-age children of ern-

,ployed parents. School hours rarely coincidewith adult working hours,'and school holidaysand long vacations cause specialproblems formothers who work. To redude the .neglect ofschool-age children is, therefore, another ofthe challenges facing the states as they planways to strengthen the family.

The demand for day care cuts across socialand economic lines. Ath Alabama survey ofstate day care needs fand "a majority ofmothers need additional child-care services(79.8 percent), with the request being greaterfor full-day care- than for half-day care setv,ices, regardless of residential locations, race,socioeconomic status or ages of thildren."4The largest users of day 'care are familieswhose incomes place them slightly abovepoverty level in the blue-collar or low- tomiddle-income brackets. These families musthave two incomes to get by; and day care fortheir preschool and school-age. children is amatter .of economic necessity. But demandfor day care by larger- income families is alsogrowing. Day care is in demand not onlyAsyparents who wish or need to work, but by awide .range of social and health services as anecessary . part of a comprehensive familysupport system. Day care can provide anisolated parent, or parents attempting to dealwith a complexity of 'problems, with much-

----needed-assistance while at the-same-timeproviding the child with valuable experiencesof playing with and relating to other children.A day care setting May allow parents theopportunity to exchange ideas and shareconcerns about the growth of their childrenand can give them access to specialists in childdevelopment and child health. At the veryleast it can help combat the sense of helpleas-ness and isolation that engulfs many families

4UEC, Inc., Alabama Day Care Needs and Day CareResources, final report (Alabama: Department ofPensions and Security).

as they strive to meet the needs of growingchildren.

Before suggesting some state initiatives in daycare programming, a brief survey of existingprograms is in order.

B. ThfeeApproaches to Day Care

There are at least three formal approaches today care-family day care provided in privatehomes (including group homes serving slightlylarger numbers of .children), care providedin.day care centers and mixed systems combin-ing homes and centers. Most arrangements,made by parents are informal, howevet;ing the child in the care of a relative or aneighbor. ,0

1. Family day care.Family day care'is the most widely used typeof formal day care,, being essentially anextension of the even more common informal.arrangements. According to a WestinghouseLearning Corporation survey in 1970, themajority (55 percent) of children in full-daycare are cared for in private homes. Yet,despite state laws reqUiringlicensure, less thantwo percent of these homes are licensed, ascompared to almOst 90 percent of the centers.These family day care arrangements oftenoperate outside the. law and are unregulatedand unsupervised by any government or socialservices agency. A licensed or registered fam-ily day care hothe usually serves no more thansix children, including the care-giver's ownchildren, and of these no more than two maybe infants. The primary caretaker' is, usually afamily day care mother, a women who enjoyschildren and has either already reared her ownor prefers to remain at home during the earlyyears of her own children. While this permitsher to earn extra money, most family daycare mothers typically earn a poverty-levelincome.

Family day care is the type most selected notonly by parents, but by socialservice agencies.advising low-income families. Its popularity isdue-largely--to-the-lack-of-other-facilities_andits low cost resulting from the level ofpayment to the care-giver.

Because the care-giver operating a fatally daycare home is considered under the law to be

-self,employed-,--this type -of child care fallsinto the "private for-profit" category de-scribed below in relation to centers.

Family day care systems or linked day carehomes operating in a satellite relationship to acentral administrative core that offers them

2.& ongoing training, supportive services and cen-

22

tral administration are becoming popular. Thesystem offers greater stability than the inde-pendent home, and a greater potential forquality. ,It is not cheaper than center care,however, if.the cost of the support system isconsidered a part of the service. For costpurposes, a family day care system can bethought of as adecentralized center. Costs arelargely determined by staff salaries and adult-child ratios, whether in centers or homes.Family day care, with its typical one-to-threeratio, is not in the long run a cheap answer tothe day care need.

2. 'Center;basechlay care.Only about three percent of the children inday care are in center-based care. Althoughlittle definitive c.in formation is available toexplain the slow growth of center care, it maybe assumed that the slowgrowth is a result ofthe fact that the high operating costs associ-ated with 'generally desired quality programsrcannot be met by parents' who need theservice and that the government has beenreludtant to assist these families to meet theirneed for such child care.

Title organizational forms and the 'variety ofsponsorships of day care centers are describedin the following four categories.

a. Publicly supported centers. Most pub-licly supported centers have been financedindirectly through the use of funds availableunder Title IV-A of the federal SocialSecurity Act (Aid to Families with DependentChildren), which provides 75 percent of thecost of day care services for certain childrenin low-incOme families. The state provides theother 25 percent in matching funds eitherthrough 'State appropriation, matching of in-kind contributions or local funds given to thestate for this purpose. This program has twoeffects: it limits most publicly supportedcenters to poverty-level families, and it sub-jects those centers :to federal funding regula-tions, which are usually higher than state,licensing requirements.

One state with a substantial state-supporteday care program is California, where the

"Children's Centers" program is run by thestate education department. 'Under a slidingfee schedule, .parents may pay part 'or all ofthe cost of day care.

Another example of a state-supported daycare program is Connecticut's, foundedthrough the Department of CommunityAffairs, which includes funds for buildings.

51n regard to Title IV-A see section on Title- XX inthis report (p. 41). ,

b. Private for-profit centers. These cen-ters, which are taxpaying, comprise at least 60percent of the total number of day carecenters:6 There are two quite different forms,of which by far the larger is the proprietor-ship. This is the small, often Mom-and-popoperation, serving working families earningvery little' money. Some of the best and someof the worst day care in the country isprovided by proprietors. At best, they aresmall and responsive to parents' needs insuchmatters as hours, vacations and the like. Theform of organization. is simple and the propri-etor, by taking full responsibility, has thefreedom to make decisions without sharingthe decision making with a board of directors.Mom-and-Pop- day care centers do not paytheir owners a salary; the "profit" is what theowner has left over to live on after allexpenses are paid, usually considerably lowerthan the salary paid the administrator in anot-for-profit center.

6

2923

The other legal form of for-profit centers isthe corporation. Here decision making isshared w Rh, a board, and personal "respo nsibil-ity of the _operator is reduced. For-profitcorporate day care usually takes the form of achain of centers, taking advantage of econo-mies of scale. These centers, too, have oftenbeen found to be responsive to parents'-needsand wishes. Again, quality ranges widely. Thistype of day care is more likely to servemiddle - income

Like nonprofit centers, both of these typei offor-profit centers are subject to state licensing'regulations and, if they use federal funds,must also meet federal requirements. Strongstate licensing isneeded to prevent unscrupu-lous operators from unfairly competingagainst those. who are paying the costs ofmaintaining quality care for children.

c. Private nonprofit centers. Like the for-profit corporation, nonprofit centers are in-corporated and have boards of directors. Theymay be sponsored by a wide range of auSpices, such as community- service agencies,antipoverty agencies, parent cooperatives andOthers.--Sometimes a nonprofit- Center is affili-ated with a church. Some states exemptchurch-affiliated centers from licensure.

An example of a successful cooperative centeris the Greeley Parent Child Center, a programfor migrant seasonal and rural poor childrenand their families living in and around Gree-ley, Colorado.

Among _nonprofit centers the quality varies

6U.S, Senate Committee on Finance, op. cit.

widely, depending on the commitment of theoperators, the demands of the parents and theeffectiveness 'of state licensing programs.Many of the better day care programs fallwithin this category, while others lack thefinancing and administrative skills to providea quality program.

Most family day care systeins are organized inrelation to a private nonprofit administrativeagency and are classified, as nonprofit. How-ever, such a system could legally be organizedby a for-profit corporation:

d. Emerging private sponsors. Only recent-ly have business and industry begun to pro-vide day care for, the families who work. forthem. Many industries that assist their em-,ployees in meeting child care needs do notthemselves operate day care programs. Onecorporation, for example, has recently ex-panded its commitment to child care, butprefers that the centers be run by a privatenonprofit organization that involves parents.This has been the pattern many industries

-have preferred. Unions have begun to demandthat provision of day care -services be writteninto their contracts. Universities and hospitalsare also testing the feasibility of runningemployee day care centers. At least one statelegislature has considered allowing employersa tax credit on net income for building daycare facilities or purchasing equipment to beused by children of employees.

3. Mixed systems.Mixed systems, which include both centersand day care homes brought -together underone central administration, provide more op-tions for parents and cam combine the bestfeatures of both types of day care. Parentscan keep their children close to home,m)hileassociated centers can provide curricula, ma-terials and equipment, emergency service andstaff training for comprehensive child care.

Examples of mixed systems include the Fun-.ily Day Care ,Career Program in .New YorkCity and the Mile High Child Care Associationin Denver, Colorado. The New York programcomprises 21 stibcenWrs, elehTh40 to 60' homes in the neighborhoods theyserve, The system serves nearly 4,000 chil-dren, Mile High operates 12 centers and 250day care homes, serving 1,200 children, Theprograms are coordinated by central offices,which provide technical support to the cen-ters.

Sometimes family day care systems are mixedsystems. For example, Massachusetts has con-tracted for day care with 25 family day care

3024

systems, some of which include a center astheir hub.

A mixed-system approach can permit central-ized, funding and a systematic response todemand, while caring for large numbers ofchildren in small decentraliied facilities. Onthe other hand, red tape and delays may befound in systems more often than in singlecenters.

C. Implications for State Initiatives

In planning statewide child care policies;states should encourage diversity of day=careprograms. In addition to improving and ex-panding public facilities, states can offer anumber of incentives to private efforts, in-cluding tax incentives to industries that devel-op quality day care services, low-cost loansfor the construction or renovation of facilitiesand tax relief to families who have children indevelopmental day care. Aair and effectivelyimplemented licensing program,,is an essential:ate role. Such a program functions as a

major consumer protection, protecting therights of children and their families whileinsuring the Constitutional rights of thosewho provide services.

1. A major policy question.Should a state invest in programs designed toupgrade the quality of formal and informalfamily day care, or shoUld it turn all itsresources to increasing the availability andquality of group facilities? This has become amajor policy question for many states consid-ering greater investment in day care services.

As indicated above; when adequate rates canbe paid to assure an appropriate salary for theday care mother, the operating cost of familyday care is not cheaper than center-based daycare. However, care in homes does not requirethe capital investment required by centers.

The issue, however, is not merely that of cost,alone. It is also essential to determine themost appropriate way to meet the, develop-mental and situational needs of each child and

fani1 -For many children and families, fam-ily day care may not only be.the arrangementof choice, but also thearrangement of neces-sity, either because of availability or becauseof the assessed developmental needs of- thechild. Just as not every center is the rightplace for every child, not every home is rightfor every child, nor is one type of arrange-ment necessarily right for all children,

States should study patterns of use and needin their own communities, determine howfamilies select a particular kind of day care

2.

service and how satisfied they are with theservice, evaluate the different strengths of-fered in different centers and homes anddevelop a means for assuring that a variety ofarrangements are available so that an individ-ual plan can be made in light of each child'sneeds.

