Child Abuse & Neglect:
Protecting Massachusetts Children

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Protection of children from harm is not just an ethical duty, it is a matter of national survival…With each childhood that is destroyed, the nation loses a piece of its soul.
U.S. Advisory Board on Child Abuse and Neglect

 

The Numbers are Staggering

Today, one can rarely read the newspaper or watch television news without being jolted by stories of beaten, sexually abused, or severely neglected children. More than 100,000 Massachusetts children were reported in 1996 as victims of abuse and neglect. (1) In fact, reports of child maltreatment in Massachusetts increased by 95% between 1985 and 1996 (2), far outpacing the corresponding national increase of 51%. (3) Experts attribute this steep rise to a combination of actual increases in the number of abused and neglected children and heightened public awareness and concern for the safety of children. (4)

The people of Massachusetts clearly recognize the need to protect children. In fact, 46% of 408 Massachusetts residents surveyed in 1998 ranked safety from all forms of abuse, neglect, and violence as by far the most important element necessary to a child's well-being.

What is Most Important to a Child's Well-Being?" -Massachusetts 1998

Source: Massachusetts Campaign for Children, Public Opinion and the Status of Children in Massachusetts in 1998. (DiNatale and Hock Research)

It is important to understand that most maltreated children grow up to lead normal adult lives, and they don't grow up to abuse their own children or others. However, studies show abused and neglected children are all at greater risk for mental health problems (5), suicide attempts (6), alcohol abuse (7), drug use (8), and poor school performance. (9)

Perhaps most disturbing: physically abused and neglected children are significantly more likely than children with no histories of maltreatment to commit violent crimes as juveniles and adults. (10) Pronounced differences between abused and neglected children and their non-abused counterparts can begin to emerge as early as age 8 or 9. (11)

While parents are responsible for most physical abuse and neglect of children, studies show that more than half of the sexually abused boys, and 15-25% of the sexually abused girls, are abused by older youth. (12) At any given time, of 12,000 children in foster care in Massachusetts, about 1500 act out in sexually aggressive ways. (13) Without specialized mental health treatment, these children are at high risk of sexually offending later in their lives.

Confirmed Reports

Source: DSS, Child Maltreatment Statistics, 1996.

The link between child neglect and future violence is especially noteworthy because: -Neglect is by far the most common type of maltreatment reported to child protection authorities, and generally involves a pervasive and ongoing pattern of behavior; -Neglect reports have increased steadily over the last six years;(14) -Neglect disproportionately affects infants and preschoolers,(15) who are at their most vulnerable developmental stage.(16)

Research points to several important factors associated with higher incidence of child maltreatment: poverty,(17) domestic violence,(18) parental substance abuse,(19) and mothers who are teens when their first children are born.(20) All these factors are also clearly related to child abuse reporting rates in Massachusetts.

Approximately equal numbers of boys and girls are neglected, physically abused, and emotionally maltreated. A large majority of sexually abused children (74%) are girls.(21)

Source: DSS, Child Maltreatment Statistics, 1996

*Average number of civil restraining orders issued in District Courts serving these towns, 1997.Source: Research & Planning Department, Administrative Division, Office of the Commissioner of Probation, 1998
**Average rate of treatment admissions to Bureau of Substance Abuse agencies, FY93-FY95Source: Health & Addictions Research, Inc., February 1998

The Massachusetts Department of Social Services (DSS) is required by law to receive and investigate reports of suspected child abuse or neglect.

DSS received reports involving 101,180 children in 1996 (the latest year for which annual statistics are available). About half of these reports were deemed necessary to investigate. Of those investigated, half again resulted in confirmed findings of abuse or neglect involving 27,219 children. (22)

There are several reasons why so many reports are not investigated. For example, the child was older than 18, the abuse was committed by a stranger so the police are called to investigate, or the case is already active with the DSS. Other reports are investigated and, because of the lack of evidence a finding of abuse or neglect cannot be confirmed, e.g., physical signs of abuse have been healed, or no witnesses can confirm the abuse. A small number of reports are simply false.

Responding to Reports of Abuse or Neglect

Source: DSS, Child Maltreatment Statistics, 1996

Low Birthweight: Age and Race/Ethnicity

The number of confirmed cases in 1996 approached peak levels reached in 1990. Most of this increase is explained by steadily rising reports of child neglect.

