The Role of Federal Education and Labor in School Based Health Clinics

Karen R. Effrem, MD

Written Testimony
June 6, 2000
Subcommittee on Oversight and Investigations
Committee on Education and the Workforce
U.S. House of Representatives

INTRODUCTION

Thank you for holding hearings and for the opportunity to submit testimony on this very important topic. My other title for this subject is "The Clinic in the Classroom." This matter has grave implications for the health, freedom, and privacy of America's precious school children and their families. These issues have raised serious concerns for me as a mother, a physician, and a taxpayer.

Provisions of, loopholes in, or goals of the Healthy People 2000 program, the Goals 2000 Educate America Act, the School to Work (STW) Opportunities Act, the Early Periodic Screening, Detection and Treatment (EPSDT) program under Medicaid as outlined in the Omnibus Budget Reconciliation of 1989 (OBRA), Title I of the current Elementary and Secondary Education Act (ESEA)/Improving America's Schools ACT (IASA), and a joint program of the Departments of Education and Health and Human Services called Caring Communities have resulted in a massive restructuring and merging of health, education and labor programs.

The schools are "one stop shopping centers" for all of these services. School-based or school-linked clinics (SBCs) are the vehicles and tax dollars, especially through Medicaid, are the funding mechanism. The emphasis in our public schools is no longer on the academic liberal arts education required of responsible citizens in a free republic, but instead on medicalized and psychologized mixture of attitudes beliefs, feelings, behaviors, and job skills. Our children are seen no longer as individual human beings with unlimited potential, but as human resources or human capital in a planned and managed economy.

Throughout this testimony, the major programs, examples of problems and abuses and the consequences will be outlined. Although there are many disturbing consequences, the three worst are:

HEALTHY PEOPLE 2000

This 1990 policy document from the Department of Health and Human Services lays the groundwork for health care reform as it was attempted in 1993 and then later merged with the education goals of Goals 2000 to develop the extensive delivery of health care and social services through the schools that has developed currently.

The report consists of 300 "measurable" health care goals divided into 22 areas, such as Mental Health and Mental Disorders, Family Planning, and Educational and Community-Based Programs. These three are the most relevant to what is happening in education and school-based clinics today.

Under Mental Health and Mental Disorders category, one objective that raises concern for school children is the following: "(Developmental) Increase the proportion of children with mental health problems that receive treatment."1 As will be seen below in the discussion of EPSDT and Medicaid, tax dollars are being used to treat children with powerful drugs and counseling without parental involvement for nebulous disorders or poorly applied and vague criteria for others. This objective appears to be a prominent reason why.

The Family Planning category contains several objectives that are responsible for the other major function of school-based and school-linked health clinics, that of reproductive health care:2
 

Although most parents and physicians would agree with all of these goals or at least their intent, the philosophy and science behind some of them and how they are taught and implemented is fraught with controversy. For instance, to increase intended pregnancies or reduce adolescent pregnancies, do abortion referrals increase? That sexual abstinence before marriage and monogamy within marriage is the safest and most effective way to avoid pregnancy and sexually transmitted diseases is indisputable. However, this is not communicated effectively in school-based clinics or sex education classes. Abstinence is often given only lip service while condoms and other contraceptives are distributed or abortion referrals are made in these clinics without parental knowledge or consent. Teens are often not informed about the failure rates of condoms and other barrier contraceptives to prevent HIV infection and their total lack of effectiveness against human papilloma virus (HPV) infection which causes cervical cancer and kills more young women per year than HIV/AIDS. There is much more to say about the reproductive health aspect of SBCs, but the profiling/mental health/data privacy/parental rights/health care reform aspects will be focused on today.

Finally, in the Educational and Community Based Programs category is the following objective: "Increase the proportion of middle, junior high, and senior high schools that provide comprehensive school health education to prevent health problems in the following areas: unintentional injury; violence; suicide; tobacco use and addiction; alcohol or other drug use; unintended pregnancy, HIV/AIDS, and STD infection; unhealthy dietary patterns; inadequate physical activity; and environmental health."3 Among the many concerns and objections to comprehensive school health programs are three main ones. First, these programs take time from legitimate academic subjects when our public school students are struggling to stay competitive internationally. Secondly, much controversy exists about the philosophy behind how these subjects are taught, as alluded to above in the discussion on reproductive health. Finally, efforts to prevent these risk behaviors results in the ever greater collection of personal medical and family data on children and the profiling of children, frequently incorrectly, based on that data.

GOALS 2000

Goals 2000 is the other head of the two headed beast embodying health and education reform. The eight mandates described as goals in this legislation provide the content standards or philosophy for the performance standards embodied in School to Work, as well as for the other programs that implement these mandates.

Goal (mandate) number one states, "All children will start school ready to learn." This is a noble sounding goal, but it raises obvious questions like: How and at what point will a child be ready? Who determines that readiness? How soon and how much will a child be monitored to see if he is ready? What means will be used to make a child ready? What about the beliefs and desires of her family?

To answer some of the above questions, then Surgeon General Joycelyn Elders stated at a dinner on September 16, 1993 that part of fulfilling that goal (mandate) was to make sure that every child was a planned and wanted child so that it would be seen to that that child would start school ready to learn. To accomplish this, she spoke of the need for partnerships between government, schools, churches, homes, and community, as well as the need for SBCs, school/community services and the implantable contraceptive, Norplant.4

Goal (mandate) number eight states, "Every school will promote partnerships that will increase parental involvement and participation in promoting the social, emotional, and academic growth of children." This is another laudable goal, but it also raises questions such as: Who determines and by what standards adequate social, emotional, and academic growth ? What sort of parental involvement will the schools demand? Who has the primary responsibility for raising children, parents, as affirmed by the US Supreme Court in Pierce vs. Society of Sisters, or government schools?

