increase in the number of mothers working outside the home and (2) the increase in the number of single-parent families. Today, 63 percent of mothers with school age children work outside the home. The figure for moth- ers of preschool children is 60 percent. Among women with children less than 1 year old, 54 percent work outside the home. Moreover, the Department of Labor estimates that, by the vear 2010, labor shortages will draw even more mothers into the work force. Today more than 25 percent of all American children and 50 per- centofblack children grow up in single-parent families. Research on the impact of daycare on children, Dr. Zigler noted, has shown that good daycare is good for children and bad daycare is bad for children. We know how to provide good care, but we don’t want to pay what it costs. “The general state of childcare as experienced by children in this country is abysmal,” he stated. “This country is getting what it pays for.” The average annual turnover in childcare facilities is about 40 percent. As many as 90 percent of daycare centers in the U.S. are completely unregulated. No national standards exist, and there is wide variation among States. Even where standards exist, they are too lax to be of much use. Based on studies recently completed in California, Dr. Zigler estimated that about one-third of centers in this country are so poorly managed and the quality of care isso low that children are being “seriously compromised.” He went on to say, “We cannot treat children the way we are currently treating them in the childcare setting in America and expect this to be a great nation.” Although the 1990 Childcare Block Grant has been hailed by many as a victory for childcare reform, Dr. Zigler expressed doubt that it will have any signifi- cant positive effect. Seventy-five percent of the funds allocated to the Block Grant are earmarked for poor or nearly poor families. The middle class, which is equally in need of good childcare, will see almost no benefit, and Dr. Zigler expressed his fear that this situation may lead to backlash against the grant and against childcare reforms in general. He stressed the relationship of good daycare to achieving the President's six National Education Goals. “Five lousy years of childcare will 126 Parents Speak Out for America’s Children ATi auve guarantee that they [children] will show up at school not ready to learn.” In Dr. Zigler’s opinion, the svstem as it currently exists does not work and cannot be made to work. Instead of trving to retrofit the current system, he proposes a whole new system that he calls the School of the Twenty-First Century. The program, as Dr. Zigler envisions it, will incorporate the following key features: * Two systems will exist: first, the formal, 9-month, 8:00 am to 3:00 pm school, and second, the 12- month, 7:00 am to 9:00 pm school. * Children will enter the system at the age of three for full-day, developmentally appropriate school. In communities that already have Head Start programs, Head Start could simply be blended into the system; parents with earnings above the poverty line will pay an enrollment fee. * Before- and after-school childcare will be pro- vided for children aged 6 to 12. * Each family will be assigned a home visitor who will conduct developmental screening, offer sup- port to parents, etc. * All family daycare programs will be tied in to the school, which will offer support and periodic training sessions for childcare providers. * The school will contain a comprehensive informa- tion and referral system that can direct families to appropriate health and social servicesagencies (such as immunization clinics or night care providers). Successful pilot programs to build Schools of the Twenty-First Century already exist in several States, including Missouri, Connecticut, Colorado, Wyoming, Texas, Kansas, Idaho, Arkansas, and Mississippi. Another proposal Dr. Zigler is attempting to present to Congress is the “Children’s Allowance for America.” This plan would allow a new parent to withdraw up to $5,000 from his or her own Social Security account to allow the parent to stav home or to help pay for good childcare. Nancy Van Doren President, Travelers Companies Foundation Director, National and Community Affairs Division The Travelers Companies Ms. Van Doren spoke on behalf of the Travelers Com- panies Foundation about the role that businesses and private organizations can play in securing good care for children and pregnant women. The Travelers are headquartered in Hartford, Connecticut—one of the poorest cities in the country, located in one of the richest states. Disproportionately large numbers of children in Hartford are born to teenage mothers, are underimmunized, and have asthma, attention deficit disorders, or learning disabilities. All of these condi- tions are usually preventable. As one of the organization's social responsibility commitments, the Travelers are working to improve the health of children and the prenatal care of mothers in the greater Hart- ford area. When a new children’s hospital was proposed for Hartford, the Travelers commissioned an independent analyst to conduct an evaluation of Hartford's health care delivery needs. The consultant found that, while Hartford would indeed benefit from having another hospital, it was even more important to increase availability of primary and preventive health care for children and expectant mothers. Ms. Van Doren said that it has been a challenge to persuade contributors and decisionmakers to redirect their hmited resources from “glamorous,” high-visibilitv projects such as new hospitals to more mundane (but effective) applications such as prenatal and perinatal health clinics for low-income mothers. Ms. Van Doren said that she is motivated in her efforts by a mixture of rage and shame that people in her community are unable to have even their most basic needs met. She urged the audience to let their rage and shame move them to act and to search for opportunities to push for the redirection of resources to the places where they can do the most good. Hartford has been successful so far in its drive to reallocate resources from prisons to schools, and from neonatal intensive care units to preventive care. Ms. Van Doren emphasized the importance of preventing health crises rather than remedving them. Panel 4A CHILDREN WITH SPECIAL HEALTH CARE NEEDS: LESSONS LEARNED This panel offered valuable insights about setting up systems that address the problems of children with special health care needs. The speakers offer three perspectives—all key to successful programs: (1) par- ent empowerment, (2) program-level development, and (3) State-level involvement. The panel was moder- ated by Rear Admiral Julia R. Plotnick, M.P.H., R.N.C., who holds the rank of Assistant Surgeon General and is the Associate Director, Division of Services for Children with Special Health Care Needs, at the Maternal and Child Health Bureau. Report of the Surgeon General's Conference 127 Diana Robinson Parent/Child Advocate Center for Successful Child Development Ms. Robinson serves as a parent/child advocate at the Robert Taylor Community—known to be the largest public housing division in the United States—where she has resided