Executive Summary Executive Summary AteAlthy CHilaveN n February 9-12, 1992, in Washington, DC, Surgeon General Antonia Novello hosted the “Healthy Children Ready to Learn: The Critical Role of Parents” Conference, sponsored jointly by the National Gover- nors’ Association, the Department of Health and Human Services, the Depart- ment of Education, and the Department of Agriculture. The 3-day Conference Oo was part of the Surgeon General’s Healthy Children Ready to Learn Initiative, developed in support of the first of six National Education Goals established by President George Bush and our Nation's Governors in February 1990. This goal states, “By the year 2000, all children in America will start school ready to learn.” At the Conference, approximately 225 parents, representing the 50 States, the District of Columbia, and the U.S. Territories, joined with more than 500 government officials and representatives from public and private health, educa- tion, and social service agencies to search for new ways to advance the health and education of America’s children. The parents were selected by their States and Territories to represent their area’s economic, social, and cultural diversity. Parents from diverse backgrounds and other participants directed their efforts toward these challenging goals: * To identify the strengths of parents and families in their roles in preparing children to be healthy and ready to learn. * Tovoice parent and family needs to the health, education, and social service professionals responsible for programs that address the goal of preparing children to be healthy and ready to learn. * To highlight Federal, State, and community-based programs that effectively address these needs. * To identify cross-cutting public/private /voluntary strategies that build a parent-and-family/professional partnership within the scope of existing programs. year 2000, all childre vill start school ‘Teady to 2 Parents Speak Out for America’s Children Conference Structure uring the Conference, the State Parent Del- egates attended Parent Work Groups to dis- cuss three phases of involvement in health, education, and social service systems (the patchwork of health, education, and social service programs and activities throughout our Nation): awareness of and entry into the systems, participation in the systems, and transition as families move through the systems. The delegates were grouped into Parent Work Groups by regions, and special Work Groups were established for Native Americans and Migrant families to ensure that their issues were not lost. (The Native Americans and Migrant families were also represented in the Regional Work Groups.) At the close of the Conference, three representa- tives from the Parent Work Groups (one for each stage discussed, i.e., awareness and entry, participation, and transition) reported their findings to the Conference at large. The issues they raised were addressed by a panel of Government officials, directors of Federal programs that administer key health, education, and social service programs. As the State Parent Delegate Work Groups were meeting, other participants attended presentations by panels of professionals and parent advocates involved with health, education, and social service systems. The focus of these presentations was on howto make programs fit families, instead of making families fit the programs. The following topics were covered in the panel presenta- tions: (1) Early Childhood Issues That Affect School Readiness and Health; (2) Helping Families Get Services: Some New Approaches; (3) Healthy Children Ready to Learn: What Are the Roles of Parents, Educators, Health Professionals, and the Community? (4) Special Issues That Impact Children and Families: Substance Abuse, Human Immunodeficiency Virus (HIV), and Violence; (5) Disabilities; (6) Exploring Comprehensive Health and Education Models for Young Children; (7) Children with Special Health Care Needs: Lessons Learned; (8) Parenting: The Critical Role; (9) Childcare: Two Perspec- tives; and (10) Healthy Start, Head Start, Even Start, and the Supplemental Food Program for Women, Infants, and Children (WIC): Integrating Health, Education, and Social Service Programs. Over the course of the 3 days, President George Bush and members of his Cabinet expressed their com- mitment to the Surgeon General’s Healthy Children Ready to Learn Initiative by addressing the Conference participants. President Bush, Secretary of Health and Human Services Louis Sullivan, Secretary of Agriculture Edward Madigan, and Secretary of Education Lamar Alexander each described the efforts of the Administra- tion in meeting the first National Education Goal. The Conference also provided 28 workshops cov- ering a variety of health, education, and social topics from which the participants could choose. During the breaks, a special exhibition containing information about Federal, State, and community programs con- cerned with the health, education, and well-being of children was open to Conference participants. Also during the breaks and before the opening session, the Conference featured entertainment provided primarily by local children’s groups. Charge to the Participants s Surgeon General, Dr. Novello is responsible for the health of our Nation’s people, and as a pediatrician, she ismost passionately concerned about her responsibility to our Nation’s children. There- fore, Dr. Novello has made the health of our Nation’s children the cornerstone of her agenda. In her Charge to the Conference, Dr. Novello stated that the first National Education Goal holds special importance for her. “Health and education go hand in hand; one cannot exist without the other,” she said. “To believe any differently is to hamper progress.” She cited the three specific objectives in the comprehensive goals statement for the first National Education Goal: Report of the Surgeon General's Conference 3 * All disadvantaged and disabled children will have access to high-quality and developmentally appro- priate preschool programs that help children pre- pare for school. * Every parent in this country will be their child’s first teacher and devote time each day helping his or her preschool child learn; that parents will have access to the training and support they need. * Children will receive the nutrition and health care needed to arrive at school with healthy minds and bodies, and the number of low-birth weight babies will be significantly reduced through en- hanced prenatal health systems. Dr. Novello spoke about some of the barriers that our country faces in developing healthy children ready to learn: failure to immunize against childhood dis- eases, Acquired Immunodeficiency Syndrome (AIDS), childhood injuries, and violence. She stated that, al- though the statistics are staggering, she is hopeful that we can make a difference. She announced her commit- ment to the arduous task and challenged the Confer- ence participants: “I see our task as improving the health and welfare of our Nation’s children in every way we can.” She urged the participants to work together, to teach and to learn from one another. “When it comes to health and. education,” she said, “we need total intuitive conviction to remove every barrier and reach every child.” She urged the parents and professionals present to help make the Conference “a blueprint for bonding education and health— an essential task, ifour children are to succeed.” Parent Work Groups n their discussions of the stages ofinvolvement with health, education, and social service systems (aware- ness and entry, participation, and transition), the parents examined three main questions related to the different stages: 4 Parents Speak Out for America’s Children * What is my role as a parent? % What are the barriers and issues of concern? * What are some solutions and existing model pro- grams incorporating those solutions? Several