SO WE'RE GOING TO GO AHEAD AND START ON TIME BECAUSE WE HAVE VERY RICH PRESENTATIONS ON HOME VISITATION AND WE WANT TO ALLOW TIME FOR OUR SPEAKERS TO REALLY GET INTO SOME EXCITING DATA ON A VERY IMPORTANT ISSUE. I'M PLEASED TO WELCOME YOU. MY NAME IS CHERYL BOYCE AND I COCHAIR THE NATIONAL INSTITUTES OF HEALTH, CHILD ABUSE NEGLECT AND WORKING GROUP ALONG WITH MY COLLEAGUE VALERIE HOLMES. AND A TRADITION OF THIS CONSORTIUM HAS BEEN NOT ONLY MENTORING OF I WOULD SAY AMAZING AND TALENTED EARLY CAREERS AND ALSO INTEGRATION I WOULD SAY ACROSSGBu9(‡QPj IN TERMS OF TRANSLATIONAL INTERDISCIPLINARY RESEARCH HAS BEEN AN OUTREACH TO MAKE SURE THAT THE INFORMATION IS DISEMMINATED TO THE COMMUNITY. AND IN THAT VAIN FOR THE PAST FIVE YEARS, A COMPONENT OF THE MEETING HAS ALWAYS BEEN AN AFTERNOON COMMUNITY COMMUNITY-BASED SEMINAR FOR THE PUBLIC, AND THEY ARE ARCHIVED ON THE WEBSITE FROM THE PAST FEW YEARS AND WE'RE VERY PLEASED ABOUT TO HAVE YET AGAIN AN OUTSTANDING NOT ONLY ONE PRESENTER BUT THIS TIME WE HAVE SEVERAL PRESENTERS. AND WE ALSO ARE PLEASED TO WELCOME SOMEONE FROM THE COMMUNITY WHERE WE ARE ACTUALLY HAVING OUR MEETING TODAY AND I AM VERY PLEASED TO INTRODUCE HER FIRST TO GIVE OPENING REMARKS. MISS ALICE HAS BEEN DIRECTOR THE OF THE CHILD WELFARE SERVICE FOR OVER 20 YEARS. TO SAY SHE'S DEDICATED WOULD BE A LITTLE BIT OF AN UNDERSTATEMENT. SHE HAS A STAFF OF 200 PROVIDERS THAT PROVIDE AN ARRAY OF SERVICES TO CHILDREN AND THEIR FAMILIES. BEFORE SHE CAME TO MONTEGOMERY COUNTY, SHE WAS THE DIRECTOR OF PARTIAL HOSPITALIZATION PROGRAMS FOR SEVERELY MENTALLY ILL ADULTS AT A MEDICAL CENTER IN PENNSYLVANIA AND A TRAINER OF FAMILY THERAPIST IN WISCONSIN, ISRAEL, AND PENNSYLVANIA. SO WE'RE VERY PLEASED THAT YOU HAVE TAKEN ON THAT JOB HERE IN MONTEGOMERY COUNTY AND COULD TAKE TIME AWAY TO JOIN US TODAY. SHE HAS A MASTER'S DEGREE IN PSYCHOLOGY IN CHILDREN AND FAMILY THERAPY AT THE PHILADELPHIA CHILD GUIDANCE CLINIC AND SHE'S REALLY FOCUSED ON DEVELOPING PARTNERSHIPS WITH THE COMMUNITY AND WORKING TO INTEGRATE SERVICES FOR AT-RISK CHILDREN AND THEIR FAMILIES AND I KNOW YOU'VE IMPLEMENTED A LOT OF WHAT'S HERE TODAY THAT'S EVIDENCE-BASED IN MONTEGOMERY COUNTY. SO WITH THAT, I'LL TURN IT OVER TO YOU TO GIVE US A WARM WELCOME. >> THANK YOU, WELCOME BACK WELCOME, EVERYBODY. MONTEGOMERY COUNTY IS A VERY INTERESTING COUNTY IN THAT IT'S CONSIDERED A WELL-TO DO COUNTY AND OFTEN THE FACTOR THAT'S IGNORED IS THAT ALMOST 40% OF THE POPULATION IS FOREIGN-BORN. AND THE CHALLENGE FOR US IN CHILD WELFARE IS TO FIND STAFF WHO CAN WORK WITH MANY OF THE FOREIGN-BORN FAMILIES WHO DO YOU MEAN OUR ATTENTION AND THAT INCLUDES NOT ONLY HISPANIC FAMILIES BUT MANY OF THE AFRICAN, DIFFERENT AFRICAN COUNTRIES. IN ORDER TO ENGAGE MANY OF THESE FAMILIES WHO ARE REPORTED TO US IN CHILD WELFARE, WE REALLY ARE AGGRESSIVELY FOCUSED ON FINDING STAFF WHO COME FROM MANY DIFFERENT CULTURES, MANY DIFFERENT COUNTRIES. AND SO ABOUT 50% OF OUR STAFF ARE FAMILIAR WITH A DIFFERENT ETHNIC GROUP. IN TERMS OF THE WORK THAT WE DO, WE INVESTIGATE ABOUT 150 NEW NEGLECT CASES EACH MONTH AND INVESTIGATE SOMEWHERE BETWEEN 250 AND 325 NEW INVESTIGATIONS EACH MONTH. BUT OF THOSE, ABOUT 48% ARE NEGLECT. AND I THINK THAT WE PICK UP MANY OF THESE CASES FIRST OR SECOND TIME OF THE CALL RATHER THAN CALLERS REPORTING THESE FAMILIES MULTIPLE TIMES. WE FIND THAT ECONOMICS IS CERTAINLY A CHALLENGE PARTICULARLY FOR MANY OF THE IMMIGRANT FAMILIES. BUT THAT IS NOT THE BULK OF OUR CASE. THE BULK OF OUR CASES IN NEGLECT ARE OFTEN FAMILIES WHO HAVE SUBSTANCE ABUSE AND MENTAL HEALTH PROBLEMS. AND THAT CERTAINLY IS A CHALLENGE FINDING ADEQUATE RESOURCES AND THE RIGHT RESOURCES FOR THE PARENTS OF THOSE KIDS. WE'RE VERY FORTUNATE IN THAT MONTEGOMERY COUNTY, ABOUT 12 YEARS AGO DECIDED TO COMBINE HEALTH AND HUMAN SERVICES UNDER ONE LEADERSHIP. AND SO MENTAL HEALTH, FOR EXAMPLE, IS FAIRLY EASILY ACCESSIBLE IN A SYSTEM THAT IS QUITE COMPLEX. WE ALSO HAVE A RELATIVELY EASY-TO-ACCESS SUBSTANCE ABUSE PROGRAM BECAUSE OF THE COUNTY'S SYSTEM. IT DOESN'T MAKE IT EASY TO WORK WITH MANY OF THESE FAMILIES, BUT WE FEEL THAT WE'RE VERY FORTUNATE BECAUSE THE LOCAL COUNTY GOVERNMENT, WHO WE HAVE WORKED WITH !„ DILIGENTLY, HAS VERY, VERY& REALLY BOUGHT INTO THE FACT THAT THESE FAMILIES, THESE KIDS WHO HAVE BEEN NEGLECTED, HAVE LONG-TERM OUTCOMES THAT ARE GOING TO BE NEGATIVE AND SO WE OUGHT TO JUMP ON THEM RIGHT NOW. SO WITH THAT, I'LL GO AHEAD AND LET THE OTHER SPEAKERS TELL YOU ABOUT IT. I'LL HANG AROUND, IF ANYBODY WANTS TO KNOW ANYMORE ABOUT THE COUNTY. WE'RE VERY FORTUNATE TO HAVE NIH HERE AND TO HAVE THIS WORKSHOP HERE AND SO WELCOME. >> THANK YOU, AGNES. I AM WITH THE NATIONAL INSTITUTE ON DRUG ABUSE AND IN THE PREVENTION RESEARCH BRANCH AND I HAVE THE HONOR AND THE PLEASURE OF INTRODUCING OUR TWO PRESENTERS FOR TODAY. OUR FIRST PRESENTER DR. DAVID, FIRST I WANT TO SAY I HAVE THE HONOR OF INTRODUCING HIM BECAUSE HE HAS BEEN IN THE PREVENTION RESEARCH BRANCH AND HE'S A GRANTEE IN MY PORTFOLIO. SO I AM VERY HAPPY TO INTRODUCE YOU AND HEAR MORE ABOUT YOUR FINDINGS SPOT. FESOR OF PEDIATRICS, PSYCHIATRY, PREVENT—w% MEDICINE AND NURSING AT THE4vÖ UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER WHERE HE DIRECTS THE PREVENTION RESEARCH CENTER FOR FAMILY AND CHILD HEALTH. HE HAS DEVOTED HIS„% INVESTIGATING METHODS OF PREVENTING HEALTH AND DEVELOPMENTAL PROBLEMS IN CHILDREN AND PARENTS FROM LOW-INCOME FAMILIES. THE PRIMARY FOCUS OF HIS WORK HAS BEEN ON DEVELOPING AND TESTING IN A SERIES OF RANDOMIZED CONTROLLED TRIALS A PROGRAM OF PRENATAL AND FANCLY HOME VISITING FOR NURSES WITH SOCIALLY DISADVANTAGED MOTHERS KNOWN TODAY AS THE NURSE FAMILY PARTNERSHIP. THE PARTNERSHIP HAS BEEN FOUND TO IMPROVE WOMEN'S PRENATAL HEALTH, REDUCE CHILD ABUSE, NEGLECT AND INJURIES AND PROVE SCHOOL READINESS AND REDUCE CRIME AND SUBSTANCE ABUSE. [APPLAUSE] >> THANKS, JACQUELINE AND THANKS, EVERYONE FOR INVITING ME TO BE A PART OF THIS CONFERENCE. I AM LEARNING A LOT AND I AM GOING TO USE MY TIME TO TALK ABOUT WORK THAT MY COLLEAGUES AND I HAVE BEEN CONDUCTING OVER THE LAST 35 YEARS AIMED AT PROMOTING A WHOLE RANGE OF MATERNAL AND CHILD HEALTH OUTCOMES. AND I'D LIKE TO GIVE SPECIAL ACKNOWLEDGEMENT TO A FEW OF MY COLLEAGUES THAT ARE PRETTY WELL-KNOWN TO THIS GROUP WHO DIRECTS THE RUCKEN BRENNER TRANSLATIONAL RESEARCH CENTER ON CHILD ABUSE AND NEGLECT AT CORNELL. HARRIETT KITSMAN, WHO IS NURSE INVESTIGATOR AT THE UNIVERSITY OF ROCHESTER AND CHUCK HENDERSON, WHO IS A STATISTICIAN WHO HAS BEEN WORKING WITH US ALSO FOR WELL OVER 30 YEARS. THE WORK THAT MY COLLEAGUES AND I HAVE BEEN CONDUCTING IS NOT FOCUSED EXCLUSIVELY ON THE PREVENTION OF MALTREATMENT OR NEGLECT EVEN. IT'S FOCUSED ON PROMOTING A WIDE VARIETY OF MATERNAL AND CHILD HEALTH OUTCOMES AND WE THINK THAT THAT APPROACH HOLDS CONSIDERABLE PROMISE FOR ACTUALLY REACHING SEGMENTS OF THE POPULATION THAT WE REALIZE WOULD NOT BE ABLE TO REACH IF THIS PROGRAM WERE SIMPLY KNOWN AS A CHILD MALTREATMENT PREVENTION EFFORT. AND I'D LIKE TO SHARE WITH YOU WHY WE THINK THAT. LET'S SEE IF I CAN GET THESE SLIDES TO WORK. GREAT. I PERSONALLY GOT INVOLVED IN THIS WORK IN 1970 WHEN I FINISHED GRADUATE SCHOOL IN BALTIMORE, WHERE I'D WORKED ON MARY AMES WORTH BALTIMORE STID STUDY OF INFANT ATTACHMENT. I WAS A PRODUCT OF THE 60S. I THOUGHT THAT I JUST NEEDED TO GET OUT THERE AND MAKE THINGS BETTER FOR POOR PRESCHOOLERS AND IF WE COULD HELP IMPROVE THEIR EMOTIONAL EXPERIENCE IN THE CLASSROOM AND THEIR COGNITIVE STIMLATION THAT THEY HAVE A BETTER CHANCE OF SUCCEEDING IN ELEMENTARY SCHOOL AND LATER ON IN LIFE. AND I SOON REALIZED THAT FOR A LOT OF THE CHILDREN IN MY CLASSROOM, IT WAS ALREADY TOO LITTLE AND TOO LATE. A LITTLE BOY HAD BEEN EXPOSED TO ALCOHOL DURING PREGNANCY AND HE COULDN'T TALK. ONLY GESTUREED. SO THE CHILDREN IN MY CLASSROOM WERE BEING ABUSED OR NEGLECTED AND THEIR BEHAVIOR WAS ALREADY DISREGULATEED. I REALIZED THAT WE NEEDED TO DO MORE WITH PARENTS, SO I CREATED PARENT GROUP MEETINGS, WHERE PARENTS WOULD COME IN FROM THE COMMUNITY IN THE AFTERNOON TO TALK ABOUT THE CHILDREN'S DEVELOPMENT. AND WHAT STRUCK ME WAS THAT THE PARENTS WHO SHOWED UP WERE THE PARENTS WHO WERE OF LEAST CONCERNED OF CHILDREN ABOUT. THE PARENTS I WAS MOST CONCERNED ABOUT I NEVER SAW. AND SO I HELD ON TO THIS BELIEF THAT PARENTING WAS IMPORTANT BUT WHEN YOU WALKED OUTSIDE OF THE DOOR OF OUR DAYCARE CENTER, LITERALLY ACROSS FROM THE FROM OUR CENTER WAS A LITTLE STORE LIKE THIS, WHERE THEY SOLD TWINKIES AND CANNED GOODS AND YET OUR CENTER WAS A GREAT DEAL OF EMPHASIS ON EATING HEALTHY DIETS. AND SO BUT IF YOU WALKED FOR MILES ARN UR -- AROUND OUR CENTER, THERE WAS NO SOURCE OF FRESH FRUITS AND VEGETABLES. THE RATES OF UNEMPLOYMENT IN OUR COMMUNITY WERE JUST OFF THE CHARTS. THE HOUSING STOCK WAS TERRIBLE. THIS PARK WHERE I'D TAKE THE CHILDREN TO PLAY WAS UNSAFE FOR CHILDREN. THE RATES OF CRIME WERE ALSO OFF THE CHARTS. THIS IS THE NEIGHBORHOOD THAT THE HBO SERIES, "THE WIRE" WAS SUPPOSED TO BE BASED ON. I REALIZED THAT I DIDN'T KNOW ENOUGH. IT WAS A SOBERING EXPERIENCE, AND I STARTED TO WRITE TO THIS PROFESSOR AT CORNELL, AND HE WROTE BACK TO ME. WHILE THE KIDS WERE TAKING NAPS SOMETIMES, WY WRITE TO HIM ON A YELLOW PAD AND HE WROTE BACK. AND I ENDED GOING TO CORNELL AS A GRADUATE STUDENT AND EVENTUALLY DEVELOPED THE PROGRAM THAT I AM GOING TO TALK ABOUT THIS AFTERNOON KNOWN AS CENTER FAMILIES CENTERS PARTNERSHIP. I SHOULD TELL YOU AT TACHMENT THEORY AND HUMAN ECOLOGY THEORY HAVE PLAYED A SIGNIFICANT ROLE IN THE DESIGN OF THIS INTERVENTION. BUT I THINK THAT NEITHER OF THEM WAS SUFFICIENT WITH RESPECT TO FIGURING OUT HOW TO PROMOTE ADAPTIVE BEHAVIORAL CHANGE. WHAT ARE MOTIVATIONS AND SO I SHOULD TELL YOU THAT THE PROGRAM THAT WE'VE DESIGNED ALSO SYSTEMAT CLIINTEGRATES EFFICACY THEORY AS A CORE ELEMENT IN THE INTERVENTION DESIGN. IT'S A PROGRAM