for more than 20 years. Her video presentation highlighted the daily struggles of a com- munity with highly concentrated and severe poverty and its associated problems: extreme overcrowding, extremely high infant mortality and morbidity rates, high incidents of low birth weight, high percentage of teenage mothers, and high rates of violence. The community is further crippled by threatened family unity; psychological and physical absence of fathers: anger, depression, and despair; and social isolation. Ms. Robinson's determination to help herself and fellow community members led to her advocacy work on the Beethoven Project at the Center for Successful Child Development. The Center provides community-based services that address the health, education, and social needs of the community. The Center's philosophy is based on two beliefs: that each individual has the ability toachieve and be independentand in control of his or her life, and that strong family relationships are important. Services are tailored to the needs of individual families. in a tvpe of holistic service plan. Instead of focusing on the barriers to improving community life, said Ms. Robinson. the Center builds on community strengths to deal with the problems. From her experience at the Center, Ms. Robinson shared two basic problems and approaches to solving them. (1) Economic entrapment and isolation leads to a month-to-month struggle to meet basic needs. To address this problem, the Center offers ongoing emplovment training, counseling, and referrals. The Center also provides other tools to make life easier and help people to help themselves. Project staff are empathetic rather than sympathetic, and support groups abound. (2) Educational opportunity is lacking in the community. Project staff help parents to become better persons as well as better parents. The Center recognizes that parents who feel powerless and/or inadequate as parents don't read to children. Staff 128 Parents Speak Out for America’s Children members stress the importance of reading to their children and other approaches parents can use to foster school success. The staff encourage strong parent-child relationships and emphasize taking pride in the child’s academic achievement. Finally, parents are taught to become accountable and take an active role in their children’s lives and in their community. Said Ms. Robinson, “Healthy parents ready to learn will provide us with healthy children ready to learn.” Polly Arango New Mexico Parents Reaching Out Governor’s Task Force on Children, Youth, and Families New Mexico Children’s Continuum Ms. Arango introduced her audience to New Mexico from the viewpoint of New Mexico’s parents of children with special health care needs who have been working to improve the State's medical and educational systems. While New Mexico isa State of great physical beauty and diversity, italso faces many challenges: * One of seven New Mexico children livesin poverty, % New Mexico ranks 51st in the Nation in the per- centage of women receiving prenatal care. * The State's teen suicide rate is dismal. Therefore. New Mexico's families have arranged to make the lives of their children better, one family and one issue ata ume, Ms. Arango became involved as an advocate when she and her family learned that their youngest son, Nick, has cerebral palsy and developmental delays. As with many middle-class families, the Arangos discov- ered that few avenues existed to assist them as they struggled to pay Nick's medical and preschool bills. For example, although Nick was adopted, his adoption occurred before the emergence of adoption subsidies. Nick is an American Indian, but his birth parents chose not to enroll him in the tribe, a decision honored by Nick’s adoptive family. As a result, Nick is not eligible for services through Indian Health Service or the Bu- reau of Indian Affairs. Because they were decidedly middle class, the Arangos could not meetincome guide- lines for the State's crippled children program. To deal with her frustration, Ms. Arango joined with other parents to found a statewide organization called Parents Reaching Out (PRO) for anv and all families with children who have chronic conditions, disabilities, or illnesses of anv kind. Twelve years later, PRO has 500 members who are from every part of the State and everv ethnic background and who have chil- dren with manv challenges. Manv of PRO’s members are the professionals, friends. and relations of families who have children with special health needs. PRO began as an organization to provide peer support and information to families, and this function continues to: be the heart and soul of its efforts today. However. PRO’s parents soon tackled bigger issues such as writing the legislation that created a Compre- hensive High Risk Insurance Pool for New Mexico. The list of issues thev have addressed goes on and on. The following elements have contributed to their success in changing the svstem: * Ordinary parents have united to form a common bond. * They have forged strong partnerships with health. education, and other professionals. * One parent usually has risen to the forefront as a symbol! of the movement. * Public and private agencies have supported the campaigns with technical assistance and in-kind contributions as a way of enlightening and educat- ing the public. * At least one policymaker who is willing to “bleed and die” for the issue has become involved. * The highly visible work and people are supported by a broad-based grass-roots community of fami- lies and professionals who volunteer at home, * Everyone remembers the bottom line: improving the health of children and ensuring that their fami- lies can raise them with dignity, respect, and love. Beverly McConnell Director, Parent Participation Program Children’s Special Health Care Services Michigan Department of Public Health When Ms. McConnell’s child required an oxygen tank. she had to learn about health care systems and how to make them work. Because of her experience, McConnell was hired by the Michigan Department of Public Health to work on a peer level with “weightv” issues for a newly created parent participation program. The program, born out of decentralization at the State level, needed more parent involvement at the local level. Ms. McConnell described the initial ambivalence of one supervisor who did not understand the need for parent involve mentat the State level. However, as the program gained wide acceptance, she gained this person’s full support. Ms. McConnell’s job was to build relationships; create task forces; make approvals; and set policies for hospitals, physicians, and home health services. She is proud of the fact that all hospitals in her State now need parentadvisory committees and parent staff. She stressed the benefits gained from building relationships among parents, community, and government: the establishment of enormous power bases that took action when funding cuts were threatened. Thev influenced senators so that “Families have both an immediate vested interest to get things changed and the freedom to act... .” Report of the Surgeon General's Conference 129 parents received needed appropriations. They helped establish boilerplate in laws thatrequired