issues and themes recurred in the parents’ discussions, forming a kind of national consensus on the issues among the parents. The conclusions from this national consensus follow. Awareness of and Entry into Health, Education, and Social Service Systems Roles and Responsibilities of Parents First parents must identify their children’s needs. Then, they must find the programs offering services that meet those needs. They should consider them- selves full partners with the professionals in making decisions for their children. Parents should be advo- cates and should network with other parents to share information and moral support. Barriers to Awareness and Entry Information about the full range of programs available to families is not readily accessible. In addition, the bureaucracy devoted to administering most programs is daunting to most parents. The paperwork is over- whelming, both in volume and in language. Eligibility criteria are inflexible. Social service workers, who often suffer from employee burnout or are culturally insensi- tive, can be patronizing and intimidating. Inflexible office hours and difficulties with transportation add to the problem. The systems seem to suffer from a lack of accountability. Parents feel frustrated and do not know where to turn for help. Solutions An easy-to-read, universal application form for all ser- vices was a major proposal, along with consistent, flex- ible eligibility criteria. Agencies should operate during hours that are more convenient to working parents. Programs should be instituted in elementary schools to develop social competency and effective parenting skills. Funds should be made available for support groups. Parents need a. way to talk back to the systems. A campaign should be conducted to increase public aware- ness of the importance of healthy children. Participation in Health, Education, and Social Service Systems Roles and Responsibilities of Parents The parents’ primary role is to nurture their children. They should also serve as role models not only to their children but also to other families who need service, and they should enlist those families into programs. Parents need to be fully involved partners with the service providers—in making care decisions, communi- cating cultural sensitivities, and evaluating services. Barriers to Participation The same difficulties exist here as with gaining access to the system: paperwork, inflexible hours, transporta- tion problems, and gaps in service. These problems seem to stem principally from a lack of coordination among programs and the absence of a family-centered Executive ¥ Summary philosophy. Again, the parents saw a need for family support groups and funding to organize them. Solutions First, training in parent skills should begin early. Im- proved communications among agencies would solve many problems. “One-stop shopping” (i.e., receiving a multitude of ‘services at a convenient location) with flexible hours and simplified paperwork would go a long way toward easing parents’ burdens. Adirectory of services also would be helpful. Consistent funding for programs and parent involvement on the boards over- seeing programs would help provide quality service. A “national psychology” that supports families should be encouraged; i.e., our society must be encouraged to value the family and support the efforts of parents in raising their children, particularly for families who need help. To that end, people should vote for candi- dates who espouse that view and who will work to further it when elected. Transitions Through Health, Education, and Social Service Systems Roles and Responsibilities of Parents Parents need to be active participants in transitions from program to program because they are the best evaluators of their children’s needs. They must be prepared for and remain involved in the transition process and, in turn, prepare their children. Again, they should be advocates for the child to ensure that the child is truly getting what he or she needs. Other important aspects of the parents’ role are loving their children and helping develop self- esteem for themselvesand for their children. Forsmoother transitions, parents must also be good recordkeepers and request written reports. Barriers to Smooth Transitions A lack of communication among agencies regarding available services complicates the transition process for families. Reports that are not written in the language of the parents make transitions confusing: Culturally Report of the Surgeon General’s Conference 5 insensitive service workers isolate parents. Unstable funding makes it difficult to predict the availability ofa particular program when a transition occurs. Solutions Improved communications was one of the most often- cited needs, along with information clearinghouses, hotlines, service directories, support groups, and com- munity outreach. Service providers should receive sensitivity training. Once again, the parents cited the need for a streamlined system for handling paperwork, one-stop shopping, and sensible hours. Characteristics of Programs Parents Grade A+ Parents said that programs must have the following characteristics: be child centered and family friendly, be easily accessible, have broad eligibility standards, be antidiscriminatory and multilingual, be well-promoted, provide individualized service, be staffed sufficiently, and be open at convenient hours. In addition to having these characteristics, programs must coordinate with one another to facilitate entry and participation in the systems and to avoid duplication or gaps in services. Above all, programs should empower families as they serve them. The parents strongly recommended pro- grams that involve parents directly as a way to empower them. Furthermore, they stressed that programsshould involve the parents in making the decisions that affect their children, decisions ranging from policies to staff- ing and budgets. Parent Presentations n the final day of the conference, three repre- sentatives from the Parent Work Groups sum- marized their conclusions. One representa- tive focused on the discussions of awareness of and entry into health, education, and social service systems, an- other on participation, and the third on transitions. 6 Parents Speak Out for America’s Children Awareness of and Entry into Health, Education, and Social Service Systems Sherlita Reeves Parent Delegate from Arkansas In summarizing the reports from the groups on aware- ness and entry, Ms. Reeves said that the parents’ roles and responsibilities should include becoming informed about their own child’s needs, acting as an advocate for the child, meeting their own needs so that they can be equal partners with service providers and profession- als, and networking with other parents. The issues of concern were too much paperwork, difficulty in getting into the system, materials not writ- ten in parents’ language, and providers who do not understand the culture of those that they serve. Inflex- ible hours of operation, lack of transportation, and environmental barriers for physically impaired people were noted as barriers. A significant problem is the lack of accountability in the systems. Solutions to these problems focused on establish- ing school-based programs that develop social compe- tencies, building support networks within the commu- nity, producing directories of resources with toll-free numbers, designing one-stop shopping for all man- dated programs, creating a universal application form, and giving parents a way to talk back to the system. Participation in Health, Education, and Social Service Systems Ellie Valdez-Honeyman Parent Delegate from Colorado Ms. Valdez-Honeyman stated that parents need to pro- vide for the needs of their children. Food, clothing, safety, health care, and quality time are essential, but parents also need to instill a spirituality that encourages