Attributes of Effective Services for Young Children: A Brief Survey of Current Knowledge and Its Implications for Program and Policy Development

Lisbeth B. Schorr

School of Medicine, Harvard University

with

Deborah Both

National Research Council

The purpose of this paper is to set the stage for consideration of strategies to improve services for young children by the workshop participants. It focuses on what is known about the attributes of services that seem to be effective in changing outcomes for children who have been least well served in the past, in the belief that effective policies and strategies must accurately reflect what is known about what works at the level of the local program, where the service or support meets the client/participant/pupil/patient/family.

The first section describes briefly where the services, programs, and interventions under consideration fit within antipoverty policy and the broader range of social policies for children and families. The second section addresses the question of how one can make reasonable judgments about whether programs are successful and about the program attributes that seem to be essential. The third section describes a set of attributes that seem to characterize effective programs. The final section is an attempt to tease out some of the implications of current findings about the attributes of effective programs, perhaps the most important of which is that the development, spread, and successful operation of effective programs requires changes in the systems within which programs are funded, held accountable, evaluated, and within which they recruit and retain personnel.

THE POLICY CONTEXT

The services, programs, and interventions that are the focus of this paper are a subset of the broader range of antipoverty policies and other social policies needed to improve outcomes for children and families in the United



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Effective Services for Young Children: Report of a Workshop Attributes of Effective Services for Young Children: A Brief Survey of Current Knowledge and Its Implications for Program and Policy Development Lisbeth B. Schorr School of Medicine, Harvard University with Deborah Both National Research Council The purpose of this paper is to set the stage for consideration of strategies to improve services for young children by the workshop participants. It focuses on what is known about the attributes of services that seem to be effective in changing outcomes for children who have been least well served in the past, in the belief that effective policies and strategies must accurately reflect what is known about what works at the level of the local program, where the service or support meets the client/participant/pupil/patient/family. The first section describes briefly where the services, programs, and interventions under consideration fit within antipoverty policy and the broader range of social policies for children and families. The second section addresses the question of how one can make reasonable judgments about whether programs are successful and about the program attributes that seem to be essential. The third section describes a set of attributes that seem to characterize effective programs. The final section is an attempt to tease out some of the implications of current findings about the attributes of effective programs, perhaps the most important of which is that the development, spread, and successful operation of effective programs requires changes in the systems within which programs are funded, held accountable, evaluated, and within which they recruit and retain personnel. THE POLICY CONTEXT The services, programs, and interventions that are the focus of this paper are a subset of the broader range of antipoverty policies and other social policies needed to improve outcomes for children and families in the United

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Effective Services for Young Children: Report of a Workshop States today. Among the concerns that have prompted increasing public anxiety, and that seem to have stimulated interest in communities throughout the country to take action to improve the conditions of children and families, are the following: High rates of childhood poverty. High rates of single-parent families, school-age childbearing, and welfare dependency. High rates of school dropout and school failure. Lack of skilled, motivated workers to keep the U.S. economy productive and competitive. High rates of drug and alcohol abuse and family disintegration; children growing up abused, neglected, unsupervised, and ill prepared to benefit from schooling. High rates of violence; high social costs of rising rates of imprisonment and violent crime. An increasingly polarized society, a growing gap between the haves and have-nots, the existence of populations that may remain permanently and intergenerationally outside the mainstream of U.S. society. All of these problems are interrelated. Effective responses to any of these problems can be expected to ameliorate each of them. However, effective remedies are not entirely interchangeable. Most notably, income poverty, the category of disadvantage which affects the largest number of children and families in the United States,1 will respond to economic solutions, whereas other forms of disadvantage will not respond to economic solutions alone.2 Somewhere between one-fifth and one-third of poor children, who have 1    See Bane and Ellwood (1989); National Center for Children in Poverty (1990); Danziger and Stern (1990). 2    Studies of youth employment have found that "improvements in the national economy will not solve the chronic and concentrated unemployment among a subgroup of the youth population. . . . Whatever happens to the economy overall, a significant number of youth (especially poor and minority youth) cannot find or remain in jobs and are likely to experience chronic joblessness as adults" (Hahn and Lerman, 1985). In its section on "The Truly Disadvantaged," the W.T. Grant Foundation Commission on Work, Family, and Citizenship (1988) concluded that those most likely to suffer from persistent poverty and an "ominous future" were single mothers and chronically nonemployed young men. The commission recommended that identifying and removing the antecedent risk factors was society's "most cost efficient chance of reducing the stacked odds" for these young people and recommended toward this end "comprehensive, flexible, and coordinated services beginning early in life including family planning, prenatal health care, preparent training, continuing parent counseling and support, nutritional services, child care, early childhood education, and health education."

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Effective Services for Young Children: Report of a Workshop been called the truly disadvantaged, are unlikely to be lifted out of poverty by a rising economic tide or to be helped significantly by income policies alone (such as an expanded Earned Income Tax Credit, a higher minimum wage, or stronger child support programs). These children must be helped to escape poverty through a range of interventions, some of which would raise the current incomes of the families in which they live, and some of which would raise in other ways their chances of school success, of productive, well-paid employment, and of being able to create stable families of their own. Although the families in which these children live are found in both urban and rural areas, they are becoming increasingly concentrated in innercity neighborhoods characterized by high rates of single-parent families, school dropout, early unmarried childbearing, long-term welfare dependency, unemployment, violent crime, social isolation, and inadequate schools and services (Wilson, 1987). Improved health, education, and social services would raise the chances of a productive life for all children, particularly for all poor children. For the most disadvantaged children, improved services are essential to buffer them from the most serious consequences of their accumulated risks. Even expanded economic opportunities may remain beyond the reach of young people whose health has been neglected, whose early lives have left them without hope, and whose education has failed to equip them with essential skills. In neighborhoods where persistent poverty and social dislocation are concentrated, the absence of good services and schooling have actually become additional risk factors for this generation as well as the next. The institutions and services now in place have not interrupted the downward spiral for these children or ameliorated the consequences of their poverty, because needed services are typically inaccessible, of poor quality, or simply do not exist. Available services are often the wrong ones, too cumbersome to reach, too fragmented, too late, too meager, or too narrow in scope. With a few noteworthy exceptions, the children who, along with their families, need the attention of the most skilled, experienced, and wise professionals, the best organized and best funded institutions and agencies, and the most comprehensive services, are dependent on doctors, clinics, social agencies, child care, and schools that are tragically overwhelmed, and offer the worst and the least. The absence of good services has contributed to the perpetuation of the intergenerational effects of disadvantage. The educational and service interventions that could raise the odds that youngsters will succeed at school and be equipped with the skills they need to become productively employed at jobs that could support a family—which would in turn increase their chances of avoiding too early parenthood and of being able to form stable