that families and consequences to them be considered before programs are changed or funds are withdrawn. In effect, the legislation mandated State government to work with families. Ms. McConnell noted that parents are willing to take risks to support the continuance of needed services. “Even if thev are not sure the steps are right,” she said, “[parents] are willing to follow their instincts.” Ms. McConnell introduced four strategies to help families meet children’s special health care needs. (1) Support. State agencies should nurture and facilitate the develop- ment of statewide coalitions of and support groups for persons with disabled children. State agencies should encourage referrals to these groups. Financial support 18 also very important. Parent consultants must get reim- bursed for their time and expenses. Another type of support involves helping parents acquire a wealth of knowledge. They need information, for example, about who in the community has had a bad experience with clinics, etc. (2) Dissemination of Information. State agencies must establish effective, routine mechanisms for receiving information from parents and parent support groups and for disseminating information to them (fam- ily support networks). Agencies must provide families with clear written information describing programs, ser- vices. and mechanisms for accessing those services. Agen- cies must provide ready access for parents to unbiased and complete information from their child's records. (3) Collaboration. Families that participate across the State must represent the cultural and economic diversity of the State. They must participate fully with professionals in policy development, program implementation, coordi- nation of services, and evaluation of programs. State agencies must financially support parents involved in these activities. (4) Integration (the ultimate goal of services). State agencies must have a written policy that reflects the pivotal role of families. Integration recognizes the concept of family-centered services. However, parent inputis needed to ensure that services are family centered. Therefore, mechanisms for parent and professional col- laboration should be used routinely at all levels and in all program areas. 130 Parents Speak Out for America’s Children In closing, Ms. McConnell shared the following “lessons learned” from her experience: (1) Families have both an immediate vested interest to get things changed and the freedom to act (they have no boss in this endeavor, nothing to lose, and everything to gain). (2) Concepts trickle down to benefit health care for children in general, not just for those with special needs. (3) Financial support and encouragement are vital. (4) Advocacy can result from one-on-one relation- ships, either parent to parent or parent to professional. (5) None of the panelists are specialists in special health needs. In other words, parents should be recruited on the basis of their commitment, not educational de- grees. (6) Gaining new territory is worth the risk. esd at=) et) PARENTING: THE CRITICAL ROLE As she introduced the speakers on this panel, Modera- tor Barbara Heiser of the La Leche League stressed the importance of parent involvement in children’s lives both at home and at school. As children’s main support svstem, first teachers, and caretakers, parents exert a lifelong influence on their children’s development. Ann G. Cagigas, R.N., 1.B.C.L.C. Lactation Consultant For this panel's opening presentation, Mrs. Cagigas shared some of her experiences as the mother of three children, two ofwhom had severe sleep apneaas children. As infants, all of her children had to be constantly monitored lest they suddenly stop breathing. Mrs. Cagigas, a former emergency room/ trauma nurse, found herself wholly devoted to a new, 24-hour, acute care detail athome. Her eldest daughter, who is now 13 vears old, has fought several medical problems, including thyroid failure and Tourette's Syndrome. Mrs. Cagigas said she believes that the commitment she and her husband made to their children and their determination to stay active in their roles as parents carried them through some difficult times. She also stated that breastfeeding her children as infants helped her to feel connected to them later in life and kept the maternal bond strong even during very stressful periods. Mildred M. Winter, M.Ed. Executive Director Parents as Teachers National Center University of Missorri - St. Louts Ms. Winters presented the methodology and history of Missouri's Parents as Teachers program. Children are born learning. she said, “but thev don’t come with instruc- tions.” As children’s first and most influential teachers, parents should help their children learn all they can. The Parents as Teachers program helps parents give children “good beginnings.” The kev. according to Ms. Winter, is to reach children as early as possible. We learn more as children than we do during any comparable period of our lives. To make the most of this ferdle learning period. the Parents as Teachers program promotes the develop- ment of a parent-school partnership. A home visitor program brings trained parent educators into the children’s homes to talk with parents about opportuni- ties for the child to learn, things the parents can do to stimulate the child’s imagination, and what skills the “As children’s first and most influential teachers, parents should help their children learn all they can.” child should be developing. Home visitors also act as listeners and offer the parents support and a svmpa- thetic ear. The Parents as Teachers program involves as manv family members as possible, including fathers and grandparents. Anv family is eligible to enroll in the program, and special efforts are made to attract low- income families and teenage mothers. To date, four independent evaluations of the pro- gram have been conducted; all have shown that children whose families participated in the Parents as Teachers program to score higher in language development, intel- lectual development, and social development than chil- dren who were not itvolved in the program. Thirteen states, including Missouri, have Parents as Teachers programsin place. Manv use fandsfrom Even Start, Chapter I. Chapter IE. children’s trust funds, private corpora- tions and foundations, and public service groups such as the Kiwanis Club. In closing, Ms. Winters said that while the Parents as Teachers program does not solve all of the prob- lems that face children and their families today, she and her organization are proud to be part of the solution. Following Ms. Winter's presentation, a member of the audience [Sandra McElhany of the National Mental Health Association] urged attendees to write their representatives in Congress toask them tosupportan amendmentto the Bill for Educational Research and Education thatwill be proposed by Senator Kitt Bond of Missouri. The amendment, which has the support of Senators Kennedy (Massachusetts), Dodd (Connecticut), and Pell (Rhode Island), would grant States funding—$20 million per year for 5 years—to start or expand Parents as Teacher programs. Mary Louise Alving, M.Ed. Project Director, Parent Leadership Traming Citizens Education Center Ms. Alving