values, morals, and respect for themselves and for others. As families begin to participate in the systems, just as when theyare entering the systems, parentsneed to continue to be advocates—for their own children, for other families, and for components of the systems that work for them. They should be involved in their communities. Ms. Valdez-Honeyman related other areas of con- cern identified by the parents. They felt that a stigma is attached to receiving services, the stigma of being poor. Eligibility criteria can also be a problem because they are not flexible enough to include all who have need. Also, language not native to the parents and system jargon make dealing with the systems confusing. Trans- portation is an issue in rural areas where services are limited and parents must travel long distances. Pro- grams often do not have convenient locations or hours for obtaining services. The solutions identified by the parents fell into two categories: local initiatives that deal with local service delivery, and Federal initiatives that reach across all levels to create a standard in which service systems welcome and embrace families. The principles would then be embodied in the design, delivery, and evalua- tion of services. Transitions Through Health, Education, and Social Service Systems Larry Bell Parent Delegate from Delaware Mr. Bell provided a laundry list of issues that the parents had discussed regarding transition. First, parents need to participate in the transition process so that they can help prepare their children for the transition. They can Executive ad Summary & Piao be better prepared for the transitions themselves if a resource manual or some form of information about new locations or programs, including contact names, were available to them before the transitions occur. The parents acknowledged their responsibility to maintain copies of their children’s records to ensure that they are not lost during transitions. The parents also have a significant responsibility in ensuring that the roles of parents and professionals in the transition process are clarified and that the family is treated with respect. Programs and staff must be culturally sensitive and relevant, and they must help develop self-esteem not only for the children but also for their parents, who then can be good role models. Parents should not be afraid to confront the systems if necessary to ease the transition process. The parents stressed that, to ease transitions, parental involvement in programs should be consis- tent.. Furthermore, parental involvement should in- clude program design and policy-making decisions. Mr. Bell also presented concerns that were raised by the other representatives. The parents cited the need for improved communication among the various systems that serve them in the transition process. Im- proved communication would help avoid duplication of services and promote continuity of service as transi- tions occur. They recommended an interstate com- puter network to ease the application process as fami- lies move from State to State. They urged that school credits be accepted more readily from State to State. They repeated the plea for one-stop shopping, less paperwork, flexibility of service, and help with transpor- tation problems. They also promoted the use of school social workers who could act as advocates for parents and children in the transition process. Finally, Mr. Bell presented the parents’ recom- mendation for legislative action to help improve the transition process and urged the parents to elect offi- cials who are family advocates. He summarized his remarks by reminding the participants of the three C’s of successful transitions: consistency, continuity, and coordination of services. Report of the Surgeon General's Conference 7 Responder Panel James O. Mason, M.D. Assistant Secretary for Health U.S. Department of Health and Human Services Assistant Secretary Mason, head of the U.S. Public Health Service, answered the parents’ challenge for action by the officials by promising to meet with the State and territorial health departments and their com- missioners to discuss the issues raised by the parents. He reinforced the parents’ contention that leadership must come from all levels. Dr. Mason stated that he agreed with 98 percent of what the parents said and his agency is working toward creating a user friendly system of health care. As an example he offered a new Model Application Form, which isa simplified, unified, uniform application avail- able for use in the States. He stated that both the Federal Government and the parents want the same features in the systems, but that each must work from opposite ends to achieve them at the middle levels where the programs are implemented. He also outlined Healthy People 2000, a national program with 300 measurable health goals for the year 2000; 170 of these goals relate to mothers, infants, children, and adolescents. He closed by expressing the willingness to work together as partners. John T. MacDonald, Ph.D. Assistant Secretary for Elementary and Secondary Education U.S. Department of Education Assistant Secretary MacDonald said that schools need to return to things that parents and children need. He shared a vision of schools as the hub of one-stop shopping, where education is the central mission butwhere children and families can use other family services as well. This facility would operate from early in the morning until late at night, including weekends and during summer and holidays. It would virtually never close. He also said we need a massive urban intervention program using Federal resources in conjunction with State and local resources to provide for communities. 8 Parents Speak Out for America’s Children Assistant Secretary MacDonald explained that many current programs can help one another. He cited Even Start as an example. A program for children 0 through 7 years old that provides not only parenting and childcare butalso job training and placement, Even Start can be used to buy or expand Head Start services or to create its own services. He emphasized that Federal agencies are working to integrate their services, and they will continue to do so with the support of America’s families in persuading Congress to make needed changes. Catherine Bertini Assistant Secretary for Food and Consumer Services U.S. Department of Agriculture The Department of Agriculture spends more than half of its budget on food assistance programs for the poor and children. Ms. Bertini explained how the Depart- ment currently is working with directors around the country to promote joint services for immunization and WIC. She also described direct certification of school lunch and breakfast programs through a computer marriage of the school lists with files from the Aid to Families with Dependent Children (AFDC) program in an effort to simplify eligibility factors and expand ac- cess. The two-signature policy for Food Stamps has been eliminated and the agency has launched a pilot program called Electronic Benefit Transfer (EBT) us- ing bank cards for the food stamp program. In closing, Ms. Bertini discussed the importance of school breakfast for children coming to school ready to learn. Half of the schools that have school lunch programs also have breakfast, but through expanded access the schools can feed more kids. She urged parents to work with and support the regional agencies that provide services and to help persuade Congress to support proposals for change in the systems, Wade Horn, Ph.D. Commissioner Administration for Children, Youth and Families U.S. Department of Health and Human Services Dr. Horn admitted that Head Start works because it is built upon parental involvement and community sup- port. Head Start also integrates health services and social services and is one of the largest delivery systems of health services to poor children in our