2. The question of quality.,If day care services are to serve as an adequateextension . of the family, providing. warm,nurturing support for all facets of a child'sgrowth, then day care facilities must providefor more than the child's physical safety. Justwhat constitutes .a quality program continuesto be a subject of professional debate, butthere is no disagreement that any facility.thatcares' for children from four to eight hours aday or-longer must be staffed by persons whocare about the social, emotional, cognitiveand physical development of the children.

A federal study, Standards and Costs for DayCare, identifies and defines three qualitygradeS:

Minimal: the level essential to maintainingthe health and safety of the child, but withyelatlyely little attention to developmentalneeds.Acceptable: a basic program of develop-

, mental activities as well as minimum cus-todial care.Desirable: the full range of general andspecialized developmental.activities suitableto individualizid development.

r.:

The minimal grade, primarily custodial, isregarded by many developmental experts aslikely to be more harmful than beneficial tomany children. Children subjected to suchcare for long periods of their early years, whodo not otherwise receive needed stimulationand love, often show measurable losses intheir mental, motor and social development.Yet many dare care arrangements fall belowthis minimal level and are in fact harmful orendangering to children.

3. The costs of quality day care.The costs61 quality ay care, which areestimated as running pp to $3,000 or moreper child per year, are not always easilyassessed. Also, states are cautioned that,because good day care programs usually in-clude a,high degree of nonmonetary elementsin their budgets (for, example, free space,volunteer time), comparison of budgets can-not: be made solely on the basis of cashexpenditures. Even minimal care as definedby federal regulations costs over $1,000 per

. child per year. Because of their higher adult-child ratio, quality day care home programs

25

may cost as much as centers, despite the lackof a center facility to maintain. Only forinfants and handicapped children are homesless expensive than centers. Adding extra"services such as health and social servicesincreases the cost per child by about $200 to$300, although it is questionable that the costof these services should be attributed to daycare. A day care home or center may be agood- site -for delivery of health care .to_children who are in day care, but healthservices are not day care services-,they areservices all children need regardless ofwhether they are at home with their familiesor in day care.

1

4. The need for trained personnel.The lack of trained personnel to plan, directand operate day, care services is one of thegreatest barriers to the expansion of childcare, according to 'a federal report by theAuerbach Corporation. One of the reasons forthis situation is, of course, that low salariesand a limited number 'of available positions inday care are slight inducements to thoseprofessionals who have the training and exper-ience for planning and directing roles. Never-theless, states should cbnsider way& to encour-age their higher education institutions todevelop programs that will; as day careprograms expand, produce professionals with

_the broad-based training required of plannersand '!.sectors of day care , programs. Thehighest priority in the use of state and federalfunds available for training should probablybe given to providing training to those personswho already are day care administrators' andare in need of professional skills. Also, itwould probably be wise;or states to empha-size inservice training, providing free or low-cost courses- and requiring that the staff inday care take such courses to meet lidensingrequirements.

One of the primary means of upgrading thequality of day care is to provide the care-givers with some training in child develop-ment as well as health and safety. Personswishing to become day care mothers could berequired to _participate in w_orkshbps_or_courses relating to the care of young children.A major program of this type was undertakenby the Colorado Department of Education inconjunction with the Community College ofDenver and the Mile High Child Care Asso-ciation.'

Training could be expanded into a moresubstantial procedure providing day caremothers with the opportunity to advance up a'U.S. Office of Education, Developing TrainingSupport Systems for Home Day Care (Washington,D.C.: U.S. Government Printing Office, 1973).

career scale so that their talents might be usedin the varying aspects of day care as aides,

'assistants, paraprofessional 'teachers, socialworkers, parent involvement specialists andmanagers.

The Family Day Care 'Career Program in NewYork City has two career development paths,one internal to the program and one outsidethe syStem for mothers seeking other types of

,careers. A vocations counselor -works witheach career mother_ to see that she receivestesting, training and job placement as appro.priate as possible to her interests andabilities.8 -

Despite their potential, however,'these pro-grams have a number of serious difficulties.Systems of family day. care homes and singleCenter programs do not usually have robin forsignificant advancement of staff from within.One means of increasing prOmotion opportu-nity is to create more jobs within the corestaffs by 'building a career ladder of aides,assistants, paraplofessionals and so on. Butthis is basically artificial because the promo-tions are not recognized outside the system,and more and more poSitions must be createdsince there is little turnover. Large mixedsystems of homes and centers offer greateropportunity for more workers of differentcompetencies,- although these too are limited.

TO offset the limitation of credentials andcareer mobility outside a particular day caresystem, the Child Development AssociateConsortium is developing on a national level acompetency-based credential (the CDA cre-dential) to be awarded to individuals whodemonstrate certain competencies with 3- to5-year-old children. The primary purpose ofthe CDA credential is to upgrade the quality-of -staff working with young children incenter-based programs by establishing criteriafor competency at various staff leveis.9

5. Parent involvement.Active parent involvement is critical to thesuccess of a day care program for a number ofreasons._Perhaps the foremost reason-- is -to-insure that day care becomes a means forintegrating parents in the lives of their chil-dren. Participation in the classrooms as teach-er aides or in policy making as advisors or fullparticipants gives parents a significant under-

__ _standing_ and voice in an institution directly?affecting their children's lives.8Richard Ruopp, Brigid 'O'Farrell, et al., A Day CareGuide for Administrators, Teachers and Parents(Cambridge, Mass,: MIT Press, 1$73).

9More information can be obtained from the ChildDevelopment Consortium, Suite 601 East., 7315Wisconsin Ave., Washington, D.C. 20014.

26

32

Moreover, according to a number of observ-ers, parent participation strengthens the qual-ity of the prOgram and enures that it isdesigned to meet the needs of its constitu-ency. Parents I want programs that respecttheir rights as parents and the value, andtraditions of their cultural milieu. If they areactively involved in. the program, they aremore likely to understand and apprO,Are theprogram's policies and feel assured their chil-dren are learning the skills and values they_Consider essential.

Such . parental support can do much .tostrengthen the day care. program's relationshipwith the community and proNide access tocommunity resources. Parents may canvasstheir 'neighborhoods for contributions of sup-plies, equipment and money, organize fund-raising events and obtain the services ofcommunity members with special skills. Car-penters, plumbers, lawyers and doctors maycontribute their time and abilities to a pro-gram th has become a vital institution- intheir co munity. Parents become a uniquemanpow r resource to the program, at thesame time learning m ch about how to dealwith the political an social forces in theircommunities.

In addition, parents need information abouthow their children are doing in the center anda chance to work along with the staff on theirchildren's problems and progress..Parents whowork in day care programs often feel theylearn a great deal about their child and childdevelopment in 'general and can apply theseinsights and skills at horne. No less importantis the significance of parent involvement forthe children. Not only does it enable theparent to understand and better meet theneeds of his child, but it provides the childwith a sense of continuity between theprogram and the home. It can be .extremelyvaluable for a child's self-image to see hismother or father in a position ofmuthorityand responsibility in the center.

Despite its importance, parent participation is--not-easy-to attile-ve. Most parents are already

busy people and are often reluctant to give upmore of their time. Many feel their child is inthe hands of experts and ,there is nothingmore that they can 'do. If day . care is tostrengthen and not weaken the family, thatattitude-needs-to be corrected: If the diy careprogram is not pareht-initiated, obtainingparent involvement will require the deliberate'efforts of the director. Parent participationtends to be highest in programs where parents'have at least some decision-making authority,and where there are a variety of opportunitiesto get involved, such as parent teachers,

C

c oim aides, staff selection, admiuistra-

I

;

0

ti id admissions policies. The state shouldparent-involvement an essential Part of

programming for day care.

. Licensing and setting standards.n most states, the day care licensing ;author-ty is the department of welfare or its

equivalent. Unfortunately, most of thesedepartMents are understaffed, and the licens-ing staff may nolbe sufficiently trained-in thespecific needs of day care facilities. To obtaina license, a' day care operator must meet fire,health and building regulations. Usually theseare set individually by the separate depart-ments and it is not unusual fOr them tocontradict each' other. It too often falls to theoperator seeking the license to resolve theseproblems.

Clearly, what is needed is a more coordinatedapproach. There is a need for the power tocoordinate various agencies, to issue provi-sional licenses, to revoke licenses and.closeunlicensed facilities and to allow for deviationfrom prescribed regulations under special cir-cumstances. This is necessary to encouragerather than discourage the growth of newfacilities. A recent project sponsored by theOffice of Child Development entailed a care-ful review, by broadly representative taskforceS, of the various elements of day carelicensing and the development of a set oflicensing code_guides. These may prove usefulto states as a starting point in examining theirown licensing standards and processes.

Iri addition- to licensing, welfare departmentsadminister most of the public day care pro-grams, and there is often no central agencywith authority to plan for statewide day careneeds across the socioeconomic spectrum.The result in many cases is fragmentation andlack of quality control. The need is for anintegrated network of day care services, in-cluding health, education and social services,to meet the multiple needs of various consum-ers. States should consider whether any exist-ing department or agency can protide, sorb ftlanning and coordinating function. Althoughmost states administer day care servicesthrough the welfare department, Californiaoffers a system proded through the educa-tion department. And in Illinois the Depart=ment of Labor has developed day care pro-

-trams hirrerelation tote h-WiiirIncentive (WIN)program. Other possibilities are the healthdepartnient, a large "umbrella" agency suchas a department of community, affairs or acoordinating agency such as an office of childdevelopment.

3327

!

SERVICES TO PA RENTS ANDCHILDREN WITH SPECIAL NEEDS

Services to meet special needs are necessarilyan integral part of a comprehensive servicesystem. Family situations representing specialneeds endompass,a wide /range of difficulties,including a mentally; physically or emotion-ally harididapped child, ',mentally ill parent, adelinquent older child, teenage parents whoare essentially still dill en! themselves, childabusing parents and single /parents who mustbear alone the heaVy fintrcial, legal, socialand -psychological responsibilities for raisingone, or more children. .

. i. r.

While each type of spe ial difficulty mayaffect a minority of the opulation, the totalnumber of persons involv d is substantial. For ,example, 1 child Out o 10 stiffen'. from -ircondition that handthap his or her ability tofunction fully in *the. ayerage school setting.Approximately 60,0100 /children are seriouslyabused by their parents or caretakeica eachyear, with the figur rising annually as

,reporting procedures mprove. Nine millionchildren, or one Out. Of every seven personsUnder age 18, are beiing raised by only oneparent,, and 30 percept of these children areunder age .6.1 Many much parents are likely toneed help from ;their community in rearingtheir children. Finally, as has been pointedout in the chapter oili day care, families whereboth parents - mist -work- to maintain even. alow income need /the help of communityresources for the fulfilling of their parentalrole.

iTheSe facts are particularly critical to 'thewelfare of very young children fbargsevekalreasons. First; yoiting children are especiallyvulnerable to! various sorts of family disrup- ..,

tion, whether itibe the throes of divorce or .

the stress of the presence Of a mentally' llriparent. Second, children under age .6 are the

most common victims of child abuse, themost serious i juries falling generally on l-and 3-yearfok4. Third, very young children

_are-most-responsive to preventive -and'tive treatmeni, and ,Pearly a third of latercrippling /conditions can/ be eliminated iftreatment is made available during the pre-school yeais.