If the answers to the above questions are found in quotes from major stakeholders in the Goals 2000/School to Work system and from government documents, there is not much comfort for freedom loving Americans including parents who want to direct the upbringing of their own children free from government interference. Consider these examples:

The first quote does not mention parents at all and if it did, would apparently hold them responsible for the upbringing of children according to government standards. The second one would have the school become the parents if not meeting the requirements of the schools. In the third quote, it is the schools, not parents that must break the barriers to learning, nebulous conditions like stress are included, and again one wonders who it is that will decide and by what standards if a child is mentally and emotionally healthy. The language in this third quote from a state business group is remarkably similar to the national goal (mandate) number eight.

Perhaps another way to induce parental involvement is the use of parent report cards, as is being done in Chicago, Illinois. These report cards evaluate parents on such items as whether the child has had breakfast or if he remembered his eyeglasses.8 Apparently, the school board does not think that parents are solely responsible for the education of their children and that the parents should answer to the school instead of the other way around.

Still another way to achieve parental involvement is exemplified at the Leonardo da Vinci Magnet School (K-8) in Sacramento, California where parents sign contracts with the school. Each family is required to participate 40 hours per school year for one child. Activities receiving credit include baking, driving, baby-sitting children of families working at the school, and parent training. Activities not receiving credit include parent conferences and classroom observation. It is an odd paradox that those activities that would actually enhance a student's academic performance do not receive credit. In addition, the contract states, "All hours submitted are subject to verification and discretionary approval by the parent coordinator." This "voluntary" participation must meet the school's standards.9
 

SCHOOL TO WORK

Shortly after Bill Clinton was elected president in 1992, Marc Tucker, president of the National Center for Education and the Economy (NCEE), wrote a letter to Mrs. Clinton in which he outlined his vision for the merging of education and labor in what would become Goals 2000 and STW. He says, "First, a vision of a kind of national – not federal – human resources development system the nation could have. This is interwoven with a new approach to governing that should inform that vision. What is essential is that we create a seamless web of opportunities to develop one's skills that literally extends from cradle to grave and is the same system for everyone - young and old, poor and rich, worker and full-time student."10

Here is one prominent place where our children are referred to as "human resources." It is also quite obvious that the "seamless web...that literally extends from cradle to grave" is prominent in America if one looks at the myriad connecting and overlapping programs of health, education and labor that have been put in place using the principles outlined in his letter and other writings. Marc Tucker joined with Hillary Clinton and Ira Magaziner to develop Goals 2000 and School to Work, starting when Bill Clinton was Governor of Arkansas.

It is interesting that the exact language from Marc Tucker's letter is in other federal programs and in states all across the country that supposedly have unique plans developed voluntarily on the state and local levels. For example, Secretaries Riley and Shalala say in their 1994 joint statement on School Health, "The benefits of integrated health and education services can be achieved by working together to create a seamless network of services, both through the school setting and through linkages with other community resources."11 Similarly, Minnesota's STW contract with the federal government says "Minnesota's vision is to create a seamless system of education and workforce preparation for all learners tied to the needs of a competitive economic marketplace."12

What are some of the consequences of STW? Because other panelists have covered this much more in depth today, only this brief list will be offered:

The work-based learning aspects raise safety, child labor and liability issues. A St. Cloud, Minnesota teen lost an arm while using dangerous machinery during a STW program. Young children who visit hospitals may be exposed to contaminated blood and body fluids. Much needs to be discussed in this area.

In order to track students into careers based on the needs of the local economy, the data collection aspects of STW must be substantial. The assessments involved are based on attitudes and beliefs as exemplified in Pennsylvania's Educational Quality Assessment (EQA), whose interpretive literature stated that it was trying to determine a student's "locus of control," whether he is "intrinsically or externally motivated," "amenable to change," "conforms to group goals," "willingly receives stimuli," or "will comply with authority figures."14 Other assessments are related to individual performance tasks and packages that are part of the curriculum. Surveys on a variety of topics are also used liberally. Parents are given the possibility to opt their children out, but many never find out about them until after they are given.

Several Minnesota government documents link the state level Goals 2000 (called the Profile of Learning) and STW programs to each other and to their federal counterparts. One key component of both of these programs on the state level is the "lifework plan." It is defined this way in Minnesota's STW contract with the federal government: "Individualized Lifework Planning and Guidance - ALL Minnesota learners will develop a lifework plan which will be included as one component of the stated Profile of Learning....The lifework plan includes the following components:

Learners demonstrated mastery of academic and work skills (a portfolio of the learner's progress);

The following discussion of portfolios was obtained from the program of the 2000 Minnesota STW Conference: "Looking for a way to record student's career exploration activities starting with kindergartners (emphasis added)? Then this session is for you. We have developed an electronic career portfolio, career exploration and information center. A program that students (K-12), teachers and parents can use to explore and store student personal information (emphasis added), plus a link to vast information on the Web. The program can be personalized and adapted to meet your school needs. The Program can run on one machine, network or web based."

The Minnesota Goals 2000 Technology plan says: ""To receive a diploma a student must produce a record of work in a number of content standards. This record will show a student's achievement in relation to the high standards. (Profile of Learning)...The purpose of this record is to inform students, parents teachers and related services personnel about the progress of all students. In addition, the record is intended to communicate student achievement to future employers. (emphasis added)15"

Special accommodations and/or services a learner may require to successfully achieve educational and career goals;

A cumulative history (emphasis added) of the practical knowledge learners gain in relation to applied learning and work-based experiences......."

Another Minnesota Department of Children Families and Learning (DCFL, formerly Dept. of Education) document says the following about lifework planning:

"A lifework plan is a personal information system. It is a personal plan for the future that takes account of work and other aspects of a person's life."

"A lifework plan should: cover all areas of the learners life....take account of a behaviors and skills....reflect on the learner's dreams and ideals... include a record of the past as well as plans for both the short term and long term future."