country. However, Head Start still has much work to do. It is undertaking three new challenges: administering more money to serve more kids; increasing services to adults with children in Head Start, particularly adult literacy and substance abuse; and providing job training for Head Start parents. Dr. Horn also warned that Head Start is not an inoculation against everything that can possibly go wrong ina child’s community. We must do a better job of creating a good environment for children when they leave Head Start. To that end, he has been working with Assistant Secretary MacDonald to establish better connections between Head Start and our Nation’s public schools. Christine Nye Director Medicaid Bureau Health Care Financing Administration Ms. Nye described the massive effort that Medicaid makes to serve our people; it spends more than $100 billion for services to 30 million Americans, 17 million of whom are children. She continued that, although Medicaid is expanding services and eligibility, it still falls shortin many areas. However, she cited some bright spots: expansion of eligibility for children to the maximum in as manyas 20 States and increased flexibility in providing waivers to keep children with special health care needs at home rather than in institutions. One expanded program for children is the early Periodic Screening, Diagnostic and Treatment Program, the greatest child health reform since the enactment of Medicaid. Ms. Nye also described efforts to make access to Medicaid easier: streamlining application forms, increas- ing payments to community health centers, and working to overcome barriers between physicians and Medicaid. She expressed her commitment to continuing these ef- forts, but cautioned the participants that Medicaid is administered by the States and that the parents should work with the State Medicaid staff and inform them of the findings of the Conference. In closing, she thanked the parents for rejuvenating her own commitment to imple- menting changes in the program. Lou Enoff Principal Deputy Administrator Social Security Administration Although most people think of Social Security as a retirement program, Mr. Enoff informed the partici- pants that it pays more than $1 billion to more than 3 million children under its programs every month. These children either have disabilities or they are the off- spring of retired or disabled workers or deceased par- ents. Social Security has expanded access with a nation- wide 800 number that operates 12 hours a day with bilingual help if the client needs it. In addition, Supple- mental Security Income (SSI) hasan outreach program to find those people who are eligible. Social Security has begun integrating services where possible with other agencies. Also, Social Security has published standards of service for its offices, which will be modified as goals in providing services are met. For instance, Social Security cards are now issued within 10 days after the application is filed; the same process formerly took up to 4 weeks. Mr. Enoff urged the parents to call if they have a problem with or concern about Social Security. He reminded them of the 800 number and added that, ifthey received no satisfaction from the service providers on the toll-free line, they could call him directly at 410-965-9000. Report of the Surgeon General’s Conference 9 Keynote Speeches George H. Bush President of the United States The President said that, in his administration, families come first. Pointing to the critical role of parents, he said that, as a child’s first teachers, they offer the love and nourishment that no government program can ever hope to provide. Citing programs that promote the health and education of young children, President Bush stated that, since 1988, Federal dollars for immunization have more than tripled. In the last 3 years, funding for Head Start has almost doubled; this year’s proposed increase of $600 million is the largest single increase in the program’s history. President Bush also outlined the provisions of his health care reform plan: providing a $3,750 tax credit for low- income families and an equal tax deduction for middle- income families; cutting costs to make health care more efficient, and cutting waste and abuse. The President called it a common-ense reform that will maintain high-quality care, Cutcosts, ensure maximum freedom of choice, and give every family access to health care. Louis W. Sullivan, M.D. Secretary of Health and Human Services Secretary Sullivan said we must invest in children. To support that investment, the President’s 1993 budget proposes to increase funding for programs serving children to $100 billion. Infant mortality is a national priority, and an expansion of the Healthy Start initia- tive will concentrate $143 million on 15 communities with stubbornly high infant mortality rates. We must also focus on prevention. The President has requested $52 million for immunization activities and $40 million for Centers for Disease Control (CDC) Lead Poisoning Prevention Grants to support 30 state- wide programs. Finally, we must empower parents. The President’s $600 million increase in funding for Head Start will serve an estimated 157,000 additional children in 1993 10 Parents Speak Out for America’s Children and will involve their parents. In addition, the tax provisions of the President’s health care reform pro- posal will help more than 90 million Americans and will cover 95 percent of the uninsured. Edward Madigan Secretary of Agriculture Secretary Madigan outlined the many Department of Agriculture programs that have direct impact on chil- dren. He cited the following examples: WIC, a gateway to other governmentservices such as immunization; the Child and Adult Care Food Program, which serves meals to preschool-aged daycare children (including Head Start meals), a service that is expanding; the National School Lunch and Breakfast Programs, which are being cross-matched with AFDC files to ensure that entitled children are reached; various summer food assistance programs; Food Stamps, the largest food assistance program; and various other programs for distribution of commodities. In addition to providing food, the Department of Agriculture also provides nutrition education through various programs. The Nutrition Education and Training Program (NET) trains school food-service personnel, teachers, and students. The National Food Service Man- agement Institute, which operates at the University of Mississippi, trains school-lunch operators. Also, WIC provides nutrition education as an integral part of its program. Secretary Madigan urged the participants to work locally to ensure the success of these programs. Lamar Alexander Secretary of Education Secretary Alexander reiterated the Administration’scom- mitment to Federal standards for quality education. He recounted the implementation of the Healthy Children Initiative in Tennessee during his term as Governor. That program sought to expand prenatal care, identify doctors for newborns, and encourage employers to provide childcare opportunities for their employees. Secretary Alexander stated that, although na- tional policies and State programs are important be- cause they affect funding, the fundamental problem is a matter of parents, families, and communities taking care of children and putting a priority on them. He said the Department of Education now has 27 different Federal programs that are available for children under 5 or 6 years old, but the challenge is to spend the money more wisely. As an example, Secretary Alexander pointed to the Decatur, Georgia, school district, which has turned the school community around by setting and enforcing tough standards and by using the school as the organiz- ing point to integrate community services for the chil- dren. In closing, Secretary Alexander encouraged the audience to assist their communities in becoming