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This summary is adapted from an article which first appeared in the November-December 1998 issue of Texas Journal of Corrections, Vol 24, No 6, pages 10-13. For further information, please contact John D. Walker, M.D., Texas Department of Health, Austin, Texas.

At the turn of the century, Sir William Osler¹ established a new goal for the next generation of physicians: "No longer is our highest aim to cure, but to prevent disease."  Prevention is now recognized not only as a powerful public health tool in fighting disease, but also as an effective strategy in reducing delinquency and crime. The most successful prevention programs:

These five key principles represent the essential core elements of the art and science – the craft – of prevention. Programs of proven worth, such as prenatal care, intensive home visiting, early childhood intervention, preschool education, school-based parent training and support, and mentoring for at-risk youth, each possess one or more of these critical attributes. One program that successfully incorporates all five prevention principles is the award-winning Parents as Teachers Program.

Parents as Teachers is an early childhood family education and support program designed to empower all parents to give their children the best possible start in life. Based on an outstanding curriculum covering child development information from the third trimester of pregnancy to age 5, the program provides parents with training that enables them to enhance their children’s emotional, social, intellectual, language, and physical development. Support services include personal visits by a trained parent educator, group meetings, a child development resource center, developmental screening, and referrals for other services when appropriate. The Parents as Teachers program, which originated in Missouri in 1981, has been implemented in more than 2,000 sites in 48 states and seven countries. Over 7,000 families were served in 114 programs in Texas in schools, churches, childcare centers and nonprofit organizations in 1997.⁵

Henry David Thoreau observed that for every thousand attempts to strike at the leaves of a problem, there is one blow delivered to the root. The Parents as Teachers program delivers a powerful blow to the preventable origins of many costly social problems:

• Low birth weight and developmental delay related to parental substance abuse before birth^7,42,46-48 
• SIDS and childhood respiratory disease related to environmental tobacco smoke from parental substance abuse after birth^{7,23,42,45,47,50,52}  
• Childhood accidents and injuries related to parental substance abuse and incompetence after birth^39,49
•  School failure, lack of job skills, and unemployment related to prior parental incompetence during critical developmental windows of opportunity for intellectual growth in early childhood^20,51
• Psychological and behavioral problems in childhood related to antecedent emotional abuse^{10,32-34,54,57,64} 
• Alcohol, tobacco, and illegal drug dependency related to antecedent physical abuse^{7,20,22,25-32,43-45,53,54-58} 
• Delinquency, gang activity, and crime related to antecedent exposure to violence in the home^{7,15-20,24,39,42,59} 
• Difficulty with interpersonal relationships, irresponsible sexual behavior, HIV infection, and other sexually transmitted diseases related to antecedent sexual abuse^{7,21,25,26,32,55}
• Intergenerational transmission of domestic violence including child abuse and neglect^35-42,59-63

These social problems are linked in a vicious cycle of intergenerational cause and effect, with significant repercussions in terms of years of potential life lost and direct and indirect economic costs for Texas. 

Long before Sir William Osler established a higher standard for the medical profession, "No longer is our highest aim to cure, but to prevent disease," the Hippocratic tenet, "to help, or at least to do no harm" left no doubt as to the ethical duty of physicians to, if at all possible, prevent harm. Dr. Vincent Felitti and his coworkers⁷⁴  have raised the bar even higher for the medical profession, by establishing a dose-response relationship between childhood abuse and household dysfunction and many of the leading causes of death in adults. This biological gradient (demonstrated previously with cigarette smoking and lung cancer) provides physicians with strong evidence of causality, and an ethical duty to make every effort to utilize methods which have been proven effective in preventing these adverse childhood experiences.

Population Attributable Risk is a mathematical technique that has been used by epidemiologists to establish the link between cigarette smoking and lung cancer.⁴  The same mathematical formula can be used to estimate  the human and economic costs of failure to nurture children.  For Texas in 1993, the 158,710 years of potential life lost linked to the root cause of failure to nurture children, exceeded the years lost due to all other leading causes of premature death.

Failure to nurture children is the most costly of all social and public health problems, both in terms of years of potential life lost and direct and indirect economic costs.

These costs are not a theoretical abstraction.  Texas citizens will continue to pay for these costs in higher taxes, higher insurance costs and overall higher costs of goods and services until effective preventive measures are taken to break the vicious cycle of failure to nurture children.

Increasing the nurturing capacity of future parents is the best investment Texas citizens can make.  Many independent evaluations have demonstrated the effectiveness of the Parents as Teachers program in helping families interrupt this intergenerational cycle.

• At age three program children were significantly more advanced in language, problem solving, and social development than comparison children, despite the fact that the sample was over represented on all traditional characteristics of risk. More than half of the children with observed developmental delays overcame them by age three.^67,71
• Program children scored higher on standardized measures of reading and math at the end of first grade than did comparison children.⁶⁶ 
• Parents as Teachers children still scored significantly higher on the Stanford Achievement Test than the control group in the fourth grade.⁷²
• Program parents were more familiar with age-appropriate child development and child-rearing practices and more confident in their parenting skills.^65,,70
• Parents who graduated from the program continued to read more to their children and be more involved in their children’s school experiences long after finishing their Parents as Teachers training.^66,68
• Child aggression was reduced in the most vulnerable group: boys from single parent homes. (Texas follow-up study of Parents as Teachers children in grades K-3)⁷³
• Parents as Teachers families have shown a lower incidence of child abuse and welfare dependency.⁶⁹

These research findings translate into enormous benefits to Texas, both in terms of years of potential life and in direct and indirect economic savings. Full implementation of the Parents as Teachers program in Texas would save Texas citizens more than 14,856 years of potential life and over 4.3 billion dollars each year.

Surveys of representative Parents as Teachers programs nationwide indicate that the average annual cost of Parents as Teachers services per family is $646. Start-up costs include $475 per parent educator for initial week-long training and curriculum, plus travel and lodging at the training site. The cost of teaching materials is very reasonable, because parent educators are encouraged to use "everyday items" that can be found in homes. Master copies of parent handouts are included in the curriculum, eliminating the need for ongoing direct purchase of consumables. Facilities costs are minimal, because as a home-based program, Parents as Teachers requires only limited center space. Office space and room for parent-child activities and meetings in a multi-purpose facility are generally adequate.⁵

The Parents as Teachers program pays for itself after 20 years in direct special education and grade retention savings to Texas school districts alone; and over the lifetime of the program participants, generates more than a $25 dollar return for every dollar invested.*

*An annual cost per family of $646, and an average of 60 families served per program, generates an average annual cost of $38,760 per elementary school. Full implementation of the Parents as Teachers program in 3955 elementary schools in Texas would cost an estimated $153.3 million dollars per year.

References

This summary is provided by the Texas Youth Commission. For more information about programs and research relating to children, youth, and family issues, contact us by e-mail at prevention@tyc.state.tx.us or by telephone at (512) 424-6336.

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