presented a set of proven guidelines for setting up parent involvement programs. Although it is widely known that parent involvement improves children’s self-esteem and school performance, 75 percent of parents still do not get involved. Ms. Alving offered ways to increase parent involvement in school programs. The Parent Leadership Training Project at the Citizens Education Center began in Seattle in 1986 Report of the Surgeon General's Conference 131 ““ . . .parent involvement improves children’s self-esteem and school performance. Lee to address the needs of Migrant families. Since then, it has expanded to include families and schools of all backgrounds. Ms, Alving first talked about the four myths. that people use to say that parent involvementis not practical. The first was that “parent involvement” means volunteer- ing for school activities. Ms. Alving disagreed, saying that a parent who helps his child with her homework, or who takes an active role at school board meetings. is at least as involved as the volunteer. The second mvth is that parents don't have time to participate in school activities. She pointed out that parents do come to school when thes have what they think is a good reason (for example. debates about condom distribution in high sehools). “Parents are hard to reach" was the third myth. Ms. Abing asserted that it is the schools, not the parents, who are unwelcoming. The fourth myth she confronted was the “at risk” classification of families from certain’ ethnic groups or economic levels. She said that all families are at risk at some time, and that these kinds of classifications promote division within the community. Ms. Alving presented eight “do's” for successful pargnt involvement programs. These were repeated in the video that was shown at the end of the session. * Allactivities and programs should be based on the idea that all families have something to share. 132 Parents Speak Out for America’s Children * Parent involvement programs should inchide members of other programs—such as Chapter I and Head Start—and should collaborate with other programs. * Most successful programs focus on the child’s teacher. Parents want to meet and get to know their children’s teachers. Teachers are often the best wav to reach parents. * The program should be coordinated by a team, a good program will rapidly expand to a size where it simply cannot be administered by only one person. Teams should consist of the school prin- cipal, two parents, two teachers, a school district © representative, a business/community represen- tative, a social services professional, and a cul- ture/language specialist (as required). Before | the team begins planning, they should attend a 5- dav training session. % Successful programs always allow room for adjust- . ment. Every school is different, and programs must be adapted to fit theiraudiences. * Teacher training is an important part of parent involvement programs, Teachers often have no training on how to work with parents. * Ongoing funding for parent involvement pro- grams should be obtained. Too often, when funding runs out, the parent involvement pro- gram goes with it. Begin to work for permanent funding early. * Building a developmental evaluation process into the program means that staff can evaluate their progress at any point and can make any necessary adjustments. Letitia Rennings, M.S. Even Start Coordinator U.S. Department of Education Last to speak in this session was Ms. Rennings, who discussed the Even Start program. This family literacy program has increased in Federal funding from $14,820,000 in 1989 to $70 million in 1992. President Bush is recommending that funding for the 1993 fiscal vear be $90 million. There are currently 240 funded programs, including 9 Migrant programs. Even Start is open to children from birth through age seven living in a Chapter I elementary attendance area and a parent who is eligible for adult basic education. Even Start is composed of three core compo- nents—parenting education, early childhood educa- tion, and adult education. The projects build on eNIst- ing programs in the community, such as Head Start, Chapter I, Chapter H, adult education, programs for children with disabilities, JTPA. and JOBS. The program's goal is to break the evcle of illiteracy that plagues so many American families. The benefits of Even Starts focus on literacy are many. Parents who learn to read develop an interest in school, and some of them choose to go back to school as a result of their involvement. In addition, children feel proud of their parents and work to emulate their parents’ academic success. In some projects, parents have formed their own support networks and have learned the importance of proper health care and nutrition, talking and reading to their children. and serving as good role models. The self-esteem and confidence of participants—adults and children alike— is greatly increased. The results of first vear (1989) program evalua- tions show that 70 percent of families served have annual incomes of less than $10,000. Even Start has reached 45,000 adults and 48,000 children across the country. The majority of adult participants are between the ages of 21 and 29. To close her presentation, Ms. Rennings offered the audience some specific illustrations of the good Even Start can do for families and for whole communities. She Report of the Surgeon General's Conference 133 briefly described three successful programs—one ina trailer park in Fort Collins, Colorado, one in a very poor community in Sneadville, Tennessee, and one in the town of Hidalgo, Texas, on the Mexican border. Each of these programs has tailored its services to fit the specific needs of the community and families it serves. Recognizing that families’ basic needs must be met before they can begin to apply themselves to studving, the Colorado program offers not only General Equivalency Diploma (GED) training for parents, butalso teaches parenting skills, basic nutrition, and hygiene, and coordinates a food donation program. In Sneadville, where many people have never been inside a school building, 150 families almost everv- one in the county—is involved in Even Start. More than 500 people attended the program's spring picnic, with evervone in the community participating. The town sheriff cooked. and the staff of the barbershop gave free haircuts—some to women who had never had their hair cut by someone outside their immediate family. At the end of the year, 48 women enrolled in Even Start had passed the GED and 10 of them received drivers’ licenses. In Hidalgo, Texas, the Even Start program serves a community that is mostly Hispanic and poor; the families participating in Even Start had no plumbing or sewer systems. Their homes resembled small toolsheds. Nearly 120 parents and 130 children are enrolled in the program. Before Even Start came to Hidalgo, many women, who had had even less education than their husbands. were completely illiterate. Many families were entitled to food assistance, but could not negotiate the system because they could not read. The Hidalgo Even Start home visit has proved the most effective means of improving families’ literacy skills in a cultur- allv sensitive mariner and of assisting families in dealing with social service agencies. 