part of the America 2000 program. Roger B. Porter, Ph.D. Assistant to the President for Economic and Domestic Policy Dr. Porter stated that the President’s commitment to the goal that all children start school ready to learn permeates his administration. The President’s Educa- tion Policy Advisory Committee, which is made up of educators, business and labor leaders, and media repre- sentatives, has spent much time discussing ways to enhance parental involvement in the health and educa- tion of our children. In addition, the President has established a partnership with the Nation’s Governors in adopting the six National Education Goals. Dr. Porter stated three convictions that synthesize the spirit of the National Education Goals. One, fami- lies come first. Two, we must never allow things that matter most to be at the mercy of things that matter least. We, as a society, must honor those activities that involve one generation transmitting to the rising gen- eration a set of fundamental values and aspirations, which includes good health and a commitment to learning. Three, we are all in this together. Closing Remarks n her closing remarks, Dr. Novello observed that everyone came together at the Conference for only one purpose: to improve the lives of children and families. She said thatreforms in the health, education, and social service systems of this country will be ad- vanced through the families. It was her belief that the Conference did one thing beautifully: It vindicated parents. Parents will no longer be silent partners; they will be activists and advocates. Dr. Novello asked attendees to join her in sharing the responsibility for making their families and chil- dren well. She reiterated some of the concerns raised at the Conference: the importance of fathers in the family, the need for flexible services and cultural sensi- tivity, the needs of teenage parents, and the desire for self-esteem for all of our children and their parents. She urged the participants to become involved and share with those at the local and at the State levels, in the public and in the private sectors. Our children’s well- being is no longer one person’s responsibility, and we must “get real.” There is too much at stake. This Conference, then, can be just the beginning of a coalition of parents trying to determine, through their collective actions, what this Government can do. In closing, Dr. Novello challenged the participants one last time. “I’m with you,” she said. “Are you with me?” Report of the Surgeon General’s Conference 1 Chapter | xeAlthy CHilarén “Providing for health, ‘nourishment, | active parenting are basic introduction n February 9-12, 1992, at the Ramada Renaissance Techworld in Washington, DC, the Surgeon General, Dr. Antonia Novello, hosted the “Healthy Children Ready to Learn: The Critical Role of Parents” Conference. This conference was jointly sponsored by the National Governors’ Association, the Department of Health and Human Services, the Department of Education, and the Department of Agriculture. The Conference was held as part of the Surgeon General’s Healthy Children Ready to Learn Initiative, which in turn supports the first of six National Education Goals established by President George Bush and our Nation’s Governors. This goal states, “By the year 2000, all children in America will start school ready to learn.” Recognizing the crucial role of parents in ensuring their children’s good health and preparing them for school, Dr. Novello invited them to join with Government officials and represen- tatives from public and private health, education, and social service agencies to open the channels of communication and to explore innovative steps to support the care and education of our Nation’s children more effectively. Approximately 225 parents, representing the 50 States, the District of Columbia, and the U.S. Territories, gathered with more than 500 professionals concerned about the care of children to express the needs of families and explore ways that those needs can be addressed. Appendix A lists the more than 700 participants of the Conference. providing a suitable foundation for normal growth and emotional well- being, a foundation that fosters the ability to learn and ensures school readiness.” 14 Parents Speak Out for America's Children Report of the Surgeon General's Conference 15 Background he seeds for the Conference were planted in February 1990, when President Bush and the Nation’s Governors made education a national priority and established the six National Education Goals. The first goal is an extremely important one because it focuses on the foundations of learning: physical, social, and emotional health and well-being, and cognitive development. Providing for health, nourishment, and active parenting are basic ways of providing a suitable founda- tion for normal growth and emotional well-being, a foundation that fosters the ability to learn and ensures school readiness. However, deficits in any of these areas during the critical early period in achild’s development are difficult, if not impossible, to overcome. To achieve the first National Education Goal, our Nation must provide access to health care and proper nutrition, education for parents, and educational programs for all ofour children. In August 1990, through the announce- ment of her Healthy Children Ready to Learn Initiative, the Surgeon General accepted the challenge to support achievement of this readiness goal. Dr. Novello’s initia- tive focuses on the health component of the first Na- tional Education Goal because children’s ability to learn is dependent on their health. To assist her in undertaking this challenge and to explore the best means to meet the goal, Dr. Novello formed an Advisory Group of highly qualified represen- tatives from the White House staffand the Departments of Education, Agriculture, and Health and Human Services. (The Advisory Group members are listed in Appendix B.) The role of the Advisory Group is to recommend steps to improve the health and well-being of children so that they are healthy and ready to learn when they begin school. This role encompasses the following tasks: (1) determining the health needs of preschoolers and their parents; (2) identifying Federal resources that can be used to meet those needs; (3) discovering gaps where resources to meet the needs are 16 Parents Speak Out for America’s Children lacking; (4) clarifying the relationship between the Federal Government and the States in meeting these needs and the responsibilities of each; (5) developing strategies to minimize barriers to cooperation among Federal, State, and local agencies and private organiza- tions involved in the health and education of young children; and (6) identifying ways to expand the Nation’s resources through cooperation and collaboration to meet the challenges of this readiness goal. Among other recommendations, the Advisory Group advised seeking parents’ perceptions of needs that must be met if our Nation is to reach the readiness objective. The design of this Conference was based on the Advisory Group’s recommendations. The Surgeon General set these challenging goals for the Conference: * Toidentify the strengths of parents and familiesin their roles in preparing children to be healthy and ready to learn. * To voice parent and family needs to the health, education, and social service professionals respon- sible for programs that address the goal of prepar- ing children to be healthy and ready to learn. * Tohighlight Federal, State, and community-based programs that effectively address these needs. * To identify cross-cutting public/private/volun- tary strategies that build a parent-and-family/ pro- fessional partnership within the scope of existing programs. In preparation for the Conference, the Surgeon Gen- eral requested that the States identify parents who would make up a State Parent Delegation at