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Effective Services for Young Children: Report of a Workshop families (Danziger and Stern, 1990; Furstenberg et al., 1987; McLanahan, 1988; Plotnick, 1987)—are typically missing. We now have it within our power to interrupt this cycle. A persuasive body of research and experience shows that the knowledge exists on which to build the interventions that will significantly improve outcomes among children and youth at risk, including the children who are truly disadvantaged. THE BURDEN OF PROOF: WHAT IS THE NATURE OF THE EVIDENCE THAT WE SHOULD CONSIDER PERSUASIVE? More than 20 years ago, when social policy was formulated in an atmosphere of boundless optimism, the combination of a little theoretical research, fragments of experience, and a lot of faith and dedication were enough to justify a new social program. Today budget deficits, fears of wasting money and perpetuating dependency, ambivalence about helping the poor, and a gloomy sense of social problems beyond solution have combined to reinforce demands for tangible evidence of effectiveness as a condition for support of any social program. Several obstacles complicate the search for such evidence. The attempt to achieve the quantitative precision of research in the biological and physical sciences has interfered with meaningful evaluation of many kinds of human services. The pursuit of quantitative elegance has been particularly destructive in the evaluation of programs for the disadvantaged, because the very elements that make these programs effective among disadvantaged populations pose the greatest hurdles to the evaluator. Programs offering a broad array of individualized interventions, which may be most powerful in their interaction and which have multiple outcome objectives, may be anathema to the evaluator faced with the task of designing a manageable and precise evaluation plan. Often the scope of the inquiry becomes unduly narrow—many evaluation efforts attempt to identify a single effective ingredient in an immensely complex and interactive system. They tend to measure what can readily be measured and may miss the effect of the intervention on more crucial outcomes. For example, the first evaluation of Head Start measured only IQ changes, despite the fact that the purposes of the program included increasing social competence, parent involvement, and improved access to health, nutrition, and social services. In the interests of achieving clear evaluation results, the ability of successful programs to respond to the particular needs and desires of a given community or client population is often diminished by pressures to implement interventions that are uniform across sites or to incorporate centrally designed program elements. Other important elements of successful programs (such as that services

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Effective Services for Young Children: Report of a Workshop are provided respectfully and ungrudgingly, in an atmosphere that is supportive and caring) are hard to standardize, measure, and document or even to describe in words that mean the same thing to different persons. Because of the difficulty in measuring significant outcomes, many evaluation efforts limit themselves to measuring or describing processes (Do participants attend, do they express satisfaction with the program, do providers express satisfaction with the program?) These process indicators, or interim outcome measures, can be extremely useful in both policy development and program management—especially when research has provided relevant information that reliably links process indicators and outcome measures. Without such information, however, process measures are unlikely to be persuasive to skeptical policy makers. The combination of these obstacles is formidable, but they need not be paralyzing. In making judgments about what works, the human services field could use some of the insights coming out of the management literature, which suggest that American business has often been handicapped by its practices of considering as facts only the data one can put numbers on; assuming that a truly rational analysis bypasses "all the messy human stuff"; and achieving precision by so reducing the scope of what is analyzed that the most important questions are ignored (Peters and Waterman, 1982). Approaches that combine relevant quantitative data with other kinds of information from theory, research, and experience across domains should make it possible to make rigorous and informed judgments about what has worked in the past and what is likely to work in the future, even among complex, multifaceted, and interactive interventions. There is little argument that the pressures of politics and the needs for immediate action on urgent social problems force policy and program people to draw conclusions from less rigorous information than they, or the researchers they rely on, might wish for. The disagreement comes around the question of how rigorous the methodology must be, about how precise a quantification of both inputs and outcomes is required, to assure those relying on the findings that they are not being misled. The approach taken in this paper combines information from theory, research, and experience from such different domains as preschool, primary, and secondary education; health care; child care; social services; family support; and job training. It combines informed judgments with a synthesis of quantitative data to the extent they are available and seems to reflect program operations and outcomes sensibly and accurately. One can think of this as a meta-analytic approach that includes but is not confined to quantitative data. Table 1 displays some of the available quantitative data on effectiveness from the domains of family planning, prenatal care, preschool education, and family support. By moving beyond isolated assessments of program effectiveness and

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Effective Services for Young Children: Report of a Workshop TABLE 1 Quantitative Effects of Selected Interventions Intervention Sponsor Outcome   School-based health clinic St. Paul, Minnesota. 1973-present. St. Paul-Ramsey Co. Medical Center Childbearing among female students in first two participating high schools decreased by more than 50% within three years. (Edwards et al., 1977, 1980)   School-related health clinic serving junior and senior high school with all black, low-income student bodies, totaling over 1,700 students. Baltimore, Maryland. 1982-1984. Johns Hopkins University School of Medicine Among 695 female respondents (of whom about 3/4 were sexually active), the proportion of sexually active 9th-12th grade girls who became pregnant declined by 25%; rate in comparison school went up 58% in same period. (Zabin et al., 1986)   Comprehensive prenatal care for 744 school-age pregnant girls, mostly black and single, all poor. Baltimore, Maryland. 1979-1981. Johns Hopkins University School of Medicine Low birth weight (<2,500 gm) rate       among participants: 9.9%*     among comparison group: 16.4%     Very low birth weight (<1,500 gm) rate       among participants: 1.9%     among comparison group: 3.9%     (Hardy, 1981)   Comprehensive prenatal care for 7,000 low-income women in 13 California counties. 1979-1982. California State Department of Health Low birth weight (<2,500 gm) rate       among participants: 4.7%*     among comparison group: 7.0%     Very low birth weight (<1,500 gm) rate       among participants: 0.5%     among comparison group: 1.3%     (Korenbrot, 1984)   Homevisiting to 305 pregnant teenagers by lay ''Resource Mothers'' in rural South Carolina. 1981-1983. South Carolina State Health Department Low birth weight (<2,500 gm) rate       among participants: 10.0%*     among comparison group: 13.0%       Very low birth weight (<1,500 gm) rate       among participants: 1.0%     among comparison group: 4.5%     (Unger and Wandersman, 1985)  