OF PRENATAL AND FANCY HOME VISITING BY NURSES WHERE NURSES BEGIN WORKING AS EARLY IN PREGNANCY AS POSSIBLE AND FOLLOW THE FAMILIES THROUGH THE CHILD'S SECOND YEAR OF LIFET FOCUSES ON LOW-INCOME MOTHERS BECAUSE THAT'S WHERE SO MUCH OF THE ACTIONS, AS WE'VE HEARD TODAY IS. AND THOSE WHO ARE HAVING THEIR FIRST LIVE BIRTH, BECAUSE THIS REPRESENTS A MAJOR LIFE TRANSITION THAT WE THINK MAKES WOMEN, PARENTS, FAMILIES, MORE RECEPTIVE TO OFFERS OF HELP. AND WHEN PATTERNS OF BEHAVIOR AND EVEN MY GUESS IS NEUROCIRCUITRY GETS LAID DOWN TO SHAPE THE KIND OF PARENTS AND ADULTS THAT MANY OF THESE FIRST-TIME MOTHERS ARE GOING TO BECOME. IT MAKES THEM PARTICULARLY RECEPTIVE TO ACCEPT HELP FROM NURSES BECAUSE THEY ARE CONCERNED ABOUT WHAT LABOR AND DELIVERY ARE GOING TO BE LIKE. WHAT CARE THE NEWBORN IS GOING TO BE LIKE. AND I THINK THAT OWL OF OUR KINDS OF PREVENTIVE INTERVENTIONS DEPENDS FUNDAMENTALLY ON ENGAGEMENT IN THE TARGET POPULATION. WHY WOULD THEY WANT TO SHOW UP? AND WHY WOULD THEY WANT TO CHANGE THEIR BEHAVIOR? THESE ARE FUNDAMENTAL QUESTIONS THAT WE NEEDED TO ASK OF ALL OF OUR EVIDENCE-BASED SERVICES AND INTERVENTIONS NEED TO BE DESIGNED WITH THAT FUNDAMENTAL ISSUE IN MIND. WE THINK THAT THE PROGRAM HAS POWER IN PART BECAUSE IT ACTIVATES AND SUPPORTS SOMETHING THAT'S FUNDAMENTAL IN ALL OF US AS HUMAN BEINGS, AND THAT'S REALLY OUR INSTINCT TO PROTECT OUR CHILDREN. NOW, THOSE INSTINCTS MAY GET HIJACKED BY EXPOSURES TO DRUGS, LIKE WE HEARD EARLIER TODAY, LIKE COCAINE OR MAY GET HIJACKED OR SUBDUED BY HISTORIES OF TRAUMA. BUT UNDERLYING ALL OF THAT, WE THINK, IS A FUNDAMENTAL HUMAN OR MAMMALIAN INSTINCT TO PROTECT ONE'S CHILD. AND IF WE THINK THAT IF WE DIG DEEPLY ENOUGH AND LISTENED CAREFULLY ENOUGH, WE WILL BE ABLE TO BUILD ON THAT FUNDAMENTAL INSTINCT. I'LL TELL YOU MORE ABOUT THAT IN A MOMENT. WE ALSO THINK IT'S CRUCIAL THAT THE PROGRAM BE CLEAR ABOUT WHAT IT'S TRYING TO ACCOMPLISH AND HOW IT'S GOING TO GO ABOUT DOING THAT, AS YOU WILL SEE IN A MOMENT WE TRIED TO DO THAT. NOW THE NURSES IN THIS PROGRAM HAVE THREE MAJOR GOALS. THE FIRST IS TO IMPROVE THE OUTCOMES OF PREGNANCY BY HELPING WOMEN IMPROVE THEIR PRENATAL HEALTH. WE'RE PARTICULARLY CONCERNED ABOUT REDUCING WOMEN'S USE OF SUBSTANCES DURING PREGNANCY AND ESPECIALLY TOBACCO, BECAUSE TOBACCO IS SO FREQUENTLY OCCURRING AND IT IS PROBABLY THE MOST LARGEST ATTRIBUTABLE RISK FOR POOR PREGNANCY OUTCOMES OF ANY EXPOSURE THAT PREGNANT WOMEN HAVE FOR COMPROMISING FETAL GROWTH AND DEVELOPMENT AND NEWER LOGIC DEVELOPMENT. WE'RE CONCERNED ABOUT PREVENTING ALCOHOL, REDUCING ALCOHOL EXPOSURE OR USE OF OTHER SUBSTANCES. BUT TOBACCO IS THE BIG HITTER. WE'RE CONCERNED -- NURSES ALSO THINK DEEPLY ABOUT HELPING WOMEN IDENTIFY EMERGING PREGNANCY COMPLICATIONS AND HAVE THEM TREATED MORE PROMPTLY AND RELIABLE A BEFORE THOSE PREGNANCY COMPLICATIONS START TO DEVELOP, COMPROMISE. WE KNOW THAT COMPROMISED DEVELOPMENT AS A RESULT OF UNTREATED PREGNANCY COMPLICATIONS OR EXPOSURES TO SUBSTANCES INCREASE THE DIFFICULTY THAT CHILDREN ARE GOING TO EXHIBIT IN THE NEWBORN PERIOD, WHICH IN ITSELF INCREASES THE RISK FOR ABUSE AND NEGLECT. WE'RE ALSO CONCERNED ABOUT HELPING PARENTS IMPROVE THEIR CHILDREN'S SUBSEQUENT HEALTH AND DEVELOPMENT BY HELPING THEM PROVIDE FOR COMPETENT CARE WITH THE BABY. THE NURSES HAVE DETAILED VISIT-BY-VISIT GUIDELINES BEGINNING OVER AND ACTUALLY COVER A 64-VISIT SEQUENCE OF ACTIVITIES THAT NURSES CAN RELY ON AND ADAPT TO THE INDIVIDUAL NEEDS OF EACH FAMILY TO ADDRESS TO HELP THEM BECOME BOTH MORE COMPETENT CAREGIVERS BUT ALSO ADDRESS THE OTHER GOALS OF THE PROGRAM. AND THIRD GOAL IS TO HELP PARENTS BECOME MORE ECONOMICALLY SELF-SUFFICIENT. WE BELIEVE THAT ECONOMICS IS IMPORTANT IN ITS OWN RIGHT BUT WE ALSO KNOW THAT IT INCREASES THE -- THAT POVERTY AND ECONOMIC INSUFFICIENCY INCREASES THE RISK FOR NEGLECT. AND SO HOW DO THE NURSE DOZEN THAT? THEY HELP FAMILIES START TO DEVELOP A VISION FOR WHAT LIFE MIGHT BE LIKE AND START TO MAKE APPROPRIATE CHOICES ABOUT STAYING IN SCHOOL AND FINDING WORK. AND MAYBE MOST IMPORTANTLY, THINKING ABOUT THE PLANNING OF SUBSEQUENT PREGNANCIES BECAUSE THIS IS THE FIRST LIVE BIRTH. AND THIS IS AN OPPORTUNITY TO HELP WOMEN START IMAGINING HOW THEY'RE GOING TO CARE FOR THEMSELVES AND THAT NEXT CHILD AND WHERE IN THE SEQUENCE OF THE CHOICES THAT THEY MAKE ABOUT THEIR OWN LIFE IS THE PLANNING OF THAT NEXT BABY GOING TO FIT INTO THE VISION THAT THE NURSES ARE CHARGED WITH HELPING FAMILIES START TO DEVELOP. THE NURSES INVOLVE OTHER FAMILY MEMBERS IN THE PROGRAM, ESPECIALLY FATHERS AND HELP THEM SEE THE ROLE THAT THEY CAN PLAY IN PROTECTING THEIR CHILD AS WELL. AND THEY LINK FAMILIES UP WITH OTHER NEEDED HELP IN HUMAN SERVICES IN PART TO HELP FAMILIES ADDRESS SOME OF THE OFTEN UNBEARABLE STRESS THAT'S BEAR DOWN ON THEM AND MAKE IT MORE DIFFICULT TO CARE FOR THEMSELVES AND FOR THEIR CHILDREN. NOW, WE'VE TESTED PROGRAM AND THREE SEPARATE RANDOMIZED CONTROLLED TRIALS OVER THE LAST 35 YEARS. NOW, WE DECIDED TO TEST THIS PROGRAM IN JUST BECAUSE WE HAPPEN TO DEVELOP IT. I NEEDED TO KNOW WHETHER IT WOULD MAKE A DIFFERENCE FOR THE VULNERABLE FAMILIES -- TO TOUCH THE VULNERABLE FAMILIES THAT I WAS SERVING IN INNER CITY BALTIMORE. FIRST WE DEVELOPED AND TESTED THE PROGRAMS WITH LOW-INCOME FAMILIES AND THE SAMPLE WAS -- THERE WERE MORE NON-RISK FAMILIES IN THAT SAMPLE THAN IN OUR LATER TRIALS. AND WHEN WE FIRST STARTED PUBLISHING THE RESULTS OF THE TRIAL IN THE MID 80S, IT TOOK HOLD. PEOPLE SAID YOU HAVE A PROGRAM THAT PREVENTS MALTREATMENT AND MAY PREVENT INFANT MORTALITY. MAY DO ALL KINDS OF OTHER GOOD THINGS. WE NEED TO MAKE IT MORE WIDELY AVAILABLE. WE TOOK THE POSITION THAT WE OUGHT NOT TO DO THAT, THAT WE NEEDED A COUPLE OF THINGS. ONE OF THEM WAS THAT WE NEEDED TO KNOW WHETHER THE PROGRAM EFFECTS WOULD REPLICATE ESPECIALLY MINORITIES LIVING IN MAJOR URBAN AREAS AND EQUALLY IMPORTANT ACTUALLY FROM WHERE I SAT WAS WHETHER WE CAN DO ENOUGH ABOUT THE PROGRAM'S ESSENTIAL ELEMENT AND HOW TO SUPPORT NEW NURSES AND COMMUNITIES AND ORGANIZATIONS IN DEVELOPING THE PROGRAM THAT, THEY WOULD HAVE A CHANCE OF CONFIDENTLY REPLICATING THE PROGRAM IN NEW COMMUNITIES. SO WE HELD OFF. WE CHOSE NOT TO REPLICATE THE PROGRAM AND WITH FUNDING FROM NIH AND OTHER FEDERAL AGENCIES, NINE FUNDING SOURCES, IT TURNS OUT AND FOUR YEARS TO RAISE THE MONEY. WE REPLICATED THE STUDY IN MEMPHIS, TENNESSEE WITH A SAMPLE OF LOW-INCOME AFRICAN-AMERICANS WITH 1100 FAMILIES REGISTERED DURING PREGNANCY AND 740 OR SO REGISTERED POST NATALLY AND WE WENT TO MEMPHIS FOR A COUPLE OF REASONS. ONE IS THAT THE LEVELS OF CONCENTRATED SOCIAL DISADVANTAGED ARE VERY HIGH THERE. AND BECAUSE WE COULD REGISTER THE ENTIRE POPULATION OF INDIGENT PREGNANT WOMEN THROUGH A SINGLE HEALTHCARE SETTING AND TRACK FAMILIES' UTILIZATION IN THAT SYSTEM BECAUSE IT WAS SEGREGATED ECONOMICALLY. AND SO IN THE MEANTIME PEOPLE AROUND THE COUNTRY WERE DEVELOPING HOME VISITING PROGRAMS AND SPREADING THEM WIDELY USING THE RESULTS OF THE ELMIRA TRIAL TO MAKE A CASE THAT HOME VISITING WORKS. AND AT FIRST OUR TEAM DIDN'T OBJECT TO THAT. BUT WHEN WE STARTED LOOKING AT CONTROLLED STUDIES OF HOME VISITING PROGRAMS MORE BROADLY IN THE MID TO EARLY 90S, WE REALIZED THAT THE EFFECTS ACTUALLY WERE SOMEWHAT SOBERING. AND SO WE ASKED PEOPLE TO STOP USING THE RESULTS OF OUR ORIGINAL TRIAL TO PROMOTE ALL KINDS OF HOME VISITING PROGRAMS. AND ONE OF THE THINGS THAT WAS CLEAR TO US WAS THAT THE PROGRAMS THAT WERE HIRING PARAPROFESSIONAL VISITORS, VISITORS HIRED FROM THE COMMUNITIES WERE NOT PRODUCING THE KINDS OF RESULTS THAT WE'D SEEN IF OUR ORJAL -- ORIGINAL TRIALS AND WE DIDN'T KNOW WHY. WAS THAT BECAUSE THERE WAS SOMETHING LIMITING AND HAVING TO DO WITH THE VISITOR' MANY BACKGROUND OR GIVEN TO DELIVER INSUFFICIENTLY DEVELOPED? SO WE DECIDED TO ADDRESS OUR ISSUE IN OUR THIRD TRIAL BY RANDOMLY ASSIGNING FAMILIES IT A GROUP VISITED BY NURSES OR A GROUP VISITED BY PARAPROFESSIONALS, THAT IS PEOPLE HIRED FROM THE COMMUNITIES WHO FOLLOWED ESSENTIALLY THE SAME MODEL THAT NURSES HAD BEEN TAUGHT AND EDUCATED TO DELIVER IN OUR FIRST TWO TRIALS. AND THAT WILL GIVE US A BETTER ESTIMATE ABOUT WHAT IT IS PERHAPS ABOUT VISITOR BACKGROUND THAT MAY MAKE A DIFFERENCE IN ACCOUNTING FOR FACTS. NOW, THIS SLIDE SHOWS THOSE FINDINGS THAT WE HAVE THE GREATEST CONFIDENCE BECAUSE WE SEE REPLICATED IMPACTS ACROSS TRIALS WITH DIFFERENT POPULATIONS LIVING AT DIFFERENT POINTS IN OUR COUNTRY'S HISTORY. WE ARE CONFIDENT THAT WE CAN REDUCE -- WE CAN IMPROVE WOMEN'S PRENATAL HEALTH AND ESPECIALLY CUT DOWN ON THE USE OF TOBACCO DURING PREGNANCY, IMPROVE DIETS, FOR EXAMPLE. WE SEE SIGNIFICANT REDUCTIONS IN CHILDREN'S INJURIES REVEALED ON A MEDICAL RECORD. THAT'S IMPORTANT BECAUSE INJURIES THE LEADING CAUSE OF DEATH. WE SEE SIGNIFICANT REDUCTIONS IN THE RATES OF PREGNANCY AND INTERVALS BETWEEN THE BIRTHS OF FIRST AND SECOND CHILDREN. THIS IS IMPORTANT BECAUSE CLOSELY SPACED SUBSEQUENT PREGNANCIES INCREASED THE RISK FOR PRETERM DELIVERY AND COMPROMISED DEVELOPMENT IN SUBSEQUENT BORN CHILDREN. WE SEE SIGNIFICANT IMPROVEMENT IN WOMEN'S PARTICIPATION IN THE WORK FORCE AFTER CHILD CARE ISSUES BECOME LESS SEVERE. IN OUR FIRST TWO TRIALS PRIOR TO WELFARE REFORM WE SEE A SIGNIFICANT INCREASE REDUCTIONS IN THE FAMILY'S USE OF WELFARE AND FOOD STAMPS. AND AMONG CHILDREN BORN TO MOTHERS IN POVERTY WHO HAVE FEW PSYCHOLOGICAL RESOURCES AND I'M GOING TO TELL YOU BRIEFLY WHAT PSYCHOLOGICAL RESOURCES MEAN HERE. IT MEANS HIGH RATES OF DEPRESSION, HIGH RATES OF ANXIETY, LIMITED SENSE OF CONTROL OVER THEIR LIFE CIRCUMSTANCES, LIMITED INTELLECTUAL FUNCTIONING -- SOME OF THE KINDS OF THINGS THAT WE HEARD IN PROFESSOR BROWN'S PRESENTATION EARLIER OR SOMEONE'S PRESENTATION ABOUT WHAT THE RISKS FOR NEGLECT ARE. WE SEE SIGNIFICANT IMPROVEMENTS IN CHILDREN'S DEVELOPMENT, WHETHER IT'S INTELLECTUAL DEVELOPMENT, LANGUAGE