Category Archives: Prevention

Health Policy Opportunities to Prevent Violence Against Women, Children & Families

On Wednesday, April 30, Futures Without Violence and the National Health Collaborative on Violence and Abuse (NHCVA) conducted a Capitol Hill briefing to address strategies to utilize the health care system in a way that can prevent family violence. Speakers included Richard Krugman, MD, the Office of Health Affairs, University of Colorado Denver; Deb Levine, MA, Executive Director, Youth + Tech + Health; Diana Cheng, MD, Project Connect Maryland; Howard Koh, MD, MPH, Assistant Secretary for Health, Department of Health and Mental Hygiene; and Brigid McCaw, MD, MPH, Chair, National Health Collaborative on Violence and Abuse.

Dr Krugman, discussed his work on child abuse and neglect issues. He was a member of the U.S. Advisory Board on Child Abuse and Neglect when they issued their findings in 1990. He summarized what was concluded then, and continues even today, that we have hundreds of thousands of children being abused and neglected each year. Further, that the system we have designed to address these families is dysfunctional and that we end up spending billions of dollars a year to address the failure to respond. He concluded that the Commission he was on had too many recommendations (31), and because they did not offer Congress a “silver bullet” to fix the situation, the recommendations were ignored. He also noted a lack of commitment to the issue by all administrations, noting the Clinton Administration’s lack of interest in the topic at the time he was on the Commission.

Dr Krugman also talked about the need for much more research, pointing out that children respond differently to being victims of abuse but we have a limited ability to understand this result. He suggested that the March of Dimes model might be the best model for advocacy, noting their history of forming in response to the past polio epidemics of the forties and fifties that took a little over 1,000 lives per year. They mobilized around a single cause and grew from there.

Dr.Cheng focused her discussion on recent research and on-going work in Maryland. Starting in Baltimore, research determined that the number one killer of women who are pregnant or within a year of their pregnancy was homicide. Further work and research determined that in two-thirds of these homicides the perpetrator was the partner or former partner. In some instances these homicides also include the infant. They also determined through surveys of pregnant women that 7 percent were experiencing physical abuse during their pregnancies. Building on these finding Maryland is working on addressing intimate partner violence (IPV), training providers including Obstetricians and Gynecologists, and integrating IPV assessment into Title X Family Planning Programs and other health provider contacts.

Additionally, the briefing highlighted further opportunities in health care to reduce domestic and dating violence and adverse childhood experiences (ACE), and new technology (apps) that promote safe and healthy relationships. 

Strong Start Early Childhood Bill Could Have Republican Counterpart

Senator Tom Harkin’s (D-IA) Strong Start for America’s Children Act (S. 1697) would attempt to create a new universal pre-kindergarten (pre-K) program, similar to the President’s early childhood proposal.  A Republican alternative was indicated on Thursday, April 10, when Senator Lamar Alexander (R-TN) announced he was working on a block grant proposal that would require a great deal less in terms of state quality requirements for pre-K services. Alexander indicated that his proposal would be similar to the Child Care and Development Block Grant (CCDBG).

S. 1697 would provide access to pre-K for 4-year-olds with funding conditioned on states providing a match of federal funds. It would promote full-day pre-K for 4-year-old children from families earning below 200 percent of the Federal Poverty Level (FPL). States would pass funding onto local providers that would have to meet high-quality standards including minimum teacher qualifications, rigorous health and safety standards, small class sizes and low child-to-staff ratios, evidence-based comprehensive services for children, strong parent and family engagement, and health screening and referrals. The bill also outlines requirements around better coordination and collaboration between child care and Early Head Start and child care partnerships that are intended to improve the quality of child care.

It is not yet clear exactly how the early childhood block grant approach would be structured, but Alexander indicated that states would have more flexibility, similar to CCDBG. The current structure of CCDBG requires very little in terms of quality standards. In fact, the very nature of the CCDBG funding means that increasing coverage for families, improving child care quality, and providing better reimbursements for providers each compete for the same block grant dollars.

Senator Alexander has raised past criticisms that there are too many programs addressing child care. A Government Accountability Office (GAO) report has indicated that they found 45 different programs that deal with early childhood education and child care that receive over $14 billion a year. Critics of that viewpoint say that two-thirds of the programs identified as overlapping actually have different missions than providing child care. For example, the Child and Adult Feeding Care Program focuses on nutrition services and does not provide child care. The report also counts the $1.5 billion in Defense Department child care funding, which is limited to military families and unlikely to ever be turned over to state control. It also counts $8 billion in funding for Head Start and Early Head Start. While some Republican lawmakers, including Representative Matt Salmon (R-Ariz.) and Senator Mike Lee’s (R-Utah), have bills that would turn Head Start into state block grants, there has been strong bipartisan opposition to such an approach in the recent past.