"Beginning at age 14, every student must have a written plan for transition that address long and short term goals and activities in five areas: employment, post-secondary education, home living, community participation and recreation - leisure."16

Since when did the government through the schools begin recording and monitoring dreams and plans for home life and leisure for future employment?

Besides these data collections on the local and state levels, Minnesota, California and two other states are part of a pilot project of the Department of Labor to develop a nationwide employment data system that is currently called Occupation Information Network (O*NET) This system contains a list of "model worker characteristics." Some of these characteristics are moral values, social orientation, and adaptability that are then going to be kept in a federal government database for use by potential employers.17

Several key points about data privacy and STW are obvious from reading the above quotes. First, data in this system follows the student from kindergarten. Actually, as will be described below, due to the early childhood programs, data is recorded from birth and includes medical data. Secondly, these academic, medical, and employment data are or will be merged and follow a child throughout his life on all levels of government, similar to the dossiers in the former Soviet Union and Communist China, literally from "cradle to grave." Finally, the government will be monitoring attitude, belief, and value data of individual citizens. How long will it be before there could be state controlled thought? Is this what we want in a constitutional republic?
 

MEDICAID/EARLY, PERIODIC, SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)/ELEMENTARY AND SECONDARY EDUCATION ACT (ESEA)/ INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)

After the failure of the Clinton health care reform plan in 1993, documents were found in the National Archives from the Health Care Task Force revealing plans to implement universal health care through the schools via Medicaid. Public schools were called "a captive audience...for school-based clinic initiatives and ...into the broader system of health care."18

At a 1993 dinner speech, then Surgeon General, Dr. Joycelyn Elders, publicly nodded "yes" when hearing this statement from a floor microphone: "As I see it, the infrastructure is in place for Medicaid to become the universal health care coverage." 19

During the health care debate, Ira Magaziner agreed with her, saying, "...the traditional health insurance industry will disappear...Medicaid would merge into the main health care system." Mr. Magaziner was involved not only in health care reform, but in education reform as well.

In 1994, Dr. Elders gave a speech on adolescent pregnancy and said, "In a part of the federal health care reform bill, there is a piece called the Youth Initiative, and there's money in there for comprehensive health education from K-12, and there's money in there for over 5,000 school-based clinics for schools that have a high percentage of high risk students in their schools."20

As mentioned, school-based clinics are the mechanism for the increased delivery of health and social services in the schools. While no one would disagree that they provide some valuable services, such as athletic physicals, their two main areas of function are fraught with controversy and hold the greatest dangers of loss of parental control in the health care of their children, data privacy concerns, and philosophical differences that can have life altering consequences for the student and the family. Those areas are mental and reproductive health care services.

Often students are referred for these services without parental knowledge or consent or after a blanket consent that is supposed to cover routine physical health care. If the parents do find out, they often cannot see the records due to legal constraints while their insurance is still billed for the services affecting the parents' coverage limits and the child's future employability and insurability.

Medicaid funds have been used for a myriad of purposes in schools, sometimes for purposes that have little to do with health care or academics. Consider the following two passages from a 1996 letter written by Medicaid consultant Jean Rowe chastising a school district in Illinois for not taking enough advantage of Medicaid funding:

"Medicaid...has been expanded to cover not only therapies, but also social work and psychological services, nursing and audiological services, hearing/vision screening, and transportation."

"Medicaid dollars have been used for...audiometers to mini-buses, from a closed captioned TV for a classroom, to an entire computer system, from contracting with substitutes to employment of new special education staff, from expanding existing social education programs to implementing totally new programs. The potential for dollars is limitless." (emphasis added)

The list of diagnoses and situations covered by Medicaid/EPSDT is long, and as can be seen from the partial list below, some of these conditions like math or reading deficiencies caused by the breakup with one's boyfriend or girlfriend are far fetched at best. It must be remembered that the Diagnostic and Statistical Manual (DSM) of the American Psychological Association has no entry for normal:

There is the diagnosis of attention deficit disorder, which is sadly becoming the most frequently diagnosed mental disorder of childhood. Again, one needs to ask serious questions about the validity of a diagnosis often made in 15 to 20 minutes in a harried pediatrician's office when there is federal funding at stake for the school and or the child's family. Even if there are true attention problems not attributable to classroom, home, nutritional or other problems, not a single study in 50 years of use and evaluation in the peer reviewed medical literature has found Ritalin to have long term academic or social benefits. The drug has serious side effects that need to be further evaluated, and there are no long term studies on the effects this drug has on the brains of growing children.

Identification and referral requires more gathering of data as well as the spending of taxpayer dollars to identify clients who will require the spending of more taxpayer dollars for things such as an aid to ride home with Johnny if he is stressed by the class bully.21 The family planning referrals are fraught with medical and social controversy. If all else fails for the social planners in the schoolhouse, there is the category of "at risk." Any child who does not meet the behavioral and mental health goals of Goals 2000 or Healthy People 2000 is at risk of being at risk.

Some problems with Medicaid involvement in SBCs are listed below:

From the child's and family's perspectives, the biggest problems on this list are the lack of autonomy of the parents, the data privacy concerns, being tagged with a diagnosis that will follow the child forever affecting employability and insurability, and finally the risk of having physicians or nurses in SBCs prescribe medications without a full medical history. From the constitutional/taxpayer perspective, no legislative oversight and implementing unpopular programs surreptitiously are the gravest problems.

CARING COMMUNITIES

In 1993, the Departments of Education and Health and Human Services jointly published a document called Together We Can: A Guide for Crafting a Pro-family System of Education and Human Services. This was one of the first government discussions of the merging of health care with education, just as Marc Tucker's letter was the first discussion of the merging of labor and education. The foreword states, "Together We Can is a practical guide that can assist local communities in the difficult process of creating a more responsive education and human service delivery system. The guidebook emphasizes the effective delivery of supports for families, a crucial step toward assuring the future success of America's children...It encourages a holistic approach in treating the problems of children and families; easy access to comprehensive services; early detection of problems and preventive health care services; and flexibility for education, health and human services."22

It appears, according to this, that there is a program for every problem and that families are just one of many partners in raising their children. This quote makes one think that families cannot do a single thing for themselves or their children without looking to the government. The "village" mentality is everywhere. This attitude is confirmed when one of the items on the checklist in the Appendix asks, "Has the collaborative conducted a comprehensive community assessment that...produced a profile of child and family well-being in the community?" Since when is it the government's job to do that?