the Confer- ence. The term “parent” was broadly defined to include anyone who is guardian of a small child, i.e., parents, grandparents, adoptive parents, foster parents, etc. The individual State delegations were asked to hold pre- Conference meetings to discuss issues relating to health, education, and social service systems of importance to the parents. Conference Organization he Conference, which was the result of 18 months of planning by the Surgeon General and her Advisory Group, assisted by the Planning Committee (listed in Appendix C), provided a unique opportunity for parents and families to meet with Fed- eral, State, community, and private professionals from health, education, and social service systems. The agenda (Appendix D) was carefully planned to make the Conference an effective forum for information exchange. The State Parent Delegates attended three Parent Work Groups to discuss their needs and issues relating to three phases of involvement in the health, education, and social service systems: awareness of and entry into the systems, participation in the systems, and transitions as families move through the systems. The delegations were grouped according to geographical regions, and special work groups were established for Native American and Migrant families (who were also represented in the re- gional work groups) to ensure that their special concerns were not lost. The Facilitators and Recorders for these discussions are listed in Appendix E. In her Charge to the Participants, found in Chap- ter 2, the Surgeon General emphasized that these Par- ent Work Groups were the focus of the Conference. Chapter 3 of these proceedings summarizes the issues discussed in the Parent Work Groups. The summaries examine a broad national consensus from issues raised in several of the work groups and then explore the narrow focus of the individual work groups. Chapter 4 contains the findings as presented to the full Confer- ence at the closing session by three State Parent Del- egate representatives. It concludes with the remarks of the Responder Panel, directors of government pro- grams that provide services, who responded to the issues presented by the parents. During the Conference, President Bush and key members of his Administration expressed their personal commitment to Surgeon General Novello’s initiative and emphasized its importance to our Nation’s future by their attendance at the Conference and their remarks to the participants. The speeches delivered at the Conference by President Bush, Secretary of Health and Human Ser- vices Louis Sullivan, Secretary of Agriculture Edward Madigan, Secretary of Education Lamar Alexander, and Assistant to the President for Economic and Policy Devel- opment Roger Porter are found in Chapter 5. Concurrent with the Parent Work Groups, panel presentations that explored current services, both pub- lic and private, and parent support groups were con- ducted for General Participants (those who were not State Parent Delegates). These presentations, by panel- ists who were experts in their respective fields, focused on ways to customize services to fit families instead of trying to fit the families into the services. Chapter 6 contains summaries of the Panel Presentations. All participants had a choice of 28 informative workshops covering a variety of topics from nutrition, health care, and injury prevention to violence and its impact on children. These workshops, led by profession- als in the fields, are described in Appendix F, Addition- ally, the Conference presented a special exhibition of Federal, State, and local programs dedicated to the health and education of children. Program representatives shared information about the programs and distributed materials. Appendix G contains a listing of the exhibitors. Participants were entertained during each of the breaks by an array of performers, most of whom were children. Appendix H recognizes each group who shared their talents with the participants. Report of the Surgeon General's Conference 17 e to the Conference no Jayde) Chapter 2 Antonia C. Novello, M.D., M.P.H. Surgeon General ood morning. Twould tke to welcome vou to the “Healthy Children Reads to Learn: The Critical Role of Parents” Conference. This Conference is the culmination of 18 months of plan- ning, outlining, and meeting with the bestand brightest individuals concerned with the health and education of our Nation's children. President George Bush has mace the education of our Nauon’s children a major priority of his Presidency. The Department of Health and Human Services and Secretary Sullivan have made caring for children a comerstone of the Department’s agenda, and as the Surgeon General, Phave made the health of our Nation's children the cornerstone of mine. Health and ecduca- lion go hand in hand: one cannot exist without the other. To believe anv differently is to hamper progress, Just as our children have a right to receive the best education available, they have a right to be healthy. As parents, legislators, and educators. 1 is up to Us Lo sec that this becomes a reality. Therefore, we are meeting to improve the educa- tion and health ofour Nation's children and to improve these things through the eves of parents, through the collective participation of the family. This is one of the most serious tasks for anv society. and it should not be anv less serious for all of us gathered here today. As T welcome vou and ask vou to give this task vour Most serious attention, Lam going to ask even more of vou. Carl Jung. the great psychologist. said that “We should not pretend to understand the world only bv intellect: we apprehend it just as much by feeling.” Lam going to ask vou to use vour experience and intellect, but also Tam going to ask vou to express vour feelings about this challenge. Pwant vou to bring not only vour love and concern but. if necessary, even vour anger to this issue. Tam asking vou toe get involved. Adding 20) Parents Speak Out for America’s Children I lechng todniedicet will bring dhe best in each one of us out andl will bring as the best of what this Conference can give to the smdiest of America’s citizens. Tami asking vou. as a parent, official. teacher, or health care provider. to bring vour honest perceptions of what can help families ane childven to be healthy and readw to learn, Ifwe do not face the barriers or address the concerns, then we become a partof the problem and not apart ol the soliton, We know we have problents, but we also have great resources and strengths, not the least of which is America’s devotion to is children. We need a commitment from each person here today and the organizations they represent so that they will bring their best knowledge and most profound human commitnent to this issue. Perhaps our greatest challenge is to join hands and recovera true American spirit, This is the most caring country in the world, wid today we will bring this concern to the tives of our children. xteAlthy Crilavéy “Heady-to Tear We are focusing on the role of parcnts—all of us. whether the President, Cabinet officers. Federal of fi- cials, Governors, or State officials. Some of us might be parents; others may not, But today. for the duration of this Conference. lets take the honorable position that each adiltis each child’s parent. Each American child belongs to each of us. No one parent or program can help each and every child. but together we can strive for the common goal of making cach child as healthy and ready to learn as possible, Twould also remind vou not to get discouraged about the Federal Government. This is vour Govern- ment, and it isa powerful one. We are going to teach vouwhata powerful toolit canbe. We are going to teach vou how to use it. We have created. iniproved. ane extended Head Start. We have changed immunization policies to protect children agaist a deadly revival of measles and other childhood