1

1.

A, State Ettorts_in_three_Significant Areas

In recentj years, states and the federal govern-ment haye taken large strides in three areas of

I Georgia Dullea, "The Increasing Single-Parent Fam-ilies," The New York Times, December 3, 1974.

special need, particularly important to thewelfare': of young children and their parents.These are the education and development .ofhandicapped children, the prevention andtreatment of child abuse and neglect, andprograms for school-age parents. Followingare brief descriptions of state efforts in theseareas:

1. Handicapped children.All 50 States_ now_ have laws that mandate(rather than permit) some kind of educationalservices for handicapped children. Only asmall number of these, hoever, mandatecomprehensive services for all` children. Somerequire only planning, others mandate pro-grams only when the local school district orparents, in the community request such serv=ices. Most mandate selected services for cer-tain categories of handicapped, although the!ist may be wide-ranging. Despite recognitiOnof the-benefits of- -providing help early, only afew estates have mandated early educationservices for preschool-aged handicapped chil-dren. An increasing number of states havepermissive legislation allowing programs forchildren below age 6'and sonietimesas earlyas birth.2

State efforts for handicapped children havebeen accelerated in recent years by courtdecisions declaring the 'right of all children,regardless of handicap, to a free public educa-tion appropriate to each child's needs andcapacities. In 1971, the U.S. District Court ofthe Eastern District of Pennsylvania ruled thatthe state dust provide such education formentally retarded children. In 1972, a federaldourem Washington,. D.C., ruled similarly,giaranteeing the right'of all handicapped andemotionally disturbed children to a free edu-cation.

Other court decisions mandate an educationappropriate to each child's needs,,even whenthat includes toilet training and self-grooming,as well as the right to appropriate treatmentand therapy within a reasonable period oftime -(usually days after application) andthe right to due process for parents question-ing the placethent of their child.

a. Federal legislation. The move towardproviding educational services for all handi-capped-children-has-been-supported-by-a-widerange of , federal legislation, including theRehabilitation Act of 1973, the Education ofthe, Handicapped Act, arid the Elementary andSecondary Education Act including the 1974amendments. Each of these acts states, in2 Adctitional informatiqn is available from_ the Ele-mentary/Secondary Department, Education Commis-.sion of the States, Denver, Colorado

effect, that school districts receiving federal.Monies may not maintain discriminatory poli-cies or practices against handicappesl children.Public education services must be provided toall children, with special services according toneed, and in the least restrictive environmentor a setting as close as possible to that of aregular classroom.

Federal. concern for preschool-aged handi-capped children has led to the development ofthe Federal Model Early Childhood EducationCenters, which serve approximately 100,000handicapped children each year. In addition,recent changes in' Head Start regulationsrequire that 10 percent of the children en-xolled in these programs have a recognizablehandicap. The Bureau of Education for theHandicapped and the Office of Child Develop-ment have funded several special! projects todemonstrate the efficacy of integrating handi-capped -children into-aregular-preschoolsetting.

While the right to educational services can beseen as a definite victory for the welfare ofhandicapped children, the present emphasison a single type of service, such as education,does not meet, a handicapped perion's totalneeds. Handicapped children require the serv,ices of a number of state and local agencies.They must first be .identified, requiring thecooperation of.doctors, nurses, social workersand school teachers; better screening anddiagnostic procedures need to be developed;individualized and prescnptive education pro-grams need to be designed. Yet the coordina-tion among the education, social services andhealth agencies necessary to -achieve thesegoals is too often minimal. .

b. Identifying the handicapped. One ofthe major roadblocks to expanding stateservices for handicapped preschoolers is thedifficulty in identifying such children. Be-cause there is no formal institutional niecha-nisin for checking on the development of ,

children after they, leave. the.,hospital's -new-born nursery until they enter school, earlyidentification of handicaps is highly sporadicat best. Although diagnostie and testing in-struments are themselves not yet entirelyadequate, it is clear from the results of HeadStart screening programs that Many_physical,

m-eriterand ebiotiorialliandicaps can be de-tected and treated at an early age if theopportunity is presented.

There are several procedures for identifyingpreschool handicapped children that statesmight promote, including developing a "highrisk" registry activated at the time of birth,coordinating. referrals from well-baby clinics,

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nursery. schools or day care centers andexpanding the school census to assure report-ing on all handicapped children Irom birth toage 21. An 'approach favored by the RandCorporation report for the U.S. Departmentof Health Education and Welfare, ImprovingServices . to Handicapped Children, is regularscreening through "some type of 'free check-up' system" available to all children betweenages 0 and 5.3 Such a system for earlyscreening and diagnosis has been discussed-inthe health care section of this chapter.

In addition to formal identification programs,persons in frequent contact with preschoolChildrenparents, day Tare workers; nurses,'Pediatricians, nursery school and kindergartenteadhers=should be given instruction in theuse, of relatively simple tests for signs ,,,ofdevelopmental deviations. Those who, see chil-dren, over a period of time are in a position tonotice differences that may not bespotted by

* doctors in health examinations. Day carecenters could be particularly useful in identi-fying actual or potential handicaps, in helpingparents obtain suitable services and in provid-ing some of the services to parents andchildren directly,.

colYewstaff training progrants. The' inte-gration of handicapped children in HeadStart,- day care and preschool programs re-

-: qtureS new training on .the ,part of manyprOfessionals. Only a few such training pro-grams are yet under way. These include _aproject at California State University in ,

Northridge.; Precise Early Education of Chil-dren withaandicaps REECH) at the Univer-sity_ of Illinois in Champaign.; the EarlyChildhood Development Training and Demon-stration Center in Atlanta, Georgia; and Tech-ieal Assistance Development Systems

(TADS) at ,t e Frank Porter Grahain ChildDevelopMent Center at the University ofNorth Carob a. The U.S. Bureau of Educa-don for the andicapped provides grants tostaffs for pr service and inservice training ofclassroomroom te chers and paraprofessional .personr el.

In addition, a number of studies and programshave \shown that, with minimal training, par-ents catr- become effective teachers of their

supplementing and strengthening theimpact of whatever professional services areavailable and providing ,continuity betweenthe home and outside resources. Such parentinvolvement is generally recognized as anessential ingredient in any program for pre-sehoolers, but some believe it can also help to3James S. Kakalik, et al., Improving Services toHandicapped Children (Santa Monica, Calif.: TheRand COrporation, 1974).

alleviate somewhat the manpower shortage ofprofessionals trained to wO k with handi-capped preschoolers.

The difficulties of identifying young childrenwith handicaps, and of providing adequatemanpower to meet their needs once identi-fied, indicate the complexities states must;face. Mandatory legislation., must take into \Naccount many factors. It is not enough tomandate the establishment of programs unlessprovision is made for identification proce-dures, facilities, materials and staffing. Legis-lation and program .development for handi-capped preschoolers should include provisionfor planning, statfing,',enforcement and pro-gram finance including transportation andmultiagency coordination.

2. Prevention and treatment of child abuseand neglect.The extent of the problem of child abuse andneglect in this country has already been cited:an estimated 60,000 children each year areseriously injured by their parents or care-takers. The majority of abused children are l-and 3- year- olds. ,But these figures representcases reported under- Current reporting lawsand procedures that are largely, inadequate.When a state enacts a stronger mandate, thenumbers rise dramatically. In Florida,.ditringthe first- year-after-the-passageOf-a strongreporting law and the institution of a state-wide Aoll-free "hot line;" the number of,reports of child abuse rose from 2,00 annuallyto 19 000, 60 percent (11,400) of.which werevalid.4

All 50 states have, some legislation requiringthe reporting of suspected child abuse topublic authorities. The majority of 'hese laws,however, fail to approach the problem from apreventive and multidisciplinary point ofview. Child abuse is usually not a singleassault, but a continuing trauma betweenparent and child. Most cases are characterizedby a number of attacks committed over aperiod of time; progressively growing moredamaging both in severity of the attack and inthe cumulative effects. Such abuse, is notlimited to any economic or social group. Itappears to be conditioned behavior passedfromgeneration-to-generation.

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Although strides have been made in the pasttwo or three years, many state laws regardingchild abuse have not yet addressed the com-plexity of the child abuse problem. Theapproach is often still punitive. The child4Early Childhood Project, Child Abuse and Neglect:Model Legislation for the States, Report No. 71(Denver, Colo.: Education Commission of the States1975). i -

must be injured severely enough to providesufficient evidence fdr a court case. Thus wehave the situation of social service officialswaiting for enough evidence, while the childremains in clearly recognized danger. Whenthe case is brought to court, the parent mayor may not be sent to jail. In most cases theterm is short, and in a matter of months thechild may be returned to a still more embit-tered parent.

A more positive approach is to reach out tothe abusive parent with a prevention andtreatment program before the child is serious-ly abused and before criminal charges arefiled. Since most abusing parents were abusedchildren theMselves, a therapeutic' approachcan do more to break the abused child-abusiveparent cycle than criminal prosecution.

The first step toward such early interventionis a strong child abuse reporting law thatprovides the following elements:

Mandates reporting by professionals fromall groups who deal with children (especiallyyoung children), including nurses, welfareagency personnel, day care center administra-tors, school'administrators and teachers. Sev-eral, states have recently passed laws mandat-

_,ing_that-all-persons-wit reason-to suspectchild abuse must report it. Many laws man-date only doctors' and nurses to report sus-pected 'abuse, but by the time injuries aresevere enough for a doctor to see them, thecase is already fir advanced and the child mayhave suffered irreversible damage.

Grants immunity from criminal o r civilactions to all persons reporting in good faith.suspected cases of child abuse, whether or notthe person was specifically required to report

.1 under the law.

, Provides for noncriminal investigation of. _reported cases, for protective custody of

children and for rehabilitative and anle4iora-.tive services for parents and children,. Areporting system should be established thatdesignates the state and community agency.Charged with child protection services, rather "than the law enforcement-agencies-as-the.primary :receiving agency- for such reports.

In addition, it is recommended that a stateestablish a central statewide registry to recordall, verified cases of child abuse. Besides itsstatistical value, such a registry can serve as adiagnostic aid in situations where a specificchild or his siblings may have been reportedto the registry for other injuries. It also servesto trace the parent who takes his child to

.'different. doctors., and hospitals in order, to

avoid detection. It is essential, however, thatsuch a registry have sufficient safeguardsagainst improper use of its information.s

A strong reporting law, however, is only afirst step in improving a state's capability totreat 'cases of child abuse or neglect. If thechild is to be returned safely to his family, thereport must be followed by a thdroughinvestigation and the investigation must be

-followed by a program of supportive servicesfor the child and his parents. In addition tothe usual child Proteetive and custody sere=ices, family counseling, day care and home-..

maker 'services are required to aidjhe familyin its home setting. Professional services canbe supplemented by other approaches such asthe "lay therapist"-a nonprofessional, whobecomes a good friend to the parent, provid-ing a long -term sustaining relationship thatcontinues when other services are terminatedor limited; self-help groups such as ParentsAnonymous; and 24-hour "crisis nurseries"

-where parents can leave the child for a periodof .a few hours or ,a few days if necessary.