134 Parents Speak Out tor America’s Children Panel 5A CHILDCARE: TWO PERSPECTIVES Childcare can be viewed from two perspectives: that of the parents and that of childcare providers. This panel, moderated by Barbara A. Willer, Ph.D., Public Affairs Director for the National Association for the Education of Young Children (NAEYC), presented the results of two national childcare surveys, one from each perspec- tive. Dr. Willer noted that these projects, which were separately funded and designed, are unique because they highlight partnerships (collaborations). The first study was the National Childcare survey sponsored by NAEYC and the Administration on Children, Youth, and Families, U.S. Department of Health and Human Services. The study used a telephone survey of parents designed and analvzed by the Urban Institute. It ex- plored general questions about childcare arrangements and included substudies of low-income families and mihitarv families. The second study, the Profile of Childcare Settings, was sponsored bv the Department of Education. 4 The study dealt with the supply of childcare services, use by low-income families, range of services, and quality. Patricia Divine-Hawkins Public Affairs Co-Director National Association for the Education of Young Children Ms. Divine-Hawkins reported immense change with respect to childcare in this country in this generation. In the 1990s, many mothers are working, resulting in a large proportion of children in preschool and a large number of children caring for themselves. She also reported a shift from informal toward formal childcare centers and homes. Census studies of parents and national studies by the Administration on Children, Youth, and Families point toward these conclusions. She noted that the consumer studies of 1974 through 1976 were prototypes of our understanding of childcare, but they did not include family daycare providers. According to Ms. Divine-Hawkins, social policies of the 1990s are oriented more toward children and the family. Childcare is a central component of employee benefits in many companies. Head Start created new partnerships between Federal, State, and local govern- ments. The continuity between early childhood educa- tion programs and elementary school has enhanced and eased the transition between early childhood and kindergarten. However, these social factors create a complex situation and thus a need to look at childcare issues more holistically. Ms. Hawkins-Divine related that NAEYC’ sresearch examines how the supply of and demand for childcare work together. Itis the first research that (1) studies the range of options for different families in different types of situations, (2) explores characteristics of individual families, (3) develops a comprehensive database with individual data tailored to individual circumstances, and (4) examines socioeconometrics. NAEYC also emphasizes the importance of partnerships in address- ing childcare issues. Sandra L. Hofferth, Ph.D. Sentor Research Associate Human Resource Policy Center The Urban Institute Dr. Hofferth was the principal investigator of the Na- tional Childcare Survey, which explored supplemental care for children (center care, family daycare, in-home care, care by a relative, or no supplemental care). The components of the survey included the number of households with children under certain ages, number of children enrolled in daycare, a parent survey, and a provider survey. The survey revealed a high percentage of supplemental care and a major shift in the providers of supplemental care: more and more children who receive care out of the home are enrolled at centers as opposed to receiving care at homes of relatives. The survey examimed primary care for the youngest pre- school child by income, for emploved mothers. Enroll- ment in center-based programs has increased particu- larly among lowest income families whose children are placed in subsidized programs and who receive direct financial assistance, ete. The working poor and low- to middle-income families, by contrast, are participating at a lower rate in center-based programs. Dr. Hofferth said it is noteworthy that the cost of care has not increased significantly relative to the cost of living. But, she affirmed, as the high-income families get tax credits and low-income families get assistance, the middle class gets squeezed out. Dr. Hofferth’s research shows that parents learn about childcare arrangements for the voungest child through relatives, friends, and neighbors (informal net- works) and from referrals. The mostimportant factors for measuring daycare are quality (above all else), reliability, teacher training, and student-totteacher ratios. The sur- vevfound that parents were generally satisfied with davcare arrangements. One-fourth of the parentssurveyed wanted to change arrangements. Of those, one-half wanted to switch to childcare centers. Childcare centers are the preferred alternative. Interviews with surveyors showed that some centers were regulated, and others were not. Nonregulated centers outnumbered regulated centers. Nonregulated centers differed from regulated ones in Report of the Surgeon General's Conference 135 that thev were smaller. had shorter operating hours, charged less, and were not run bv professionals. The major findings were that, during the preschool vears, more and more children are in childcare centers and some, especially the poor, may be suffering. Elizabeth Farquhar, Ph.D. Program Analyst Department of Education Dr. Farquhar talked briefly about the Department of Education’s role in creating policies and studies concerning early childhood education, childcare, and familv education. The Department of Education supports Chapter I creation of Even Start for adults in need of literacy skills. Preparing Young Children for Success is a Department of Education program that prepares children for schools. The Department also sponsors the Profile of Childcare Settings Study. The Department also collaborates efforts with the Department of the Health and Human Services. Since the 1980s, the Department has worked with the States, who became active in developing preschool programs. “Collaboration,” Dr. Farquhar stated, “is very effective in these studies.” Elfen Eliason Kisker, Ph.D. Senior Researcher Mathematica Policy Research, Inc. Dr. Kisker, who directed the Profile of Childcare Settings Study, described her extensive research on the supply of childcare for preschool and school-age children and on childcare utilization by low-income mothers in terms of two aspects: availability and quality. Dr. Kisker cliscussed availability in terms of formal early education and care at centers and at regulated family davcare programs. She found that the number of programs has wipled and enrollments have quadrupled since the 1970s. She con- firms that utilization rates are high and that most vacan- cies are concentrated in fewer than one-half of davcare facilities. However, more information is needed from parents to determine if shortages exist in specific areas for certain types of children. Dr. Kisker noted that not all programs provide all services. Asa starting point, one can look at admissions policies