iliesses, We have gouen Involved in improved nutrition programs, We wantvou to know that we are here to work with vou. Let me expand just a moment on measles. We have had a verv successful Fedeval State. private cam- paign to increase nunizauions, Granted that imeastes often appears in waves and that we have been tna bad wave, but let me point out chat the rate of measles has dropped 65 percent between 1990 and POOL. from 27.786 cases in 1990 to GAS cases in LOYL. We had onl about 1,500 cases of measles in 1983, so vou can see we stl have far to go to reduce measles completely. The public and the private sectors have mobilized: cvervone has responded. Dr. Sullivan. Dr. Roper. Dr. Mason. and Tare finishing a six-city tour and have visited clinics im San Diego. Detroit. Philadelphia. Rapid City. Phoenix. and Dallas to encourage Hnmunization, This past Friday. we visited aa imantuinization clint i San Diego with President Bush. Hollvwood celebrities took on measles imununization as their cause anid formed the Children’s Action Network. Phe Public Health Ser vice has responded acdinirably, but there is sul) more to be done. Let me make this point. When we join together— parents, communities. and the government—when to- gether we think and care. we can turn any epider around. We have both the means and the wet “The influence of a parent is impos- sible to exaggerate. A child looks up to a parent; children trust their par- ents to help them make their dreams become realities.” More than 2.000 vears ago. Plato said, “The direc- tion da which education starts a man will determine his future life.” Pbeleve that. Pknow it to be true in my own life. My mother has been an educator all her life. and she beheves that education is the greatest gift of all. She was the one who cneouraged me to use education as a tool for success. AH of us learn the dimensions of a larger world from our parents. The influence of a parentis impossible to exaggerate. A child looks up to a parent children trust their parents to help them make their dreams become realities. It wasa long way for me from Fajardo, Puerto Rico. to the Office of the Surgeon General, but it was not an iMpossible wav. Education made it possible. Twould ask vou to remember, too, that exceptional teacher who touched and inspired vou as a student. Think what a teacher can do. As parents. edttcators, and health professionals, we must remember the influence we can have on the future of our children, When President Bush outlined his six National Education Goals for the vear 2000. he envisioned an America where our children compete on an interna- Honallevel He knew thatthe children of today are the eXplovers. writers, teachers, aud inventors of tomorrow. Weomust teach them all thatwe know and provide them with thease tools thes need to make ther dreams come Reporpotthe S aeeon Generals Conference 217 true. Our children are verv smart; some of them are smarter than any of us ever were. They are eager to learn, and we must not fail them. We have some hard facts to face. Our educational system is unsurpassed at helping children excel at all levels, from diverse backgrounds, and often with En- glish as a second language. Our public schools and our concept of an educated society are the source of America’s strength and its potential. Still, we must face the truth. Scholastic Aptitude Tests (SAT) scores con- tinue to remain low. We are not doing well in math and science. Many of our schools are overcrowded and overburdened, and many of our teachers are set up to fail by having too many children to teach. “We can’t become discouraged. Our teachers, children, and future depend on our dedication to turn things around. Some will tell us that it can’t be done or that it just might be be- yond hope. But I know in my heart that isn’t true.” We can’t become discouraged. Our teachers, children, and future depend on our dedication to turn things around. Some will tell us that it can’t be done or that it just might be beyond hope. But I know in my heart that isn’t true. The President and the Nation’s Governors are working to remedy these problems—to make our schools the institutions for learning that they were meant to be and are capable of being. Collectively we must work to make that a reality. 22 Parents Speak Out for America's Children As Surgeon General, I am responsible for the health of the people of this great country. That means all cultures, races, mothers, and fathers. And to me, as a pediatrician, it especially means children. When I was appointed Surgeon General, I resolved that my agenda would focus on the needs of our Nation’s children. It is an overwhelming task, but it is an altogether necessary one. When the President announced his six National Education Goals, there was, and continues to be, great enthusiasm for the promise of these goals. The first National Education Goal, that “By the year 2000, all children in America will start school ready to learn,” holds special importance to me. This goal is realistic, and it is achievable. I believe those of us here in this room can be instrumental in implementing it in our own schools and communities. I know it is worth our best efforts. as part of this first National Education Goal, we must work to satisfy three objectives: *® First, that all disadvantaged and disabled children will have access to high-quality and developmentally appropriate preschool programs that help children prepare for school. * Second, that every parentin this country will be their child’s first teacher and devote time each day help- ing his or her preschool child learn; that parents will have access to the training and support they need. *® And last, that children will receive the nutrition and health care needed to arrive at school with healthy minds and bodies, and the number of low- birthweight babies will be significantly reduced through enhanced prenatal health systems, These three objectives are the keys to our children arriving at school healthy and ready to learn, and your participation is crucial. This Conference has been structured to give each one of you the opportunity to participate and to listen to what the esteemed panelists, Government represen- tatives, and keynote speakers have to say. Most impor- tantly, this Conference has been structured to give you the opportunity to participate in these discussions and in the dialog that follows. Those of vou here representing the 50 States and the Territories will be able to tell the rest of us what works and what doesn’t work in your States and commu- nities. There is always room for improvement, growth, and change. We are going to talk about the good and the bad. By doing so, we will be able to avoid mistakes along the way and help, in turn, to highlight and applaud the success stories and use them as models as we move toward the vear 2000. Today, there are 64 million children in this coun- uy. We have 19 million American children under 5 years old and 4 million under 1 year. More than 20,000 children a vear are killed by injuries. Some 1,677 have died from AIDS since its outbreak. Childhood diseases, due to a lack of vaccines, have disabled or killed thou- sands more. Although I am verv hopeful, we must be honest. The statistics are staggering. What can we, as a Nation, doy What can I, as Surgeon General, do? For one thing, | am alwavs going to keep you informed, and I am going to tell you what you can do to help the Department [of Health and Human Services] and the Nation. To start, the goal of the Department of Health and Human Services is to have 95 percent of children immunized by 1995 and, hopefully, all of our children immunized by the year 2000. If you are a parent, see that your children are immunized, and tell other parents, too. If you are an official, check out the situation in your own area and help make immunization for all children a reality. I believe that immunization is a right, and we