State child protective . agencies should' beempowered and encouraged to develop amultidisciplinary approach to the treatmentof child abuse and. to coordinate their workwith other state agencies, including health,mental health, police and public prosecutors'offices, as well as family courts. They shouldalso work more closely with private voluntary-agencies such as Boys' Clubs, charities of'religious denominations, the Visiting NurseAssociation and Parents without Partners.High priority should be given to educatingstate, agency personnel and all persons re-

. quired by law toireport suspected abuse aboutthe nature and extent of the problem, theprocedures for reporting, and following, up,and of their legal responsibility tad° so.

In_addition;- e- major'pu151ic me "ia campaignshould- be given high priority to educate thepublic at large about the nature and 'extent ofthe problemopis,public information effort isnecessary to expand public involvement in thereporting procedure and to mobilize supportfor funding the necessary-protective-rand'rehabilitative services.

\ 4vin every state where strong new laws have

been enacted, resources are needed to initiate'and expand programs and services. Funds arereciuired not only to train and educate exist-ing agency personne6 but to lure additional

A thormkgh discussion of child abuse reportinglegislation, including a detailed model, can be foundin Child Abuse and Neglect: Model Legislation forthe States, Report No. 71 of the Education Com-mission of the States.

.

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3.6

personnel. In Florida, for example, only halfof the reports that flooded the state agency asa ,result of the new reporting law could beinvestigated.

States can receive some financial help throughthe fpderal government under the 1974 ChildAbuse Prevention and Treatment Act. Thiswas the first action by the federal governmentthat recognized the prevention and treatmentof child abuse and neglect as a nationalproblem. It established a national clearing-house within the Department of Health,Education and Welfare and provided for ademonstration grants program of $5 millionfor the first year, $20 million for the secondyear and $25 million each for the third andfourtivyears.

In order to qualify for the federal 'money, astate must already have a strong reportinglaw, rehabilitative approach to services and afoundation for multidisciplinary and inter-agency cooperation. (Eligibility requirementsare described in the ECS report, Child Abuseand Neglect: Model Legislation for the States,Report No. 71.)

3. Programs for school-age parents.School -age parents (under age 18) constitute ahigh-risk group in regard to their own andtheir infants' physical and mental health andtheir social and educational well-being. Infantmortality for school-age mothers is nearlythree times as high as for women 20 to 24years of age and incidence of low birth-weightbabies is greater among teenage mothers thanany other age group. Low birth-weight notonly decreases the chance for the baby'ssurvival during the first year, but appears tohave an adverse effect on the child's laterdevelopment. Recent studies indicate lowbirth-weight babies are more likel t hP

'..mentally -retirded7wargenera y have moreperceptual and motor disturbances and morespeech problems than normal-weight babies.

yet mature themselves, many teenage parentsunderstandably have difficulty. coping withthe demands and responsibilities of an infant.A large portion of teenage Marraiges dissolvewithin a year.

In 1969 and again in 1971, the SupremeCourt ruled that, schopiTage girls who arepregnant. and, school-age' mothers cannot beexcluded from the regular -school programunless a 'physician testifies that such atten-dance is harmful to the health of the child.Yet, less than one-third of the school districtsin the United States make any provision forthe education of pregnant girls. Those that dooften serve only token numbers of thesestudents. Alternative -arrangements, -Stich asadult education classes and homebound edu-cation,-are often inferior. in scope and contentto that of regular.school curriculum.

With- respect to the aims of state educationprograms, keeping the pregnant termager inthe regular school program solves only part ofthe ,problem. Special services are required tomeet the other needs of these students:

Instruction and guidance in health andnutrition during pregnancy.Education- regarding sex and childbirth.Despite their apparent experience, mostteenagers are surprisingly ignorant of thefacts of human sexuality.Family life education and preparation forthe role of parent.Instriietion in the care, health; nutritionand safety of the child.Information about birth control and theuse of contraceptives.Provision of an infant care center where theparents can learn to care for,,their babies,and that can serve as a place to...leave-the

_-----baby-while-th-e-fraterifs, are in school.

Programs for school-age parents should either .4provide directly or give adequate referralservice to gynecological and pediatric care, ,toadequate living facilities, to help in meeting__ _

financial -needs; to-adoptichi counseling andservices and to legal counseling and services.

Girls in their teens have a greater -probabilityof serious health problems during pregnancy

. and_ delivery. than-any-other-group exceptwomen over 40. Yet pregnancy is the majorknown cause of female school dropouts in theUnited States.6

Most young parents are ignorant of what toexpect of an infant in his first year, oftenexpecting him to sit alone at six weeks, betoilet-trained by six months and recognizewrongdoing before he is 1 year old. Being not

6Elizabeth M. Whelan and George K. Higgins, -Teen-age Childbearing: Extent and Consequences (Wuh-ington, D.C.: Consortium on Early Childbearing andChildrearing, 1973).

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All of the services described above should beopen to young fathers as well as mothers.Whether the young parents -are married ornot, many of the boys and theirfamiliecarrysome responsibility for the girt'orlier,,child.For most young fathers, the pregnancy:is anexperience full of emotional confusion andanxiety. Usually little or no counseling isavailable tp.- them. It is ,iinperative that they,too, have better knowledge of themselies,their baby and the responsibilities of parent.hood.

There are a number of ways states can takeaction to further the provision of comprehen-sive services to school-age parents in allcommunities. 'A gubernatorial statement for-mally calling attention to the Supreme Courtrulings and endorsing the coordination, ofeducational, health 'and social services forthese students at the, state and local levelsmay prompt local districts to develop pro-grams and to make better use of stateresources and funds for this purpose. Lawsand policies could be introduced to assurethat-all pregnant students retain. their educa-tional rights and receive whatever other ap-propriate services are necessary. Althoughfederal. legislation (Title IX of the EducationAmendments of 1972) guarantees pregnantstudent's their educational rights, state legisla-tion is needed for reinforcement and claryi--

cation.

Michigan has enacted ap law forbidding theexpulsion of pregnant students but allowingfor voluntary withdrawal and for an "accred-ited alternative educational program" for suchstudents, to be determined by the state boardof education.

_Other approaches are to amend the education-

° al by-laws (as was done in Maryland) or thestate administrative code (as was done inCalifornia). .In Pennsylvania, a notificationfrom the state* attorney general's officeprompted the department of education toinform all chief school administrators that nostudent could be expelled from school forbeing pregnant. Such laws or 'policies mightalso State that school systems have a respon-sibility to see that girls who do not choose to

:.remain in regular schooLhaA.te- . uni yfor-eqariducation elsewhere, and that theschool system has a responsibility to "cooper-ate with other departments to see that ,neededservices areprovided.

The state cbuld gear its day _care_policy-to-_ educational-progranis that have as 'their goal

the preparation of young parents for employ-ment above the poverty level. To reverse thewelfare cycle, dify care must be available tomothers who, need to work, with earningsused to determine fees but not eligibility. \

State fun& could be made available to com-munities that launch special programs orservices for pregnant teenagers. State fundsmay be supplemented from federal sources,suet as the Office of Education,'the Office ofChild Development, the Maternal and ChildHealth Service, Model Cities and Title XX ofthe Social Security Act. Coordination ofservices at 'the state level to provide theeducation, health and social services required

could be achieved either through a singleexisting agency, an interagency coordinatingboard, an independent state agency such as anoffice of child development or a departmentof community affairs. Technical assistancecould lie offered from individual. state depart-ments or from the coordinating agency tohelp communities launch such programs.

The state could set up model programs on aregional or county basis and in major cities toprovide a full range of comprehensive coordi-nated services to school-age mothers andfathers. For example, the Delaware Adolei-cent Program, Inc. (DAPI), which started as apilot project in ,the city of Wilmington, nowoperates three-4enters in the state's threecounties, _supportillby -federal grant underTitle XX of the Social Security Act with

assistance, and funding from the State Depart-ment of Health and Social Serviceothe StateDepartinent of Physical Health an3the State._Department of Public Instruction 7'

Staff for these comprehensive programs7areUsually provided through 'the agencies in-volved. For example, the education depart-ment provides, accredited teachers and thehealth department-furnishes-public nurses. Inaddition, community volunteers and parapro-fessionals can act as aides in most aspects ofthe program. In some communities, certaintypes of necessary' staff, such as health aidesor social 'workers, may not be available. Thestate may want to help such communities ,support a training'program, through a hospitalor a state university, to develop the neededprofessional and paraprofessionaLpersminek§-7-----

B. General Principles

From the discussion of these three areas ofspecial need affecting young children andtheir. parents, several common principles be-come evident. -

Early.' identification and treatment of a?The DAPI Story (Wilmington, Del.: The DelawareAdolescent Program, Inc.).

8 A detailed discussion of state programs, policies andfinancing for programs for pregnant school-age girlsis available in an "Information Series" packet of fourbookelts, published 'by the Consortiuni on EarlyChildbearing -.A Childrearing, Suite 618, 1146 19thSt. NW; Washington, D.C., 20036. -

Two other organizations that can provide technicalassistance and information to state and local groupsinterested in improving services to schoolage parents

' and their infants al:: The National, Alliance Con-cerned with School-age Parents, 3746 Cumberland' St.NW, Washington, D.C. 20016; and the InteragencyTask Force on Comprehensive Programs for School-

:a 8 age Parents, U.S. Office_ of Education, Room 2181,400 Maryland Ave. SW, Washington, D.C. 20202.

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'problem is essential if substantial ameliorationor correction is to be achieved.

a Services nee I to be addressed to bothchildren and parents. Besi,results are achievedwhen the family is helped as a unit and theinherent parent-child dynamic is strength-ened.

No one type of service such as health,social services or educationcan adequatelymeet any of these needs. A comprehensiveappioach must be developed through thecoordination of all state agencies servingyoung children and their parents.

In response to new federal laws and courtdecisions mandating expanded and coordi-nated services, the education and training ofagency staff at the state and local levels, andof other professionals dealing with youngchildren and their parents, is required.

Perhaps the major difficulty with most stateprogramsand services to meet special needs isthat they are planned as a response to specific

0.

types of cases. For example, many state lawsmandate treatment for specifically .namedhandicaps. If a child's handicap does not fallinto one of .the named categories, then he orshe is not eligible for aid. Some child abuselaws continue to mandate intervention only ifthe child is younger than 12 years of age.Many states fail to recognize that the mental-ly retarded, regardless of age, deserve thesame protection from abuse as othei children.