In 1996, 85% of the children and families who were the subjects of confirmed reports received services. (The remaining 15% of cases involved alleged offenders who were not family members or who lived outside the home and the children's parents responded appropriately to the abusive situation.(23) )

Although a number of different services are described by DSS as available in confirmed cases, the agency in unable to provide a breakdown of how many families are receiving which kinds of services. Based on information from DSS workers, however, it appears that for many of these children and families, "services" translate most often into intermittent home visits by overburdened caseworkers.

While many children remain with their families while DSS provides services, in July 1997, there were 11,957 Massachusetts children living in substitute care, e.g., foster homes, residential programs, or adolescent shelters. (24) Massachusetts is far more likely than other states to remove children from their homes: In 1995, 65 of every 1,00 maltreated children were removed from their homes, compared to 49 of every 1,000 maltreated children for the nation as a whole. (25)

Most children who are removed from their homes as a result of abuse or neglect are placed in foster homes. Massachusetts relies more heavily on foster care as a substitute placement than most other states: In 1995, for every 1,00 children in substitute care in Massachusetts, 531 were in foster homes, compared to 437 for the US as a whole. (26)

Substitute Care Providers

Source: DSS, Demographic Report on Consumer Populations, July 1997

In July 1997, Massachusetts's children in placement were, on average, 10 years old and had spent 1.4 years out of their homes. (27) More than one-third of the children (36%) had already experienced three or more placements in their lives. (28)

Studies suggest that multiple placements can have serious adverse consequences, particularly for young children: Adult male sex offenders who experienced more changes in caregivers during their childhood tended to commit more serious crimes. (29)

How effective are Massachusetts' efforts to protect these vulnerable children? One way to assess this is to consider how many families' cases are closed and never re-enter the DSS system. Using this criterion, the system's effectiveness raises serious concern. In 1996, 64% of the children whose abuse or neglect was confirmed had already been involved with DSS as a result of a prior supported incident of abuse or neglect. (31)

Additionally, in 1995, 11 children known to DSS died as a result of abuse or neglect. (31) This record does not escape the public's scrutiny: Two-thirds of over 400 citizens surveyed rated the current child protection system a "C" or lower. (32)

Address Factors that Contribute to Abuse and Neglect
Child maltreatment results from a variety of stressors on individuals, families, and communities. To address these effectively, Massachusetts must:

Bring children out of poverty

About 250,000 Massachusetts children live in poverty. (33) At the same time, our economy is booming and we enjoy the third highest per capita income in the nation. (34) Surely our wealthy state can do more to bring families out of poverty and reduce economic stresses that for some families lead to abuse and neglect.

For example, beginning December 1, 1998 an estimated 8,000 children and 4,000 mothers, who do not have jobs and posses few skills, will have their public assistance terminated. No comprehensive program exists to provide these "hard-to-employ" mothers with the education and training they need to find lasting, living wage jobs that would economically benefit them and their children. (35)

Despite wide support for "ending welfare as we know it," there is no support for plunging children into poverty. For example, over 60 percent of Massachusetts residents surveyed strongly endorse legislative proposals that would help working poor families, such as expanding access to child care and after-school programs, and increasing the minimum wage. (36)

Expand treatment services for families dealing with substance abuse

Substance abuse places a large burden on our children protection system. Nationally, 40% of confirmed cases of child maltreatment involve the use of alcohol or other drugs. (37) Parental substance abuse is an important factor in the decision to place children in care. Furthermore, children of chemically dependent parents stay in foster care longer and are more likely to experience multiple placements.(38)

In Massachusetts, the Department of Public Health supports more than 50 specialized substance abuse treatment services for women, including some particularly for women who are pregnant or parenting. The Department works closely with DSS to locate services for care taking parents who are under DSS supervision, but existing programs remain inadequate to meet the demand for those requesting it. The Department of Public Health also assigns two substance abuse specialists to DSS area offices. (39) This expertise should be available to each of the 25 DSS area offices in the state.

Enhance efforts to address domestic violence

In the coming fiscal year, Massachusetts will spend nearly $24 million for programs and services related to domestic violence, an increase of almost $5.5 million over the last year. These funds support 24-hour hotlines; emergency shelters; transitional living programs; individual counseling; support groups; legal, housing, and economic advocacy; and services for children who witness violence. (40)

More than half of the state's domestic violence budget is allocated for shelter and counseling services managed by DSS, including 11 Domestic Violence Specialists. In addition, Domestic Violence Interagency Teams, which involve police, probation, and shelter workers from the local community, now operate in only 6 DSS area offices. Every area office should benefit from a specialized Domestic Violence Interagency Team.