There are plans, especially through private foundations to expand the medical and social services of school-based clinics to provide comprehensive school health as described above. Other names for this phenomenon are full service schools and community schools.

OTHER RESULTING AND RELATED PROGRAMS

A number of state and national programs have arisen out of efforts to comply with the goals (mandates) of Goals 2000, Healthy People 2000, and all of these other programs. Some were in operation before Goals 2000 and the other national programs became law and have expanded since then, while others have developed in conjunction with or because of them. Many of the programs were funded by large foundation grants either in the beginning to get them started or later to keep them going after they have been rejected by elected members of representative government. That is the case with health care reform which was kept going by the Kids First program for SBCs funded by the Robert Wood Johnson Foundation.

One example of these related programs is Parents as Teachers. This program began in Missouri in 1981 based on research by psychologist Dr. Burton White and his Harvard Preschool project. The program was based on his efforts to test his belief in the concept that "...public schools guide a child's learning from birth rather than from kindergarten."23 This program is one of the first in the country to employ the concept of the home visitor/educator, and has now expanded into 40 states and 4 foreign countries. It involves certified parent educators who visit young parents either at home or at a school and offer advice on childrearing. Extensive data gathering occurs for the child and family that follows the child throughout life. Checklists have vague items such as: "Parent does not compress lips, grimace, or frown when making eye contact with the child."

In addition to the checklists, there are also twelve "at risk" designations that can be quite subjective and there is no category for normal. Two examples are:

The parent educators are mandated child abuse reporters. Although intentions are wonderful and some of the things listed above are important to children's health and development, questions still need to be asked, such as: How much potential is there for a charge of child abuse and neglect due to philosophical or religious differences between the parent educator and the parents? How well can some of these very nebulous standards be assessed? Are parents aware of the autonomy and privacy that they may potentially lose when they sign up for this program? What is the quality and amount of training that the parent educators receive?

Dr. White resigned his position as head of Missouri's program because he felt there was not enough training for the educators and that there was not rigorous enough evaluation. The training was less, the pay lower and the turnover higher than in the original pilot project. There has been a study from Texas showing no gain for children in the program there due to what he says are these types of problems.25

Apparently he was not worried about parental rights abuses in his program or in his philosophy when he spoke about the related issue of licensing parents saying, "If it is indeed true that what parents do with their very young children has lasting, powerful effects, then it seems that licensing may not seem to be such a farfetched notion."26

Another is the Healthy Families America home visitation program developed by Prevent Child Abuse America (formerly the National Committee to Prevent Child Abuse). No study has found any statistically significant reduction in child abuse and neglect reports in families enrolled in the various forms of the program throughout the country, and some have had actual, though not statistically significant increases in these reports.27 Substantial data gathering occurs in this program as well. This data collection concerned Congressman Henry Hyde, chairman of the House Judiciary Committee so much that in an October, 1998 letter to colleagues he called home visiting "cradle-to-grave tracking of newborns" and "big brother intervention as we have never seen before."28

Other worrisome issues related to these programs include unconsented review of private medical records, whether consent is informed and voluntary for participation, that the home visitors are required to have only a minimum of 5 days of training, that they may be presenting information that is not scientifically supportable or violates the government's duty to maintain neutrality with respect to deeply held personal beliefs, that the investigative role of the home visitors is not made clear, and that participants are submitting to a search of their homes without informed consent violating their 4th Amendment rights.29

Before concluding with proposed solutions, two final examples of Minnesota state documents that exemplify the goals of Goals 2000 as well as the "village" mentality are provided. The first is the list of Early Childhood Outcomes and Indicators produced by the Minnesota Department of Children, Families, and Learning (DCFL). Area VII, Children Reach Their Individual Developmental Potential, is particularly illustrative and the outcomes are listed below:

The same type of questions must be asked yet again. How does the state standardize individually developmentally appropriate outcome, and do we want the state doing that for very young children? This very same state bureaucracy publishes a brochure titled "Their Minds are in Our Hands." This brochure features on its cover a pair adult hands holding the head of an infant with that title and the DCFL logo in the corner. Although quite unintentionally, this arm of the state government has created a powerful and frightening image and it is appended to my testimony.

Finally, there is a document in the Minnesota School Health Guide (handbook for school nurses) called Guidelines for Early Identification of Mental Health Needs in Children and Youth. It contains criteria for identifying different mental health problems in children from newborn to adolescent. At the end of every section divided by age is the following statement: "From observation, is there anything unusual or disquieting that was observed in the interaction between the parent and the child that could reflect a lack of knowledge of appropriate parenting skills or a possibility of maltreatment? Record your observation and consider this sufficient for a referral (emphasis added)." The identical concerns continue to be raised by these documents. A referral to child protective services or for mental health services can stay with a child or family forever. Shouldn't these potentially life altering referrals be free from potential conflicts of interest related to ideology and federal funding?


 

SUMMARY AND PROPOSED SOLUTIONS

First, starve the beast of Medicaid funding through all of these various federal programs, such as EPSDT, Goals 2000, IDEA, and ESEA. The pressure and conflict of interest for a school to 'bring home the bacon" would be eliminated as would this back door implementation of national health care that has failed miserably in other countries.

Secondly, increase Congressional and state legislative oversight of these programs. This will likely include decreasing foundation participation and partnerships, which too often prevents proper oversight.