DEVELOPMENT, ACADEMIC ACHIEVEMENT, IMPROVEMENTS IN EXECUTIVE FUNCTIONING. BUT THOSE EFFECTS ARE LIMITED TO CHILDREN BORN IFTO MOTHERS WHO ARE MORE HAVE MORE DIFFICULTY PROTECTING THEMSELVES AND PROTECTING THEIR CHILDREN. THIS SLIDE SHOWS A SUMMARY OF FINDINGS THAT CAME FROM ONE OF OUR EARLY PUBLICATIONS FROM THE ELMIRA TRIAL. AND I'D LIKE TO -- AND BY THE WAY, ON THIS WE SEE THE LIKELIHOOD OF THE CHILD BEING IDENTIFIED AS HAVING BEEN ABUSED OR NEGLECTED IN THE FIRST TWO YEARS OF THE CHILD'S LIFE THROUGH IN NEW YORK STATE ACTUALLY AND >DÖ PROTECTIVE OTHER CHILD SERVICE SYSTEMS. AND WHAT WE SEE IS THAT THE TREATMENT CONTROL DIFFERENCE IS MORE PRONOUNCED WHEN SOCIOECONOMIC RISKS INCREASES. NOW, THIS IS ONLY A TREND. AND IT'S ONE OF THE REASONS THAT WE CHOSE NOT TO REPLICATE THE PROGRAM BECAUSE IT WAS JUST A TREND. IT WAS AN IMPORTANT TREND, AND IT WAS BASED ON AN OBJECTIVE MEASURE. BUT WE -- I WANT TO SHOW YOU ANOTHER FINDING THAT CAME FROM THAT EARLY PHASE OF THE PROGRAM. AMONG THOSE CHILDREN BORN TO MOTHERS WHO WERE POOR, UNMARRIED AND TEENAGED, THE TREATMENT CONTROL DIFFERENCE PRESENT BESIDE A 820% -- THAT EFFECT WAS EVEN MORE PRONOUNCED AMONG CHILDREN WHOSE MOTHERS HAD LIMITED SENSE OF CONTROL OVER THEIR LIFE CIRCLES MEASURED AT REGISTRATION. SO THERE WAS THIS CONCENTRATION OF SOCIAL DISADVANTAGE AND MOTHERS WHOSE PSYCHOLOGICAL RESOURCES TO MANAGE THAT ADVERSITY WERE LIMITED AND IT'S IN THAT GROUP THAT WE SEE THIS TREATMENT CONTROL DIFFERENCE MOST PRONOUNCED. AND IN THE SECOND YEAR OF THE CHILD'S LIFE IN THE ELMIRA STUDY WE FOUND THAT WHEN WE LOOKED AT THE NUMBER OF EMERGENCY DEPARTMENT VISITS IN THE SECOND YEAR OF THE CHILD'S LIFE, THAT THE -- AND THIS WAS A SIGNIFICANT DIFFERENCE BY THE WAY -- THE TREATMENT CONTROLLED DIFFERENCE WAS ALSO -- THIS WAS FOR THE SAMPLE AS A WHOLE -- WAS MORE PRONOUNCED AMONG CHILDREN BORN TO MOTHERS WITH LIMITED SENSE OF CONTROL OVER THEIR LIFE CIRCUMSTANCES. SO THIS STARTS TO GIVE US SOME CLUES ABOUT WHAT THE RISKS FOR BOTH MALTREATMENT AND PERHAPS IN THE CASE OF ENTRIES LOWER LEVELS OF NEGLECT OR NON-ATTENTIVE CARE MIGHT BE CONTRIBUTING TO VARIOUS FORMS OF NEGLECT OR ABUSE. 15 YEARS LATER WE FOUND THAT OVERALL BASED ON STATE CENTRAL REGISTRY RECORDS THAT THE RATES OF SUBSTANTIATED ABUSE AND NEGLECT FROM RECORDS THAT WERE DERIVED THROUGH THE NATIONAL DATA ARCHIVE ON CHILD ABUSE AND NEGLECT IN THE CONTROLLED GROUP WAS OVER TWICE AS HIGH IN THE CONTROL GROUP AS THE NURSE -- AND A GROUP DURING PREGNANCY ALONE HAD ABUSE AND NEGLECT RATES THAT FELL IN BETWEEN THE TWO EXTREMES. NOW, -- AND WHAT WE FOUND -- AND THESE GLIDES -- SLIDES COME FROM A REPORT PUBLISHED IN PSYCHOPATHOLOGY THAT SHOWED THAT OVERALL -- THESE ARE SURVIVAL ANALYSES TO THE TIMING OF THE FIRST REPORT OF CHILD ABUSE AND NEGLECT. AND WHAT WE SEE IS THAT THERE WAS THIS OVERALL TREATMENT CONTROL DIFFERENCE FOR THE SAMPLE AS A WHOLE AND THAT THAT EFFECT IS MUCH MORE PRONOUNCED WHEN WE LOOK AT NEGLECT. AND THAT THIS SLIDE SHOWS THE CORRESPONDING DATA ON ALL FORMS OF MALTREATMENT AND NEGLECT BUT LIMITED TO THOSE FAMILIES WHERE THEY WERE IDENTIFIED AS BEING AT RISK AT REGISTRATION WHERE THE MOTHERS WERE LOW-INCOME AND UNMARRIED. NOW, NOTICE THAT EARLY ON THERE WERE FEW TREATMENT CONTROL DIFFERENCES IN THE OFFICIAL RECORDS. AND THIS REPRESENTS THE TIME PERIOD, THE TWO-YEAR TIME PERIOD THAT I WAS SHOWING YOU IN THOSE EARLIER SLIDES AND THIS SHOWS YOU FOR THE TWO-YEAR PERIOD FOLLOWING THE END OF THE INTERVENTION AT AGE TWO. AND YOU COULD SAY THAT THERE IS ALMOST NOTHING THERE. ALTHOUGH WE LOOKED AT THE RATES OF THOSE CASES WHERE THERE WAS OFFICIAL REPORT OF CHILD ABUSE AND NEGLECT IN THE CONTROL GROUP IN THE NURSE-VISITED GROUP AND FOUND THAT USING OTHER OBJECTIVE MEASURES, THAT THOSE CHILDREN IDENTIFIED AS HAVING BEEN ABUSED OR NEGLECTED IN THE NURSE-VISITED CONDITION WERE AT SUBSTANTIALLY LOWER RISK THAN THEIR COUNTERPARTS IN THE CONTROLLED GROUP. IN OTHER WORDS, IT LENT STRONG SUPPORT TO THE IDEA THAT NURSES WERE IDENTIFYING MALTREATMENT AT LOWER THRESHOLDS OF SEVERITY THAN THEIR COUNTERPARTS IN THE CONTROLLED GROUP. OF COURSE, THEY ACTIVATE CONCERNS ON THE PART OF OTHER FAMILY FAMILIES LIKE GRANDMOTHERS OR SISTERS WHERE THEY'RE MORE LIKELY TO MAKE A REPORT OF A FAMILY MEMBER OR THEIR DAUGHTER OR THEIR SISTER WHEN THEY SEE THAT THAT DAUGHTER IS GOING OFF THE RAILS AND THEIR GRANDSON OR GRAND DAUGHTER OR NEPHEW IS BEING PUT AT RISK. NOW, NOTICE IN ALL THESE SLIDES THAT THE THE LIKELIHOOD OF BEING IDENTIFIED FOR MALTREATMENT IN THE CONTROLLED GROUP GROWS OVER THAT FIRST 15 YEARS FOLLOWING BIRTH OF THE FIRST CHILD. AND THAT THE LIKELIHOOD OF HAVING BEEN IDENTIFIED AS BEING AS ABUSING OR NEGLECTING THE CHILD OR NEGLECTING THE CHILD HERE IN THE NURSE-VISITED CONDITION STOPS. AND WE THINK THAT THAT'S IMPORTANT INFORMATION. NOW, WE WERE PLEASED WITH 350% REDUCTION IN THE VERIFIED REPORTS OF CHILD ABUSE AND NEGLECT. BUT ONE OF THE QUESTIONS WE ASKED OURSELVES IS WHY DIDN'T WE WIPE IT OUT? THIS SLIDE SHOWS THE MAIN FINDINGS FROM A PAPER PUBLISHED BY JOHN EKEN ROAD ABOUT 12 YEARS AGO THAT SHOWED THAT THE IMPACT OF THE PROGRAM OF THE STATE VERIFIED REPORTS WAS ATTENUATED IN HOUSEHOLDS WHERE THERE WERE MODERATE TO HIGH LEVELS OF INTIMATE PARTNER DOMESTIC VIOLENCE. THIS IS THE RATE OF CHILD MALTREATMENT, THE FITTED REGRESSION OF THE IMPACT -- RATE OF CHILD ABUSE AND NEGLECT IN THE CONTROL GROUP AND THIS IS THE NURSE-VISITED GROUP. AND WHAT YOU START TO SEE IS THAT TREATMENT CONTROL DIFFERENCE ATTEN WAITS IN SITUATIONS WHERE THERE WAS MODERATE TO HIGH LEVELS OF PARTNER VIOLENCE. THAT'S IMPORTANT FROM WHERE WE SIT BECAUSE WE NEED TO UNDERSTAND NOT ONLY FOR WHOM THE PROGRAM WORKS BUT FOR WHOM IT DOESN'T BECAUSE WE ARE -- THIS IS A WORK IN PROGRESS. AND I'LL COME BACK TO THAT POINT A LITTLE LATER. WE ALSO FOUND AND PUBLISHED IN THE ARCHIVES OF PEDIATRICS AND MEDICINE A COUPLE YEARS AGO THAT THE RATES OF LIFETIME ARRESTS AMONG YOUTH AGE 19 WERE ABOUT CUT IN HALF FOR A NURSE-VISITED GROUP COMPARED TO THE CONTROL GROUP. BUT ESPECIALLY IN THE SECOND HALF OF ADOLESCENCE THIS WAS REALLY LIMITED TO FEMALES. SO YOU HEARD SETH POLLACK'S PRESENTATION EARLIER TODAY IN WHICH HE SHOWED THAT THE OXY TOSEIN STORY AND SHOWED THE FINDING FOR FEMALES. BUT I ASKED HIM AFTERWARDS. I ASKED HIM WHAT HAPPENED TO MALES AND HE SAID THERE WERE NO MODERATIONS OF NEGLECT HAVING TO DO WITH CORTISOL AND OXY TOSEIN FOR MALES. I DON'T KNOW WHY THIS FINDING IS LIMITED TO MALES, AND I THINK WE NEED TO TAKE THAT ON BOARD AND THINK DEEPLY ABOUT WHAT MIGHT LIMIT THIS EFFECT. WE SHOWED, BY THE WAY WE FOUND TREATMENT CONTROLLED DIFFERENCES IN ARRESTS FOR MALES AND FEMALES THROUGH AGE 15, BUT IN THE SECOND HALF OF ADOLESCENCE IT WAS REALLY LIMITED TO FEMALES. WE CONCENTRATED THE SAMPLEING IN OUR MEMPHIS STUDY ON MOTHERS WHERE THERE WAS CONCENTRATED SOCIAL DISADVANTAGE BECAUSE THE RESULTS OF THE TRIAL SHOWED THAT THE IMPACTS WERE MOST PRONOUNCED WHERE THERE WAS CONCENTRATED SOCIAL DISADVANTAGE. SO THIS WAS A SAMPLE THAT WAS 92% AFRICAN-AMERICAN, ALMOST ALL UNMARRIED, 85 -- 85% OF SAMPLES AND TWO THIRDS OF THE SAMPLES WERE UNHEARD AND THE FAMILIES IN THIS TRIAL WERE AMONG THE VERY TOP WERE LIVING IN THE MOST CHALLENGED NEIGHBORHOODS IN THE COUNTRY. IN THE TOP 12,000THS OF NEIGHBORHOOD USING A COMMONLY USED NEIGHBORHOOD ADVERSITY MEASURE. IT'S IMPORTANT FOR US TO KEEP THAT IN MIND. THE STUDY WAS ALSO CONDUCTD IN WHAT WE WOULD CALL AN EFFECTIVENESS TRIAL. THE PROGRAM WAS ADMINISTERED THROUGH THE MEMPHIS SHELBY COUNTY HEPATOAND REACHED -- HEALTH DEPARTMENT BECAUSE WE WERE ABLE TO REACH THE TARGET POPULATION THROUGH THAT SINGLE HEALTHCARE DELIVERY SYSTEM THAT I MENTIONED TO YOU BEFORE. AND THE STUDY WAS CONDUCTED AT THE HEIGHT OF A NURSING SHORNG. THERE WAS TURNOVER SO THAT MEANT THAT THE FINDINGS THAT WE DRIVE FOR MEMPHIS WERE NOT BECAUSE THIS WAS A UNIVERSITY-ADMINISTERED STUDY WHERE THINGS WERE CONDUCTED UNDER OPTIMAL CONDITIONS. WE KNEW THAT WE WOULD NOT SEE PROGRAM EFFECTS ON VERIFIED REPORTS OF CHILD ABUSE AND NEGLECT IN MEMPHIS BECAUSE WE HAD CONDUCTED EXEXTENSIVE PRETEST AND PILOT WORK AND HAD FOUND THAT THE RATES OF STATE VERIFIED REPORTS IF THAT POPULATION IN THE MID 1980S WAS ONLY 3% TO 4%. AND SO THOSE RATES WERE FAR TOO LOW FOR US TO BE ABLE TO RELIABLY DETECT A REDUCTION IN THE REPORTS OF CHILD ABUSE AND NEGLECT. AND WHAT WE DIDN'T KNOW AT THE TIME WAS THAT THE SYSTEM IN TENNESSEE FOR REPORTING CHILD PROTECTIVE SERVICE REPORTING WAS BROKEN. AND WHAT WE HAD NOT FULLY UNDERSTOOD WHEN WE BEGAN THIS WORK IS THE IMPACT OF SURVEILLANCE BIAS UNDETECTING MALTREATMENT THAT OTHERWISE WOULD GO UNDETECTED. BUT WE DID EXPECT, BECAUSE OF THE PRETEST OF PILOT WORK THAT WE HAD DONE THAT, WE WOULD SEE REDUCTIONS IN INJURIES TO CHILDREN REVEALED THAT WOULD BE CONSISTENT WITH A REDUCTION IN CHILD ABUSE AND NEGLECT AND WE FOUND THAT THE IMPACT OF THE PROGRAM ON ALL TYPES OF HEALTHCARE ENCOUNTERS WHO WERE REDUCED AND THERE WAS ESPECIALLY A REDUCTION IN THE NUMBER OF DAYS WHERE CHILDREN WERE HOSPITALIZED WITH INJURIES AND INGESTIONS. AND BECAUSE OF THOSE EFFECTS THAT WE'D SEEN IN THE ELMIRA TRIAL WHERE THE IMPACTS WERE MORE PRONOUNCED WITH MOTHERS WITH LOW REPORTED SENSE OF CONTROL OVER THEIR LIFE CIRCLES, WE HIGH POTTING THIGHSD THAT THE PROGRAM EFFECTS WOULD BE MORE PRONOUNCED WITH MOTHERS AMONG MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES BUT WE EXPANDED THE CONCEPT OF WHAT CONSTITUTED PSYCHOLOGICAL RESOURCES BEYOND JUST A SENSE OF CONTROL OVER THEIR LIFE CIRCLES BUT INCORPORATED. WE ASKED THE QUESTION WHAT IS IT ABOUT INDIVIDUALS OR PARENTS THAT WOULD ALLOW THEM TO MORE EFFECTIVELY PROTECT AND PROMOTE THEIR CHILDREN'S HEALTH AND DEVELOPMENT? WHEN WE THOUGHT ABOUT IT AND EXPANDED BEYOND JUST OUR SENSE OF CONTROL TO INCLUDE DEPRESSION AND ANXIETY AND INTELLECTUAL FUNCTIONING AND CREATED AN INDEX OF PSYCHOLOGICAL RESOURCES AND USED THAT AS A POTENTIAL MODERATOR IN OUR EXAMINATION OF TREATMENT CONTROLLED DIFFERENCES IN THESE AMONG FAMILIES LIVING WHERE THERE WAS HIGH CONCENTRATIONS. AND WHAT WE FOUND WAS THAT THAT 23% TREATMENT CONTROL DIFFERENCE IN THE RATES OF STATE VERIFIED INJURIES REVEALED IN THE MEDICAL RECORD THAT I SHOWED YOU JUST A MOMENT AGO WAS REALLY MUCH MORE PRONOUNCED AND LIMITED TO REALLY THOSE CHILDREN BORN TO MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES. AND WITH WE LOOKED AT THE RATES OF THE -- I THINK IT'S IMPORTANT TO UNDERSTAND THE DIAGNOSES THAT WERE UNDERLYING THE DIFFERENCE THAT'S WE SAW IN HOSPITALIZATIONS AMONG CHILDREN IN THE CONTROL AND INTERVENTION GROUP IN THE MEMPHIS TRIAL. I NEED TO SAY THAT WE FOLLOWED 740 OR SO FAMILIES POST NATALLY IN EMPHASIS MEMPHIS AND WE DOUBLED THE NUMBER OF FAMILIES ASSIGNED TO THE CONTROL GROUP VERSUS THE INTERVENTION GROUP NEED TO KEEP THAT IN MIND THAT THE NUMBER IN THE CONTROL GROUP IS 204 COMPARED TO ROUGHLY TWICE AS MANY IN THE CONTROL GROUP. BUT LOOK AT THE NATURE OF THESE DIAGNOSES. AND LOOK AT THE AGES OF THESE CHILDREN. ALL OF THESE CHILDREN ARE HOSPITALIZED AT 12 MONTHS OF AGE OR OVER. THEY WERE MOBILE AND CREATING RISKS FOR THEMSELVES BY VIRTUE OF THAT MOBILITY. LOOK AT WHAT IS HAPPENING TO CHILDREN IN THE CONTROLLED GROUP. 