and determine whether the 136 Parents Speak Out for America’s Children facility accepts infants, children who need fulltime ser- vices, and handicapped and/or sick children. In terms of quality, Dr. Kisker noted, daycare centers can take many forms. “A daycare center that is considered quality,” said Dr. Kisker, “promotes child development. ... You can’t assess childhood develop- ment by individual child, but there are certain indica- tors of quality.” These indicators include (1) average group size, by various ages (look at the various laws pertinent to the regulations); (2) average child-staff ratios, by various ages; (3) teacher qualifications, by tvpe of degree; (4) teacher turnover (profit versus nonprofit), and (5) parental fees (not changed since 1970s if adjusted for inflation). The Childcare Settings study led to new childcare policies. The 1990 baseline data were used to assess what has happened since the early education initiatives were developed, and programs have since been implemented. To illustrate Dr. Kisker’s statement, Ms. Divine-Hawkins shared that 32 projects in 32 States have evaluated the transition of Head Start graduates over the next three grades, assessed their progress, and determined under what conditions thev progress. Panel 5B HEALTHY START, HEAD START, EVEN START, AND WIC: INTEGRATING HEALTH, EDUCATION, AND SOCIAL SERVICE PROGRAMS Wade Horn, Commissioner of the Administration for Children, Youth and Families, served as moderator for this session on collaboration among various health and social service agencies. A. Kenton Williams, Ed.D Associate Commissioner Head Start Bureau “Head Startis alive and kicking because it works.” So Dr. Williams, the newly appointed Associate Commissioner for the Head Start Bureau, opened his discussion of the Head Start program. Head Start is a comprehensive child development program that works with the whole child to promote self-esteem, education and literacy, and health through four channels: education, health services (including medical, dental, psychological, and nutrition), social services, and parent involvement. President Bush has recommended that Head Start be allocated $600 million for the coming fiscal vear. Head Start is proud of its cooperative relationships with other programs and agencies, including the Health Care Financing Administration, the Public Health Service, and the Department of Education. Dr. Williams said that he is happy to be working with such a successful program and named the follow- ing priorities for Head Start in the coming vear * To better serve pregnant women and to provide optimal prenatal care to keep mothers healthy and to help them bear healthy children, * To maintain continuing relationships with pri- mary care physicians. * To improve clients’ access to secondary care. * To provide referrals to appropriate psvchological counseling, substance abuse treatment, etc. * To reduce the number of low-birthweight babies and to reduce the infant mortality rate. * To improve clients’ understanding of wellness and increase personal responsibility for health, including cessation of cigarette smoking, alcohol or substance abuse, etc. Donna F. LaVallee, M.S. Nutrition Coordinator New Visions for Newport County Dividing her work week between WIC and Head Start in her jJobas nutrition coordinator for this program in Newport County, Rhode Island, Ms. LaVallee had many insights about how to integrate efforts between these programs. Because WIC and Head Start serve the same popu- lation, both programs and their clients benefit when they work together. Ms. LaVallee offered many simple sugges- tions to help foster collaboration between local WIC and Head Start offices, such as open houses, cross-referrals, membership on each other's policy committees, guest speaker exchanges, and assistance in program evaluation. Because WIC and Head Start have so much in common, they can share many things, including resources, cospon- sored clinics and health fairs, joint newsletters, allin-one application forms, community needs assessment data, and more. Ms, LaVallee urged program staff to “commu- nicate, cooperate, and coordinate.” Thurma McCann, M.D., M.P.H. Acting Director, Office of Healthy Start Health Resources and Services Administration Dr. McCann described the Healthy Start program, which is based on recommendations from the President's Commission on Infant Mortality. Now in its early stages. Healthy Start is being implemented in 15 communities with the aim of reducing infant mortality in those communities by 50 percent. Program applicants were required to meet five basic criteria to have their proposals considered: (1) innovation in delivery svstems (e.g., user friendli- ness, etc.), (2) community commitment to Healthy Start’s goals, (3) the ability to offer increased access to health care to reduce low birth weight and other causes of infant mortality, (4) integration of medical and social services, and (5) multiagency participation. Asa whole, the Healthy Start program is unique in that it allocates unprecedented resources to prenatal and perinatal care, mandates community choice and flex- ibility, and empowers communities to build the kinds of programs that will work best for them. Although Healthy Start funding Jasts for only 5 years, Dr. McCann stressed thata community that has “bought into” the program can find a way to keep it in place even after Federal funding is withdrawn. Healthy Start encourages community involvement and has won support from various churches, civic groups, tribal councils, schools, and business organizations. Such agencies as the Public Health Service, the Health Care Financing Administration, the Department of Education, and the Department of Health and Human Services are also active partners in the natonal progran, Report of the Surgeon General's Conference 137 Patricia A. McKee Chief, Grants Administration Branch Office of Elementary and Secondary Education US. Department of Education Nowin its third year, the Even Start program is proud of its cooperative relationships with other agencies and within the communities it serves. Ms. McKee presented a brief overview of what Even Start is doing in this area. When Even Start was mandated by Congress 3 years ago, part of that mandate required that Even Start work with other agencies to achieve their common goals. The 76 programs established to date contain a total of 869 collaborative arrangements for primary (or “core”) ser- vices and 1,600 collaborative arrangements for support services. More than 67 percent of all Even Start programs work with their local Head Start programs. Howard T. Miller Coordinator Even Start Family Literacy Program Prince George's County Public Schools Mr. Miller opened his presentation witha briefoverview of the statistics on illiteracy in America and whatit costs. More than 40 percent ofall military service enlistees are functionally illiterate. More than two-thirds of all U.S. colleges must offer remedial English classes. More than one-half of all prison inmates are functionally illiterate. He stated that these and other data show that the deleterious effects of illiteracy lead to financial losses, crime, violence, poverty, and depression. Even Start's approach in Prince George's