Support the trend in declining births to teenage mothers

Nationally and in Massachusetts, the rate of teen births has dropped steadily since the 1960's. Between 1989 and 1994, births to women ages 15-17 in Massachusetts has decreased 24% , (41) and in 1995, Massachusetts' teen birth rate ranked 7th in the nation. (42)

Across the country, public education campaigns have effectively raised awareness of sexually transmitted diseases and the availability of birth control. Also, in Massachusetts, state funds support special coalitions in 17 communities with the highest incidence of teen pregnancies. These coalitions design and implement prevention programs which are uniquely tailored to the identified needs of each community. To continue and extend the positive downward trend in the teen birthrate, the state should support similar coalitions in every community that express a need for one.

Incorporate strength-based family support as a child protection response

Approximately 25 percent of families reported to the Department of Social Services (DSS) for possible abuse or neglect eventually become active cases. After costly screenings and investigations, abuse or neglect cannot be conclusively confirmed in the remaining 75 percent of the cases. (43) These families, therefore, are never offered the family support services that many would welcome to strengthen their families and improve their parent-child relationships.

To use state resources more efficiently and effectively, some states have instituted a two-track system whereby families reported to the child protection agency receive immediate assessment and either referral to community family supports or formal investigation. In Missouri, for example, under this new system, 71 percent of families were referred for community supports. Only 29 percent required costly state investigations and protection services. (44) Massachusetts should aggressively explore this and other models that are demonstrating better ways to support families and children so they will never have to enter the child protection system in the first place.

Improve the Child Protection System's Response to Families' Needs
In 1992, the Governor's Commission on Foster Care examined our child protection system and published recommendations for improvement. (45) Today, six years later, progress has been made, but several recommendations still stand:

Reduce DSS worker caseloads

Across the state, DSS child protection workers carry an average of 18.2 cases, or families. The Child Welfare League of America recommends a caseload of 15 cases per social worker. (46)

Furthermore, the statewide figure is an average. Many social workers carry even higher caseloads, balanced by others who have reduced caseloads because they are new hires, soon to retire, or on extended leave. Caseloads figures vary by region as well. In Holyoke, for example, DSS workers average 22 cases. (47)

Overwhelming caseloads lead to worker burnout, turnover, and inadequate services to children and families. A fully staffed child protection agency is essential to meet the multiple, complex needs of abusive or neglectful families.

Expand the role of Multi-Disciplinary Assessment Teams and include families in identifying needed supports

The Governor's Commission also encouraged DSS to develop teams with forensic, clinical, and social work skills to conduct in-depth assessments when a family first enters the system. (48) The benefits of this approach are many: "Less money will be wasted on services that are not helpful; the impact of trauma on children will be lessened; the chances of repeat abuse will be reduced; and fewer families will be erroneously identified as abusive or neglectful." (49)

By the end of 1998, DSS will have established Multi-Disciplinary Assessment teams in all 26 area offices. These teams bring in specialists in domestic violence, substance abuse, mental health/trauma, sexual abuse, pediatrics/medicine, and managed care. (50) At present, however, many teams act only as consultants or advisors to DSS, and the services they recommend are too often unavailable or inadequate to meet the families' needs. This shortage of community-based family supports severely limits the capacity of DSS caseworkers to do their jobs.

Multi-Disciplinary Assessment Team members must become staunch advocates who can lobby local and state policymakers to create new supports for troubled families. Also, families must be involved actively with Teams in determining which supports will be most helpful to build their capacity to care for and protect their own children.

Conduct comprehensive clinical assessments of maltreated children when they enter the DSS system, and make sure every child receives the treatment he or she needs.

Children's responses to the abuse and neglect in their lives vary according to the severity and duration of the maltreatment, the age of the child, and their own individual strengths and coping abilities. Many suffer severe symptoms consistent with post-traumatic stress syndrome. Some children express their anger by acting out aggressively against others, while others withdraw and turn their pain inwards.

Because children's responses to abuse and neglect are varied, the system's response to them should be uniquely tailored to meet their individual needs. The overall assessments of families who enter the system should include the clinical assessment of victimized children specialized mental health professionals. Early and accurate clinical assessments should result in specific plans to address the full range of needs identified.