44% WERE HOSPITALIZED PRIOR TO SIX MONTHS OF AGE. SO THEY WERE NOT MOBILE AND NOT CREATING RISKS FOR THEMSELVES BECAUSE THAT HAVE MOBILITY. 58% OF THESE CHILDREN WERE HOSPITALIZED WITH SERIOUS TRAUMA SUCH AS FRACTURED SKULLS, BILATERAL SUBDEMA HEM TOMAS, THE KINDS OF CONDITIONS THAT SUGGEST THAT THESE CHILDREN WERE EXPERIENCES EXTREMELY DIFFICULT EARLY LIFE CIRCUMSTANCES. SO WHILE WE WERE UNABLE TO REPLICATE THE FINDINGS, IF YOU WENT FROM ELMIRA BASED ON THE RESULTS OF STATE-VERIFIED REPORTS OF CHILD ABUSE AND NEGLECT IF MEMPHIS, WHEN WE OPENED UP THE MEDICAL RECORDS, WE THINK THAT THIS ESSENTIALLY REPLICATES THE IMPACTS, THE CONCLUSION THAT THE PROGRAM HAS AFFECTED MALTREATMENT WHEN YOU LOOK AT THESE TYPES OF INJURIES. AND THERE WAS JUST A WHOLE BUNCH OF CORROBORATING EVIDENCE. MOREOVER, THESE DIFFERENCES THAT YOU SEE IN THE RATES OF NUMBERS OF DAYS OF CHILDREN HOSPITALIZED WITH INJURIES WERE LIMITED TO CHILDREN BORN TO MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES. THAT TREATMENT, THAT 80% TREATMENT CONTROLLED DIFFERENCE THAT I SHOWED YOU EARLIER WAS LIMITED TO THE LOWER HALF OF THE DISTRIBUTION IN TERMS OF MOTHERS' PSYCHOLOGICAL RESOURCES. BY AGE 12 WE SEE PROGRAM EFFECTS ON CHILDREN'S INITIATION OF TOBACCO AND MARIJUANA USE AND THOL ALCOHOL. ABOUT A 70% REDUCTION AND 30% REDUCTION OF SERIOUS SYMPTOMS OF DEPRESSION AND ANXIETY. WE SEE IMPROVEMENTS IN CHILDREN'S LANGUAGE OR RECEPTIVE LANGUAGE DEVELOPMENT AT AGE SIX THAT ARE MORE PRONOUNCED AMONG CHILDREN BORN TO MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES. THEY ARE TESTED MATH AND READING TREMENT AT AGE 12 BUT LIMITED TO THOSE MOTHERS WHO HAVE LOW PSYCHOLOGICAL RESOURCES AGAIN. WE FOUND IN TENNESSEE THROUGH AGE 12 THAT THE PROGRAM COSTS ARE MORE THAN RECOVERED BY REDUCTIONS IN FAMILY USE OF MEDICAID, TANF AND AF D.C. AND FOOD STAMPS OVER THE FIRST 12 YEARS OF THE CHILD'S LIFE. WE FIND THAT THE NURSES HAVE PRODUCED EFFECTS THAT ARE CONSISTENT WITH WHAT WE HAD SEEN IN DENVER WITH WHAT WE HAD SEEN IF OUR PREVIOUS TRIAL BUT THE PARAPROFESSIONALS WERE PRODUCING EFFECTS THAT WERE CLINICALLY SIGNIFICANT. I SHOW HERE THE IMPACT OF THE PROGRAM OF THE INDEX OF EXECUTIVE FUNCTIONS WHERE WE DIRECTLY MEASURED THE CHIL'S FUNCTIONING AT AGE 123 -- AGE FOUR. THESE EFFECTS ARE LIMITED TO CHILDREN BORN TO MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES. THE WASHINGTON STATE INSTITUTE FOR PUBLIC POLICY ESTIMATES THAT THE COST RETURN PER FAMILY IS ABOUT $13,000 PER FAMILY. SINCE 1996 WE'D BEEN DEVELOPING THE PROGRAM OUTSIDE RESEARCH SETTINGS AND IT'S NOW OPERATING IN 400 COUNTIES, 41 STATES WITH ADDITIONAL SUPPORT FROM THE NEW MATERNAL EARLY CHILDHOOD HOME VISITING PROGRAM SUPPORTED THROUGH THE AFFORDABLE CARE ACT. WE HAVE BEGUN THIS NATIONAL REPLICATION WORK WITH A LOT OF APPREHENSION BECAUSE WE'VE BEEN CONCERNED ABOUT WATERING THE PROGRAM DOWN AND COMPROMISE IT AND SEEING IT COMPROMISED IN THE PROCESS OF BEING SCALED UP. SO WE'VE TAKEN IT SLOWLY. WE BELIEVE THAT WE NEED STRONG COMMUNITY ORGANIZATIONAL BUYIN IN ORDER FOR THIS PROGRAM TO WORK. WE HAVE DEVELOPED EXCELLENT EDUCATION AND CONSULTATION FOR NURSES, DETAILED VISIT VISIT-BY-VISIT GUIDELINES, A WEB-BASED INFORMATION SYSTEM THAT MONITORS OUTCOMES AND TO USE THAT INFORMATION AS A BASIS FOR CONTINUED QUALITY IMPROVEMENT. WE'VE BEEN ASKED TO DO THIS PROGRAM AND IN OTHER SOCIETIES, INCLUDING ALASKA FATEIVE AND AMERICAN INDIAN FAMILIES HERE IN THE U.S. WE NEED TO TEST IT CAREFULLY AND IF IT WORKS TO REPLICATE THE PROGRAM, INCLUDING A SOCIETY THAT HAS THE CAPACITY TO DO THIS CONDUCT OF INDEPENDENT LARGE-SCALE RANDOMIZED CONTROLLED TRIALS. HE ALSO AND BELIEVE THIS IS KIND OF AN IMPORTANT POINT, THAT THIS PROGRAM WILL ALWAYS BE A WORK IN PROGRESS. WE USED THE INFORMATION THAT COMES BACK ON PROGRAM IMPLEMENTATION TO IDENTIFY VULNERABILITIES IN THE MODEL ITSELF AND REPLICATION TO IMPROVE IT. BUT TO IMPROVE IT USING REALLY RIGOROUS METHODS. THE QUESTION FOR US IS HOW DO WE MAINTAIN THE EVIDENTIARYRY FOUNDATIONS OF A PROGRAM LIKE THIS WHILE MAKING IT DINE MIC AND IMPROVING IT? AND SO I WANT TO TELL THAT YOU WE FOUND THAT AS WE ROLLED OUT THE PROGRAM IN COMMUNITY CONTEXT, THE RATES OF RETENTION WERE LOWER THAN WHAT WE HAD SEEN IN OUR ORIGINAL RANDOMIZED CONTROLLED TRIALS AND WE'VE CONDUCT AID SERIES OF STUDIES INCLUDING A MIXED METHOD STUDY OF I PARTICIPANT RETENTION, QUASI EXPERIMENTAL STUDY OF AN INTERVENTION DESIGNED TIME PROVE PARTICIPANT RETENTION MANY, A RANDOMIZED CONTROLLED TRIAL TO HELP US KNOW WHETHER THAT INTERVENTION WOULD IMPROVE PARTICIPANT RETENTION AND WE'RE HAPPY TO REPORT WE THINK WE'RE ON THE RIGHT TRACK. BECAUSE OF THE WORK THAT I REPORTED TO YOU EARLIER, WE KNOW THAT WE NEED TO DO A BETTER JOB OF ADDRESSING PARTNER VIOLENCE WITH FUNDING FROM C.D. C. AND SUSAN JACK FROM A UNIVERSITY IN CANADA ARE CONDUCTING A CLUSTER-BASED RANDOMIZED TRIAL TO HELP NURSES ADDRESS PARTNER VIOLENCE MORE EFFECT EFFECTIVELY. WE FOUND THAT NURSES WERE USING SPENDING TIM LEST TIME ON PROMOTING COMPETENT CARE OF BABIES AND IN DOING QUALITATIVE WORK WITH NURSES LEARNED THAT WE FOUND THAT THE TOOL WE HAD GIVEN TO THEM FOR OBSERVING AND SUPPORTING PARENT-CHILD IRNGTS WAS INSUFFICIENT. SO WE SPENT SEVERAL YEARS DEVELOPING A NEW TOOL CALLED THE DANCE, A NEW PROGRAM GUIDANCE CALLED THE DANCE STEPS, TO HAVE BETTER PREDICTIVE VALIDITY. >> AND AND NURSE PROTECTION. OF MANAGING THE PLANNING OF SUBSEQUENT PREGNANCIES. WE'VE BEEN WORKING FOR SOMETIME IN DEVELOPING AN EFFECTIVE METHOD FOR NURSES TO USE IN BETTER ADDRESSING DEPRESSION AND ANXIETY. AND WE ARE WORKING ON DEVELOPING A MORE FULSOME FRAMEWORK FOR NURSES TO USE IN ASSESSING BOTH FAMILY RISKS AND STRENGTHS AS A FOUNDATION FOR MAKING THE PROGRAM BETTER. AND WE'VE TRIED TO BE RIGOROUS AND THOUGHTFUL ABOUT THE WAYS WE SHOULD GO ABOUT USING THIS KIND OF INFORMATION SO MAINTAIN THE EVIDENTIARYRY FOUNDATION USING THE KINDS METHODS THAT YOU SEE REFLECTED IN THIS SLIDE. AS THERE HAS BEEN IN THE LITERATURE AND WITH WHEN WE TALK ABOUT CHILD MALTREATMENT THERE IS A LOT OF DISCUSSION ABOUT WHAT WE NEED IS SIMPLY A BETTER SYSTEM. AND I HAPPEN TO LIKE THE IDEA OF DEVELOPING SYSTEMS, BUT I THINK THAT THE ELEMENTS, THE COMPONENTS OF THOSE SYSTEMS HAVE TO HAVE STRONG EVIDENCE THAT THEY REALLY WORK. OTHERWISE, WE'RE SIMPLY STITCHING TOGETHER THINGS THAT ARE NOT LIKELY TO MAKE THE KIND OF DIFFERENCE THAT'S WE ALL ARE CONCERNED ABOUT. SO I THINK ONE OF THE CHALLENGES THAT WE ALL HAVE, AND I SEE IT REALLY EVOLVING HERE AT THIS MEETING SO IT'S WONDERFUL TO SEE THIS HAPPENING -- IS TO DEVISE PROMISING INTERVENTIONS AND PUT THEM TO RIGOROUS TESTS AND THEN LET'S STITCH THOSE PIECES TOGETHER SO THAT WE CAN HAVE A TRULY EFFECTIVE SYSTEM. AS WE THINK ABOUT MOVING THIS KIND OF WORK FORWARD, I THINK FOR US AT LEAST AND I THINK THAT IT'S SHARED BY ALL OF NEW THIS ROOM, WE NEED TO ADD THIER TAI FEW COMMON PRINCIPLES. ONE OF THEM IS CLINICAL RIGOR, INCLUDING HOW DO WE ENGAGE IN RELIABLY REPRODUCE ADAPTABLE BEHAVIORAL CHANGE? THAT'S NOT EASY. I THINK IT'S AN ELEMENT OF A STRATEGY LIKE THIS IS THAT IS ALL TOO OFTEN OVERLOOKED. WE WANT SCIENCE. WE WANT OUTSTANDING INTERVENTION DEVELOPMENT. WE NEED TO HAVE AN APPROACH THAT MANLETSS SCIENTIFIC INTEGRITY AND AS WE GO FORWARD, WE NEED TO CONTINUOUSLY HOLD ONE ANOTHER ACCOUNTABLE FOR WHAT WE ARE TRYING TO DO AND THIS I THINK IS WHAT WE'RE TRYING TO DO. SO THANK YOU VERY MUCH. [APPLAUSE] >> THANK YOU. I THINK WE HAVE TIME FOR MAYBE ONE ORaxNxÖ TWO CLARIFYING QUESTIONS. [INAUDIBLE] >> THE QUESTION IS HOW DO WE MEASURE LOW PSYCHOLOGICAL RESOURCES? WE USED ESSENTIALLY THE RANDOM HEALTH EXPERIMENT NO HEALTH BATTERY TO ASSESS SYMPTOMS OF DEPRESSION AND ANXIETY. WE USED THE SHIPLEY PERFORMANCE TEST TO MEASURE INTELLECTUAL FUNCTION ASKING WE USED THE PEARL AND MASTER RISCALE TO ASSESS WOMEN'S SENSE OF MASTERY AND WE CREATED A SUMMED Z SCORE OF THOSE THREE MEASURES STANDARDIZED TO TO VALUES OF 100 WITH STANDARD DEVIATIONS OF TEN, WHICH IS WHAT YOU SAW IN THOSE SLIDES. YES, SIR. [INAUDIBLE] >> YEP. [INAUDIBLE] THE QUESTION IS DID WE ASK WHAT PARENTS REALLY WANTED IN OUR STUDIES? AND HOW DO THEY FEEL ABOUT THEIR HOME VISITORS, WE ASKED THAT QUESTION IN OUR DENVER TRIAL BECAUSE WE WERE SO CONCERNED ABOUT BACKGROUNDS OF VISITORS. AND WHAT WE LEARNED WAS THAT ALL FAMILIES LOVED THEIR HOME VISITORS, WHETHER THEY WERE NURSES OR PARAPROFESSIONALS. WHAT WAS SO REVEALING WAS THAT WHEN WE LOOKED AT THEIR ACTUAL IMPLEMENTATION DATA, THE VISITOR, THE FAMILIES WHO WERE VISIT BID