To compare, the President’s pre-K and early childhood education proposal would build on initial seed money of $250 million included in the FY 2014 budget. There would be $1.3 billion in matching federal funds for states that already have pre-K programs, with funds to be used to expand the quality and availability of current services. States would have to meet rigorous standards beyond what they have been required to provide under CCDBG. Finally, the pre-K portion would be funded by increasing the current tobacco tax.

Is Foster Care Really the Supply Chain for Domestic Sex Trafficking?

On Tuesday, April 8, the Center for American Progress sponsored a forum: “Combating Sex Trafficking of Minors in the U.S.” The panel included Senator Amy Klobuchar, (D-MN); Malika Saada Saar, Executive Director, Human Rights Project for Girls; and John Temple, Attorney-in-Charge, New York County District Attorney’s Office Human Trafficking Program.

Much of the discussion was by Senator Amy Klobuchar (D-MN) regarding legislation she is sponsoring, S.1733, “The Stop Exploitation Through Trafficking Act.” The legislation would encourage changes by law enforcement in the way they address domestic sex trafficking and sexual exploitation, specifically as it impacts minors. Key provisions of the legislation require states to treat minors who engage in a commercial sex act as a victim. It discourages the prosecution of victims for the crime of prostitution by creating “safe harbor” laws that would apply to minors. In addition it encourages the diversion of victims to child protection services and directs the U.S. Justice Department to develop a national strategy.

The discussion after the Senator’s remarks returned to a familiar theme heard many times in Washington, D.C. in the past two years. That discussion focused on the child welfare system with foster care receiving the primary blame for domestic sexual exploitation (a large part of trafficking involves international victims). At one point panelist Malika Sada Saar indicated that 80 to 90 percent of the children who are victims of sexual trafficking come from foster care and that “foster care is the supply chain for sexual trafficking victims.” Claims similar to this have been retold countless times in numerous briefings and discussions in Washington, D.C. The narrative portrays a child welfare system that takes children into care and turns them into victims of sexual trafficking. But is this really an actuate portrayal?


So, what do we know?

First, the statistics often cited in support of the child welfare-only explanation:

  • Of 88 child victims of sex trafficking in the state of Connecticut, 86 were “child welfare involved.”
  • In 2012, 56 of 72 commercially sexually exploited girls in an Los Angeles-based court program were “child-welfare involved.” Fifty-eight percent of these 72 kids were in foster care.
  • In 2007, New York City identified 2,250 child victims of trafficking. Seventy-five percent of those experienced “some contact with the child welfare system,” mostly in the context of abuse and neglect proceedings.
  • In Alameda County, CA, 41 percent of 267 victims in 2011-2012 were kids in foster care.

But there is additional information and research that paints a broader picture of this complex problem—a problem that started to get more national attention only as recently as 2000 with the passage of the Trafficking Victims Protection Act (TVPA, P.L. 106-386). The emphasis of the child welfare-only explanation ignores the population of homeless and runaway youth who are not necessarily the same children in foster care—currently the foster care population is just under 400,000 children with 254,000 entering foster care and 241,000 exiting care in 2012. According to HHS data,

  • Every day, approximately 1.3 million runaway, throwaway, and homeless youth live on the streets of America.
  • Children, both boys and girls, are solicited for sex, on average, within 72 hours of being on the street.
  • Approximately 55 percent of street girls engage in formal prostitution; 75 percent of those work for a pimp. About one in five of these children becomes entangled in nationally organized crime networks and is forced to travel far from home and isolated from friends and family.
  • A girl will first become a victim of prostitution between the ages of 12 and 14, on average.

The child welfare-only explanation also ignores other factors that influence victimization, especially children who have been victims of sexual abuse. A 1994 National Institute of Justice report states that, “minors who were sexually abused were 28 times more likely to be arrested for prostitution at some point in their lives than minors who were not sexually abused.” It is often assumed that all children who are victims of sexual abuse are part of the child welfare system, but they are not. Typically less than ten percent of the approximate 700,000 children substantiated for child maltreatment annually are substantiated for reasons of sexual abuse (as opposed to physical abuse or neglect).

The Urban Institute recently released a U.S. Justice Department funded report, “Estimating the Size and Structure of the Underground Commercial Sex Economy in Eight Major US Cities.” The report looked at both the perpetrators (pimps) and the victims.

  • Seventy-eight percent of victims were woman, nearly 20 percent were transgender, and nearly 3 percent were male.
  • In some instances a person may have begun their lives in sexual exploitation as young as 11 and as old as 39. Seventy-eight percent started between the ages of 15 through 27 and 11 percent began before the age of 15.
  • The report indicates that, “Sex workers first started trading sex on the street for a wide variety of reasons, including economic need; homelessness; the encouragement of family members, friends, and acquaintances; a desire for social and emotional acceptance; as a natural continuation of other forms of commercial sex work, such as stripping and dancing and to support substance use. For many, a combination of these reasons served as the impetus to begin trading sex.”