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Effective Services for Young Children: Report of a Workshop Intervention Sponsor Outcome   Nurse visiting of high-risk mothers during pregnancy and for 2 years after birth (Participants and controls selected by random assignment). Elmira, New York. 1978-1983. University of Rochester Medical School Among poor, unmarried women:       Returned or completed school, 10 months after giving birth:       participants: 75%     controls: 50% (Comparisons are with randomly assigned controls.)   Subsequent pregnancies 4 years after first birth:       One-half as many among participants as among controls.       Abuse or neglect among children:       participants: 4%     controls: 19%     Among 14-16 year olds: participants had babies weighing an average of one pound more than controls.       Among mothers who smoked:       Premature births: 2%     participants: 10%     controls:       (Olds et al., 1986)   Comprehensive health, child care and social services for 18 infants aged 0-21/2 and their families. New Haven, Connecticut. 1968-1972. Yale University Child Study Center At 10-year follow up: Average years of education completed by mother:       participants: 13.0     comparison: 11.7     Average number of children in family:       participants: 1.67     comparison: 2.2     Proportion of families self-supporting:       participants: 86%     comparison: 53%     Children with serious school problems:       participants: 28%     comparison: 69%     (Seitz et al., 1985)  

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Effective Services for Young Children: Report of a Workshop Intervention Sponsor Outcome     Intensive in-home crisis and family-preservation services. Tacoma and Seattle, Washington. 1974 to present (evaluation, 1983-1985) Catholic Children's Services and Homebuilders In 88% of families in which removal of child was imminent when intervention began, family was intact and child had not been removed one year later. (Kinney et al., 1977; E.M. Clark Foundation, 1985)      Preschool education and weekly home visits over The Perry Preschool Program High/Scope Of 121 responding at age 19: Partic. Control two-year period for 3-and   Employed 59% 32% 4-year-old randomly assigned   H.S. Grad 67% 49% poor black children. Ypsilanti,   Post H.S. Ed. 38% 21% Michigan. 1962-present   Arrested 31% 51% (evaluation of 1962-1964 participants).   Of 112 responding:         Years in spec. ed. 16% 28%     Among 49 females:         T.A. Preg. 32% 59%     (Berrueta-Clement et al., 1984)   Summer preschool education and weekly home visits during remainder of year, for black 3-5-year olds and their mothers. Murfreesboro, Tennessee. 1962-1965. The Early Training Project Peabody Teachers College At age 21, one-third more dropouts in comparison group than among participants; control children placed in special education classes at six times the rate of participating children. (Gray, et al., 1983; Lazar et al., 1982)      Changing elementary school climate through applying principles of child development and basic management; new relationships among principal, teachers, parents. New Haven, Connecticut. 1968-present. Yale University Child Study Center At outset, intervention schools ranked 32nd and 33rd of 33 New Haven elementary schools in reading, math, attendance, and behavior. 15 years later, with no change in SES of students, demonstration schools ranked 3rd and 5th in test scores, had no serious behavior problems. One had best attendance record in city 4 of previous 5 years. (Comer, 1985, 1988)    

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Effective Services for Young Children: Report of a Workshop Intervention Sponsor Outcome Intensive intervention with 1,000 low birth-weight infants in 8 cities, including comprehensive pediatric care, weekly (first year) or biweekly (thereafter) home visits, parent meetings, and care in a special child development center. 1985-1988. Robert Wood Johnson Foundation At age 3, participants had IQ scores that averaged 13.2 points higher (heavier babies) and 6.6 points higher (smaller babies) than randomly matched controls; their mothers reported significantly few behavior problems than did mothers of the controls. (Infant Health and Development Program, 1990) Early intervention programs using home visitors with available outcome data in Texas, South Carolina, and Illinois were visited and reviewed by GAO. Review completed in 1990. General Accounting Office Results included improvement in mental and physical development, health, parent-child interaction, and home environment (CEDEN, TX); fewer low birthweight babies and increased use of prenatal care (Resource Mothers, SC); fewer low birthweight babies (Parents Too Soon and Ounce of Prevention, IL). (U.S. GAO, 1990) * The Institute of Medicine calculates that $3.50 is saved in medical costs during the first year of life for every dollar spent on reducing the low birth rate by two-and-a-half percentage points, an achievement substantially exceeded by all three prenatal care programs described here (Institute of Medicine, 1985). applying judgment and intelligence to understanding the relationships among diverse findings, it is possible to identify programs that work and to search out the elements that seem to account for their effectiveness. ATTRIBUTES OF EFFECTIVE SERVICES Successful programs vary in many particulars, depending on their domain and auspices and in response to the needs of the populations they serve. But they seem consistently to share a number of common attributes. Schorr (1988) described the operation of some 17 programs in the fields of family planning, prenatal care, child health, child welfare/family support, child care and preschool education, and elementary school education that