County is based on two important assumptions: (1) parents’ level of educa- tional achievement affects their children’s success in school and (2) a child raised in a literate home will naturally learn to read, just as he will learn to talk and to feed himself, through learning “reading behaviors.” The second assumption is called “emergent literacy.” Mr. Miller stressed the importance of educators’ getting to know the families of the children they teach, to form a cooperative partnership between the school and the parent. Parents who are enrolled in the Even Start program along with their children are able to go to class when itis convenient for them, and transportation is provided. Parents learn new skillsin preparing for the 138 Parents Speak Out for America's Children “If we can help the parent become literate, these families can succeed.” GED, and they also learn parenting skills that help them teach their children. General health and nutrition services also play an important part in helping families tolearn and grow together; recognizing this importance, Even Start coordinates closely with Head Start, WIC, the Cooperative Extension, and schools. “If we can help the parent become literate,” Mr. Miller said, “these ” families can succeed ~1 Jajdey) Closing Remarks Chapter 7 Closing Remarks Antonia C. Novello, M.D., M.P.H. Surgeon General Ihave only afew comments. I think that today you have seen that when people get together, things work. But I can also tell you I am proud of your three capable representatives who communicated your wisdom about what this country needs and what this administration can do to solve our problems. This was unrehearsed; it was collectively put together; and I think it probably represents us better than anyone talking from their own pain. This is what makes this Conference unique. Moreover, it’s even more difficult for me to speak after having heard people like this. [also can tell vou that. when this Conference is done and when we all go our separate ways back to the States and communities, my impression will be that we have come together for only one purpose, and that’s the purpose of taking care of children and families. The President said his vision is that, in the vear 2000, this country and these children are going to move forward, The children of today will be the explorers, writers, teachers, doctors, and inventors of tomorrow. President Bush said that, in America, families come first, and that’s what makes this conference unique. You are here from 50 States and from Territories as far awav as Guam. Youare here from Puerto Rico, and you are here from everywhere. Contrary to what the only reporter that has come aboard asked yesterday, vou are not all Republicans. In this Conference, I have taken great pain to make sure that we are not labeled bv ethnicity, language, or gender. We are here with only one mission, no matter where we come from and who we are. That mission is to care for the children and families of this county. You have articulated what you need, and I have never heard it so well expressed. This Conference is focused on our children, and we're working toward the benefits of every child. I have been much more im- pressed than ever by people who perhaps never knew 140 Parents Speak Out for America's Children they could speak for others and be taken seriously. We said this is about respect, respect across the board. I think in these 3 days, we have shared the commonality that. even if vou don’t speak the same language, it doesn't mean that you are not intelligent. Most impor- tantly, we recognize that “poor” is a transient state of mind: today, it is vou; tomorrow, it can be me. So let’s not only be culturally sensitive, let's also be culturally responsive. I think this Conference has concentrated on that. Whatever personal circumstances we brought here and I can assure vou that some of your faces said, “Show me,” and some of your faces said, “One more conference; don’t bother me with trivia”—I can assure you that by having come here for whatever was the message vou thought you wanted to bring, you have advanced the field of every child, and vou will perhaps be as responsible for having made one more child part of these United States by just having been here. For that you should be complimented. We came here to deal with awareness, transition, and participation. After having listened to the parents, vou realize that parents do all three at once, and some- times one parent does it all. [hope now that vou realize parents are crucial for whatever we're going to doin this counuy for the families. If you don’t believe me, then [want to know where vou've been for the last 3 days. When I charged you on Monday, I told vou I was going to ask the best of vou. But I warn you, I'm going to ask even more of vou, even when vou think you're going to go home and forget about this Conference. I can tell you that we've heard the parents and the groups. I’ve felt the pain, and I've talked to you. I've talked to every one of you individually or collectively. When we leave this place, we will have everything that’s been said included in a proceedings compendium. We will complete the docu- ment as quickly as possible, but remember we must go through the General Services Administration and Gen- eral Accounting Office to have it printed. We’re going to make sure that this goes to every Governor, every one of you, and every legislator who asks for it; right now the Hill is also clamoring for it. So this is going to be a public document for all of those who need it. wealthy CHikiwen “Heady to Team But the document will be just a document if vou do not work with us to make it a realitv. You were able to see that our officials are committed. but don’t ever put the rights and the benefits of your family only on some other people’s shoulders. You have to share the responsibility; otherwise, it will not become a reality. The reforms of this county will come forward through the families; the parents spoke today, and thev no longer want to be silent partners. They want to be activists and advocates, and to do that vou also have to speak for yourself. Otherwise, we're not going to get anywhere. I also heard that parents, especially fathers, have to be part of everything that we do. | think, as I've said before, we have to find wavs by which we bring fathers into the family, not wavs by which we keep them away. I know that parents have to be respected as experts, and it is imperative that we do that. Another big area is the need for flexible hours, and in immunization, we have discovered that repeat- edly. Hours from 8:30 [a.m.] to 5:00 [p.m.] is a beauti- ful protocol, but 67 percent of the parents work ina job they cannot afford to leave for 1 hour and vaccinate a kid, and 21 percent of this country’s families are headed byasingle parent. Open the clinic when the parents can come, if vou really are serious about immunizing. For once, “Put vour money where vour mouth is.” We must make sure that we write in the language that people understand. Yesterdav, I was in a transplan- tation meeting, and they told me I need bilingual permits to donate my organs, And they say minorities do not donate. Would vou donate vour organs by signing a document