Thirdly, there should be explicit opt-in procedures after informed consent for the gathering and dissemination of student and family data. There is a merging of academic, medical, and now employment through the schools that allows government far too complete a picture of every aspect of our children's lives. In the case of home visitation programs, vulnerable young families need to be properly appraised of the potential loss of autonomy and constitutional rights inherent in these programs.

Fourth, there also need to be explicit consent obtained for screening, testing, assessing, and referrals for physical and mental health treatment in the schools and an option for parents to review and object to any test, survey, screening, or curricular materials.

Finally, and most importantly, we need to remember the primary mission of our schools. It is to teach our children core academics of a liberal arts education that will allow them to become responsible citizens in our constitutional republic and give them the framework to pursue any career that our fast-growing, entrepreneurial economy needs at the time they are ready to pursue it. They do not need goals, attitudes, beliefs or job skills to be tracked into entry level jobs. We have the most freedom and the greatest economy of any country on the face of the earth. Let us not sacrifice our precious children and our freedom to ideas that have failed miserably everywhere they have been tried. Thank you.
 

Footnotes:
 

1 Healthy People 2000 and 2010: National Health Promotion and Disease Prevention Objectives, US Department of Health and Human Services, 1990 and 2000, http://www.health.gov/healthypeople/Document/tableofcontents.htm (Although the 2000 report is referenced here, the objectives are the same).

2 ibid.

3 ibid.

4 As discussed in Health and Education Reform: Freedom's Voluntary Demise?, Smith, 1997, Life's Silver Linings, St. Louis, Missouri, p. 331

5 Roots and Wings design team of the New American Schools Development Corporation (federally funded model for outcome based education) as quoted in Brave New Schools, Kjos, 1995, Harvest House Publishers, Eugene Oregon, p. 162

6 Eight Principles that Must Guide the Transformation of Today's Iowa Schools into the World Class Schools of Tomorrow - Iowa Roundtable, as quoted in ibid., p. 163

7 Eight Principles that Must Guide the Transformation of Today's Iowa Schools into the World Class Schools of Tomorrow - Iowa Roundtable, as quoted in ibid., p. 163-4

8 http://www.cnn.com/2000/US/05/19/grading.parents.ap/index.html (Webmaster's note:   This currently appears to be a dead link.)

9 Parent-School Compacts...Mandatory Volunteerism for Parents? as quoted in School to Work, Goals 2000, and other Curricular Atrocities, Holgate, Parents National Network, Palm Desert, California

10 — Marc Tucker, President, National Center On Education and the Economy,

Letter to Hillary Clinton [following the 1992 election]

11 "Joint Statement on School Health," April 7, 1994, Secretaries of Education, and Health and Human Services, Journal of School Health, Vol. 4, No. 64

12 Minnesota School to Work Initiative, August 26, 1996, p. 1

13 Holgate, op. cit.

14 As quoted in The Cloning of the American Mind: Eradicating Morality Through Education, 1998, Eakman, Huntington House, Lafayette, Louisiana, p. 13

15 Minnesota Goals 2000 Technology Plan, p.4

16 Quotes from "Lifework Planning," from the MN DCFL, pages B-3 through B-11.

17 U.S. Department of Labor, Occupation Information Network, Content Model Worker Characteristics (http://dolea.gov.programs/onet/workchar.htm) (Webmaster's note: This currently seems to be a dead link.)

18 Eakman, op. cit., p. 370

19 Dinner speech at the invitation of the Missouri Public Health Association, U. S. Surgeon General Dr. Joycelyn Elders, September 16, 1993, Henry VIII Restaurant, St. Louis, Missouri, as quoted in Smith, op. cit. p. 112

20 "Teen Pregnancy and Prevention: Colorado Call to Action," U.S. Surgeon General Dr. Joycelyn Elders, February 16, 1994, Colorado Conference of Health Officials audiotape as quoted in Smith, op.cit., p. 108

21 Eakman, op. cit., p. 336

22 Together We Can: A Guide for Crafting a Profamily System of Education and Human Services, Contract #RP912060001: PrismDAE, a division of DAE Corporation, 1993, Rockville, Maryland.

23 The New First Three Years of Life, White, 1995, Fireside division of Simon and Schuster, New York, New York, p.351

24 Revised Edition 1990, Missouri Department of Elementary and Secondary Education, National Parents as Teachers Center

25 White, op. cit., p. 353

26 ibid., p. 349

27 The Parent Trainers: A Nationwide Study of Home Visitation Programs, Lightfoot and Weed, 1999, Physician's Resource Council of the Alabama Family Alliance, Birmingham, Alabama, p. 32

28 Infant Home Visiting: Families Under Surveillance, Brase, Citizen's Council on Health Care Issue Brief, February 12, 1999

29 Lightfoot and Weed, op. cit., p. 43-51



Questions and Answers Related to June 6, 2000 Testimony

Karen R. Effrem, M.D.

Subcommittee on Oversight and Investigations

Committee on Education and the Workforce

U.S. House of Representatives



Q: Please outline the types of individual personal and medical data gathered on America's school children in elementary and secondary schools and where it goes.

A: The Minnesota Goals 2000 Technology Plan says:

"To receive a diploma, a students must produce a record of work in a number of content standards. ...The purpose of this record is to inform students, parents, teachers, and related services personnel about the progress of all students. In addition, the record is intended to communicate student achievement to future employers."1

Teachers enter data on each student for the school and district into an electronic file folder or portfolio. The district can then choose from a number of vendors such as National Computer Systems, TIES and Skyward to put this data in a common format, store it, and send it on to the state or whomever requires it.2 The president of TIES was on the Minnesota Goals 2000 Technology Panel.3


 

TIES, which stands for Technology and Information Education Services, brags on its Internet site that it can track everyone in the district, be they preschool, nonpublic students, or adult household members.4 How do they do that and why do they need to monitor people not in the schools?