A 2009 U.S. Department of Health and Human Services (HHS) funded literature review, “Human Trafficking into and within the United States: A Review of the Literature,” found the key factors that influence victimization include, age, poverty, sexual abuse, family substance/physical abuse, individual substance abuse, learning disabilities, loss of parent/caregiver, runaway/throwaway, and sexual identity issues. The National Institute of Justice also points to the role of substance abuse, “Multiple studies suggest that girls involved in prostitution are more likely to come from homes where addiction was present. For example, one study of 222 women in Chicago involved in prostitution found 83 percent had grown up in a home where one or both parents were involved in substance abuse. Further, prostituted girls are more likely to have witnessed domestic violence in their home; specifically, girls are likely to have seen their mother beaten by an intimate partner.” Substantive studies also highlight methods of recruitment that include solicitation by boyfriends, friends, and  family members across a range of locations that include the street, juvenile justice facilities, shopping malls, schools, shelters, group homes, and the internet.

One point does seem to be clear from the recent Washington debate, there are few treatment options for victims and there are on-going debates on what that treatment should be, including residential, lock-down, and home-based. During last week’s panel discussion, John Temple from New York City discussed that city’s efforts to address trafficking of girls and boys. He indicated that within New York City, a city of 8.3 million people, there are only “about 20 to 25 beds that were available for treatment” for children victimized by sexual traffickers. There are differences in the number of beds available, but a national survey last year by an Illinois-based group funded by the U.S. Justice Department found 33 residential programs totaling 682 beds. The treatment needed is complex and has to address factors such as trauma bond, underlying issues like substance abuse, trauma from previous sexual abuse and other trauma such as exposure to violence. Ironically the call for more treatment via child welfare comes up against a backdrop of current child welfare reform debates and discussions that are increasing calling for caps, restrictions and limitations on the use of residential care.

The HHS review of literature determined that when it comes to treatment key needs include,

  • Emergency Services:  safety, housing, and food/clothing and
  • Short-term and Long-term Services: legal assistance, intensive case management, medical care, alcohol and substance abuse counseling/treatment, mental health counseling, life skills training, education, job training/employment, and family reunification.

The problem with the current debate.

The problem regarding much of the recent debate that focuses solely on child welfare is that it ignores all of the other sources of sexual exploitation. It suggests a solution can be carried out by simply amending child welfare law and that child welfare can address the problem without any additional funding.

Recent proposals ignore the need to address the front end whereby child maltreatment, including sexual abuse, may plant the seeds for future victimization. These proposals also discount the need to address all youth in care so that none transition to the streets. Proposals that would simply mandate new directives without the resources create a “zero-sum game.” The same child welfare agencies will have to use the same dollars to expand care (and under some proposals expand child welfare services up to age 25). Advocates within the child welfare community know we are not doing enough to serve infants and toddlers, that far too many youth (over 24,000 in 2012) leave foster care not because we found them a family but because they grew too old to stay in care, and that we have over 100,000 children and youth officially listed as waiting to be adopted.

In regard to sexual trafficking the Administration has started to recognize the need for greater effort regarding the domestic side of sexual and human trafficking but from a more comprehensive approach. The proposed FY 2015 budget includes an increase of $8 million to $10 million to expand services for domestic victims of human trafficking. The January FY 2014 appropriations created a small $2 million initiative that will provide competitive grants to pilot projects by state, local, and tribal governments, or non-profit organizations that can work with trafficking victims or work with at-risk populations including runaway or homeless youth or those who have experienced intimate partner violence, sexual abuse, or other forms of maltreatment. The proposed focus will include intensive case management services to facilitate follow-up care, such as access to mental and behavioral health services, and information and referral to public benefits and other services. Grantees will be expected to coordinate services between entities that encounter trafficking victims including police, hospitals, culturally specific community based organizations, sexual violence organizations, community mental health agencies, and immigrant service providers. Demonstrations will target areas with high rates of domestic trafficking.

The Urban Institute study discussed strategies: “Cities and counties should address sex trafficking as a complex problem that requires a system wide response, and schools, law enforcement, and social service agencies must work collaboratively to combat sex trafficking in their communities. Prevention campaigns must ensure that both boys and girls are educated about the role of force, fraud, coercion, and exploitation in sex trafficking. Public schools should implement awareness campaigns. Local law enforcement should present in schools and share stories related to real cases, as well as encourage student outreach and reporting to law enforcement officials. Increasing the awareness of school officials will also help them identify at-risk or involved youth. Cross-training of local school officials and teachers and awareness raising within the schools will encourage the active involvement of school authorities in detecting possible cases of sex trafficking.”