Piecemeal responses to individual needs leavemany persons unprotected and unable toobtain .aid. Legislators and other state policymakers should regard individual difficulties asparts of the broad spectrum of family needsand take steps to remove categorical andsocioeconomic barriers to state services. Theimplication of regent federal legislation andcourt decisions (e.g., those regarding handi-capped children and school-age, parents) isthat all citizens are entitled to the benefits ofneeded public services and that services andprograms must be adapted to ,meet the needsof a wider range of persons,

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rf

w

VI. DEVELOPING A COMPREHENSIVE APPROACH TO SERVICESFOR YOUNG CHILDREN AND THEIR PARENTS

It is clear that any services for youngchildren-and their parents are already avail-able within the states. Too often, however,such services are fragmented among severalstate agencies and a variety. of private, andlocal groups are creating critical gaps, duplica-tion and-waste. What is required is a statewidecomprehensive approach, initiated and sup-ported at the highest levels of state govern-ment and implemented by local communitiesaccording, to their. need.

A coordinated, comprehensive program ofservices to young children and their parentsshould be -preventive in orientation and pro-vide services on a continuous, not solely anemergency basis. It should utilize to thegreatest extent possible the family's ownchild-rearing and child-cating capabilities. Itsprimary goal should be to permit access to allservices by all members of the community...who need them, rather than restricting serv-ices toselectecl population within the commu-nity.

In the past three years a number of stateshave moved to establish a coordinated ap-proach to planning and delivering services toyoung children sand their faniihes. Their ex-perience suggests the following points:

The importance of public- recognition bythe governor and legislature of services foryoung children and their parents as a statepriority.The need for a state-level coordinatingmechanism.The need for a state plan.The significance of community-level in-volvement for 'maintaining and expandingthe state commitment.

/;"4. The Importance of Public Recognition

Such recognition can serve two purposes.First, it can focus public attention on the

. issue and make it visible as a state priority.Second,:it can provide high-level impetus forcoordination and cooperation among \tradi-tionally independent agencies and priousinterest groups.

In many statesparticularly if services toparents with young children is a new con;ceptthe governor, legislature or a U.S. Con-gressman might' hold a statewide conference

0

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4 O.

on the topic. The purposes of such a conference are several. Essentially, it provides. aprominent fprum in which the issues relatedto the needs of parents and young childrencan be aired, public. attitudes assessed anddirection and impetus offered from the gover-nor and legislators. It also serves as anoccasion for a preliminary gathering and-presentation of data regarding the needs, offamilies throughout the state wad the abilityof existing resources to meet those needs.And it provides, an opportunity to ',bringtogether state and lodal leaders, representa-tives of the wide variety of groups involved inthe field (inchiding, for example, the Ameri-can Academy of Pediatrics, the League ofNursing and,the Parent Teachers 'Association)and; of course, parents.

If such a state conference does not seemfeasible, the governor could ask an existingstate agency to sponsor a study of the state'sneeds and resources and report to him the ,)

results, or the legislature might undertake aninterim study of the status of services tochildren and parents, preliminary to reccim-rnendations for a coordinating mechanismestablished by legislation or executive order.A legislative study of approaches to improvedservice plivery might start with the variousalternatives discussed in this report.

Whatever techniques .are adopted to focuipublic attention on this issue, a major out-come should be the identification of specificappropriate actions to advance a comprehen-sive, service approach to serving parents andyoung children, to assure that existing pro-grams and services directed to young childrenarc Supportive of the family as a unit and toutilize rather than bypass the family's child-rearing resources.

B. The Need for a State-level CoordinatingMechanism

A coordinating and planning office is usuallyexpected to assess state needs sand resourcesfor providing services to young children andtheir families, draw up a state plan fordelivery of services and ditect the implemen-tation of the, plan. To accomplish this, the'

--office shOuld have authority and staff toreview department budgets and make recom-mendations, propose' legislation and develop

;

public policy to further a comprehensiveApproach to improved service delivery.

In the past several years,- 17 states have:

established state offices of child development;^ or the equivalent. The experiences of these

states suggest several elementsoessential to theeffectiyeriess-kof a coordinating and planningmechanism directed specifically to improvingservices to young children and their parents.First, such 'an office needs totbe established ata leVel sufficiently high in the governmentalhierarchy to be able to effecti the cooperationof directors of other agencies. The exactposition will vary from slate to state. Oftenthe necessary status is best 'attained 'as anindependent agency or as ,an agency withinthe governor's office.

If there is enough active interest On the partof the governor, a coordinating mechanismcan also function well within an "umbrella"department of human services. This, has beenUwe case in Texas; where the Office of EarlyChildhood Development is located within theDepartment of Community Affairs. In WestVirginia, on the other hand, the governorcreated by executive order an InteragencyCouncil for Child Development Services com-prised of the heads of the state agencies thatprovide services for children under age 5 andtheir parents. The governor himself serves aschairman of the council.

Attempts to' place a coordinating and plan-.ning body within a special. service. agency,such as the department of education, tends,tobe less successful, because services are thenoften restricted to pre-existing concepts withwhich the agency is accustomed to working.Such a position` usually affords neither thepolitical status nor the independence neces-sary to obtain the cooperation and support ofother state agencies providing child and 'fam-ily services.

The new office must be launched with asufficiently strong mandate to allow it tocarry out the difficult tasks of statewideplanning and coordination of services foryoung children and their parents. A memoran-dum or directive from the governor may be afirst step toward creating such a mandate, butultimately the office should carry the author-ity of an executive order or actual legislation,

. ,

The staff of the office should he professionaland full-time. Voluntary or part.time staff, orprofessionals who have other primary duties,will seldom have the commitment or theenergy to develop more than an advisorycapacity, leaving the office without sufficientstature to effect necessary changes.

Since its purpose is to bring together tradi-tionally separate and independent agencies,each with its' own set or approaches andpriorities, a new' office is likely to be resistedas a threat to the established governmentalorder. Therefore, even with a strong executiveor legislative mandate, the' office, will require,the active commitment of the governor,- atleast during its first years.

A mechanism found ,important in severalstates for furthering interagency cooperationin program planning and budgeting is aninteragency, ,council, established by executivedirective to work' with the coordinating of--fiOe. Such a *council is,m6st effective whencomprised. of agency directors. By providingfor 'the involvement of ieency decision mak-ers in° the plannine,,process the councilensures greater cooperation, in the implement-

', ing of a comprehensive service approach.

In most-states the new office acts primakilyto coordinate planning end delivery of sent-ices. Actual program operation iscarried outby existing agencies. The aim is to: use the-existing governmental structure 'more effec-tively and to control increasing expendituresby reducing the duplication of services anddirecting state planning toward a preventiveorientation. The coordinating office may pro-vide staff and technical assistance to agenciesas needed to carry, out the plan.'

C. TheNeed for a State Plan.

At the core of a comprehensive approach toChild and family services is a state plan tocoordinate the work of state and local, publicand private agencies. Such a plan will enable astate to develop the means to use its .man-power and budgetary resources for maximumimpact and cost,benefits.

There is a general agreement that competentplanning and determination of prioritiesshould be based upon a careful assessment ofa state's present and future needs for earlychildhood and family services. Such an assess-ment is prerequisite. to understanding boththe magnitude and the nature of the need andis a necessary first step toward establishing acoordinated approach to services.

'Need is usually detekmined by two factors: astandard Or ideal, such as the kind of pro-gram, service, health statistic or other quality-' Further discussion of approaches to dieatingrt statecoordinating mechanism is presented in two other,reports of the Early 'Childhood Project: Report Na30, Establishing a State Office of Early Childhood,Development: Suggested Legislative Alternatives,1972; and Report No. 55, State Offices of ChildDevelopment, 1975.

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of-life indicator desired; and thp presentsituation, an accurate assessment or the statusquo, As part of the latter, the existingstatutory mandates and permissions to thevarious state agencies are determined. "Need"of course, is the difference between, the two.

Examinatiokof the data regarding the state'sneeds and resources and future directionshould take place within some sort of generalframework articulating wastate philosophy,goals and objectives consistent with the con-tent of this report. For example, servicesshould be de'signed to.support families, not tosupplant them; services should be preventivein.orientation and available to all families on acontinuous rather than' an emergency basis;services should be coordinated on local andregional as well as state levels.

To have maximum impact, a needs assessmentshould be comprehensive in scope.-It shouldbe based on information gathered from a widerange of data regularly collected by a varietyof human service agencies. Such-data includepopulation size, migration patterns of chil-dren and their families, numbers of deathsand live births, marriages and divorces, educa-

--tionalAttainment, employment, income, sizesof Households;' health , (including mental'health and nutrition) atid child, care provi-sions. These categories can provide the-basisfor'descriptions and comparisons of geograph-ic areas and various populations, a reasonablyaccurate characterization of the present needsof young children and their families, and aprojection of future needs.

Though extensive, however, these data shouldbe regarded, only as a beginning. To berealistic, a needs assessment must includesome indication of what people really wantand will,want in services to parent's and youngchildren. For example, a large number ofworking mothers within a community usuallyindicates the need, for some kind of day 'careprovisions for their young children. But itdoes little good to build a day care center in acommunity 'where transportation is poor and

'the parents have developed more convenientarrangements for care of their children.

To ensure that action is suited to the need,Several states have established local councilsor committees through which communitiesare' directly involved in the planning processfor child and family servicm These coinmu-nity councils catrtake stock of existing localservices and programs, identify. needs of fami-lies with young children and set priorities fordealing with these needs. This can be done.through 'group meetings, individualized meet-ings, questionnaires and other data collection

or.

techniques. This phase is necessarily value-laden and populist and provides the oppor-tunity for community, attitudes and concernsregarding family programs -and conditions to,be aired.

These local councils should'be encouraged tosponsor pliblic forums. on a local, or at leastregional, basis. Such forums not only providea more accurate realization of the expanse,depth and characteristics of child.and familyproblems, but also permit local and parentalinvolvement in the planning process.

A statewide household survey should beundertaken with the, aide of these councils toverify and expand on the more general datadiscussed above, providing a community orconsumer perspective. Besides obtaining moreaccurate demographic information, such asurvey can focus on specific services, such ashealth care or child care arrangements, andthe consumer's response to themwhetherthey fit consumer needs, expectations andfinancial limitations.

More detailed suggestions for implementingneeds assessments of varying depth and detailare present in two other reports by the ECSEarly Childhood Project: Early ChildhoodPlanning in the States: A Handbook forGathering Data and Assessing Needs. andChildren's Needs: The Assessment Process.

Once a comprehensive needs assessment iscompleted, state policy makers and the publicwill have a clearer idea of what \services andprograms exist, what further resources areneeded and what kinds of services are desired.The general framework of philosophy, goalsand objectives will be augmented by thisassessment on the basis of new factual data.Based on the expressed concerns and prior-ities of parents and communities, a state plancan be structured.

A State plan, 'by its very nature, must beflexible and sensitive. To be effective it mustbe adaptable to the divergent sizes, culturesand complexity of resources of the manycommunities in theSIate. Planning strategymust give full consideration to existing localconditions:

For this reason, the first steps in designing asubstantive program should be taken by thecommunity councils, which can identify andconsider alternative solutions and design asubstantive program. The state can providetechnical assistance to the community in theform of persOnnel, guidelines and funds to

4 2 assure the proposed program will be consis-

36

tent with the requirements of the state plan.The plan can then be submitted to a regionalcouncil, if there is one, and then to the statefor approval and funding.