must all get involved to make that righta reality. To be successful, all vaccines must be used if they are going to work; they do us no good by sitting in a clinic or a doctor’s office somewhere. I must make one point perfectly clear: We do not suffer from lack of vaccine: we suffer from failure to immunize. The immunizations are available: we need to get them to all of our children. With regard to the terrible pandemic of AIDS, it is here that we must increase our vigilance to stop its spread. We must educate about AIDS, help everyone involved in the care of those with HIV disease, and send “It is my sincere hope that our true legacy will be evident in the children who will benefit from our collective efforts.” the message that we must fight the disease, not the people with the disease. The number of pediatric AIDS cases continues to increase. Before 1985, 58 percent of the children reported with AIDS were from New York City, Newark, or Miami. After 1985, however, only 36 percent of children with AIDS were from these cities. AIDS in women and children is spreading beyond the large cities to smaller towns and even rural settings. The greatest increases in numbers of cases reported to the CDC [Centers for Disease Control] were in rural areas and in metropolitan areas with populations of under 100,000. From 1988 to 1989, there was a 12 percent increase in the number of pediatric AIDS cases. From 1989 to 1990, there was a 37 percent increase. As of August 1991, 3,199 children under 13 with AIDS were reported to the CDC, more than half of them in the last 2 years alone. Of these cases, 84 percent were infected perinatally, and 52.4 percent, or 1,677, have died. Based on the National Survey of Childbearing Women, the CDC estimates that 5,000 to 6,000 HIV-infected women gave birth in the past year. Based on a 30 percent transmission rate, itis estimated that 1,800 to 2,000 HIV- infected infants were born. Children of minoritv families have had more than their share of AIDS. For example. although only 15 percent of all children in the United States are Report of the Surgeon General’s Conference 23 Mirican-American, they are known to account for 51 percent of all AIDS cases. Although only 8 percent of all children in the United States are of Hispanic de- scent, they account for 26 percent of AIDS cases in children. Clearly, all of us here must be prepared to deal with children and families with AIDS. But to do that. we must have culturally sensitive programs. We must know Harlem to design a program for Harlem, and we must know the barrios of Texas to be able to work there, Some programs must be in Spanish or in any language that is necessarv. Parts of Appalachia can be as desolate as any inner city slum. We should not design programs for our communities unless we have walked in their shoes and in their streets. We must be humble and consult those who know those communi- ties when we design any interventions. The third point on which we all must continue to focusts that of childhood injuries. According toa recent health report issued by the Bureau of Maternal and Child Health, injuries are the most significant health problem affecting our Nation’s children and adoles- cents, however we measure it—whether by numbers of deaths, dollar costs for treatment, or relative rankings with other health problems. Injurv need not maim and hull so many ofour children. The tde of injuries is an epidemic we can control, Childhood injurvis one of the principal public health problems in America todav, causing more deaths than all childhood diseases com- bined and contributing greatly to childhood disability. The United States is also a Nation plagued bv violence. American children are LO times more likely than German children, 11 times more likely than French children. and 15 times more likely than English chil- dren to be victims of homicide. We could debate whether itis poverty or race that so intensifies patterns of morbidity and mortality, that so-darkens the picture for violence, but now, sutfice it to sav that this has to stop. As Abraham Lincoln said in 1860, “Let us have faith that right makes might.” Knowing we are right, let’s dare to do our duty as we understand it. f may as well admit that Isee the Office of the Surgeon General as a way of reaching families, a way of reaching children. [have probably held more babies 24 Parents Speak Out for America’s Children than anv Surgeon General in history, Mv schedule— ask my staffif vou don’t believe me—goes off the rails when I visita pediatric clinic, an Indian Health Service hospital, a pediatric AIDS unit. Thave talked in more high schools and in more small towns than I can remen- ber. The Black Foot Indian Nation gave me the name “Princess Flying Woman.” I believe they knew that I wanted to. touch all Americans. For the time thatis mine to serve as Surgeon General, lam absolutely committed to make a difference. Fam making these confessions to warn vou. I did not accept the responsibility for this Healthy Children Ready to Learn Initiative for reasons of status. Tam as serious as vou are. Tsee our task as improving the health and welfare of our Nation’s children in every way we can. By attending this Conference. vou have made an excellent commitment on behalf of other parents and children from your State, and for that commend vou. I urge you to participate fully in the panel sessions and discussion groups. We are here to teach and to learn from one another. We are going to, as the kids sav, “get real.” I know that any of vou here would jump from vour seat and take off in a dead run to grab a child from the path ofacar. You would shield a child about to be hurt. You would endanger yourself to protect a child from a dangerous fall. When it comes to health and education, we need a dead run; we need total intuitive conviction to remove everv barrier and to reach everv child. This Conference is geared to be that “dead run.” When I was appointed I vowed to speak for all of the children. I vowed to be the Surgeon General for all Americans, especially for all American children, whether rich or poor, African-American, white, Hispanic, Asian Pacific Islander, or Native American—whether docu- mented or not, from the President's grandchild to the child of a Migrant worker. All our children need this attention, but there are some who especially need my voice. One in five American children lives in poverty: I speak for them. Thirty-eight percent of Hispanic chil dren live below the poverty line; 43 percent of all African-American children live in poverty. I speak for them, too. In the words of the Chilean poet, Gabriela Mistral: Many of the things we need can wait; The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer ‘Tomorrow: His name is ‘Today.’ Today, as parents, you are both the expert and the student, and I ask all experts today to think also as parents. Byall means, play both roles. By the year 2000, chances are that any one of us may be only a distant memory. Itis my sincere hope, however, that our true legacy will be evident in the children who will benefit from our collective efforts. They will be children who started school healthy and ready to learn, children who learned and learned well, children whose parents taught them first and set the stage for the teachers who followed, children who were immunized and well nour- ished, children who have had all that America can give. The time has come for me to turn the focus back on vou and ask all of you within this room to work together. We have a precious opportunity to spend 3 days at this Conference to think, argue, forge new initiatives, prioritize, and get involved. It is my fervent hope that the goals of this Conference will become a blueprint for bonding education and health—an essen- ual task, if our children are to succeed. I wish vou the best in vour endeavor. God bless vou all. Report of the Surgeon Generals Conterence 25