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Effective Services for Young Children: Report of a Workshop had shown evidence of reducing rates of damaging outcomes in adolescence or their antecedent risk factors among disadvantaged children. These programs were examined for the factors that seemed to account for program effectiveness, and a number of common attributes were identified. It now seems timely to revisit the conclusions drawn almost three years ago and to refine and expand them in the light of subsequent findings from the same and other domains. To arrive at an updated set of essential attributes of effective programs, I have reviewed my own earlier findings, as well as the findings of others who have reviewed successful programs for young children in health, child care, preschool and elementary education, mental health, and social services. I have also incorporated findings from studies of effective schools, job training programs, programs for teenage mothers, and other interventions aimed primarily at adolescents and young adults, to the extent that they shed light on overarching characteristics of effective services. (I have made no attempt to include findings particular to only a single domain—e.g., staff/child ratios in preschool programs.) The appendix lists the sources on which the following set of attributes are based. There is evidence of a growing consensus—especially among practitioners—that the following points constitute the major essential attributes of effective programs for disadvantaged children and families. Although there may be some disagreement around the details of the individual attributes, when they are seen in their totality, a clear picture of policy and program implications emerges. Successful programs are comprehensive, flexible, and responsive. They take responsibility for providing easy and coherent access to services that are sufficiently extensive and intensive to meet the major needs of those they work with. They overcome fragmentation through staff versatility, flexibility, and by active collaboration across bureaucratic and professional boundaries. In the interests of providing continuity and a rich, comprehensive mix of services, these programs put previously disparate services together and add missing pieces by breaking down or crossing traditional barriers in ingenious and innovative ways. In responding to a wide range of needs, these programs do not, in fact, provide everything to everyone, but all offer more than a single category of service or support. The effective prenatal care program may not itself provide housing assistance or drug treatment, but neither does it ignore the impending eviction or the sudden revelation of a drug problem by one of its patients. A Homebuilders therapist may help an overwhelmed mother to clean her kitchen, or the elementary school principal may add a washing machine to her office equipment. It is the unrigid, responsive stance of individual staff and of the program or institution as a whole that is characteristic, the fact that no one says,

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Effective Services for Young Children: Report of a Workshop "This may be what you need, but helping you get it is not part of my job or outside our jurisdiction" (Schorr, 1988). While always keeping their primary mission in mind, staff seem to be forever willing to "push the boundaries of their job description" (Bane, 1990) or to take on an "extended role" in the lives of their students (or patients or clients) (Whelage, 1989). They seem not to give up even when progress is slow or unsteady. Successful programs deal with the child as an individual and as part of a family and with the family as part of a neighborhood and community. Most successful programs have deep roots in the community and respond to needs perceived and identified by the community. They collaborate with parents and local communities to create programs and institutions that respond to unique needs of many different kinds of populations. Successful programs are not imposed from without, they are not "parachuted" into communities but are carefully and collaboratively integrated with local community needs, resources, and strengths (Council of State Policy and Planning Agencies, 1990). They tend to be explicit about taking a developmental approach, recognizing the stages of the family life-cycle and of child development. Most take a two-generational approach, responding simultaneously to the needs of children and their families. In the Comer schools in New Haven, as well as in many Head Start programs, parents become long-term supporters of their children's education as their own needs are recognized and met. Successful programs respond to the immediate needs of an individual child, but they do not stop there. The clinician treating an infant for recurrent diarrhea sees beyond the patient on the examining table to whether the family needs a source of clean water or help from a public health nurse or social worker to obtain nonmedical services. Staff in successful programs have the time, training, skills, and institutional support necessary to create an accepting environment and to build relationships of trust and respect with children and families. They work in settings that allow them to develop meaningful one-to-one relationships and to provide services respectfully, ungrudgingly, and collaboratively. Staff of these programs tend to be well-qualified, highly motivated, and to possess relevant life experience. The "centrality of human relationships" (Lightfoot, 1989) and the creation of "a warm, supportive environment" (Weiss, 1988) is repeatedly stressed when program staff are asked to reflect on program effectiveness, as is the need to draw disadvantaged populations into "a sense of membership in the community" (Whelage, 1989) by reducing the size of the institution and emphasizing intensive, personal, caring, face-to-face relationships with responsible adults in many varied settings. Front-line workers in these programs are provided with the same respect, nurturing, and support by program managers that they are expected to extend to those they serve (Bruner, 1990).

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Effective Services for Young Children: Report of a Workshop government bureaucracies. Harvard political scientist Steven Kelman writes of this effort in a somewhat broader context as involving the essential "renewal of the public sector" (Kelman, 1990). Nothing less is implied by current findings regarding the attributes of effective programs. The design of strategies aimed at the wider implementation of effective programs for disadvantaged children and their families must take account, therefore, of the following seven propositions: 1. If effective services are to reach far larger numbers, information about the essential common attributes of successful programs must be widely disseminated and accompanied by information about strategies to overcome the major impediments to implementing programs with these attributes. We have operated too long on the assumption that program success alone will guarantee long-term survival and growth. In the absence of supportive and responsive systems, successful programs do not contain the seeds of their own replication because they do not create systems change. Even the dissemination of information about successful models does not result in their replication in the absence of systems change. Local communities have to own and shape local programs, but local communities can't change state and federal regulations or funding incentives; nor can they protect their innovations from bureaucratic pressures that stifle the unusual. Strategies based on the creation and dissemination of models are less likely to succeed than strategies that combine identifying and disseminating the essential common attributes of successful programs with identifying and reducing the major impediments to implementing effective programs. These impediments include prevailing methods of financing and regulating programs, of holding programs accountable, and of training professionals; policies governing eligibility and targeting; lack of widespread availability of appropriate technical assistance and of continuing information about promising new approaches to encouraging needed systems change; and lack of public understanding of the key issues. 2. New funding mechanisms must be developed for targeting resources to geographic areas in which poverty and other risk factors are concentrated. Successful programs seem to have been able to attract high-risk populations to utilize a range of services, including preventive services, without basing eligibility on proof of individual failure or on identification of individual handicaps. The absence of high-quality services in these areas, despite their desperate need, suggests the utility of targeting resources on distressed neighborhoods, with eligibility based on residence in the area. One way this could be accomplished is by combining a certain proportion of current expenditures into a flexible funding stream that would support a coherent array of intensive services in these areas. Through the use