PARAPROFESSIONALS OPENED THEIR DOORS LESS FOR PARAPROFESSIONALS THAN THEY DID FOR NURSES. THE PARAPROFESSIONALS AND NURSES WERE ATTEMPTING VISITS AT THE SAME FREQUENCY BUT THE NURSES WERE MORE SUCCESSFUL IN GETTING FAMILIES TO OPEN THEIR DOORS. AND I THINK THAT'S INCREDIBLY REVEALING. THE DIFFERENCE THAT'S WE SEE IN PROGRAM IMPACT BY VISITOR BACKGROUND ARE NOT ATTRIBUTABLE SIMPLY TO THE QUANTITY OF PROGRAM DELIVERY. THERE IS SOMETHING ELSE GOING ON AND I THINK THAT IT HAS TO DO WITH THE EXTENT TO WHICH FAMILIES RESPECT AND VALUE WHAT THEIR VISITORS ARE ACTUALLY PROVIDING TO THEM. AND I THINK THAT WHEN YOU ARE DEALING WITH PREGNANCY, YOU ARE DEALING WITH LABOR AND DELIVERY AND EARLY CARE OF THE CHILD, THAT FAMILIES PREFER HAVING SOMEONE WHO IS KNOWN IN THE COMMUNITY AS HAVING THE KIND OF KNOWLEDGE THAT WOULD HELP PREGNANT WOMEN ADDRESS CONCERNS THAT ARE UNIVERSAL TO ALL PREGNANT WOMEN. SO I THINK THAT'S LIKELY TO ACCOUNT FOR THE DIFFERENCE YOU ARE ASKING ABOUT, THANK YOU. YES, MARK. >> [INAUDIBLE] YES. THE QUESTION IS KY COMMENT ABOUT THE MODERATING EFFECTS FOR THE QUESTION ABOUT UNIVERSAL VERSUS TARGETED EFFECTS. I THINK THAT THIS IS A VERY PRECIOUS SERVICE THAT I'VE JUST DESCRIBED FOR YOU. AND I THINK THAT IT'S CLEAR TO ME OVER AND OVER AGAIN THAT ITS BENEFITS ARE MOST PRONOUNCED AMONG FAMILIES WHERE THERE WAS CONCENTRATED SOCIAL DISADVANTAGE. AND THAT MEANS I THINK IT MEANS FOCUSING THESE SCARCE RESOURCES IN COMMUNITIES WHERE THERE ARE HIGH RATES OF SOCIAL DISADVANTAGE. WE'RE WORKING THIS ISSUE OUT BY THE WAY WITH THE UK, UNIVERSAL CHILD HEALTH SERVICE WHERE THIS PROGRAM IS BEING MADE AVAILABLE NATIONALLY NOW. AND THEY'VE ASKED US TO HELP THEM DEVISE A SYSTEM OF WHAT THEY CALL PROGRESSIVE UNIVERSALISM THAT RESPONDS SENSEIVELY TO FAMILIES' LEVELS OF RISK. AND I THINK WE HAVE A LOT OF WORK TO DO IN THIS AREA. BUT I DON'T SEE ANY SENSE IN MAKING THIS PROGRAM AT THIS LEVEL OF INTENSITY AVAILABLE TO EVERYONE. >> THANK YOU. [APPLAUSE] >> THANK YOU. OUR NEXT PRESENTER IS DR. ANN DUGGAN, WHO IS PROOFFICERS PEDIATRICS AT JOHN HOPKINS SCHOOL OF MEDICINE AND HOLD A JOINT APPOINTMENT IN THE MANAGEMENT IN THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH. SHE HAS TO YEARS' EXPERIENCE IN RESEARCH. HER WORK INCLUDES STATE WIDE MULTISITE RANDOMIZED TRIALS IN HOME VISIT AND PLANS ROLES IN THE EARLY CHILDHOOD HOME VISITING PROGRAM AND THE NATIONAL HOME VISITING RESEARCH NETWORK. DR. DUGGAN. [APPLAUSE] >> I THINK THE PROGRAM HAD THE TITLE FOR THIS TALK AS CHILD NEGLECT AND HOME VISITING FROM TWO PERSPECTIVES. AND BETWEEN THE TIME THAT I SUBMITTED THE ABSTRACT AND TODAY, WE WERE FORTUNATE TO HAVE A NEW GRANT FUNDED. SO I AM GOING TO USE A LITTLE BIT OF TIME TO GIVE YOU A THIRD PERSPECTIVE. I HAVE THREE MAIN OBJECTIVES TODAY. THE FIRST IS TO ACCEPT THE CONTEXT FOR YOU BY GIVING YOU SOME BACKGROUND ON THE NEW EARLY CHILDHOOD HOME VISITING PROGRAM, AND I IMAGINE SOME IN THE ROOM ARE VERY FAMILIAR WITH THIS. BUT FOR OTHERS IT MIGHT BE SOMETHING RELATIVELY NEW AND BELIEVE ME, IT'S A GAME CHANGER FOR HOME VISITING. SO IT'S IMPORTANT FOR EVERYBODY TO BE AWARE OF IT. THE SECOND IS TO PRESENT SOME BACKGROUND ON AN IMPLEMENTATION SCIENCE FRAMEWORK THAT WE'VE USED IN OUR RESEARCH AND CONTINUE TO USE GOING FORWARD, PARTICULARLY AS IT APPLIES TO HOME VISITING. THE FIRST WILL BE TO GIVE YOU JUST ONE SMALL EXAMPLE OF THE IMPLEMENTATION SCIENCE WE'VE DONE AS PART OF A RANDOMIZED TRIAL OF A HOME VISITING PROGRAM. THE SECOND WILL BE TO INTRODUCE YOU TO THE METHOD OF MY HOPE, WHICH IS THE NATIONAL EVALUATION OF THE MATERNAL INFANT AND EARLY CHILDHOOD HOME VISITING PROGRAM. AND THE THIRD IS TO TELL YOU A LITTLE BIT ABOUT THE NEW NATIONAL HOME VISITING RESEARCH NETWORK. WE WERE FUNDED TO PUT THE INFRASTRUCTURE FOR THIS TOGETHER, JUST STARTING THIS PAST JULY 1st AND WE FIND IT VERY EXCITING AND I'M REALLY EXCITED TO HAVE THIS CHANCE TO SHARE THE NUTS AND BOLTS OF IT WITH YOU. I HOPE YOU WILL ALL BE PLAYING A MAJOR ROLE IT IN IN IT IN THE YEARS AHEAD. AND I WILL SUMMARIZE THE KEY POINTS THAT I HOPE TO MAKE. FIRST OF ALL THE FOCUS ON MY CHB. IT WAS CREATED AS PART OF THE AFFORDABLE CARE ACT, WHICH DEVOTES $1.5 BILLION NEW FEDERAL INVESTMENT IN HOME VISITING NATIONALLY. THE INTENT OF THE HOME VISITS IS TO MOVE OUTCOMES IN EIGHT BENCHMARK AREAS THAT ARE DWIGHT DIVERSE RANGING FROM IMPROVED BIRTH OUTCOMES TO FAMILY ECONOMICS SELF-SUFFICIENCY, PREVENTION OF CHILD MALTREATMENT, IMPROVE SCHOOL READINESS AND SO ON. NEARLY ALL OF THE FUDGED IS MADE TO STATES, TERRITORIES, AND TRIBAL ORGANIZATIONS VIA GRANTS FOR SERVICE DELIVERY AND INFRASTRUCTURE DEVELOPMENT. THESE ENTITIES ARE REQUIRED TO DEVOTE AT LEAST 75% OF THOSE FUNDS TO EVIDENCE-BASED HOME VISITING MODELS. THEY ARE ALSO REQUIRED TO MONITOR THEIR MOVEMENT OVER TIME IN MOVING THEIR BENCHMARK AREAS AND THEY'RE ALL EXPECTED TO SHOW IMPROVEMENT IN BENCHMARK AREAS WITHIN THE FIRST THREE YEARS OF FUNDING. THIS WILL BE NO SMALL TASK. WHAT I AM SHOWING HERE IS A SLIDE SUMMARIZING THE EFFECTS SIZES IN EACH OF THE MAIN DOMAINS FOR THE MODELS THAT HAVE BEEN DETERMINED TO BE EVIDENCE-BASED. AS PART OF AN INITIATIVE CALLED HOM V, WHICH INVOLVED VERY EXTENSIVE REVIEW OF THE HOME VISITING LITERATURE. AND AS YOU CAN SEE, MOST OF THE SIZES ON AVERAGE FOR THE MODELS THAT WERE DETERMINED TO BE EVIDENCE-BASED ARE IN FACT, QUITE SMALL. THERE ARE PRETTY SUBSTANTIAL RANGES ACROSS THE RANDOMIZED TRIALS. NO SINGLE MODEL WAS FOUND TO IMPROVE OUTCOMES IN ALL OF THE BENCHMARK AREAS. SO OUR QUESTION, AS WE GO FORWARD WITH M IECHB HOME VISITING IN PART FOR THE PURPOSE OF PREVENTING CHILD NEGLECT IS TO TRY TO UNDERSTAND HOW WE CAN DESIGN OUR SERVICE SYSTEMS SO THAT THE RESULTS THAT WE GET ARE IN FACT THE RESULTS THAT WE WANT. WHAT I AM SHOWING IN THIS SLIDE IS A PRETTY SIMPLE CONCEPTULE FRAMEWORK AND AS YOU CAN SEE IT LOOKS LIKE A LOGIC MODEL WITH INPUTS, OUTPUTS AND OUTCOMES. NO PROGRAM SITE OPERATES IN ISOLATION. NO PROGRAM SITE SAYS I AM GOING TO ADOPT A NATIONAL MODEL AND CARRY IT OUT EXACTLY AS IT WAS DESIGNED, I HAVE COMPLETE CONTROL OVER HOW I DO THIS. RATHER, IMPLEMENTING AGENCIES COME AT HOME VISITING WITH THEIR OWN INSTITUTIONAL MISSION, VALUES, PHILOSOPHY. THEY MOST LIKELY GET FUNDING FROM NUMEROUS SOURCES. EACH OF THOSE SOURCES MAKES THEIR OWN DEMANDS AND ON TOP OF THIS, IMPLEMENTING AGENCIES NEED TO CONFORM TO THE REQUIREMENTS AND THE WISHES OF FEDERAL, STATE, AND LOCAL ENTITIES. AND SO WE HAVE FOR ANY GIVEN PROGRAM SITE A GROUP OF INFLUENTIAL ORGANIZATIONS THAT TOGETHER DEFINE THE SERVICE MODEL AND THE IMPLEMENTATION SYSTEM. NOW THE SERVICE MODEL IS HOW A HOME VISITING PROGRAM LOOKS ON PAPER. AND WE'RE CONCEPTUALIZING IT AS HAVING A FEW MAJOR COMPONENTS. THE FIRST WOULD BE THE SPECIFIED THEORY OF CHANGE. AND THEN BEYOND THIS THE PROGRAM'S INTENTIONS IN TERMS OF THE OUTCOMES IT WANTS TO MOVE, THE FAMILIES IT WANTS TO TARGET, THE SERVICES THAT IT INTENDS ITS PROVIDERS TO DELIVER, AND THE STAFFING CONFIGURATION FOR DELIVERY OF THOSE SERVICES. AND SO WE SEE A LINK, ONE WOULD HOPE, FROM THE SERVICE MODEL ON PAPER TO ACTUAL SERVICE DELIVERY. BUT THAT LINK IS MODIFIED BY THE IMPLEMENTATION SYSTEM, AND THE IMPLEMENTATION SYSTEM IS THE SET OF RESOURCES THAT ARE PUT TOGETHER FOR THE PURPOSE OF TAKING THAT MODEL OFF PAPER AND INTO REAL LIFE. AND WE'VE CONCEPTUALIZED IT HERE DRAWING ON THE MODEL OF FIXING IT ALL-AND-AS INCLUDING STAFF DEVELOPMENT, CLINICAL SUPPORT, ADMINISTRATIVE SUPPORT, AND SYSTEMS INTERVENTIONS, WHICH MEANS LINKAGES WITH OTHER COMMUNITY RESOURCES. SO THE QUALITY, THE ADEQUACY OF THAT IMPLEMENTATION SYSTEM INFLUENCES THE FAITHFULNESS OF ACTUAL SERVICES IN RELATION TO THE SERVICE MODEL. SO WE HAVE THE SERVICES AND WHEN WE COMPARE THEM TO WHAT IS INTENDED WE COME UP WITH OUR MEASURES OF FIDELITY, WHICH CAN BE MEASURED IN LOTS OF DIFFERENT WAYS. VERY SIMPLE APPROACHES AND WE COULD ALSO LOOK AT CONTENT. WE COULD LOOK AT QUALITY OF SERVICE DELIVERY. SO WE SEE THE FORCES AT MULTIPLE LEVELS SHAPE BEHAVIOR AND WHAT WE'RE REALLY INTERESTED IN LOOKING AT THOSE HOME VISITING PROGRAMS WOULD BE THE BEHAVIOR OF THE FRONTLINE STAFF, THE HOME VISITORS AND THE RECIPIENTS OF PARENTS AND OTHER CAREGIVERS. BUT AS YOU CAN SEE, ALL THESE OTHER LAYERS IN THIS HIERARCHY INFLUENCE THE BEHAVIORS OF THOSE HOME VISITORS AND THE FAMILIES. AND SO WE NEED TO INSERT FAMILIES AND STAFF AND THEIR OWN PERSONAL CHARACTERISTICS AS FURTHER MODERATORS OF THAT LINK FROM THE SERVICE MILLION-DOLLAR TO ACTUAL SERVICE DELIVERY. IF WE'RE TALKING ABOUT SERVICE DELIVERY AS A SET OF HOME BEHAVIORS, THEN WE CAN TURN TO SERIES OF BEHAVIOR TO HELP US UNDERSTAND AND EXPLAIN AND IMPROVE THE CONGRUNS BETWEEN WHAT HOME VISITORS DO AND WHAT WE WOULD LIKE THEM TO DO AND WE CAN THINK, FOR EXAMPLE, OF THOSE FACTORS FOR BEHAVIORS AS FALLING INTO CATEGORIES SUCH AS PREDISPOSING, ENABLING AND REINFORCING FACTORS. PREDISPOSING FACTORS BEING THOSE THAT OCCUR BEFORE SERVICE DELIVERY AND THAT PROVIDE THE MOTIVATION FOR A HOME VISITOR TO CARRY OUT HER EXPECTED ROLES AND RESPONSIBILITIES. PREDISPOSING VARIABLES WOULD INCLUDE WHETHER OR NOT THE HOME VISITOR BELIEVES THAT DOING X Y OR Z IS HER RESPONSIBILITY. WHETHER SHE FEELS COMFORTABLE, EFFECTIVE DOING IT AND SO ON. ENABLING FACTORS ARE THOSE ELEMENTS OF THE IMPLEMENTATION SYSTEM THAT ALLOWS HOME VISITORS TO ACQUIRE AND MAINTAIN THE KNOWLEDGE AND SKILLS THAT THEY NEED TO CARRY OUT THEIR JOBS EFFECTIVELY EVEN IN THE FACE OF CHALLENGING SITUATIONS. AND REINFORCING FACTORS TO PROMOTE THEIR CONTINUED MAINTENANCE OF SKILLS AND THE APPLICATION OF THOSE SKILLS IN THE CONTEXT OF HOME VISITS. WE ALL KNOW FROM OUR PERSONAL LIFE THAT WE PROBABLY HAVE WAY TOO MUCH ON OUR PLATES TO DO AND IF WE THINK ABOUT THE THINGS THAT WE DO AND THE THINGS THAT WE DON'T DO, WE TEND TO DO THE THINGS WE LIKE, THE THINGS WE FEEL GOOD ABOUT DOING, AND THE THINGS THAT OTHERS IN OUR