TIES Internet site also states that it integrates student information with school finance, human resources, and payroll information.5 To what end? Is this to monitor teacher performance? Does it relate to School to Work?

According to one prominent education researcher, this data is used to monitor teacher performance in transmitting the outcomes of Goals 2000 and School to Work. Beverly Eakman says:

"As indicated, with the microrecord teacher characteristics can be linked, too, to pupil performance. This means that the teacher will not be able to avoid teaching the objectives (outcomes) set forth by the state and district, no matter how idiotic these objectives may be, and the tests he or she gives will be scored for these particular objectives, whether they reflect opinions and worldviews or true academics."6

The central educational data gathering agency in Minnesota is MARSS -- Minnesota Automated Recording Student System -- part of the Department of Children, Families and Learning Its data element handbook is 52 pages long and includes such elements as the social security number and every other conceivable descriptor of students and their status in school, including medical data.7 Minnesota state statute, Chapter 13.32, subdivision 2 says the following:

Subd. 2. Student health and census data; data on parents. (a) Health data concerning students, including but not limited to, data concerning immunizations, notations of special physical or mental problems and records of school nurses are educational data (emphasis added).8

Data from MARSS is then sent on to the National Center for Education Statistics. The data element outline from the National Student Data Handbook is six pages of single line entries in two columns, and contains elements such as extensive medical information, the religious background and dwelling arrangement of our children. The entire 2000 edition of the NCES data handbook is 298 pages.9

There are 26 coded entries for religious background.10 What business is that of the federal government? For what purpose is that information used? Under the First Amendment to the Constitution and the Declaration of Independence, we are all equal and free to exercise the religion of our choice. It should not be in a dossier that is kept by the federal government and looked at by employers.

There are 14 different entry codes for dwelling arrangement, ranging from homeless shelter to institution.11 To make sure that the federal education bureaucracy can reach out and touch you, there are 18 different codes for communication type ranging from home telephone to beeper number to telex.12 This information might be necessary for a local district for emergency contact purposes, but why does it need to be in a federal database?

The medical information kept by the NCES is the most disturbing. It begins before the cradle by keeping prenatal data on students like the gestational age of the baby when the mother had her first doctor visit and the number of doctor visits the mother had during pregnancy. The database continues with birthmarks, number of teeth decayed, oral soft tissue condition, and every kind of physical and emotional disturbance and disease.13 In the explanation of data elements, emotional disturbances are characterized by the following incredibly vague characteristics:

1. An inability to learn that cannot be explained by intellectual, sensory, or health factors;

2. An inability to build or maintain satisfactory relationships with peers or teachers;

3. Inappropriate types of behaviors or feelings under normal circumstances;

4. A general pervasive mood of unhappiness or depression; or

5. A tendency to develop physical symptoms or fears associated with personal or school problems14

The Minnesota state data outline uses exactly the same phraseology to describe emotional disturbance.15 Who decides what is appropriate? Is it a state bureaucrat or district official looking at a diagnosis that will provide more federal dollars from programs like IDEA or Medicaid where "the potential for dollars is limitless?" Perhaps it is a psychologist or social worker who has the same philosophy as Harvard psychologist, Chester Pierce, who said,

". . .Every child in America entering school a the age of five is insane because he comes to school with certain allegiances toward our Founding Fathers, toward his parents, toward belief in a supernatural being, toward sovereignty of this nation as a separate entity . . It's up to you [psychiatrists and psychologists] to make all these sick children well by creating the international child of the future."16

There is not a single thing in the information that is given to the local school district that is understood by the parents to be confidential and for local use that does not end up in a huge federal database where many eyes can see it and potentially steal or abuse it.

SPEEDE / ExPRESS (Standardization of Postsecondary Education Electronic Data Exchange / Exchange of Permanent Records Electronically for Students) is the final collector of all federal education data. It takes the NAEP, NCES, and numerous other sources of data and catalogs it for uniform recording and transfer among postsecondary institutions, which is its stated purpose. The data also goes to corporations and other entities, however.

In fact, there are 29 automatic recipients of this data. Included are the US National Goals Panel (implementing Goals 2000), all of the national computerized testing companies, the Rand Corporation, and the US Department of Defense Manpower Data Center. One of these automatic recipients of NAEP data is the same company that developed Osiris, a software package that collects supposedly local student data from individual school districts here in Minnesota. The fact that these supposedly confidential data are being examined and used by this many people in this many different entities is disturbing enough, but what is being done with the data must still be more thoroughly examined. Funding to continue this development of dossiers on innocent children should be eliminated.

Q: How is the National Assessment of Educational Progress (NAEP) involved in gathering data about the values, attitudes, beliefs, and behaviors of America's school children?

A: One of the main developers of the NAEP was a psychologist by the name of Ralph Tyler. He was Chairman of the University of Chicago's Department of Education before he became chairman if the Carnegie Foundation for the Advancement of Teaching, where the NAEP was written. In his 1949 text, Basic Principles of Curriculum and Instruction, he stated that the "real purpose of education is not to have the instructor perform certain activities but to bring about significant changes in the students' patterns of behavior."17 This child-centered curriculum of his combined with Carnegie colleague Benjamin Bloom's philosophy, saying that the purpose of education was to "change a student's fixed beliefs,"18 along with several others of like mind were responsible for outcome based education that has been manifested through Goals 2000 and School to Work. They believed that, according to researcher Beverly Eakman, "that what a child believed and felt was more important than what he knew."19 This was the beginning of the death of knowledge-based education in this country.

The NAEP has been the foundation for many of the state assessments, either through banks of questions from the NAEP or because Ralph Tyler was hired by individual states to write their assessments. This was confirmed by a mother in Pennsylvania who filed a complaint against the Pennsylvania Department of Education for the invasive psychological questioning that occurred in the Pennsylvania Educational Quality Assessment.20 The test had 375 questions and only 60 had anything to do with academic subjects. Interpretive literature for that assessment found that the goals for the assessment were to find the student's "locus of control," whether he is "intrinsically or externally motivated," "amenable to change," "conforms to group goals," "willingly receives stimuli," or "will comply with authority figures."21 Through a four year investigation beginning in 1985 and battle, the EQA has been discontinued, but parents have never been able to get the information stored on their own children. A new legislatively ordered study of the current assessments is going to happen this summer (2000).