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Effective Services for Young Children: Report of a Workshop of automatic waivers and other regulatory or legislative changes, funds from maternal and child health programs, compensatory education, family support, child care, mental health and social services would become a predictable source of support to comprehensive programs targeted on a high-risk population that would be defined geographically. Neighborhood targeting would minimize barriers of access, reduce fragmentation, and impact the powerful neighborhood-level determinants of child and family well-being. An initiative aimed at modifying public funding practices in this way could be modest in scale without being trivial. It would begin to change lives among the populations at highest risk; simultaneously, such a strategy would generate information about how to grapple with a broad range of systems issues. It would give expression to a public policy that would get away from making eligibility for services contingent on individual proof of failure, but would recognize that whole communities may be so depleted that a critical mass of new sources of opportunity and support will be required if ordinary youngsters are to succeed in climbing out of poverty and despair. Where systems have failed whole communities in the past, change probably must achieve a visible, critical mass to have a significant impact and to inspire confidence in both clients and program staff that this time change is real and here to stay. A neighborhood focus would make it possible to achieve such a critical mass with substantially less money than would be required by programs that would also extend to less needy populations. 3. Systematic efforts are needed to bring about a major shift toward the use of outcome measurement to ensure accountability in social programs. It is unlikely that the programs that are essential to changing outcomes for disadvantaged youngsters will receive adequate funds under more flexible conditions in the absence of their ability to document their effectiveness in improved real-world outcomes. An enhanced capacity to measure outcomes would move the discussion about both policies and programs to a focus on changes in the lives of people. By shifting accountability from a reliance on rigid rules and on documenting processes to a reliance on substantive results, human service programs could more easily adopt the attributes of effective programs (see Kelman, 1987, 1990; Hornbeck, in this volume; Gardner, 1989). It will require a great deal of sustained and thoughtful work to develop the critical outcome indicators that would allow informed judgments of whether a program is in fact accomplishing its intended purpose. Outcome measures must be designed carefully, so they will not become instruments of program corruption or distortion. But it seems more consistent with what we have learned about successful programs to engage in this struggle, than to continue past practices that put a premium on blind adherence to rules at the expense of accomplishing the program's purposes. A shift toward reliance on outcome measures would encourage ''the wise exercise of discre-

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Effective Services for Young Children: Report of a Workshop tion, judgment, and creativity to achieve agreed upon ends'' (Kelman, 1990) that characterizes effective programs. 4. New training mechanisms must be developed, and existing training mechanisms must be modified to enable more individuals to function as competent front-line workers or managers in effective programs. As we have seen, front-line workers as well as program managers in successful programs exhibit skills and attitudes that do not seem to be the products of conventional professional training. Obviously their ability to build trusting, collaborative relationships, to work flexibly and to cross disciplinary and professional boundaries, to exercise front-line discretion and to address a complex interplay of problems, as well as the ability of managers to utilize distinctive skills—all these are not solely the product of training. But the creation of new training capacity would increase the numbers of skilled individuals that could function inorganizations that incorporate and create these expectations and who could comfortably adopt an expanded definition of what it means to act like a professional. The availability of high-quality professional training could also help to make work in effective programs attractive to a new pool of talented, eager, and committed individuals. 5. States, communities, and local agencies will need competent technical assistance, both in program development and in their efforts to change policies and practices to better reflect the lessons of successful programs. Organizations that seek to improve outcomes for disadvantaged children need more than information about successful programs to put such programs in place. Many communities may recognize the need for change but don't know how to get started on making change happen. States that expect to reform their policies and practices to create more supportive settings for effective programs will need highly skilled, knowledgeable, and individualized technical assistance. 6. Continuing efforts are needed to build the magnitude of public understanding that will support needed action. The needed political support necessary to attack today's most urgent domestic problems is unlikely to materialize unless the following concepts become part of the general understanding of a majority of Americans. The most serious problems of disadvantaged children, youth, and families are inextricably bound up with structural changes in the American society and economy that are far more powerful than the changes that can be made by individuals and families through their own talents and efforts. Society's stake in investing in promising solutions is so great that continuing failure to undertake promising or proven programs of intervention and support will be destructive of the national interest. The elements of many promising solutions are now reasonably well

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Effective Services for Young Children: Report of a Workshop known, and the widespread implementation of effective interventions requires fundamental systems changes. Effective interventions are a cost-effective investment even when they require substantial initial funding. There are no quick, cheap fixes. A long-term view is essential, for the impact of effective services or their absence must be seen intergenerationally. The long-term needs of the next generation must not be sacrificed in order to achieve short-term savings in this generation. The results of effective interventions are worth waiting for, even though they can rarely be documented during a single budget cycle or during the term of office of their political champion. 7. The time is ripe for systematic action to promote systems change. Efforts currently under way in many states and communities to improve services to disadvantaged children and their families are hampered by the absence of strategic thinking, clear leadership, and shared relevant information. Exploration of how this need might best be met is now timely. Among the functions that are not now being performed in an integrated fashion, that might usefully be performed by one or more organizations (existing or newly formed for this purpose, are the following: To be a source of reliable and up-to-date information regarding the attributes of effective programs and the attributes of effective or promising systems change. This would entail the capacity to perform continuing assessments of current efforts in program and policy development and implementation, to determine whether there are common patterns that characterize the most promising efforts, and to identify the most successful strategies for overcoming major obstacles and to communicate widely findings regarding both effective and ineffective efforts. In an analog to the Manpower Demonstration and Research Corporation, this function could include the capacity to fund and evaluate a coordinated series of demonstrations of neighborhood-wide or community-wide funding and delivery of comprehensive, effective services. To provide opportunities for joint learning and problem solving around such issues as financing, training, technical assistance, governance, accountability, and evaluation. To encourage and assist in the development and utilization of well-designed outcome measures; to encourage the widespread use of evaluation approaches that take into account the distinctive attributes of interventions that are most likely to be effective among disadvantaged populations. To encourage coordinated action to overcome these barriers to "going-to-scale" that successful programs are least likely to be able to overcome through local action alone. To be a source of leadership in efforts to educate the public on the