NETWORK ENCOURAGE AND REINFORCE OUR DOING. THIS IS THE SAME PRINCIPLE HERE. SO TO SUMMARIZE THIS BACKGROUND FOR STUDY, I BELIEVE THAT INFLUENTIAL ORGANIZATIONS NEED TO WORK TOGETHER TO CREATE A CLEAR COHERENT SERVICE MODEL AND TO ASSURE A STRONG IMPLEMENTATION SYSTEM THAT TOGETHER WILL PREDISPOSE, ENABLE AND REINFORCE PARTICIPANTS TO CARRY OUT THEIR ROLES IN ORDER TO ACHIEVE FIDELITY OF ACTUAL SERVICES TO THE SERVICE MODEL FOR ALL TARGETED RECIPIENTS FOR ALL INTENDED OUTCOMES. AND THAT LAST PART I THINK IS PARTICULARLY IMPORTANT WHEN WE'RE TALKING ABOUT HOME VISITING. AS DAVID MENTIONED, RATHER THAN HAVING A MODEL THAT JUST FOCUSS ON A PARTICULAR ONE SMALL OUTCOME, HIS MODEL AND MANY OF THE OTHER HOME VISITING MODELS DO, IN FACT, AIM TO MOVE A RANGE OF OUTCOMES. BUT THE KNOWLEDGE AND SKILLS TO CARRY OUT THE ACTIVITIES TO MOVE ONE AND NOT NECESSARILY ADEQUATE TO CARRY OUT THE ACTIVITIES TO MOVE ANOTHER. AND SO WHAT WE'VE SEEN AND WHAT I'LL SHARE A LITTLE BIT WITH YOU IS THAT FOR SOME MODELS AND SOME IMPLEMENTATION SYSTEMS, WE SEE A VERY CLEAR MODEL, A VERY STRONG IMPLEMENTATION SYSTEM FOR ONE INTENDED OUTCOME, NOT SO MUCH FOR ANOTHER. SO WHAT DOES IT MEAN TO CREATE A CLEAR COHERENT SERVICE MODEL? AND ESSENTIALLY I THINK IT MEANS THAT EACH COMPONENT OF THE SERVICE MODEL IN, IN FACT, FULLY SPECIFIED AND THAT TOGETHER THEY MAKE SENSE. I THINK IT'S WORTH ADDING HERE THAT FOR SOME OF THE EVIDENCE-BASED HOME VISITING MODELS THERE IS AT THE NATIONAL LEVEL FOR SOME THERE IS A VERY FULL SPECIFICATION OF THE SERVICE MODEL. FOR OTHERS, THERE IS BY DESIGN NOT SUCH A FULL SPECIFICATION BUT THERE IS THE EXPECTATION THAT THE LOCAL IMPLEMENTING AGENCY WILL, IN FACT, ADAPT THE MODEL AND FILL IN THE BLANKS. WHAT DOES IT MEAN TO ASSURE A STRONG IMPLEMENTATION SYSTEM? AND HERE WHAT WE MEAN IS THAT EACH ASPECT IS ADEQUATE TO MOTIVATE AND REINFORCE PARTICIPANTS TO CARRY OUT THEIR ROLES TO ASSURE THAT PARTICIPANTS ACQUIRE AND MAINTAIN THE KNOWLEDGE AND SKILLS TO CARRY OUT THEIR ROLES AND IT PROVIDES AN ENVIRONMENT THAT MAKES EASY FOR THEM TO CARRY OUT THEIR ROLES. AND I THINK GOING FORWARD WE CAN ALL APPLY THIS FRAMEWORK AND PRINCIPLES OF IMPLEMENTATION SCIENCE AND THEORIES OF BEHAVIOR TO STRENGTHEN HOME VISITING'S EFFECTIVENESS IN PREVENTING CHILD NEGLECT AND I'D LIKE TO GO THROUGH JUST ONE SMALL EXAMPLE FROM THE RESEARCH THAT WE'VE DONE OVER THE PAST 15 OR 20 YEARS. SO THE STUDY I AM GOING TO USE AS AN EXAMPLE WITH THE RANDOMIZED TRIAL WAS THE ALASKA PROGRAM. SIX SITES COUPLED WITH A PRETTY THOROUGH IMPLEMENTATION STUDY. THE RESULT I WANT TO FOCUS ON IS THAT WE FOUND NO OVERALL IMPACT IN PREVENTING CHILD ABUSE OR NEGLECT OR IN IMPROVING ONE OF THE MAJOR RISK FACTORS FOR CHILD NEGLECT THAT IS POOR MATERNAL MENTAL HEALTH. WE COULD GO INTO THE DETAILS. WE DID FIND POSITIVE IMPACTS FOR SUBSETS OF THE POPULATION, JUST LIKE DAVID REPORTED FOR THE PARTNERSHIP AND FOR THE PURPOSE OF THIS TALK I WANT TO FOCUS ON THESE OVERALL EFFECTS. NO EFFECT IN CHILD PREVENTION AND SO THE QUESTION WE WANTED TO ANSWER WERE THE INPUTS ADEQUATE TO ENSURE FIDELITY AND DID VARIATIONS IN FIDELITY EXPLAIN THE IMPACTS OR LACK THEREOF? SO ONE OF THE THINGS WE DID WAS TO ASK THE HOME VISITORS TO RATE THEIR TRAINING AND THIS SHOWED NEW THE DIFFERENCE IN RULETS -- RESULTS AND QHE WE ASKED THEM TO PROMOTE POSITIVE CHILD-PARENT INTERACTION AND MATERNAL MENTAL HEALTH. 91% OF THE HOME VISITORS SAID YEAH, I GOT GOOD HOME VISITS BUT ONLY 44% SAID SO REGARDING IMPROVING MATERNAL HEALTH. SO BIG DIFFERENCE IN THE QUALITY OF TRAINING AT LEAST AS PERCEIVED BY THE HOME VISITORS. THIS DIFFERENT PERCEPTION OF TRAINING IS RELATED TO A CASCADE OF OTHER PREDISPOSING ATTRIBUTES. SO FOR EXAMPLE, IN THE LOWER LEFT IT WE LOOK AT THE HOME -- FOR THOSE WHO FELT THEIR TRAINING WAS INADEQUATE, ONLY 56%. WELL, HOW ABOUT COMFORT? HOW DOES THAT RELATE TO THEIR FEELING EFFECTIVE? LE 4% SAID THEY FELT EFFECTIVE IN ADDRESSING MENTAL HEALTH. AND OF THOSE WHO FELT EFFECTIVE, 79% SAID YES, THIS IS SOMETHING I OFTEN DO WITH FAMILIES AS OPPOSED TO ONLY 38% OF THOSE WHO DID NOT FEEL EFFECTIVE. AND WHEN WE REVIEWED THE HOME VISITING RECORDS OF THESE HOME VISITORS AND THE FAMILIES THAT THEY FOLLOWED, AND WE FOCUSED ON THE FAMILIES WHERE THE MOTHER SCORED POSITIVE FOR DEPRESSIVE SYMPTOMS AND/OR ANXIETY AT PROGRAM ENROLLMENT, WE FOUND THAT THAT TRAINING AND THOSE THREE PREDISPOSING FACTORS WERE IN FACT PREDICTIVE OF THE LIKELIHOOD THAT A HOME VISITOR WOULD IN FACT ADDRESS POOR MENTAL HEALTH. SO FOR HOME VISITORS WHO ENDORSE NONE OF THE FOUR ITEMS THAT I JUST LISTED, WE FOUND THAT IN ONLY 38% OF DEPRESSION-POSITIVE MOTHERS DID THEY SHOW ANY SIGNS OF RECOGNIZING AND ADDRESSING THAT ISSUE AS OPPOSED TO 62% FOR HOME VISITORS WHO ENDORSED ALL FOUR. I WANT TO COMMENT FOR A MOMENT ON HOME VISITOR PSYCHOLOGICAL WELL-BEING AND BURNOUT BECAUSE THIS IS AN INCREDIBLY IMPORTANT ISSUE IN PROVIDERS WHO WORK WITH A HIGH-RISK FAMILIES. AND I WANT TO POINT OUT SOME OF THE POSITIVES AND SOME OF THE NEGATIVES OF THE HOME VISITORS THAT WE SURVEYED IN ALASKA. ABOUT THREE QUARTERS FELT THAT THEY HAD ACCOMPLISHED WORTHWHILE THINGS IN THEIR JOB. I GUESS THAT'S GOOD BUT IT MEANS THAT ABOUT A QUARTER DON'T FEEL THEY'VE ACCOMPLISHED ANYTHING WORTHWHILE. 83% OR SIX OUTS OF SEVEN, SAY -- NEARLY A THIRD OF THE HOME VISITORS REPORTED FEELING DISSTRESSED WHEN FAMILIES PLACED TOO MANY DEMANDS ON THEM AND ALMOST A THIRD FELT EMOTIONALLY DRAINED FROM THEIR WORK AND NEARLY ONE IN FIVE FELT BURNED-OUT FROM THEIR WORK. THIS FEELING OF BURNOUT HAD AN INDEPENDENT EFFECT ON THE LIKELIHOOD THAT A HOME VISITOR WOULD ADDRESS POOR MATERNAL MENTAL HEALTH. SO THAT AMONG THOSE WHO DIDN'T FEEL BURNED OUT LOOKING BACK AT THOSE FACTORS WE OUTLINED EARLIER, FOR THOSE WHO ENDORSED NONE OF THE FACTORS FOR 44% OF THE FAMILIES WE SAW EVIDENCE OF RECOGNITION UP TO 67% FOR THOSE WHO ENDORSED ALL FOUR. BUT AMONG VISITORS BURNED OUT IT WAS ONLY 14% TO 46. HIGHLIGHTING ANOTHER AREA THAT OUR IMPLEMENTATION SYSTEMS. REALLY NEED TO ACKNOWLEDGE AND ADDRESS. BUT THIS NOTION OF RECOGNITION RAISES ANOTHER QUESTION. IT IS VALUABLE ONLY IF IT IS ASSOCIATED WITH IMPROVED OUTCOMES. SO A QUESTION WE WANTED TO ADDRESS NEXT WAS WHETHER RECOGNITION WAS ASSOCIATED WITH PROGRAM IMPACT ON MATERNAL MENTAL HEALTH. AND WE WANTED TO DO THIS BECAUSE OF REASONS FOR FAILURE TO ACHIEVE OUTCOMES WHICH INCLUDE POORLY APPLYING THE RIGHT TREATMENT OR PROPERLY APPLYING THE WRONG ONE. THIS SLIDE SUMMARIZES WHAT WE FOUND WHEN WE STRATIFIED THE SAMPLES OF MOTHERS BY WHETHER THAT BASELINE MENTAL HEALTH WAS SEVERELY POOR OR IN THE MODERATE RANGE. AND THEN WITHIN EACH OF THOSE STRATA, WE DIVIDED THE HOME VISITED GROUP BY WHETHER OR NOT THE MOTHER'S MENTAL HEALTH WAS RECOGNIZED BY THE HOME VISITOR. AND WHAT WE FIND IS THAT AMONG THE THOSE WITH SEVERE POOR MENTAL HEALTH, RECOGNITION WAS NOT ASSOCIATED WITH AN IMPROVED LIKELIHOOD OR ODDS OF IMPROVED MEANT AT THE TWO-YEAR FOLLOWUP. SO EVEN THOUGH THERE WAS RECOGNITION, THAT RECOGNITION WASN'T ASSOCIATED WITH IMPROVED OUTCOMES. ON THE OTHER HAND, FOR THE MOTHERS WHO FELL MONDAY RAT RANGE, WE SEE THAT RECOGNITION WAS STRONGLY ASSOCIATED WITH AN IMPROMTED OF OUTCOMES RELATIVE TO THE CONTROL GROUP. SO IN SUMMARY, THIS PARTICULAR SET OF RELATED FINDINGS FROM THIS ONE SINGLE TRIAL WE SEE THAT THE QUALITY OF TRAINING AS PERCEIVED BY THE HOME VISITOR IS RAILED TO THE VISITOR'S PREDISPOSITION TO ADDRESS POOR MATERNAL MENTAL HEALTH. THE HOME VISITOR BURNOUT IS ALSO RELATED TO RECOGNITION OF POOR MENTAL HEALTH. THE RECOGNITION WAS ASSOCIATED WITH BETTER OUTCOMES FOR SOME MOTHERS AND WHAT I'D LIKE TO ADD IS THAT BETTER OUTCOMES AND IMPROVEMENT WAS ALSO ASSOCIATED WITH IMPROVEMENTS IN THE QUALITY OF PARENTING. SO FOR EXAMPLE, WE CAN SEE THAT AMONG THE MOTHERS WHO ENROLLED WITH POOR MENTAL HEALTH, FOR THOSE WHOSE HEALTH IMPROVED, WE HAD VERY POOR HOME SCORES WITH 20%. BUT FOR THOSE WHERE MENTAL HEALTH DID NOT IMPROVE, IT WAS 35%, A SIGNIFICANT DIFFERENCE. NOW, THIS STUDY AND OTHER STUDIES THAT WE'VE DONE STLOR THIS ARE LIMITED IN SEVERAL VERY IMPORTANT WAYS THAT I WANT TO COMMENT ON. FIRST OF ALL, THE FIRST SET OF LIMITATIONS RELATES TO THE SAMPLE AND THE SETTING. SMALL SAMPLE SIZE AND IN THIS PARTICULAR STUDY WE HAD SIX SETTINGS. WE HAD 50SOME HOME VISITORS AND A FEW HUNDRED FAMILIES. WE ONLY STUDIED ONE MODEL OF HOME VISITING. AS FAR AS NAESHT LIMITATIONS, WE DIDN'T ACTUALLY -- MEASUREMENT. WE DIDN'T DO A CONTENT ANALYSIS OF THE TRAINING THAT THE HOME VISITORS RECEIVED. WE ONLY ASKED THEM FOR THEIR PERCEPTION OF THEIR TRAINING. WE HAD ONLY A SINGLE MEASURE OF HOME VISITOR PSYCHOSOCIAL WELL-BEING AND A CRUDE METHOD OF DELIVERY. THE SFKS I HAVE GIVEN YOU FOUND NO EVIDENCE OF RECOGNITION. THERE IS NO SENSE OF HOW OFTEN, WHETHER OR NOT THE HOME VISITOR LINKED THE FAMILY WITH COMMUNITY RESOURCES -- NO ASPECT OF OUR MEASURE THAT HAD TO DO WITH QUALITY OF SERVICE DELIVERY. SO THAT'S KIND OF THE BAD NEWS OF THE STUDY THAT I JUST REPORTED. THE GOOD NEWS IS THAT THE NATIONAL EVALUATION OF MIECHB ADDRESSES IT AND MANY MORE AND I WANT TO SHARE THE DESIGN OF THAT STUDY WITH YOU. SO THE STUDY IS SPONSORED BY HERSA AND BY THE ADMINISTRATION FOR CHILDREN AND FAMILIES AND LAUREN IS THE PROJECT OFFICER AND SHE WAS HERE EARLIER. THERE SHE IS IN THE BACK. OKAY. THE STUDY IS BEING CONDUCTED BY LEAD AGENCY MDRC AND BY JAMES BELL ASSOCIATES, JOHNS HOPKINS AND MATH MATCA AND THE COPIS AND JOE AND IS THE LEAD FROM JAMES BELL, DIANE FROM MATH MATCA. AND FOR ME THIS IS LIKE A WHOLE NEW WORLD WORKING WITH RESEARCH FIRMS. I FEEL LIKE I DIED AND WENT TO HEAVEN. WE'RE LOVING IT. SO THE NATIONAL EVALUATION IS GOING TO ANSWER SOME QUESTIONS THAT HAVEN'T BEEN ANSWERED BEFORE. THE FIRST WOULD BE WHAT ARE THE EFFECT OF MIECHB-FUNDED PROGRAMS ACROSS ALL DOMAINS OF INTERESTS AND MEASURED CONSISTENTLY ACROSS EVIDENCE EVIDENCE-BASED