In a statewide coordinated system, localcommittees or' councils on children couldcontinue to ad as the central coordinatingand planning mechanism at the communitylevel. Serving a function analogous to thestate coordinating agency, they would reviewlocal proposals, make recommendations and,to some degree, administer program funding.Actual services, however, would be operatedin most.cases by the usual agencies.

D. Comnitinity-level Involvement

Active community involvement in the plan-ning and implementation of, child and familyservices is important because it provides moreaccurate information about' local resources,needs and desires, helps to build flexibilityinto the state plan and ensures respect forlocal values, traditions and mores.

A further benefit from active communityconcern for child and family programs is theadvocacy role that naturally emerges fromsuch involvement. Advocacy of the state planis a necessary part of the program's develop-ment. Impressing the importance of the stateplan upon state decision makers is a signifi-cant aspect in obtaining needed funds andlegislation. Hard data cart assist such advo-cacy, but not efficiently; Only a small amountof statistics can be meaningfully reported anddigested. Without active public interest thereis little likelihood that program to meetestablished need will be adequately imple-mented. The legislature must be persuadedthat the public wants what the planners say, itneeds.

The. regional forums held in Texas as part ofthe state needs assessment procedure sur-prised planning directors with their impact asplatforms for parental and community con-cerns for child and family services. The resultsof the forums provided.geographically signif-icant data for planning, but this informationalso gained new meaning for legislators bybeing byparenta, community leadersand professionals in the field. Seven regionalforums attracted a total of 1,000 persons whocited needs for education for parenting, im-proved health services, expanded child care

. for working parents and better coordinationof services. Their demand for ideal coordina-tibn was underscored in replies to a question-naire: 48' percent wanted dervices coordinatedat the local level and 38 percent wanted themcoordinated thiough a statewide system. Less

than one percent preferrect_ that each state,agency provide services in its own way.

Nothing is so clear an advocate as the consis-tent articulate voice of the public. If.morrien-tum has been gained through public involve-ment in the planning process, it seems wise tomaintain this involvement through activestate-level support of local or regional com-missions concerned with family and children'sservices. These may be newly developed or-ganizations or existing groups such as Com-_nullity Coordinated Child. Care (4-C) orCommission's on Children and Youth. Oftenthese organizations can work more effectivelywith the state plan if they'are reorganized andgiven new powers.

In any case, the local committees should becomposed largelyof parents, with communityleaders; representatives of public and privateservice agencies and professionals .who workwith ,children (such Is doctors, teachers,nurses and social workers). There should alsobe representatives of private and volunteer .organizations such as the PTA, the League of-Women Voters and the United Fund, andrepresentation from local service agencies.

LoCal councils are operating in a number ofstates. In Texas,' many of them developeddirectly out pf the original state planningprocess. Many members were involved inorganizing the regional forums and others inimplementing the household survey. In Massa-,chusetts, Councils for Children were devel.-oped with the help of organizing funds fromthe state Office for Children and an extensivepublic inforniation program. In Arkansas,Committees for , Children have been estab-lished at the state, regional and local levels. Inaddition to an advocacy role, these commit-tees furnish continuing input- to the stateplanning effort and assist in selecting advisoryboards for new programs as they begin inregions and communities. The committeescould themselves organize for the operationof programs if they desired, but so far theirrole has been pritharily child_ advocacy andthe development of programs.

L43

37

The Massachusetts Office for Children hasdeveloped 39 Councils for Children, eachrepresenting a cross-section of children's inter-ests in every area of the state. Communityrepresentatives began by building upon the4-C groups that already existed and' bycon-:tacting every' identifiable group related tochildren and drawing their representativestogether as an organizing committee. A pub-licity campaign, complete with leaflets, 'mail-ings, newspaper and radio announcements andposters, summoned to a public organizing

meeting. a diverse range of people whosecommon denominator was their active con-cern tor children and their determination tohave a voice in the state's policies affectingchildren and families.

In less than a year, these Councils for Chil-

dren became vocal and effective advocates forchildren's services, vigorously informing legis-lators and state agency directors of theirconcerns. They played an active role in thedevelopment and passage of a consolidatedbudget for child antifamily services, providing$20 million in new state money during fiscalyear 1975.

44,38

VII. FUNDING ALTERNATIVES FOR COMPREHENSIVE STATE PROGRAMS

The total, cost of statewide comprehensiveServices for young children and their parentsis unquestionably high. In considering theeffectiveness of such expenditures, however,states might keep in- mindtwo points: (1) thecost to the state of not providing such servicescomputed both in dollars and in the livesdamaged because of the absence of neededexperiences in early childhood and (2) thatfunds can be obtained from a variety ofsources, private as well as public, and 'thattheir maximum use can be obtained through

',careful financial planning and service coordi-nation at the state and local levels.

A precise estimate of the cast of a practicablecomprehensive service approach is difficult tomake. Basic costs vary widely among thestates; different states may make differentdecisions about which services are or are notpart. of the program; funds for many servicesare buried in the general budgets of severalagencies and are rarely identified as costs fprchildren's services per se; and many expensesare met through donated goods and servicesfrom community sources, both public andprivate. In addition, an assessment of stateneeds will undoubtedly reveal a number ofneeds not .now being met. The range of theseneeds and the subsequent costs of meetingthem will vary widely from state to state.

Because of the complexity of these issues andthe general inaccessibility of Cost data, itseems more useful in this report to concen-trate on approachesto state financial planningand sources of funds, rather than on dollaramounts.

A. Approaches to. Financial Planning

There are more than 200 federal programsproviding funds that can be used, to somedegree, to meet the needs of young childrenand their parents. Only a small number arespecifically addressed to the needs of chil-dren, but even among these, objectives areoften. inconsistent,, administration at federaland state levels is fragmented and financing isdispersed. In addition to federal programs,there are innumerable state, local and commu-nity resourcespublic and nOnpublicthatcanbe directed to children's services.

In order to use-these funds more effectively,states need to know, where they are located,how they are currently being used and what

39 .

:45'

regulations or statutes govern alternative uses.States can then examine ways of weldingthese resources together to finance a compre-hensive state plan to achieve more efficientuse of their money, expand the actual numberof service recipients and reduce per-capitacosts.

1. Cooidination of state agencies.It seems reasonable that the same planningand coordinating agency described in thepreceding chapter be assigned the tasks ofidentifying all possible sources of revenuesand developing a plan for the most efficientuse of these resources.

One successful attempt to develdb such acomprehensive state financial plan for chil-dren's services is the 1974 MassachusettsChildren's Budget, the result of the coordi-nated efforts of four state-agencies to secure aconsolidated set of monies specificallymarked for children's services. For more thana year, personnel from the Office for Children(OFC), the state's coordinating and planningagency for children's services, worked withthe departments -of Public Welfare, MentalHealth, Public Health and Youth Services andthe Executive Office of Education to analyzetheir budgets isolating those funds spent onchildren's programs. In addition to identifying'the amount of funds, the OFC evaluated theirexpendituke by geographic area and types ofservices to determine overlaps and gaps inservice delivery.

The OFC and the directors of each depart-ment also worked 'with local area councils forchildren to determine priorities andneeds forchildren's services across the state. The fouragencies subinitted for the first time a consoli-dated budget rather than individual budgetscompeting for the same money. The singlebudget made visible the funds earmarked forchildren's services and- permitted local groupsto participate in the. previously obscure proc-ess of preparing and passing the state budget.This effort secured $20 million in new statemonies for children's, services.

2. Inventory of federal funds.Also needed is a similar inventory of majorfederal funds available for the support ofstate-administered services to children. Thisshould include an analysis of how the uses ofthese funds are related to each other andwhere the potential exists for strengthening

these relationships and expanding service de-livery. The state administers the vast majorityof federal funds for children -and, in principleat least, has substantial authority over how.those funds are used. In practice, however,the funds too often are received by individualagencies and processed without regard towhat other agencies are doing or what theneeds, are.

For example, most federal programs are ad-dressed to the same population groupsthepoor and chronically unemplqyed. This is trueof Aid to Families with Dep4ndent Children,Medicaid, Maternal and Child- Health pro -"grams, the Work Incentive (WfN) program andprograms financed under Title I of the Ele-mentary and Secondary Education Act. Thefunds, however, are administered throughseveral different State agencies. The samepersons may be seeking all those services, butthe service" agencies are not coordinated andseldom communicate with each other.

3. Expanding state fiscal authority.The maze of laws and regulations governingfederal programs presents a major obstacle tothe systematic development of integratedprograms. It is possible, however, for states toexpand their authority to develop more coor-dinated and more efficient child care services.Existing regulations under Office of Manage-ment and Budget (OMB) circulars enablestates to initiate comprehensive plans ofaction' in various policy areas. OMB CircularA-95, permits the state, .especially the gover-nor, to review the impact of proposed federal ,

programs prior to their inception. It central-izes review responsibilities and facilitates :

,more efficient planning and budgeting -proce-dgres. In a 1970 study, however, the U.S.Advisory Commission on IntergovernmentalRelations concluded that states have failed touse the A-95 Circular to its fullest potential.Another OMB circular, A-98, permits states toestablish standard reporting procedures con-cerning currently operating federal programs.A majority of child-related programs areincluded under the provisions of this circular.In examining state policies of child develop-ment, two analysts concluded in 1973 thatifstates used A-95 in conjunction with A -98,they could develop a "composite picture ofprogram trends, thus allowing for trackinggrants from application through fundingstages. Suchan information base would beessential for making intelligent' choices inallocating and implementing child develop-ment services."'

I David Nesenholtz and Jurgen Schmandt, "SocialPolicy and the New Federalism: The Case of ChildDevelopment Policy',". Public Affairs Comment, 46

40

A third OMB circular, A-102, provides thepower to coordinate different federal pro-grams and deliver integrated services, elimi-nates the need ,for/separate bank accounts forindividual federal !programs and, most impor-tantly,.permits the waiver of the requirementthat each federal program be'administered bya single state agency. This last requirement"has greatly. contributed to the developmentof watertight state agencies that behave moreas extensions of their federal counterparts andless as cooperative members of a family ofstate agencies."2 Circular ,A-102 thus permitsthe governor to coordinate policy planningand centralize financial control over closelyrelated programs and services. The combineduse of the three circulars could enable a stateto move agressively to shape federal programsto the needs and priorities of its own commu-nities.

B. Sources o Federtl Funds .

As stated earlier, there are nearly 200 federalprograms whose funds can be used to supportservices to, yoting children and their parents.By ..tracking these down and using the fundsto enhance individual aspects of comprehen-sive service programs, states and communitiescan frequently expand their funding re:i.sources. There are several federal programs,however, that direct large amounts of moneyspecifically o\ the needs of young childrenand represent the major source.of revenue forstate support tchildren's services.