Four out of five citizens surveyed agree that the state should provide protection, placement, and treatment for abused or neglected children. (51) Unfortunately, despite significant expansion in health insurance coverage, access to quality mental health insurance remains grossly inadequate for victims of child abuse and neglect, child witnesses of domestic violence, children with major mental illness, and children with special needs. Current managed care programs in Massachusetts further complicate the picture: The standard care of six mental health visits cannot even begin to address the serious needs of most of these children. Even the maximum of 20 sessions over 52 weeks is inadequate to support many victims of neglect, physical or sexual abuse, or domestic violence. (52)

Furthermore, despite the effectiveness of early interventions for children and adolescents who act out sexually, (53) access to specialized outpatient treatment services has been reduced over the past decade, according to experts in the field. Yet, many citizens polled believe that adolescents who commit sexual crimes against children should receive comprehensive mental health treatment. (54)

Responses to Adolescent Sex Offenders

Source: Massachusetts Campaign for Chidlren, Public Opinion and the Status of Children in Massachsuetts in 1998. (DiNatale and Hock Reseach)

Massachusetts must find a way to ensure quality mental health treatment for both child victims and child perpetrators of abuse, without regard to the limitations of managed health/mental health care systems.

Significantly expand training and support for foster parents

Children thrive in a consistent, stable environment. Unfortunately, abused and neglected children often are separated not only from maltreating parents, but also from siblings, friends, schools, and neighborhoods. In view of research documenting the link between multiple disruptions in living arrangements in young children and later sexual aggressions, DSS should impose a moratorium on multiple moves, especially for infants and preschool children. To achieve this goal, DSS must provide foster families with the required skills, financial support, and additional services to successfully cope with these troubled children.

Build Family Strengths

Offer voluntary home visiting services to all new parents who request them

The supports provided through home visiting programs consistently demonstrat positive effects on children's health and intellectural development, parenting skills, mothers' educational achievements, and, importantly, rates of child abuse and neglect.(55)

Spending money this way is cost-effective: For every $3 spent on family support programs, the state could save as much as $6 that might have been spent on child welfare services, special education programs, medical care, foster care, counseling, and housing juvenile offenders.(56)

The people of Massachusetts recognize and appreciate thea value of home visiting. More than 75 percent of citizens surveyed stated they would support increased spending to provide voluntary home visits for all newborn children of parents under 21 years ofage.(57) Although the state's FY99 budget includes $7.8 million for home visiting programs, it is not enough to reach all new teen parents who request them.

Establish family support programs and collaboratives in every community so no parent is left isolated.

Federal dollars over the past few years have allowed Massachusetts to begin building a network of effective family support services, organized and run by community collaboratives. These networks provide a comprehensive range of resources, including :

• Clothing exchanges

• Food pantries

• Parent educaiton and support groups

• Home visiting programs

• Drop-in centers

• After-school recreational activities

• violence prevention programs

Only 22 of these "Community Connections" programs exist throughout the state, however, despite their enormous potential to strengthen family skills and consequently to reduce the occurrence of serious and costly parent-child difficulties, including child abuse and neglect.(58) And, while federal funding for the Community Connections initiative is virtually assured until 2003, the state has no clear plan to go full-scale.

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To learn how to get involved in improving our state's chidl protection system and how to push for family support resources, contact the Massachsuetts Campaign for Children at 1-800-CHILDREN, or visit our Campaign for Children web pages. The Campaign is a public education and mobilization initiative that is build an informed and active citizen constituency for children in Massachusetts.

To volunteer with organizations working to prevent child abuse, contact Prevent Child Abuse Massachusetts at 1-800-CHILDREN, or visit the Prevent Child Abuse Massachusetts section of our web site.

To report suspected child abuse or neglect, call the Child-At-Risk Hotline (24 hours a day) at 1-800-792-5200.

To learn more about foster parenting or adoption, contact the DSS Foster/Adoptive Care Recruitment Line at 1-800-KIDS-508.

To receive caring support when child-rearing gets tough, call the Parental Stress Line at1-800-632-8188.

(c) 1999 Permission to copy or disseminate information from this data report is granted as long as Massachusetts Kids Count 1996 is cited as the source.