MODELS? THE SECOND WOULD BE HOW DO EFFECTS VARY FOR DIFFERENT GROUPS OF FAMILIES AND PROGRAMS? THIRD, WHAT'S THE RELATIONSHIP BETWEEN FEATURES OF LOCAL PROGRAMS AND THEIR EFFECTS? WE CALL THIS GETTING INSIDE THE BLACK BOX AND WE REFER TO THIS PART OF THE STUDY AS THE BLACK BOX. THE BLACK BOX ASPECT OF THIS STUDY IS MADE POSSIBLE BECAUSE WE HAVE PRETTY SOPHISTICATED IMPLEMENTATION STUDIES THAT ESSENTIALLY ANSWERS FOUR QUESTIONS AND SETS CREATES THE VARIABLES THAT WE'LL USE IN THE BLACK BOX ANALYSISS AND HOW DO THE PROGRAM INPUTS VARY AT THOSE MULTIPLE LEVELS? HOW DO HIGHER LEVEL INPUTS LOWER-LEVEL ONES? HOW DO THE PROGRAMS VARY, BOTH INTENTIONALLY AND UNINTENTIONALLY? AND HOW DO VARIATIONS IN THE INPUTS EXPLAIN VARIATIONS THROUGHOUT? AND AND AS OF NOW HAD BEEN IDENTIFIED BY ACS AS EVIDENCE-BASED. FOUR ARE GOING TO BE INCLUDED IN THE NATIONAL EVALUATION. AND THE MODELS VARY. THEY HAVE A LOT OF SIMILARITIES AND DIFFERENCES IN TERMS OF GOALS, FAMILY ELIGIBILITY, EXPECTED FREQUENCY OF VISITS AND SO ON. OUR SAMPLE PLAN IS TO RECRUIT 5100 FAMILIES IN 85 SITES ACROSS 12 STATES. THAT'S 20 FAMILIES ASSIGNED HALF AND HALF. HOME VISITED AND CONTROL. WE AIM TO HAVE PEOPLE IN SITES ACROSS THE FOUR EVIDENCE-BASED MODELS. AND AND PARENTS WITH TEACHERS AND EARLY HEAD START HOME VISITING VERSION. OUR MEASUREMENT INCLUDES BASELINE AND FOLLOWUP FAMILY SKBIS WEALTH OF DATA FROM ADMINISTRATIVE DATA SETS AND VERY DETAILED INFORMATION ON PROGRAM IMPLEMENTATION, BOTH QUANTITATIVE AND CU‡L TATIVE AND IN A VERY STANDARDIZED WAY SO THAT WE CAN MAKE COMPARISONS AND POOL ALL THE DATA AND MAKE COMPARISONS ACROSS MODELS. THE ANALYSIS PLAN BEGINS WITH INTENT TO TREAT ESTIMATES. THEN GROUPS OF PROGRAMS OF FAMILIES. FOR EXAMPLE, RESULTS FOR EACH OF THOSE EVIDENCE-BASED MODELS. ALSO POPULATION SUBGROUPS, FOR EXAMPLE, MOTHERS WITH DEPRESSION VERSUS OTHERS AND MOTHERS WITH LOW PSYCHOLOGICAL RESOURCES VERSUS OTHERS. AND FINALLY GETTING INSIDE THE BLACK BOX TO ANSWER THE QUESTION OF HOW DO DIFFERENCES IN PROGRAMS FEATURES ACROSS SITES COMPARE TO DIFFERENCES IN ESTIMATED EFFECT? THIS WOULD BE USING AGGRESSION MODELS. AND USING A VARIATION. MODEL I PRESENTED EARLIER, FIRST WE'LL BE LOOKING AT THE LINK BETWEEN THE SERVICE MODEL ON PAPER FOR EACH SITE AND FAMILY OUTCOMES. THEN INTRODUCING ELEMENTS OF THE IMPLEMENTATION SYSTEM. THEN STAFF ATTRIBUTES. AND FINALLY, ACTUAL SERVICE DELIVERY. NOW, I AM GOING TO GO BACK UP. AS WONDERFUL AS THE NATIONAL EVALUATION IS, PARTLY BECAUSE IT'S SO LARYNG, IT'S GOING TO BE A LONG TIME BEFORE WE HAVE RESULTS. THERE IS A REQUIRED REPORT TO CONGRESS IN 2015 FOCUSING PRIMARILY ON BASELINE DATA. WE WON'T BE REPORTING ON OUTCOMES UNTIL AROUND 2017. THAT'S KIND OF A LONG TIME TO WAIT. SO WHAT DO WE DO IN THE MEANTIME? WELL, M IECHB HAS MANY DIFFERENT COMPONENTS AND I AM GOING TO FOCUS THE LAST PART OF MY TALK ON THE ONE THAT I'VE PRINTD IN RED HERE. LET ME HIGHLIGHT ANOTHER PIECES BECAUSE FOR THOSE OF YOU WHO ARE NEW IT CAN BECOME VERY CONFUSING. FIRST WITH HOME V. THAT'S AN ONGOING REVIEW OF THE LITERATURE. IT'S THE REVIEW THAT HAS RESULTED IN THE IDENTIFICATION OF THE 12 EVIDENCE-BASED MODELS. I IMAGINE AS TIME GOES ON AND MORE RIGOROUS RESEARCH IS PUBLISHED, THE NUMBER OF EVIDENCE-BASED MODELS WILL INCREASE IN NUMBER. THEN THE VAST MIRJT -- MAJORITY OF THE FUNDING GOES TO GRANTS TO STATE TERRITORIES AND TRIBAL ORGANIZATIONS PARTLY IN THE FORM OF FORMULA DPRANTS AND COMPETITIVE GRANTS AND FOR THE STATES THAT HAVE COMPETITIVE GRANTS OR -- HAVE PROPOSED TO USE PART OF THEIR FUNDING FOR PROMISING MODELS, THERE IS A REQUIRED PIECE FOR EVALUATION. SO WE HAVE RESEARCH GOING ON WITH THAT PART OF IT. THEN THERE ARE FOUR DIFFERENT TRAINING AND TECHNICAL ASSISTANCE EFFORTS. SOME OF THEM FOCUSED ON STATES AND TERRITORIES. SOME ON TRIBAL ORGANIZATIONS. THEN THERE IS MY HOPE, WHICH I JUST DESCRIBED. THEN A SMALL PROGRAM OF INVESTIGATOR-INITIATED RESEARCH SPONSOR BID HERSA AND FINALLY ALSO SPONSOR BID HERSA THE HOME VISITING RESEARCH NETWORK. SO I'D LIKE TO CLOSE BY FOCUSING ON THAT. ROBIN HARWOOD IS THE PROJECT OFFICER FOR THE HOME VISITING RESEARCH NETWORK. AND THIS IS ACTUALLY THE TENTH RESEARCH NETWORK THAT HERSA IS FUNDING. IT HAS FUNDED RESEARCH NETWORKS SEVERAL OF THEM IN PEDIATRICS, PRIMARY, EMERGENCY, DEVELOPMENTAL PEDIATRICS AND SO ON. IT HAS FUNDED UCLA FOR A LIFE COURSE RESEARCH NETWORK. AND NOW IT IS FUNDING US FOR THIS HOME VISITING RESEARCH NETWORK. WHAT THESE NETWORKS HAVE IN COMMON IS THAT THE PURPOSE FOR EACH OF THEM IS TO DEVELOP THE INFRASTRUCTURE FOR MULTIDISCIPLINARY CENTER COLLABORATION AND THIS I THINK IS PARTICULARLY IMPORTANT FOR HOME VISITING BECAUSE MODELS TODAY REALLY HAVE EVOLVED IN THREE DIFFERENT TRADITIONS. SOME IN-HOUSE, SOME IN CHILD WELFARE, AND SOME IN EARLY EDUCATION. BUT NOW THROUGH M IECHB WE NEED TO HAVE RESEARCHERS AND TEAMS THAT UNDERSTAND AND EMBRACE ALL THREE OF THESE TRADITIONS. THE LONG-TERM FWOELESIFER ALL OF THESE RESEARCH NETWORKS ARE ESSENTIALLY TO ADVANCE KNOWLEDGE, IMPROVE SERVICES, AND PROMOTE FAMILY HEALTH AND WELL-BEING. AND SOME OF THE ACTIVITIES THAT MOST OR ALL OF THEM CARRY OUT INCLUDE DEFINING A NATIONAL RESEARCH AGENDA, GENERATING RESEARCH PROPOSALS TO FULFILL THAT AGENDA,8GCw„ SUPPORTING TRAINING OF RESEARCHERS, AND DISSEMINATING FINDINGS. NOW, OUR TEAM INCLUDES SOME OF MY FAVORITE PEOPLE AND SOME OF THEM ARE IN THE ROOM TODAY. ONE OF THEM IS MARK CHAP MAPP FROM THE UNIVERSITY OF OKLAHOMA. ANOTHER JOHN LANSBURG, AND I MYSELF AM DELIGHTED TO HAVE OF THE OPPORTUNITY TO WORK WITH THESE INDIVIDUALS WHOSE WORK I'VE ADMIRED FOR A REALLY, REALLY LONG TIME. WE HAVE FIVE OBJECTIVES. THE FIRST IS TO DEVELOP THAT NATIONAL HOME VISITING RESEARCH AGENDA. KIND OF A CHALLENGE. THE SECOND IS TO ADVANCE INNOVATIVE RESEARCH. THE THIRD TO PROMOTE DATA SHARING AND USE OF ADMINISTRATIVE DATA SETS. THE FOURTH TO SUPPORT THE PROFESSIONAL DEVELOPMENT OF HOME VISITING RESEARCHERS AND LAST TO DISSEMINATE RESULT. I WANTED TO SHOW YOU A LITTLE BIT OF AN ORGANIZATIONAL CHART. THE WORK OF THE HOME VISITING RESEARCH NETWORK IS REALLY GUIDED BY A STEERING COMMITTEE. SO THE FOLKS I JUST NAMED FORM THE EXECUTIVE COMMITTEE. AND THE STEERING COMMITTEE HAS ABOUT TO OTHER VEMGS WHO WERE CHOSEN PAWS THEY HAVE LEADERSHIP ROLES NATIONALLY IN REPRESENTING ALL OF THE CO-STAKEHOLDER GROUPS AROUND HOME VISITING. AND SO WE THOUGHT THIS WAS REALLY IMPORTANT TO HAVE' STEERING COMMITTEE WHOSE WORK IS ENFORMED PEENPUT FROM REPRESENTATIVES FROM THE CO-FEDERAL AGENCYS. AS WELL AS' SET OF VEZORS AND CONSULTANTS. AND I HAVE ACCOMPLISHED' COORD NEATH CENTER, WES HEADED BY KAY, WHO IS IN THE AUDIENCE TODAY. AND THE CENTER PROVIDES SUPPORT FOR NETWORKS, STATE LAERS INVOLVED IN HOME VISITING, RESEARCHERS AND EDUCATORS. IN ADDITION, WHAT WE'RE DOING IS CREATING A NETWORK OF HOMETOWN -- HOME VISITING PROGRAMS THAT ARE WILLING AND ABLE TO ENGAGE IN COLLABORATIVE RESEARCH JUST LIKE THE PRACTICE-BASED RESEARCH NETWORKS THAT I MENTIONED EARLIER FOR PEDIATRIC PRIMARY CARE, EMERGENCY MEDICINE AND SO ON. AND THE COORDINATING CENTER WILL PROVIDE SUPPORT TO TO THOSE SITES, SUPPORTX DESIGN TEAMS WHO WANT TO DEVELOPœp THAT ARE BEST CARRIED OUT ACROSS PROGRAM MODELS, ACROSS A LARGE NUMBER OF SITES AND PROJECT MANAGEMENT TEAMS TO MAKE SURE ARE IN FACT BEING CARRIED OUT. AND THEN THOSE OF US IN THE EXECUTIVE COMMITTEE ARE ORGANIZING WORK TEAMS TO MOVE AHEAD ON THOSE FIVE OBJECTIVES THAT I MENTIONED EARLIER. I JUST WANT TO SAY A SMALL WORD OR TWO ABOUT THOSE OBJECTIVES AND WHERE WE ARE AND WHERE WE'RE GOING. AND I'D LIKE TO YOU THINK ABOUT YOUR OWN RESEARCH PERSPECTIVES AS I GO THROUGH THIS FIRST ONE IN PARTICULAR. THIS FALL WE WILL BE SENDING WORD OUT TO GET INPUT:N]VIWHY A NATIONAL WEB-BASED SURVEY TO GET YOUR IDEAS AND YOUR INSIGHTS ON WHAT YOU CONSIDER THE MOST IMPORTANT, THE MOST TOP PRIORITY HOME VISITING RESEARCH ISSUES. DURING THE WINTER TOGETHER WITH THE STEERING COMMITTEE WE'LL BE REVIEWING AND RANKING THOSE NOMINATIONS AND THEN THIS COMING FEBRUARY AT THE PEW HOME VISITING SUMMIT IN WASHINGTON, WE WILL BEGIN THE DISSEMINATION OF THE AGENDA FOLLOWTHROUGH WITH PUBLICATION AND THE PEER REVIEW LITERATURE AND BEYOND THAT WORK WITH FUNDERS BOTH PUBLIC AND PRIVATE, TO MAKE HOME VISITING RESEARCH TO FIND THE AREAS WHERE WE CAN MARRY THIS RESEARCH AGENDA WITH THEIR OWN RESEARCH PRIORITIES. SO I'D LIKE -- I HOPE THAT WHEN YOU GET THE CALL, YOU WILL GIVE US YOUR BEST THINKING ON WHAT YOU CONSIDER TO BE THE MOST PRESSING ISSUES TO ADDRESS. THE SECOND TEAM IS FOR INNOVATIVE METHODS AND JOHN LANSBURG IS A MEMBER THAT HAVE TEAM. AND FIRST OBJECTIVE OF THAT GROUP IS TO IDENTIFY INNOVATIVE METHODS, NOT NECESSARILY USED IN HOME VISITING RESEARCH BUT IN RELATED FIELDS AS LONG AS RELATED FIELDS OF DISSEMINATION AND IMPLEMENTATION SCIENCE. IDENTIFY METHODS THAT ARE PARTICULARLY WELL-SUITED AND ALIGNED WITH THE AGENDA. AND THEN THAT TEAM IS ALSO TASKED WITH DEVELOPING THE INFRASTRUCTURE FOR THE PRACTICE OF EACH NETWORK. WE'RE LUCKY THAT THERE ARE SO MANY OTHERS AS PART OF THE CURRENT FUNDING. WE WILL BE CONDUCTING A DEMONSTRATION STUDY TO SHOW PEOPLE HOW THIS CAN LOOK AND TO GIVE THEM INSPIRATION. AND THEN WE'LL BE GOING OUT TO GARNER FUNDING FOR TO DESIGN AND IMPLEMENT OTHER AGENDA-RELATED RESEARCH. MARK IS HEADING THE DATA SHARING ZBRAUP GROUP TO IDENTIFY ADMINISTRATIVE DATA SOURCES. THES AND CONS OF EACH. MARK MAY BE SURVEYING SOME IN THIS ROOM AS PART OF IT. TO DETERMINE THE STATE'S CURRENT CUSE IN MONITORING THEIR ACHIEVEMENT OF BENCHMARK AND THEN TO PROMOTE GREATER USE OF ADMINISTRATIVE DATA SETS IN HOME VISITING RESEARCH. THEN PROFESSIONAL DEVELOPMENT COMMITTEE INCLUDES THE FIRST TO DO A SURVEY OF RESEARCH EDUCATORS TO IDENTIFY EXISTING TRAINING VENUES FOR HOME VISITING RESEARCH. TO IDENTIFY THE MOST PRESSING NEEDS AND THE MOST PROMISING STRATEGIES TO PREPARE THE