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Effective Services for Young Children: Report of a Workshop major issues relevant to bringing about the changes needed to improve services for disadvantaged children and their families. CONCLUSION Policies and programs significantly different from those that prevail are known to improve the odds for children growing up in family and neighborhood environments that do not provide them with the protection, nurturance, and social capital they need to succeed in school and in life. Most local programs operate with a funding base, and in a political, bureaucratic, and professional context that makes it nearly impossible to provide the multifaceted responses that could change outcomes for families with multiple, complex needs. To reach a high proportion of the children at greatest risk with the interventions and supports that will improve their futures requires fundamental transformation of both local programs and the policies that shape them. But the levers of change that have been available until now are not sufficiently connected to one another and are not strong or far-reaching enough to bring about needed changes in the systems within which most programs operate. Much activity and random experimentation is currently under way in local communities and states all around the nation aimed at improving the circumstances of disadvantaged children, but to little discernible long-range effect. The widespread yearning to do better could, however, be transformed into effective action. The deliberations of this workshop provide an extraordinary opportunity to identify the strategies that could arm government officials, business leaders, practitioners, program managers, philanthropists, and concerned citizens with the tools they need to bring about systematic change on a scale that has a reasonable relationship to the magnitude of the need, and therefore a reasonable chance to succeed. REFERENCES Bane, Mary Jo 1990 Paying Attention to Children Services, Settings and Systems. Paper prepared for the Workshop on Effective Services for Young Children, November 1-2, Washington, D.C. Bane, Mary Jo, and David T. Ellwood 1989 One fifth of the nation's children: Why are they poor? Science 245:1047-53. Berrueta-Clement, J.R., L.J. Schweinhart, W.S. Barnett, A.E. Epstein, and D.P. Weikart 1984 Changed Lives: The Effects of the Perry Preschool Programs on Youths Through Age 19. Ypsilanti, Michigan: High/Scope Press. Comer, J.P. 1985 The Yale-New Haven Primary Prevention Project: A follow-up study. Journal of the American Academy of Child Psychiatry 24(2):154-60. 1988 Educating poor minority children. Scientific American 259(5):42-48.

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Effective Services for Young Children: Report of a Workshop Congress of the United States 1988 Healthy Children: Investing in the Future. Office of Technology Assessment. Deutsch, M., C.P. Deutsch, T.J. Jordan, and R. Grallo 1983 The IDS Program: An experiment in early and sustained enrichment. Pp. 377-410 in As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Consortium for Longitudinal Studies. Hillsdale, N.J.: Lawrence Erlbaum Associates. Danziger, Sheldon, and Jonathan Stern 1990 The Causes and Consequences of Child Poverty in the United States. Paper prepared for UNICEF, International Child Development Center, Project on Child Poverty and Deprivation in Industrialized Countries. Edwards, L.E., M.E. Steinman, and E.Y. Hakanson 1977 An experimental comprehensive high school clinic. American Journal of Public Health 8:765-76. Edwards, L.E., M.E. Steinman, K. Arnold, and E.Y. Hakanson 1980 Adolescent pregnancy prevention services in high school clinics. Family Planning Perspectives 12(1):6-14. Edna McConnell Clark Foundation 1985 Keeping Families Together: The Case for Family Preservation. New York: Edna McConnell Clark Foundation. Furstenberg, Frank F., Jr., J. Brooks-Gunn, and S. Philip Morgan 1987 Adolescent Mothers in Later Life. Cambridge: Cambridge University Press. Gardner, Sid 1989 Failure by Fragmentation. California Tomorrow Pp. 18-25. Grant Foundation Commission 1988 The Forgotten Half: Pathways to Success for America's Youth and Young Families. Final Report, Youth and America's Future. Gray, S.W., B.K. Ramsey, and R.A. Klaus 1983 The Early Training Project 1962-1980. Pp. 33-69 in As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Consortium for Longitudinal Studies. Hillsdale, N.J.: Lawrence Erlbaum Associates. Golden, Olivia 1988 Balancing Entrepreneurship, Line Worker Discretion, and Political Accountability: The Delicate Task of Innovators in Human Services. Paper presented to the 1988 Annual Meeting of the Association for Public Policy Analysis and Management, Seattle, Washington, October 27-29. 1989 Innovation in Public Sector Human Service Programs: The Implications of Innovation by 'Groping Along.'" Unpublished paper. Hahn, Andrew, and Robert Lerman 1985 What Works in Youth Employment Policy? Report #3. Washington, D.C.: National Planning Association. Hardy, J. 1981 A comprehensive approach to adolescent pregnancy. In K.G. Scott, T. Field, and E. Robertson, eds., Teenage Parents and Their Offsprings . New York: Grune & Stratton. Harvard Family Research Project 1990 Innovative Models to Guide Family Support and Education Policy in the 1990s: An Analysis of Four Pioneering State Programs. Cambridge: Harvard Graduate School of Education. The Infant Health and Development Program Enhancing the outcomes of low-birth-weight, premature infants: A multisite, randomized trial. Journal of the American Medical Association 263:3035-3042. Institute of Medicine 1985 Preventing Low Birthweight. Committee to Study the Prevention of Low Birthweight,