The Major federal sources of revenue for childdevelopment programs include the following:

1. For ducation.ryTitle I of the Elementary and Secondary

Education Act (ESEA) is intended to improvethe ability of local school districts to delivereducatiOnal services to low-income families. Acertain/ amount of these funds, as determinedstate by state through a complex formula, canbe useid to finance kindergarten programs forlow-hcome children. Funds for the educationof grant children (Title I-Migrant)can beused to serve children under the age of 6.

Title VII of the ESEA. provides funds forbilingual programs to meet the needs ofchildren with limited ability to speak Englishor who come from a non-English-speakingbackground, including children under age 6.Under the Education Amendments of 1974(g.L. 93-380) relating to education of .thehandicapped, ESEA funds may be used for

August 1973, the Lyndon B. Johnson School ofPublic Affairs, University of Texas at Austin.2lhid.

s;'

early identification and assessment of handi-capping 'conditions in children under 3 yearsof age. Properly directed, these funds mighthelp supplement. the screening programs car-ried out under EPSDT.

All titles of ESEA are administered throughthe state education agency and are presented-to. the states with no matching provisions. Theonly major federal education program not,administered through the state education de-partment is Head Start. In line With thepractice of the Office of Economic Opportu,nity of utilizing local, public and privateagencies, Head Start programs continue to becontracted directly from the federal govern-

Anent to local organizers. Many Head Startprograms are, however, located in schoolsystems.

2. For health care.Two programs are available under Titles Vand XIX of the Social Security Act. Title V.,Maternal and Child Health, is intended toassist in reducing infant mortality and improv-ing the health of infants and mothers living inrural or economically distressed areas. Fundsare provided in Matching grants with a fed-eral-state ratio of 75 percent to 25 percent.The program is administered through the state

-.health department and disbursementof fundsto local health departments is left to thediscretion of the state agency.

Title XIX is the Medicaid program, providinggeneral health services for the needy, includ-ing children (ages 0 to 21) of poor familiesand children in foster care or state institu-tions. Approximately one-third of the chil-Aren served are under ,age 6. The new Earlyand Periodic Screening, Diagnosis and Treat-ment (EPSDT) program also falls under thisTitle. Both Medicaid and EPSDT funds- areprovided on a 75-25 matching basis, . andchanneled through the state department ofwelfare and social services. (For more detaileddiscussion of these\ programs see Chapter V,Health Services.)

3. For social servicesBy,-far the largest source of funding for socialservices is Title XX (formerly Title IV-A) ofthe Social Security ActAid to Families withDependent Children (AFDC). This programauthorizes direct payments for children oflow-income families in which the father isabsent, incapacitated or dead. At the discre-tion of the state, coverage can be extended tolow-income families with an unemployedfather still present in the household. This titlealso provides the broadest authorization for

ch

4.?41

day care for AFDC children. (For morediscussion, see Chapter V, Day Care.) Whileother services, such as family planning orhomemaker services. can also be offered,under -this .program, the majority of activitiesconsist of day care. Funds are provided on a:75-25 matching basis.

A second source of day care funds for AFDCchildren is Title IV-C of the Social SecurityAct, the Work In _ (WIN) program,which pm' ay care to children of AFDC.mothers who enter a work training program.Although thii program offers the stat,e' a very,attractive match of 90-10, it is largely under-utilized. Among the reasons for this are theproblems of training AFDC recipients foroften nonexistent jobs, the limitations on thenumber of training slots, and dependence onlargely unsatisfactory horne.care.

Title XX is the largest and the most flexiblefunding source for social services. It has thelargest potential client population, and abroad range of activities and services thatqualify for federal matching grants. With thetransition from Title IV-A to Title XX, stateplanning is subject to public review andcomment within the state rather than toreview and approval by the federal govern-ment.

The $2.5 billionseiling for Title IV-A has alsobeen imposed under Title 'XX. However in1974, while $2.5 billion in federal money wasallocated for Title IV-A services, only a littlemore than half this money was actually used.State departments have also been slow toimplement EPSDT programs on a statewidelevel, although the money and the mandatehave been available since 1968.

C. Expanding Available Funds.

States committed to providing comprehensiveservices to all young children and their fami-lies need to explore a variety of fundingresources other than federal programs. Diver-sity of funding permits diversity of service toall members of the population. While almostall states are using the funds discussed aboveto some degree, several approaches can betaken to expand substantially the amount ofmonies available to the states.

Two reasons frequently cited for the failureto use maximum federal funds are the prob-lems of raising sufficient state funds to matchthe federal funds and an aversion to extended"welfare" programs on the part of many statepolicy makers. Both objections can be over-

come by states committed to developingservices to meet the needs of all their families.

1. Using'local and private monies.There are many sources in addition to-thestate coffers from which matching funds can..be, generated. Individual school districts andcities can appropriate funds. Moreover, fundsfrom nonprofit organizations,' such as theUnited Fund, atong with foundation grantsand publicly donated monies from privatelocal sources, can all be applied to match,federal sources. Two citiesAustin, Texas andKansas City, Kansashave appropriated theirown .matching funds for day care programs.

2. Developing new state monies.Of course, many of the necessary funds mustcome from new state monies. The Massachu-setts Children's Budget demonstrates that this'is not an impoSsibility: Informed and involvedcitizens can quickly become .effective advo-cates for children's services, persuading statelegislators and administrators to make chil-dren a top state priority for tax dollars.

Many sources other than state revenue can betapped to contribute to the development ofcomprehensive state services. The most directapproach would be payment for services byrecipients on a sliding fee scale. States Mightalso offer tax credits to private ,industriesproviding day care, or extensive medical serv-ices for their employees.

3. Meeting the costs of day care.Day care is perhaps the service most indemand and most expensive to provide. Inaddition to tax credits to industry, statesmight consider guaranteeing small businessloans for persons wishing to start new centers:-Low-interest loans. could also .be granteddirectly by the state. Present home careoperators could be encouraged to upgrade thequality of their services by obtaining free stafftraining and free materials from state sourcesor from state-funded resource centers. Voca-tional rehabilitation money and WIN funds.could be applied to train welfare motheks tostart 'their own day care homes. WIN fundscould also be used to provide inservicetraining. for welfare mothers in day careJcenters. JIf such a training program wereestablished, graduates might be employedon the payroll of a local industry andstationed in the day care program as acontribution of industry. WIN and VocationalRehabilitation training would thus addresstwo problems simultaneouslythe lack ofjobs for WIN recipients and the lack of daycare places for their children.

The WoMen, Infants and Ilbhildren (WIC)program sponsored by the U.S. Department

/

of Agriculture suPplies, free juice, milk and-eggs to children up to the age of 4, providedthe mothers are registered at a local healthdepartment and are receiving regular physicalcheckups. At the state level, the coordinatingunit for this program is the department ofhealth. The use of the program by day carecenter/ would reduce costszlightly and wouldenhance the nutritional and health programsfpr children and their mothers

Numerous other relatively inexpensive mess-ures are possible to expand the availability' ofday care. For example, if a potential day caremother needs to alter her home to meetfederal or state licensing regulations or state

and local building codes, states could under-write a loan for this purpose. Social securityregulations also permit grants for ,this purposeto persons who own their own homes.

Day care centers can be set up as part Of ahigh school curriculum in family living orchild development (see Chapter V, EducatiOnfor Parenthood)., As part of the school curric:,ulum, the center would be financed partly byschool district funds, including home econom-ics and vocational education funds. In somestates, such as Massachusetts where day care isby statute a function of the schools, facilitiescan be built using state .building assistancefunds. Partially staffed by professionally su-

'pervised high school students earning coursecredits, an excellent program 'for neighbor-

=hood preschoolers couldhe run at substantial-ly lower cost than a center staffed by paidprofessionals and paraprofessionals. Super-vised work-study students could help to re-lieve staff costs in other community day carecenters.

Day care might be tacked onto a kindergartenprogram, providing a safe and pleasant envi-ronment for children whose 'parents cannotpick them up until after working hours. Thusa 9 a.m. to noon kindergarten facility couldcontinue to be used throughout the afternoonby a relatively low-cost program. Or, a centermight be started in conjunction with a seniorcitizens home, providing fulfilling experiencesfor both the older and younger persons, andsimultaneously providing free staff to theprogram.

The S.olith Carolina Office of Child Develop-ment is seeking other approaches to makemaximum use of funding sources other thanTitle XX. Emergency Employment Act fundsfrom the U.S. Department of Labor are usedto staff child care centers, and ComprehensiveEmployment and Training Act funds, also fromthe Department of Labor, are providing child

49t- care services for persons enrolled in certaintraining programs. In addition, local revenue

42- \'

shariny funds are helping to open day carecenter and ale state General Assembly hasappro s riated funds to be used primarily to.assist centers in meeting licensing require:.ments Other states and cities are also begin-ning 'o use both local revenue sharing fundsand ommunity, development funds to opennew ay ovare .centers and to keel) existingones in operation. Since day care is a labor-inten ive service, they are also finding itpossi le to use public-service job positions asa wa, of partially funding their operations.

D. nereasingState Responsibilityor Financial Planning

It is clear from many of the above facts thatstates have more .latitude in guiding funding-policies than is often supposed. They can domuch to shape the use of federal resourcesand can generate further funds from privateand local sources as well as from the staterevenue.

Several recent actions by the federal govern-ment seem to encourage the trend towardplating greater responsibility on individualstat governments to define the 'particularneed of their communities and design serv-ices 'd funding. to meet those needs. TheMatern 1 and Child Health Amendments of1973 re llocated direct grants to projects tobecome art of the formula grants to thestates. Wi stipulation that the. states mustdevelop pl s to maintain the ongoing proj-ects, the rea ocation essentially turns over tothe states the administration of 90 percent ofmonies allocat d under the law.

The Education Amendments of .1974, P.L.93-380, provides for the consolidation of anumber of existing federal programs into twocategoriesPart B (Libraries and LearningResources) and Part C (Educational Innova-tion and Support). Part B will combine theschool library program, =the guidance findcounseling programs and the equipment pro-gram. Part C.consolidates innovation, dropoutprevention, health and nutrition programs andaid to strengthen state departments of educa-tion. According to a specific formula, over thenext three years these fupds are to beconsolidated and distributed to the states forredistribution to the local education agenciesaccording to a state plan.

Title XX also offers the states greater latitudeAn determining program eligibility and in:

planning services and service delivery. Asmentioned above, Title XX sdbstantially ex-pands the population eligible to receive cer-tain benefits of the Social Security Act. Thetitle permits free services to perions with upto 80 percent at the median family income ina state and services on a sliding-fee basis forrecipients having up to 115 percent of themedian income le.vel of the state. Programsallowed includebut. are not limited to,training, employment, "Information, referraland counseling services; day care programs;child Protection services; food and health ,.support services; and progranis designed tomeet special needs, such as for the blind,retarded, physically handicapped and emo-tionally disturbed. The amendment leaves tothe states the major responsibility of namingservices; but sets certain parameters andMakes suggestions as to what those servicescan include. -1

Title XX for the first time makes possible atsome future date a single-entry, universallyavailable service system. Tho'se who are poorwill be fully subsidized; 'those .who arewealthy will pay the full cost of service; thosein between will pay on, a sliding scale accord-,ing to their ability to pay, with federal and.'state matching funds making up the differ-ence. Federal policy will] no longer, forcesegregation by economic category. The crea-tive use of this opportunity for universallyavailable service is up to each state. A modelfor the service system now made possible car.be shown by the following figure:

49.