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1. Massachusetts Department of Social Services (DSS) (1997). 1996 Child Maltreatment Statistics, I.
2. Ibid.
3. Petit, MR, & Curtis, PA (1997). Child Abuse and Neglect: A Look at the States. 1997 CWLA Stat Book. Washington D.C: Child Welfare League of America, 7. (henceforth CWLA Stat Book).
4. Ibid.; Daro, D, Research Director, National Committee to Prevent Child Abuse, Personal communication, June 6, 1998.
5. Luntz, B, & Widom, CS (1994). "Antisocial personality disorder in abused and neglected children grown up," American Journal of Psychiatry 151:670-674; Kelly, BT, Thornberry, TP, and Smith, CA (1997). In the Wake of Childhood Maltreatment. Washington DC: Office of Juvenile Justice and Delinquency Prevention.
6. Widom, CS (1998). "Childhood Vicimization: Early adversity and subsequent psychopathology," in Adversity, Stress, and Psychopathology, ed. B. Dohrenwed. NY: Oxford University Press.
7. Widom, CS Ireland, T, and Glynn, PJ (1995). "Alcohol abuse in abused and neglected children followed-up: Are they at increased risk?" Journal of Studies on Alcohol 56:207-217.
8. Kerry, BT, Thornberry, TP, and Smith, CA (1997). In the Wake of Childhood Maltreatment. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.
9. Perez, CM, & Widom, CS (1994). "Childhood victimization and long-term intellectual and academic outcomes," Child Abuse and Neglect 8:617-633; Kelly, BT, Thornberry, TP, and Smith , CA (1997). In the Wake of Childhood Maltreatment. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.
10. Widom, CS (1989). "The cycle of violence," Science 244:160-166; Maxfield, MG, and Widom, CS (1996). "The cycle of violence: Revisited six years later," Archives of Pediatrics and Adolescent Medicine 150:390-395
11. National Institute of Justice (February 1996). Research Preview: The Cycle of Violence Revisited. Washington, DC: National Institute of Justice.
12. Rogers, CM, & Terry, I (1984). "Clinical intervention with boy victims of sexual abuse." In Victims of Sexual Aggression. Stuart, IR, Greer, JG, eds. NY: Nostrand Reinhold, 99-103; Showers, J, Farber, ED, Joseph, JA, Oshins, L, & Johnson, DF (1983). "The sexual victimization of boys: A three year survey." Health Values: Achieving High Level Wellness 7:15-18.
13. Latham, C, Forensic Psychologist (August 3, 1998). Personal communication, based on his work with DSS workers across the state.
14. DSS, Child Maltreatment Statistics, iii.
15. Ibid., 24.
16. Newbarger, J (1997). "New brain development research: A wonderful window of opportunity to build public support for early childhood education," Young Children 52(4):4-9.
17. US Department of Health and Human Services, National Center on Child Abuse and Neglect (1996). Third National Incidence Study of Child Abuse and Neglect: Final Report. Washington , DC: US Government Printing Office.
18. Bowker, LH (1988). "On the relationship between wife beating and child abuse." In K. Yllo & M . Bograd (eds.), Feminist Perspectives on Wife Abuse. Newbury Park, CA: Sage Publications; McKibben, L, De Vos, E, & Newberger, E (1989). "Victimization of mothers of abused children: A controlled study," Pediatrics 84:531-535; Straus, MA, Gelles, RJ, & Steinmetz, S (1980). Behind Closed Doors. New York: Anchor.
19. US Department of Health and Human Services, National Center on Child Abuse and Neglect (1993). A Report on Child Maltreatment in Alcohol-Abusing Families. Washington, DC: US Government Printing Office.
20. Connelly, CD, & Straus, MA (1992). "Mother's age and risk for physical abuse," Child Abuse and Neglect 20:241-254; Zuravin, Sj (1988). "Child maltreatment and teenage first births: A relationship mediated by chronic sociodemographic stress?" American Journal of Orthopsychiatry 58:91-103.
21. DSS, Child Maltreatment Statistics, vi.
22. Ibid.,2.
23. Ibid.,41.
24. Massachusetts Department of Social Services (DSS) (1998). Demographic report on Consumer Populations, July 1997, 23.
25. CWLA Stat Book, 38.
26. CWLA Stat Book, 110.
27. DSS, Demographic Report on Consumer Populations, 24.
28. Ibid.,32.