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Effective Services for Young Children: Report of a Workshop Division of Health Promotion and Disease Prevention. Washington, D.C.: National Academy Press. Kelman, Steven 1987 Making Public Policy: A Hopeful View of American Government. Basic Books, Inc.: New York. 1990 The renewal of the public sector. The American Prospect 51-8. Kinney, J.M., B. Madsen, T. Fleming, and D.A. Haapala 1977 Homebuilders: keeping families together. Journal of Consulting and Clinical Psychology 45(4):667-73. Korenbrot, C.C. 1984 Risk reduction in pregnancies of low income women: comprehensive prenatal care through the OB access project. Mobius 4:34-43. Lazar, I., R.B. Darlington, H. Murray, J. Royce, and A. Snipper 1982 Lasting Effects of Early Education. Monographs of the Society for Research in Child Development. Vol. 47. Lightfood, Sara Lawrence 1989 Visions of a Better Way: A Black Appraisal of Public Schooling. Report of the Committee on Policy for Racial Justice, Joint Center for Political Studies. McLanahan, S. 1988 Family structure and dependency: Early transitions to female household headship. Demography 25(1). Madden, Nancy A., R.E. Slavin, N.L. Karweit, B.J. Livermon, and L. Dolan 1988 Success for All: First-Year Effects of a Comprehensive Plan for Reforming Urban Education. Paper presented at the annual conference of the American Educational Research Association, San Francisco. Center for Research on Elementary and Middle Schools, Johns Hopkins University. National Center for Children in Poverty 1990 Five Million Children: A Statistical Profile of Our Poorest Young Citizens. New York: School of Public Health, Columbia University. Nothdurft, William E. with Barbara Dyer 1990 Out from Under: Policy Lessons from a Quarter Century of Wars on Poverty. Based on field research by Alan Okagaki in cooperation with the Corporation for Enterprise Development. Washington, D.C.: The Council of State Policy and Planning Agencies. Olds, D.L., C.R. Henderson, R. Tatelbaum, and R. Chamberlin 1986 Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77(1):16-28. Peters, Thomas J. and Robert H. Waterman, Jr. 1982 In Search of Excellence. New York: Warner Books. Plotnick, R. 1987 Welfare and Other Determinants of Teenage Out-of-Wedlock Childbearing. Paper presented to Research Conference of the Association for Public Policy Analysis and Management. Schorr, Lisbeth B., with Daniel Schorr 1988 Within Our Reach: Breaking the Cycle of Disadvantage. New York: Doubleday/Anchor Press. Seitz, Y., L.K. Rosenbaum, and N.H. Apfel 1985 Effects of family support intervention: A ten-year follow-up. Child Development 53:376-91. Unger, D.G., and L.P. Wandersman 1985 Social support and adolescent mothers: Action research contributions to theory and application. Journal of Social Issues 41(1):29-45.

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Effective Services for Young Children: Report of a Workshop U.S. General Accounting Office 1990 Home Visiting: A Promising Early Intervention Strategy for At-Risk Families. Report to the Chairman, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Committee on Appropriations, U.S. Senate. Wilson, William Julius 1987 The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy. Chicago: University of Chicago Press. Zabin, L.S., M.B. Hirsch, E.A. Smith, R. Streett, and J.B. Hardy 1986 Evaluation of a pregnancy prevention program for urban teenagers. Family Planning Perspectives 18(3):119-26. APPENDIX Adolescent Pregnancy Prevention Clearinghouse 1989 The Lessons of Multi-Site Initiatives Serving High-Risk Youths. Washington, D.C.: Children's Defense Fund. Berrueta-Clement, J.R., L.J. Schweinhart, W.S. Barnett, A.E. Epstein, and D.P. Weikart 1984 Changed Lives: The Effects of the Perry Preschool Programs on Youths Through Age 19. Ypsilanti, Michigan: High/Scope Press. Burghardt, John, and A. Gordon 1990 More Jobs and Higher Pay: How an Integrated Program Compares with Traditional Programs. New York: Rockefeller Foundation. Charney, E. 1984 Preparing physicians in training for child health care communication. Pp. 203-16 in W.K. Frankenburg and S.M. Thornton, eds., Child Health Care Communications. The Johnson and Johnson Pediatric Round Table VIII. New York: Praeger. Comer, J.P. 1980 School Power. New York: Free Press. 1984 Home-school relationships as they affect the academic success of children. Education and Urban Society 16(3):323-37. 1985 The Yale-New Haven Primary Prevention Project: A follow-up study. Journal of the American Academy of Child Psychiatry 24(2):154-60. 1987 Children in Need: Investment Strategies for the Educationally Disadvantaged. New York: Committee for Economic Development. 1988 Educating poor minority children. Scientific American 259(5):42-48. Consortium for Longitudinal Studies 1983 As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Hillsdale, N.J.: Lawrence Erlbaum Associates. Cuban, L. 1984 Transforming the frog into a prince: Effective schools research, policy and practice at the district level. Harvard Educational Review 54(2):129-51. Deutsch, M., C.P. Deutsch, T.J. Jordan, and R. Grallo 1983 The IDS Program: An experiment in early and sustained enrichment. Pp. 377-410 in Consortium for Longitudinal Studies, As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Hillsdale, N.J.: Lawrence Erlbaum Associates. Dryfoos, Joy G. 1990 Adolescents at Risk. New York: Oxford University Press. Community schools: New institutional arrangements for preventing high-risk behavior. FLEducator 4-9. Edmonds, R. 1979 Effective schools for the urban poor. Educational Leadership 15-27.