given to vou by a person who is not cultur- ally sensitive, in a language that vou do not understand? If vou sign. I have a bridge I want to talk to vou about. This Department is making sure that evervthing is put in the language that people will understand. Most importantly, some of our groups have no more than an Sth grade education. So again vou said it, “Put it in words that people understand.” In medicine, we re alwavs talking about EKG [electrocardiogram ] and EEG [electroencephalogram].and [asked a doctor, “Whatis an EGG?” He didn't know, so I told him, “an egg.” It's also important to remember that the country is full of children having children. We have to worry about them, too. Thev do not love their children less because they are children themselves. Thev are going to need understanding, and they are going to need us to help them, too. Selfesteem was another issue raised here. Self- esteem is no longer just for the child. Italso has to come from the parents, and that is something that we cannot buy. Medicare, Medicaid, nor Social Security can buy it. That has to come from within. Butwe cannot only think of sel-esteem for the children. We have to give it for the parents. Occasionally, take your time to tell us when we do good, and, occasionally, just forget that we did bad. 1 think positive is part of where we have to go, One woman said we have to help people to help themselves. rather than offer programs that foster de- pendency. Lagree. I have the feeling that that should be away we should move toward our goal. We might use different words. We might sav “advocacy” or “empower- ment.” Either wav, we need a little more positivism in getting together. Report of the Surgeon General's Conterence 144 “ .. this Conference has done<6ne thing beautifully: It has vi the parents. realize tha silent.” The title of the Conference has been “Healthy Children Ready to Learn: The Critical Role of Parents.” I do believe—and I hope you do, too—that this Conference has done one thing beautifully: It has vindicated the parents. It has helped people realize that they can no longer be silent. No single program in this country should be done in the absence of the parents’ participation; otherwise, it will be one more useless piece of paper. I said in my opening remarks that this Conference was the result of 18 months of planning. I believe that is totally obsolete at the end of these 3 days. This is just the beginning, not the end of 18 months. I have seen all my Assistant Secretaries involved in this with me, and we’re going to make sure that whatever we plan will be with families, parents, and children in mind. For that reason, this is a success story. I know I told you not to ever get discouraged with the Federal Government. It’s a powerful one, and you have to learn how to use it as a tool. Today you had everyone at the top discussing how they see it. As I told you, perception versus reality is the problem here. You might perceive one thing, and the reality might not be so bad, but I think it worked on both sides of the table. You have heard from all of us—from the Secretary of Health and Human Services, the Secretary of 142 Parents Speak Out for America's Children Agriculture, the Secretary of Education, six Assistant Secretaries, and the President of the United States. But most importantly, we heard from you. That’s what makes this Conference unique. I think we should never underestimate the power of a coalition. Alone, we are not going to do anything, including the President himself. We all have to be able to tell the Government we’re here. We're part of the solution. Please, let’s not be part of the problem. I want all of us to get together, regardless of what we felt when we came here, because united we can doa lot of work. I know that you probably have thought, “She’s going to repeat herself again.” No one alone can work. We have to unite. But I also told you to use anger if necessary. I can tell you that I feel good that you did, because when you used anger, you were collectively expressing something that I hope the Conference hasalleviated. Perhaps now you at least know a place where you can find a solution for your problem. I know that I have told you that we have to be creative. Part of this world is discourage- ment, but I’m not going to let anyone use it to take care of you or me. Discouragement is a state of mind. I ask you to join me to share the responsibility for making your family and your children well. Share with us at the local and at the State and at the National levels and in the public and the private sectors. It’s no longer one person’s responsibility. There is too much at stake! So look at everything that works, and look at everything you think needs to be replaced. Then call and cajole and make sure that you get involved. I know that we are “conferenced out,” but I know also that we are accelerated to the “max.” You have to use that momentum when you get back to work and to your communities and say, “You know when the Surgeon General, the Secretaries, and the President speak, they are committed to make the family top priority.” Let’s get real. Let’s get real! I can tell you that when the experts go home, they are not going to be devoid of work because I am not going to be devoid of work. I have your telephone numbers, your fax numbers, and even your grandfather’s numbers. So, rest assured that this is not just the ending of 3 days, but it’s the begin- ning of a coalition of parents taken seriously, trying to determine, through their collective actions, what this government can do for you. I’m with you. Are you with me? I want to bring six people to the podium because without them I don’t think we could have done this. They are the three parents’ representatives and the three parents’ alternates. I think we should give an applause to our panel. We had six parents, three to come forward and three to be available in case they fainted. Obviously, we didn’t need the other three, but they were there and ready to go. So, I would like to do something. There’s not much I can do for you all, but I can certainly give what I call the Surgeon General’s Certificate of Appreciation, and believe me, T do not give that too freely. But, when people give of them- selves, as they did to represent you, I think a Certificate of Appreciation from me isjust the first step. I think that you should be able to thank these six people who represented you so well. Because without them, and you, this Conference would have never happened. So how about if we applaud for all of us. Ellie Valdez- Honeyman, Larry Bell—I am eating squash all my life— Sandy Slavet, Rosa Palacious, and Jesus Sada. Sherlita [Reeves] had to go and pick up her little child, so we'll keep Sherlita’s and mail it to her. We might be “conferenced out,” but! think we are motivated to go out there and do a lot for what we have tried to accomplish. Most important, is that, collec- tively, we will be able to do it. This document will not stay on anybody’s shelves; I guarantee you that. So today’s the beginning, but I need you. Remember, united we will succeed. Separated, we will not get anywhere. Today's the first day. Thank you for coming, and God bless you. Report of the Surgeon General's Conference 143