Minnesota's Comprehensive Assessments (MCAs) are not at all available to parents, teachers, or administrators for scrutiny, except for sample tests. Under Minnesota Statutes 13.34, the assessments are nonpublic data. The only information that the school or the parent, has on the child is their numerical (1-4 rubric) score. The MCA is not used for remediation of individual students, but rather to assess individual school and district compliance with our Profile of Learning which is Minnesota's program to comply with the federal Goals 2000 and School to Work contracts.

Aside from the psychological data collected on the MCAs, which will be discussed below with writing tests, there is the personal family data that is collected. Minnesota State Statute 120B.31 [SYSTEM ACCOUNTABILITY AND STATISTICAL ADJUSTMENTS] Subd. 4, enacted in 1997, reads as follows:

"In developing policies and assessment processes to hold schools and districts accountable for high levels of academic standards, including the profile of learning, the commissioner shall aggregate student data over time to report student performance levels measured at the school district, regional, or statewide level. When collecting and reporting the data, the commissioner shall: (1) Acknowledge the impact of significant demographic factors such as residential instability, the number of single parent families, parents' level of education, and parent's income level... Any report the commissioner disseminates containing summary data on student performance must integrate student performance and the demographic factors that strongly correlate with that performance."  (Emphasis added)

Again according to research done by Beverly Eakman in her 1998 book The Cloning of the American Mind: Eradicating Morality Through Education, a 1969 book by Walcott Beatty called Improving Educational Assessment and an Inventory of Measures of Affective Behavior "stated that federal funding for schools would hinge on data collection at the local level and the use of national testing (NAEP) objectives in obtaining this data, including information on attitudes and opinions, would be the key.... Beatty emphasized the collection of non-cognitive information, with the caveat that the whole arrangement avoid the appearance (emphasis by Eakman) of establishing a national test or curricula."22

According to this and many other quotes in her book and others, the intent all along has been to use the NAEP as a national test to gather attitudes and beliefs of America's school children, develop national curriculum, and continually test students on their compliance with that national curriculum. It is clear from the proposed reauthorization of the ESEA that the effort is to a establish the NAEP as the single national criterion referenced test. Criterion referenced tests measure attitudes and beliefs, not academic knowledge. The criteria are set by whomever writes the test. They are really assessments, which are subjective, not tests, which are objective, hence the name National Assessment of Educational Progress.

The Constitution provides no role for the federal government in education. That the federal government is developing databases of its children's feelings and beliefs instead of academic knowledge is unconscionable. Funding for this type of testing must be eliminated until norm-referenced academic achievement tests are restored if at all.

Q: How else is personal data collected on Minnesota students?

A: Data is collected through surveys and assessments, sometimes masquerading as academic tests. Examples of survey questions that Minnesota students are regularly asked as part of the Adolescent Health Survey given to 6th, 9th, and 12th grade students are as follows: "Has drinking by any family member repeatedly caused family, job, health, or legal problems? If so, who?"23 There is an identical question for drug use. Apparently the Minnesota Departments of Health and Children, Families and Learning (DCFL) have no ethical, legal or moral qualms about using children to report on their parents.

One of the most recent and egregious examples of using so called academic testing to obtain personal data was the Basic Skills Writing Test administered on January 27, 2000 to Minnesota 10th grade students. This test is required for graduation and had the following prompt:

"Your teacher has asked you to write about one thing you would like to change about yourself. Name one thing about yourself and give specific reasons why you would like to change it. Give enough details so your teacher will understand your ideas."

There are a host of problems with this question. It is invasive and personal and should not be required to pass a state test for graduation. The students were misled and manipulated by having the state exploit the interpersonal relationship that students have with their teacher so that they would think they are providing this personal information to their own teacher who would read and score the test, when the teachers would never see the tests. They were sent to an outside firm to be scored. Parents could not see the question and consent or protect their children from this invasion of privacy. Teachers were forced by this pervasive system to lie to their students by telling them it was they who required the information and it was to be the teachers who received and scored it, not the state. And, even if the teachers were uncomfortable with giving this question and lying to their students, they are trapped in the state system and did nothing about it.

The data becomes part of the student's personal and permanent electronic portfolio that can be sent at the touch of a button to any of the 16 other state agencies with which the Department of Children, Families, and Learning now intermingles, including the Departments of Human Services and Corrections.24 As stated above on page 4 of the Minnesota Goals 2000 Technology contract with the federal government, "In addition, the record is intended to communicate student achievement to future employers." It is also plain to see after the discussion on data collection above that this information goes on to federal education agencies and databases like NCES, which is the keeper of testing and assessment data and SPEEDE/ExPRESS.

Parents, student, teachers, and legislators across the state were outraged at this incident. Legislation was introduced in the Minnesota House of Representatives to destroy all of the tests, never use that prompt again, and develop a new test approved by the House and Senate Education Committees. All of the concern and corrective legislation were mocked and scorned as right-wing paranoia by the commissioner, the major newspapers, and those in the legislature who thought it was perfectly fine to intrude into a child's life this way. The legislation was removed from the conference report by the liberal Senate. The DCFL said that the only purpose of the test was to evaluate and score a student's writing capability related to organization, punctuation, grammar, and spelling and that what they wrote about did not matter.

It was not until the after the legislative session was nearly over that the tests were returned and it was found out that 251 of them were flagged because of their content for the student to receive further evaluation and possible psychological counseling. Content did matter and the students, whether writing of real or imaginary situations will potentially be evaluated by psychologists, which will also be in their permanent record.25

Prompts from the Minnesota Comprehensive Assessments given in 3rd, 5th and 8th grades are just as intrusive as the Basic Skills Test prompts as demonstrated by the following sample prompts from the 5th grade writing assessment:

"Think about a time when you felt you were treated unfairly. Tell about it."