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Effective Services for Young Children: Report of a Workshop Edna McConnell Clark Foundation 1985 Keeping Families Together: The Case for Family Preservation. New York: Edna McConnell Clark Foundation. Edwards, L.E., M.E. Steinman, and E.Y. Hakanson 1977 An experimental comprehensive high school clinic. American Journal of Public Health 8:765-76. Edwards, L.E., M.E. Steinman, K. Arnold, and E.Y. Hakanson 1980 Adolescent pregnancy prevention services in high school clinics. Family Planning Perspectives 12(1):6-14. Ford Foundation 1989 Early Childhood Services: A National Challenge. New York: Ford Foundation. Golden, Olivia 1988 Balancing Entrepreneurship, Line Worker Discretion, and Political Accountability: The Delicate Task of Innovators in Human Services. Paper presented to the 1988 Annual Meeting of the Association for Public Policy Analysis and Management, Seattle, Washington, October 27-29. 1989 Innovation in Public Sector Human Service Programs: The Implications of Innovation by "Groping Along." Unpublished paper. Gray, S.W., B.K. Ramsey, and R.A. Klaus 1983 The Early Training Project 1962-1980. Pp. 33-69 in Consortium for Longitudinal Studies, As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Hillsdale, N.J.: Lawrence Erlbaum Associates. Hahn, Andrew, and Robert Lerman 1985 What Works in Youth Employment Policy? Report #3. Washington, D.C.: National Planning Association. Halpern, Robert and Heather Weiss 1989 Family Support and Education Programs. Paper prepared for the Public Policy and Family Support and Education Programs Colloquium, April 26-28. Hardy, J. 1981 A comprehensive approach to adolescent pregnancy. In K.G. Scott, T. Field, and E. Robertson, eds., Tennage Parents and Their Offsprings. New York: Grune & Stratton. Harvard Family Research Project 1990 Innovative Models to Guide Family Support and Education Policy in the 1990s. Unpublished paper. Hershey, Alan 1988 The Minority Female Single Parent Demonstration: Program Operations. A Technical Research Report. New York: The Rockefeller Foundation. Hollister, Robinson, G., Jr. 1990 New Evidence About Effective Training Strategies. New York: The Rockefeller Foundation. Kinney, J.M., B. Madsen, T. Fleming, and D.A. Haapala 1977 Homebuilders: Keeping families together. Journal of Consulting and Clinical Psychology 45(4):667-73. Korenbrot, C.C. 1984 Risk reduction in pregnancies of low income women: Comprehensive prenatal care through the OB access project. Mobius 4:34-43. Lazar, I., R.B. Darlington, H. Murray, J. Royce, and A. Snipper 1982 Lasting Effects of Early Education. Monographs of the Society for Research in Child Development. Vol. 47. Lightfoot, Sara Lawrence 1989 Visions of a Better Way: A Black Appraisal of Public Schooling. Report of the Committee on Policy for Racial Justice, Joint Center for Political Studies.

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Effective Services for Young Children: Report of a Workshop Madden, Nancy A., R.E. Slavin, N.L. Karweit, B.J. Livermon, and L. Dolan 1988 Success for All: First-Year Effects of a Comprehensive Plan for Reforming Urban Education. Paper presented at the annual conference of the American Educational Research Association, San Francisco. Center for Research on Elementary and Middle Schools, Johns Hopkins University. Miller, Jerome 1989 Is rehabilitation a waste of time? The Washington Post (Outlook section), April 23. Ministry of Community and Social Services, Ontario 1989 Better Beginnings, Better Futures: An Integrated Model of Primary Prevention of Emotional and Behavioural Problems. Queen's Printer for Ontario. ISBN0-772-96148-4. Olds, D.L., C.R. Henderson, R. Chamberlin, and R. Tatelbaum 1986 Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics 78:65-78. Olds, D.L., C.R. Henderson, R. Tatelbaum, and R. Chamberlin 1986 Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77(1):16-28. Olds, David L., and Harriet Kitzman 1990 Can home visitation improve the health of women and children at environmental risk? Pediatrics 86(1):108-116. Pierson, D.E., D.K. Walker, and T. Tivnan 1984 A school-based program from infancy to kindergarten for children and their parents. Personnel and Guidance Journal 62(8):448-55. Price, Richard H. 1987 What Do Successful Programs Have in Common? Testimony given to the House Select Committee on Children, Youth and Families, April 28. Task Force on Promotion, Prevention and Intervention Alternatives of the American Psychological Association. Price, Richard H., E.L. Cowen, R.P. Lorion, J. Ramos-McKay 1989 The search for effective prevention programs: What we learned along the way. American Orthopsychiatric Association, Inc. 59(1):49-58. Provence, S., and A. Naylor 1983 Working with Disadvantaged Parents and Their Children. New Haven: Yale University Press. Purkcy, S.C., and M.S. Smith 1983 Effective schools: A review. Elementary School Journal 83(4):427-52. Rutter, M., B. Maughan, P. Mortimore, and J. Ouston 1979 Fifteen Thousand Hours: Secondary Schools and Their Effects on Children. Cambridge, Mass.: Harvard University Press. Schorr, Lisbeth B., with D. Schorr 1988 Within Our Reach: Breaking the Cycle of Disadvantage. New York: Doubleday/Anchor Press. Schweinhart, L.J., and D.P. Weikart 1983 The effects of the Perry Preschool Program on Youths through age 15. Pp. 71-101 in Consortium for Longitudinal Studies, As the Twig Is Bent . . . Lasting Effects of Preschool Programs. Hillsdale, N.J.: Lawrence Bribaum Associates. Seitz, Y., L.K. Rosenbaum, and N.H. Apfel 1985 Effects of family support intervention: A ten-year follow-up. Child Development 53:376-91. Shipman, V.C. 1976 Disadvantaged Children and Their First School Experiences. Princeton, N.J.: Educational Testing Service.

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Effective Services for Young Children: Report of a Workshop Tyack, D., and E. Hansor 1982 Hard times, hard choices: The case for coherence in public school leadership. Phi Delta Kappan: 511-515. Unger, D.G., and L.P. Wandersman 1985 Social support and adolescent mothers: Action research contributions to theory and application. Journal of Social Issues 41(1):29-45. U.S. Congress 1989 Healthy Children: Investing in the Future. 12th Congress, Office of Technology Assessment, OTA-H-345. Washington, D.C.: U.S. Government Printing Office. U.S. Public Health Service 1989 Caring for Our Future: The Content of Prenatal Care. Washington, D.C.: U.S. Department of Health and Human Services. Weikart, David P. 1989 Quality Preschool Programs: A Long-Term Social Investment. Occasional Paper Number Five, Ford Foundation Project on Social Welfare and the American Future. New York: Ford Foundation. Whelage, Gary G. 1989 Reducing the Risk: Schools as Communities of Support. New York: Falmer Press. Whittaker, James K., J. Kinney, E.M. Tracy, and C. Booth, eds. 1990 Reaching High-Risk Families: Intensive Family Preservation in Human Services. Aldine de Gruyter. Zabin, L.S., M.B. Hirsch, E.A. Smith, R. Streett, and J.B. Hurdy. 1986 Evaluation of a pregnancy prevention program for urban teenagers. Family Planning Perspectives 18(3):119-26. Zigler, E., and J. Valentino, eds. 1979 Project Head Start: A Legacy of the War on Poverty. New York: Free Press.