29. Prentky, RA, Knight, RA, Sims-Knight, JE, Straus, H, Rokous, F, & Circe, D (1989). "Developmental antecedents of sexual aggression." Development and Psychopathology, 1:153-169.
30. DSS, Child Maltreatment Statistics, 8.
31. . Massachusetts Department of Social Services (DSS) (1997). 1995 Analysis of Child Facilities, i.
32. Massachusetts Campaign for Children. Public Opinion and the Status of Children in Massachusetts in 1998. Boston, MA: DiNatale and Hock Research.
33. The Annie E. Casey Foundation (1998). KIDS COUNT Data Book: State Profiles of Child Well-Being. Baltimore, MD: The Annie E. Casey Foundation, 83.
34. The Urban Institute (1998). Federal and State Funding of Children's Programs. Washington, DC: The Urban Institute, 4-5.
35. Massachusetts Law Reform Institute, personal communication with Deborah Harris.
36. Massachusetts Campaign for Children. Public Opinion and the Status of Children in Massachusetts in 1998. Boston, MA: DiNatale and Hock Research.
37. Children of Alcoholics Foundation, Inc. (1996). Collaboration, coordination, and cooperation: Helping children effected by parental addiction and family violence. NY: Children of Alcoholics Foundation.
38. Curtis, PA, & McCullough, C (1993). "The impact of alcohol and other drugs on the child welfare system." Child Welfare League of America, LXXII (6), pp.533-542; Kropenske, V & Howard, J (1994). Protecting Children in Substance-Abusing Families. Washington, DC: US Department of Health and Human Services.
39. Thomas, K (August 17, 1998). Personal Communication. Cambridge: Institute for Health and Recovery.
40. Kirby, GG, Pavetti, LA, Maguire, KE, & Clark, RL (1997). Income Support and Social Services for Low-Income People in Massachusetts. Washington, DC: The Urban Institute, 47.
41. Massachusetts Department of Public Health (1998). Adolescent Births: A Statistical Profile.
42. The Annie E. Casey Foundation (1998). KIDS COUNT Data Book: State Profiles of Child Well-Being. Baltimore, MD: The Annie E. Casey Foundation, 83.
43. DSS, Child Maltreatment Statistics, 2.
44. Missouri Department of Social Services, Division of Family Services, Children's Services Unit (1998), Child Protection Services Family Assessment and Response Demonstration Impact Evaluation, St. Louis, MO: Institute of Applied Research, 9.
45. Special Communication on Foster Care (February 1993). Final Report, Volume I.
46. Child Welfare League of America, Inc. (1996). CWL Standards of Excellence for the Management and Governance of Child Welfare Organizations. Washington, DC: CWLA.
47. Stein, M (1998). "DSS caseload: Numbers don't tell the full story." State House Watch, Vol. Xv, No.11, 18.
48. Special Communication on Foster Care (February 1993). Final Report, Volume I, 9.
49. Ibid.,10.
50. Agosti, JJ (April 1997). "Massachusetts Department of Social Services' Multidisciplinary Assessment Teams: An Evaluation of the Implementation Process." Boston: DSS, 23.
51. Massachusetts Campaign for Children. Public Opinion and the Status of Children in Massachusetts in 1998. Boston, MA: DiNatale and Hock Research.
52. Kirby, GG, Pavetti, LA, & Clark, RL (1997). Income Support and Social Services for Low-Income People in Massachusetts. Washington, DC: The Urban Institute, 48
53. Freeman-Longo, R, and Blanchard, G (1998). Sexual Abuse in America: Epidemic of the 21st Century. Brandon, VT: The Safer Society Press.
54. Massachusetts Campaign for Children. Public Opinion and the Status of Children in Massachusetts in 1998. Boston, MA: DiNatale and Hock Research.
55. Olds, D, & Kitzman, H (1993). "Review of research on home visiting for pregnant women and parents of young children." The Future of Children: Home Visiting. David and Lucile Packard Foundation, Vol3, No.3,53-91.
56. Bryant, P, & Daro, D (1994). Building a Healthy Families America System: A Summary of Costs and Benefits. Chicago, IL: National Committee to Prevent Child Abuse.
57. Massachusetts Campaign for Children. Public Opinion and the Status of Children in Massachusetts in 1998. Boston, MA: DiNatale and Hock Research.
58. Bryant, P, & Daro, D (1994). Building a Healthy Families America System: A Summary of Costs and Benefits. Chicago: National Committee to Prevent Child Abuse.

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