43

For the first time, TitleXX provides publicfunds to meet thismissing trianglein publicpolicy.

Parents.can pay asliding fee .trj iv

based on their I t.)

lability to' pay.1 a

tg15=

oC)

Low income C High in'conie

These and other acts of the federal govern-ment tend to increase state authority insetting the direction of programs and funds toserve young children and their parents. Statescommitted to providing services for all youngchildren and their . families are increasinglyable to make maximum use of federal pro-grams without being limited, to serving only asimplementors. The trend is to return theinitiative for planning to the states, providingthe opportunity for states to shape services totheir own needs.

w

VIII. RECOMMENDATIONS

A.' Recognize Many Family Forms

States should recognize that families in Amer-ica take many forms, and that the nuclearfamily of a married man and woman and theiroffspring is. only one of a range of differentarrangements. Each form --has its ownstrengths and weaknesses, and each is capable;under favorable circumstances, of providing acohesive, warm and supportive environmentfor the healthy development of children.

B. Establish a Common:Set of ProgramObjectives

Services to support parents in their child-rearing tasks should lead to greater familycohesiveness and independence. In developingprograms to pursue this broad goal, a specificset of program objectives *should be consid-ered to ensure that state programs contributeto the strengthening of the many and variedfamilies they serve. The folrowing objectivesare, suggested, as an operational base for allstate programs designed to serve young chil-dren and their parents:

To assist parentsto become more positivelyinvolved in the lives of their children.

.1ro help parents understand better theprocess of child growth and development.

To provide experiences by which parentslearn to meet more fully the developmentalneeds of their child.

To. provide assistance when necessary, thatwill increase the possibility of the familystaging together rather than being separated.

To do this in a context that recognizes theimportance of different cultural and ethnicvalues, traditions and mores and addresses theparticular needs and concerns of individualfamilies.

C. Develop Expanded Servicesin Four Major Areas

State need to explore ways to expand theirservice capacity in four major areas of familyneed: education for parenthood, health serv-ices, day care and services to parents andchildren with special needs. These serviceshave in common several important elements.They aim to support families, not to replace 50

44

Q

them; they represent a preventive approachrather than a remedial one; they address needscommon to all families, regardless of culturalor ethnic background' or. socioeconomic posi-tion they are not emergency services, butcoritimlous, ongoing services directed primar-ily at meeting needs before they becomeproblems.

1. Education; or parenthood.-Education for parenthood should be an inte-gral part of programs provided in a Compre-hensive system of child

thefamily services.

This is consistent with the objective of utiliz-ing and supporting as much as poSsible thefamily's capacity, to 'care for its own. Mostparents need and want to know more about ,

the social, physical, emotional and intellectualneeds of young children, the.similarities anddifferences in the ways that children develop.,and the role that parents can play in theirchild's development.

Parent education may be most effective whenit is the result of direct involvement in

. programs such as day care or preschool, or inplanning and administration. Actual instruc-tion in various aspects of child growth anddevelopment can be provided' through hospi-tals and prenatal clinics, through maternal andchild clinics, through child and family re-source centers, through community organiza-tions such as the Red' Cross and Visiting

--lgurses-and-thrdugh the schools. Each of 'theseagencies can introduce parents or potentialparents to the information they need. aboutthe growth and development of their child,-and when appropriate, can help them acquireneeded skills.

It is recommended that states consider ex-panding the use of television and radio forparent education. Funds should be providedto' promote short public service announce-,ments, to be repeated frequently, as well aslonger programs produced in cooperationwith public television and radio broadcastingand with local network affiliations.

Parenting education should also he directed toadolescents to prepare them for their futureroles as parents. State departments of educa-tion might consider newly developed*aches, some of which are suggested in thisreport, to revising home economics or familyliving curricula at the junior high and highschool levels in order to provide the students

V

with experience with young children andto increase the enrollment of boys.

2. Health services. -

In order to provide full health services to allits, children, a state should consider thefollowing steps:

Extend publicly funded health and nutri-tion programs, such as M3ternal and InfantCare and the Supplemental Food Program forWomen, Infants and Children (WIC) to all'women, children and -families who requirethem, especially the "medically indigent"who are employed but cannot afford regular

.adequate healthcare for family members.

Develop a program of early screening,diagnosis and testing that will be available andaccessible to all preschool-age childrenthroughout the state.

Expand the use of family-oriented deliverysystems such as family health centers, neigh-borhood health centers and health mainte-nance organizations.

Adapt state 'taws to permit greater flexibil-ity in training and practice of nurses and

iddle-level health personnel.

sevelop a statewide plan to coordinateexist ng public and private resources, de-emph4sizing hospitalization and encouragingpreventive, diagnostic and ambulatory serv-ices.:-

3. Day care\Quality day eare should be available in someconvenient frkm, whether center-based orhome-based, on ,a sliding-fee basis to all whoneed it. States should aid communities indetermining the Services most suitable fortheir particular needs, taking the initiative tobring together a Wide range of fundingsourcesfederal, local and privateas well asdeveloping. new state monies for this purpose.

States should take steps to assure that daycare programs are of a quality to provide asafe nurturing environment \ for the child,addressing all aspects of social, emotional,educational and physical deVelopment. Inaddition, states should make the opportunity-for parent involvement an essential, part of itsprogramming for day care, through\ its fiscalrequireMents.

The states could improve their licensing proc-ess by a statutory requirement for the crea-tion of a unified system out of the preSentfragmented regulatory activities stemmingfrom four major statutory mandates: zoning,

45

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building and fire safety, sanitation and daycare licensing.$tates should think through therelation of _ licensing to fiscal monitoring.Adequate staff to manage day' care centerlicensing is an attainable goal for most states.It is' recommended that licen-sing be central-ized at the state level .in order to guaranteethe children of the state uniform interpreta-tion .and enforcement and equal protection.For family day care, new and creative ways toregulate should be initiated on an experimen-tal basis. ,

4. Services to parents and children withspecial needs.States need to develop legislation to promotecomprehensive and 'rehabilitative_ approachesto helping Parents and children with specialneeds. While this section of thereport devoteSspecial attention to three types of special.situations particularly affecting the welfare ofyoung childrenthe handicapped child, childabuse and school-age parenthoodseveral gen-eral principles for state action are recoin-mended: ,

Procedure for early identification of theproblems need to be developed:

Services should be addressed both to chil-dren and to' parents, and the family should beaided as a unit. 0

Since these needs require a mixture ofservices from the health, education and socialsectors, as well as a continuum of program-ming, a coordinated comprehensive approachshould be developed among all state agenciesdealing with parents and young children.

State policy makers should take steps. toremove categorical and socioeconomic bar-riersito state services..

Agency staff at the state' and local level'sshould receive the necessary educatical andtraining required to .implementa comprehen-sive and rehabilitative approach.

--D. Develop a Comprehensive AppioaCh'

to Services for Young Childrenand Their Parents

To help reduce the duplication, waste andgaps in service resulting'from the presentfragmented 'approach to individual services,.itis necessary that states develop -a statewidecomprehensive approach, initiated and sup-ported at the highest levels or state .govern-ment and implemented by local communitiesaccording to their need.

A coordinated comprehensive program of

A

services to young children and their parentsshould be preventive in orientation and pro-vide services on= a continuous, not solely anemergency, basis. It should Utilize to thegreatest extent possible the family's ',ownchild-rearing and child-caring capabilities. Its

,Primary goal should be to permit access to allservices by all members of the communitywho need them, rather than. restricting serv-ices to selected populations within the com-munity. On the basis of the experience' ofsevergl states in recent years, the followingsteps appear necessary in the development ofa comprehensive service approach at the statelevel:

Initiative and commitment from the high-est levels of the executive And legislativebranches of .state government, especially the,governor.

A state coordinating mechanism.

A state plan for providing continuing andcoordinated services to young children andtheir fam ilies:

Systematic community and parental in-volvement in the planning and implementa-tion of services for young children and theirparents..

.11

sA

E. Increase State Initiative in Developingand Coordinating fending Sources

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States should examine ways of welding to-gether funds from a variety of resources tofinance a .comprehensive state plan. This willguarantee a more efficient use of availablemoney and will expand the actual number ofservice recipients.

4The maze of laws and regulations governingfederal programs presents a major obstacle tothe systematic development of integratedprograms. It is possible, however, for states toexpand their authority to develop more coor-dinated and "note efficientchild care services.Existing regulations under Office of Manage-ment and Budget (OMB) circulars permitstates to initiate comprehensive plans ofaction in various policy areas. The combineduse-of these circulars could enable a state'tomove aggressively to shape-federal,--programsto the needs and priorities of its own .ccinunu-

Many sources other- than state and federal-revenues can also be tapped to contribute tothe development of comprehensive state cerv-ices. States committed to 'providing suchservices for all young children and theirfamilies can explore a variety of, fundingresources other-than federal programs. Onebeneficial result of such an, approach is thatdiversity of funding permits diversity of serv-ice to'all members of the population.

"h o

. ,-.

6.....,

.0

EARLY 'CHILDHOOD PROJECT' PUBLICATIONS' 1"-1,5'

Early Childhood Project Newsletter (published bi-monthly: no'charge)

Early Childhood Development: Alternatives for Pro-gram Implementation in the States (ECS Re-port No, 22, June 1971: $1.00)

Early Childhood Programs for Migrants: Alternativesfor the States (ECS Report No 25, May 1972:$1'.00)

Establishing a State Office of Early Childhood Duvet;opment: Suggested Legislative Alternatives(ECS Report No..30;:December 1972: $(.00)

Early Childhood Planning in the States: A Handbookfor Gathering Data and Assessing Needs (ECSReport No, 32, January 1973: $1.00)

Implementing Child Development Programs: Reportof a National SymposiUm August 1974 (ECS,ReportNo. 58, December'1974: $2.00)

Early Childhood Programs: A State Survey 1974-75(ECS Report No. 63, April 1975: $1.00)

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The Very Young and Education: 1974 State ktivity(ECS Report No. 68, May 1975: no charge)

Child Abuse and Neglect: Model Legislation for theStates (ECS Report No. 71, July 1975:43.00)

Day Care Licensing Policies and Practices: A StateSurvey, ply /97.5.(ECS Report,No. 72; August1.975: $2.50)

State Offices of Child Development (ECS-Report No.55, September 1975: $3.00) "

State Services in Child Development: Regional. Con-ferencg Highlights (ECS Report No. 75, NOvem-ber,1975: $1.00)

The:. Role 'of, the Family' in Child Develppment..Implications for State Policies and Programs(ECS Report No. 57, December 1975! $3.50)

Children's Needs: The Assessmtnt Process (ECSReport NO. 56, January 1976: $2,00)

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