NEXT GENERATION. WE ARE GOING TO BE SPONSORING WARNDS AND PROVIDE A MENTOR TO THOSE WHO WIN AWARDS TO GIVE THEM GUIDANCE ON THEIR RESEARCH. AND THE LONGER-TERM STRATEGIES INCLUDE DEVELOPMENT OF A SUMMER INSTITUTE, ONLINE COURSE AND LINKS WITH EXISTING OTHER TRAINING VENUES. AND THEN FINALLY, OUR LAST ACTIVITY INVOLVES DISSEMINATION. WE'RE BEGINNING FROM THE START WITH PRESENTATION AS PART OF THE DISSEMINATION. AND THERE ARE SPECIAL DISSEMINATION PLANS RAIL TO THE OTHER FOUR OBJECTIVES. WE'VE ESTABLISHED A WEBSITE THAT I ENCOURAGE FOLKS TO ACCESS TO LEARN MORE. SO IN SUMMARY TO SUMMARIZE THE FIRST IS TO PROVIDE A UNIQUE OPPORTUNITY FOR DISSEMINATION OF IMPLEMENTATION RESEARCH ON HOME VISITING TO PREVENT CHILD NEGLECT. SECOND, PRIOR RESEARCH AND IMPLEMENTATION SCIENCE AND THEORIES OF BEHAVIOR PROVIDE AN EXCELLENT FRAMEWORK FOR SUCH RESEARCH AND THE THIRD IS THAT MY HOPE TOGETHER PROVIDE EXCITING AND COMPLEMENTARY RESOURCES FOR SUCH RESEARCH. WE NEED AND WELCOME YOUR INVOLVEMENT IN HBRN AND I THANK YOU FOR YOUR ATTENTION. [APPLAUSE] I AM TOLD WE HAVE TIME FOR QUESTIONS. ARE THERE ANY QUESTIONS? YES. >> [INAUDIBLE] >> SURE. RIGHT NOW ONE FOLLOWUP POINT WITH CHILDREN OF 13 MOOZE OF AGE. -- MONTHS OF AGE. >> [INAUDIBLE]. >> WE WILL BE ABLE TO LOOK AT SHORT TERM OUTCOMES AND BIRTH OUTCOMES AND CHANGES IN PARENTING. YEAH. IS IT WHAT PEOPLE WANT AS THE END OF THE LINE, NO. LAUREN MIGHT WANT TO COMMENT A LITTLE MORE ON THE FUNDING FOR THE PROJECT. I DON'T KNOW IF I WANT TO GIVE OUT DOLLAR AMOUNTS. LAUREN, DO YOU WANT TO -- >> [INAUDIBLE] >> CURRENTLY, THIS FEDERAL PROGRAM IS ONLY AUTHORIZED THROUGH 2014. SO AND WE HAVE THIS REPORT TO CONGRESS WE HAVE TO ADDRESS. SO THE PRIORITY RIGHT NOW IS TO ACHIEVE WHAT WE CAN WITH THE PROGRAM AS IT'S STATED. WE HAVE A SECRETARY'S ADVISORY COMMITTEE THAT ACTUALLY COMMENTS ON THE DESIGN OF THIS AND THEY DID RECOMMEND THAT IF IT'S POSSIBLE TO FOLLOW THE CHILDREN AT LEAST UNTIL SCHOOL ENTRY BECAUSE CONGRESS HAS A PART ABOUT COST AND A COST ANALYSIS AND THEY FELT THAT THAT WAS CRITIC TOOLE AT LEAST GET THE SCHOOL ENTRY FOR THAT PORTION. BUT WE'RE CURRENTLY SLATED TO END IN 15 MINUTES. >> THANK YOU. [APPLAUSE] >> THANK YOU. SO WE HAVE OUR DISCUSSION. OUR DISCUSSION IS DR. BRANDO JONES HARDEN, WHO IS AN ASSOCIATE PROFESSOR IN THE DEPARTMENT OF HUMAN DEVELOPMENT AT THE UNIVERSITY OF MARYLAND IN COLLEGE PARK. SHE HAS WORKED MORE THAN 30 YEARS IN THE EARLY CHILDHOOD POLICY PRACTICE AND RESEARCH ARENAS AND FOCUSES ON THE DEVELOPMENTAL AND MENTAL HEALTH NEEDS OF YOUNG CHILDREN AND ENVIRONMENTAL RISKS PARTICULARLY THOSE INVOLVED WITH THE CHILD WELFARE SYSTEM. AND SHE'S TELLING ME TO STOP. I WILL TURN IT OVER TO THE DOCTOR. THANK YOU. >> I KNOW YOU ALL HAVE BEEN SETTING A LONG TIME AND I WANT TO GET THIS DONE. SO I JUST HAVE TO SAY THAT I'VE BEEN SITTING HERE LISTENING. AND I HAVE FOLLOWED ANN DUGGAN AND DAVID OLDSWORTH FOR A LONG TIME AND I THINK FOR THOSE OF YOU IN CASE YOU DON'T KNOW, THEY ARE PROBABLY THE TWO LONGEST STANDERS IN THE HOME VISITING RESEARCH WORLD REALLY. AND COLLECTIVELY HAVE DONE 60-PLUS YEARS OF RESEARCH. I REMEMBER READING IT MYSELF AND I KNOW IN THE NIH WORLD YOU SORT OF HAVE A RESEARCH PROGRAM AND YOU SIT WITH IT FOR YEARS BUT THIS IS REALLY UNUSUAL IN THE HOME VISITING WORLD. SO I WANTED TO PUT THAT OUT THERE. THEY'VE DONE A LOT OF WORK ON IMPACT BUT FOR ME MOST IMPORTANTLY I THINK WHAT THEY'VE CONTRIBUTED TO THE RESEARCH IN TERMS OF IMPLEMENTATION SCIENCE REALLY CANNOT BE OVERSTATED. SO I WANTED TO START WITH THAT. I AM JUST GOING TO MAKE A FEW REALLY BIG COMMENTS SO YOU CAN GET UP AND GET OUT OF HERE. THINGS THAT ARE REALLY IMPORTANT FOR ME AND JUST MADE ME THINK WHEN I WAS LISTENING TO WHAT THEY WERE SAYING AND WHEN I LOOKED AT THEIR PUBLICATIONS, ET CETERA, BECAUSE I FOLLOWED PUBLICATIONS A LONG TIME. THAT, WE DON'T HAVE A LOT ABOUT EFFECTIVENESS IN TERMS OF NEGLECT. WE JUST HAVE ALMOST NOTHING. WE HAVE A LITTLE BIT MORE IN TERMS OF WHAT CAN PREVENT ABUSE BUT ALMOST NOTHING ON NEGLECT. SO NOW WE'VE GOT THESE LOVELY NFP FINDINGS THAT SUGGEST THAT THESE MIGHT EVEN MORE EFFECTIVE FOR CHILDREN WHO HAVE EXPERIENCED NEGLECT. AND MY HOPE IS THAT -- OH, THAT A PUN THAT I DIDN'T INTEND. WOW. MY HOPE IS THAT MY HOPE WILL GIVE US MORE THAT HAVE KIND OF RESEARCH BECAUSE ONE OF THE OUTCOMES AS YOU ALL PROBABLY REMEMBER HEARING, IS PREVENTION, REDUCTION OF CHILD NEGLECT. SO I AM HOPEFUL THAT WE'LL GET SOME OF THAT KIND OF RESEARCH OUT. THE OTHER THING THAT I REALLY WANT TO SAY AND I'VE BEEN TRYING TO WORK ON THESE ISSUES AS A PERSON ON THE OUTSIDE TRYING TO MAKE MY OWN SMALL CONTRIBUTION. BUT ONE OF THE THINGS THAT OCCURRED TO ME MOSTLY THAT WE NEED TO THINK ABOUT TRANSENDING THE MODELS. AND I THINK HOPEFULLY THE EFFORT AND THE MY HOPE EFFORT WILL HELP US TO TRANSCEND THOSE MODELS. THERE ARE CERTAIN KINDS OF THINGS THAT I WANT TO US THINK ABOUT. ONE, WHAT IS OUR THEORY OF CHANGE? EACH LITTLE PROGRAM DOES HAVE A THEORY OF CHANGE. BUT IF WE REALLY ARE THINKING ABOUT A SYSTEM AND I KNOW DAVID IS A LITTLE WORRIED ABOUT THAT SYSTEM STUFF AND I AM, TOO, -- WE NEED TO BE THINKING ABOUT HOW WE ARE TRYING TO IMPACT CHANGE FOR ALL OF THESE FAMILIES FOR ALL OF THESE OUTCOMES. AND I DON'T THINK WE'VE DONE ENOUGH WORK REALLY THINKING THAT THROUGH ON ANY OF THE MODELS IF THEY'RE GOING TO TRY TO REACH THOSE EIGHT OUTCOMES THAT ANN TALKED ABOUT. ANOTHER THING IS FIDELITY. AND I CAN TELL THAT YOU THE MODELS MAY BE VERY WELL-DEFINED BUT WHEN YOU GET ON THE GROUND, THEY ARE OFTEN NOT CRAFRTED ALL IN THE WAY THAT THE MODEL IS INTENDED AND THAT'S ONE REASON WHY DAVID -- MOST OF THE PROGRAMS, AS YOU ALL PROBABLY KNOW, ARE DELIVERED BY PARAPROFESSIONALS WHO DON'T HAVE THE KIND OF CLINICAL SKILLS AND THIS IS ONE OF THE THINGS THAT I'VE BEEN WORKING ON IN MY KRER A LOT REALLY TRYING TO DO WORK FOR DEVELOPMENT, WHICH I AM GOING TO TALK ABOUT IN A MINUTE. BUT I THINK WE HAVE TO THINK ABOUT SOME KIND OF MONITORING SYSTEM AND ANN DIDN'T TALK ABOUT THIS MUCH BUT ONE OF THE THINGS THAT SHE'S BEEN REALLY WORKING ON IN HER WORK IS REALLY THINKING ABOUT MEASURING THE SUPERVISION AND ENHANCING THE SUPERVISION THAT THE HOME VISITORS GET. ONE, YOU CAN HELP THEM LOOK AT WHETHER THEY'RE MEETING THE THEORY OF CHANGE AS A PROGRAM BUT ALSO REALLY IN THE MOMENT DOING WHAT WILL LEAD TO THE OUTCOMES THAT THEY WANT. AND OFTENTIMES THEY'RE JUST NOT THERE. ANOTHER THING THAT DAVID MENTIONED AND I THINK ANN ALSO ABOUT WHAT WORKS FOR HOME? THIS IS A HUGE ISSUE AND I THINK DAVID AND ANN HAVE BOTH LOOKED AT THESE TARGET GROUPS A LOT. BUT I HARKEN BACK TO THE STUDIES WHERE THEY FOUND THAT FOR THE HIGHEST RISK GROUP -- DOMESTIC VIOLENCE AND DEPRESSED, SOME OF THOSE PROGRAMS MAY NOT NECESSARILY GET THEM TO THE OUTCOMES THAT THEY NEED. THE ADAPTATION MARKET TALKED ABOUT THIS WHOLE IDEA OF CULTURAL ADAPTATION. ANOTHER IS RURAL POPULATIONS. I HAVE TO TELL YOU IF YOU HAVE EVER WORKED WITH RURAL HOME VISITORS, THEY'RE DRIVING AN HOUR AND A HALF TO THE ONE VISIT AND THE MOTHER ISN'T THERE AND DRIVING AN NOW AND A HALF BACK? WE HAVE TO RETHINK THE POPULATIONS AND THESE HIGH-RISK POPULATIONS AS WELL. JUST IN TERMS OF RISK ASSESSMENT, THERE NEEDS TO BE THOUGHT ABOUT WHAT WORKS FOR WHOM. STATE SYSTEMS HELP PROGRAMS. AND ONE OF THE OTHER THINGS THAT I'M REALLY HOPEFUL WILL HAPPEN IS THAT WE SEE MORE CHILD WELFARE SYSTEM INVOLVEMENT FOR THESE PARTICULAR ISSUES OF NEGLECT. LAST THING I WANT TO TALK ABOUT IS WORK FIRST. I AM REALLY IN TEAR ABOUT WORK FORCE DEVELOPMENT. I THINK WE CAN HAVE BEAUTIFUL MODELS BUT IF WE DON'T HAVE GOOD DELIVERIES OF THE MODELS AND I AM SO HAPPY TO HEAR ANN TALK ABOUT HOW THEY ARING IT TO LOOK AT THE WHOLE WORK FORCE ISSUE THINKING ABOUT PROFESSIONALISM OF HOME VISITORS, WHETHER THEY, IF YOU ARE THINKING ABOUT NEGLECT, FOR EXAMPLE, WE GET MORE TRAINING AROUND THOSE PARTICULAR ISSUES THAT RELATE TO NEGLECT? ONE OOH OF THE OTHER THINGS IS WHAT ARE THE CORE COMPETENCIES OF HOME VISITORS AND HOPEFULLY STATES WILL BE WORKING ON THOSE KINDS OF THINGS AND MEASURING WHETHER THE HIRING PRACTICES. AND THE IMPORTANCE OF WORK FORCE DEVELOPMENT ISSUES, BIGGER THAN TRAINING BECAUSE TRAINING IS NOT AN ISSUE. I THINK IT'S VIDEOTAPING AND HAVING SOME KIND OF ACCESS TO MENTAL HEALTH CONSULTATIONS SO THEY CAN ADDRESS THE DOMESTIC VIOLENCE DEPRESSION. LAST SLIDE, RESEARCH ISSUES, IMPLEMENTATION. THEY SAID IT ENOUGH. WE REALLY HAVE TO PAY VERY CLOSE ATTENTION TO THAT AND WHATEVER KIND OF WORK WE'RE GOING TO DO. I'D LOVE TO SEE SOME MORE RANDOMIZED TRIALS OF THE PROMISING INTERVENTION THAT'S HAVEN'T MADE THE LIST. THEY'RE LOT OF THINGS GOING ON AND COUNTLESS OTHERS THAT I HOPE WE CAN SEE SOME FUNDING FOR. THE WHOLE ADAPTATION. AND ANOTHER THING IS CONTINUOUS IMPROVEMENT. DAVID AND ANN TALKED ABOUT IT IN TERMS OF ADAPTATION. I THINK WE NEED TO DO SOME WORK ON THE GROUND TO HELP THE PROGRAMS TO THINK ABOUT USING RESEARCH TO IMPROVE THEIR PROGRAMS FROM THE GROUND. AND THAT'S ALL I AM GOING TO SAY. THANK YOU. [APPLAUSE] >> THANK YOU. SO WE DO HAVE A COUPLE OF MINUTES FOR QUESTIONS BEFORE WE END. AND THANK YOU, DR. HARDON. ANY QUESTIONS? COMMENTS? NO? OKAY, I THINK WE WILL CLOSE THE SEMINAR. I WANT TO THANK YOU ALL FOR YOUR PARTICIPATION AND THANK YOU FOR THOSE OF YOU WHO ARE WATCHING BY WEBCAST. THANK YOU. [APPLAUSE] >> SO I HOPE ALL OF YOU KNOW THAT STARTING AT 5:30 ROUGHLY YOU HAVE A LITTLE BIT OF A BREAK NOW. BUT WE WILL HAVE A POSTER SESSION OVER AT THE MARRIOTT NORTH. AND THERE IS A LOVELY RECEPTION. I SAW THE MENU. FOR THOSE OF YOU WHO LIKE TO EAT, THE FOOD LOOKS REALLY GOOD. THAT IS BEING HOSTED BY AND PROVIDED BY UNIVERSITY OF SOUTHERN CALIFORNIA. AND THE ROOM -- IS IT THE WHITE OAK ROOM OR AM I JUST MAKING THAT UP? ANYWAY, IT EITHER SAYS TRC RECEPTION STARTS AT 5:30 AND WE LOOK FORWARD TO SEEING YOU ALL THERE. THANK YOU. WE'LL SEE YOU TOMORROW MORNING AS WELL.