What is needed in dealing with sexual exploitation is a comprehensive strategy whereby child welfare plays a role. What is needed in child welfare are improvements and resources that make sure all victims of abuse are treated, all children find permanent families, and no young person ages out without a family and a future. Child welfare has to be a part of any comprehensive solution to domestic sex trafficking, but the suggestion that it is the solution (and the blame) is at best off the mark. At worse, it is potentially harmful to children and youth who are in care as the last best hope when other systems—public, private and familial—have failed.

“Doc Fix” Includes Home Visiting & Demo’s On Therapeutic Foster Care

On Monday, March 31 the Senate followed up House action from the week before and approved the Medicare “doc-fix.” As a result they also gave approval to extend the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program into 2015. The Senate vote on the measure (H.R. 4302) was 64 to 35 and it became P.L. 113-93 when the President signed it on Tuesday. It extends the home visiting program for half the fiscal year through the end of next March but provides a full year of $400 million in mandatory dollars. After passage, the House held a hearing on Home Visiting that is reported below.

The “doc fix” extension legislation also includes the bipartisan “Excellence in Mental Health Act,” which authorizes the creation of a 2-year pilot program to be awarded to 8 states that compete to create federally certified Community Behavioral Health Centers. The provision designates $900 million in the expansion of services to various populations in need of mental health services and establishes new standards for providers. One of those provider groups identified in the legislation are agencies licensed by the state to deliver therapeutic (or treatment) foster care (TFC). For the first time ever, TFC is defined under Medicaid (Social Security Act, Sec. 1905) as a reimbursable service provided by state licensed child placing agencies which are accredited by nationally recognized accrediting bodies.

The Foster Family-based Treatment Association (FFTA) has been working hard to strengthen the definition and the use of treatment foster care within Medicaid for several years. Traditional foster care and treatment foster care are distinct program models intended to serve different child populations. Children are referred to TFC programs to address serious levels of emotional, behavioral and medical problems. Treatment foster care is active and structured, and occurs in the foster family home. What people view as “traditional” foster care provides nurturing, safe, and custodial care for children who require placement outside of their family. The primary reason for placement in traditional foster care is the need for care and protection. The role of the foster parent is that of caregiver and nurturer. Treatment, if any, occurs outside of the foster home. Therapeutic care combines the treatment technologies typically associated with more restrictive settings and the nurturing, individualized family environment with foster parents who receive special training.


A day after the “doc fix” extension became law, the House Ways and Means Subcommittee on Human Resources held a hearing on MIECHV. The Chair of the Subcommittee, Congressman Dave Reichert (R-WA) opened the hearing with a statement that said in part, “Our purpose today is to review what we know about the effects of this program, so we can begin thinking about next steps…we need to review whether the actual outcomes of this program are living up to its promise in terms of producing better outcomes for children and families. We also need to think about whether the program’s mix of supporting proven and promising approaches continues to makes sense. And we should consider whether this program should continue to have 100 percent federal funding, especially since some of the positive outcomes we hope to see will benefit our state partners.”

Witnesses included Crystal Towne, Nurse-Family Partnership; Sherene Sucilla, Former Nurse Family Partnership (NFP) program participant; Darcy Lowell, Child First; Jon Baron, Coalition for Evidence-Based Policy; and Rebecca Kilburn, RAND Corporation.

Crystal Towne described the NFP model explaining that it has served over 190,000 families and currently has over 28,000 first-time families enrolled in 43 states. She said that for every 100,000 families served research demonstrates that,

  • 14,000 fewer children will be hospitalized for injuries in their first two years of life;
  • 300 fewer infants will die in their first year of life;
  • 11,000 fewer children will develop language delays by age two;
  • 23,000 fewer children will suffer child abuse and neglect in their first 15 years of life; and
  • 22,000 fewer children will be arrested and enter the criminal justice system through their first 15 years of life.

Jon Barton offered a strong endorsement for reauthorization summarizing:

  • “MIECHV represents an important, bipartisan departure from the usual approach to social spending: it uses scientific evidence of effectiveness as a main factor in determining which activities to fund.
  • This evidence-based design is important because there is great variation in the effectiveness of different home visiting program activities (“models”). Rigorous studies have identified several models that produce major improvements in the lives of children and mothers – such as 20-50% reductions in child maltreatment – as well as a larger number of models that produce no meaningful effects.
  • MIECHV’s evidence-based design has succeeded, in part, in focusing funds on the subset of effective models; and, with a few modest revisions, it could do even better.”

To read all the testimony, go the Human Resources website. Organizations can still submit testimony for the record to the subcommittee by April 16. Directions for public submissions for the record can be found here.