"If you could become any animal, what animal would you choose to be? Why?"

"Think about a problem in our environment such as air pollution, or endangering species. Write a letter to a younger child identifying this problem and offering a possible solution to this problem."26

This type of evaluation of content and psychological probing was apparently planned from the beginning as described by a teacher who was involved in pilot evaluations of the Basic Skills Writing Test. She discussed how the tests were evaluated for content and that any alarming papers were to be "red flagged" for further evaluation with notification of parents and the school district as soon as possible. The need for timely notification of parents was especially emphasized in the training. It turns out that her son was one who took the trial test and was very angry about the personal nature of the tests questions from which he was allowed to choose. His paper was flagged because of his anger at the invasion of his privacy and the mother, a teacher, was not officially notified for 5 months or longer of the alleged problem.27

That this sort of data gathering is being done on a national basis was well described by education researcher Beverly Eakman. She states, "Today, there are many companies involved in large-scale data collection; for example, National Computer Systems (the company that scored Minnesota's writing test and is one of the automatic recipients of NAEP and NCES data28) provides training to subcontracting agencies and other groups in the areas of proctoring workshops, validation, writing questions, especially the open-ended opinion oriented variety. A January 1991 pamphlet states that testers will get their data from: "anecdotal records, attitude inventories, writing samples."29

She further describes the privacy consequences and less than honorable intentions involved, saying, "that things like writing samples are being used to profile students and sniff out dysfunctional parents. The intention is not primarily to assess proficiency in skills like grammar and punctuation. More significantly, these anecdotal records, attitude inventories, and even the writing samples are often used by educational (behavioral) psychologists to generate the correct political wording for a state's goals and outcomes - goals and outcomes that will eventually be sold to you, the taxpayer and parent, as though they were local initiatives."30 Through out her book, she discusses the process and examples of the gathering of data on individuals to develop profiles of communities in order to market various governmental schemes. Is this what we want our government to be doing in public education and in society in a constitutional republic?

Q: What are the consequences of Medicaid and other federal funding, data collection, mental health profiling, and the content of federal programs with regard to the skyrocketing prescription rates of psychotropic drugs like Ritalin?

A: When federal funds are involved, there is an obvious conflict of interest and a perverse incentive for schools to label as many children as possible with some diagnosis in order to receive those funds. Minnesota had the dubious distinction in 1999 of leading the nation in the classification of children as EBD (education behavior disorder). A large proportion of those students were from minority backgrounds.31 If it is true, as a Medicaid consultant stated in a letter to a school official, that "the potential for dollars is limitless,"32 then so is the potential for overdiagnosis.

This overdiagnosis is fueled by the data collection and profiling. The writing tests described above and the document entitled Guidelines for Early Identification of Mental Health Needs in Children and Youth described in the body of the testimony are specific ways that it is done in Minnesota. For example, in both the toddlers (1-3 years) and preschool/kindergarten groups the following behaviors are on the checklist of the latter document that parents are supposed to answer to school nurses, home visitors, or that these personnel are supposed to observe themselves:

Under behavior - overactive33

Under thinking - problems concentrating (toddlers) or inattentive (4-6 year olds)34

The accuracy of the application of these very subjective criteria needs to be questioned, especially in brief encounters and with very young children. It is the unusual toddler or preschooler that is not active or that concentrates on anything very long. Normal attributes of childhood are being mischaracterized as disordered to allow for the diagnosis, drugging, and control of children, and the receipt of federal funds.

Finally, the loss of academics to behavior modification and teaching of job skills will also create many bored and restless children that can then be classified as ADD/ADHD or some other disorder. This has other major associated problems, especially in the inner city, where it may lead to antisocial behavior, delinquency, and violence as described by Michael Brunner, research fellow at the National Institute of Justice, in his book Retarding America: The Imprisonment of Potential. He said the following:

"What brings about the delinquency is not academic failure per se, but sustained frustration which results from continued failure to achieve selected academic goals. When frustration can find no resolution into constructive or productive activity, one response...is aggressive, antisocial behavior....The antisocial aggression that Pavlov was able to create in the laboratory is being created in tens of thousands of classrooms across America..."35

Inner city children are particularly prone to frustration relating to academic problems because according to columnist and think tank researcher, Katherine Kersten, being "bereft of home-based resources, disadvantaged children must rely on the schools to close the knowledge and vocabulary gap with which they begin life..."36 Not teaching any child the basics is a terrible crime, but it is particularly heinous to deprive inner-city children of this knowledge, because they often will not receive it at home. It is even more heinous when academic knowledge is being replaced with psycho-behavioral mush or students are spending precious academic time going to job sites for various workbased learning activities. All of our children are at risk from this type of education, but the poor will suffer the most.

Q: What types of data are collected on families through infant home visiting programs and what is done with that data?

A: In the Healthy Families America (HFA) program, workers identify potential clients either by examining confidential medical records without consent or they verbally screen mothers in the hospital without stating that their intention is to determine that mother's child abuse potential. The mothers are not told about the review of the records or that the workers that do the verbal screens are not hospital personnel and that they may refuse the screening.37

The mothers are screened based on 15 risk factors. The screener then notifies a Family Assessment Worker (FAW) who attempts to further assess her risk by administering the Kempe Family Stress Checklist (FSC). Questions are extremely personal and include: whether the mother has received any psychological counseling, whether or not she or her husband/boyfriend have ever been arrested, whether they yell or scream when they argue, whether both she and her mate were happy about her being pregnant, and whether she considers her own parents to have been abusive.38

This FSC data is stored in a national database called Program Information Management System (PIMS) along with "information on household characteristics, participant characteristics, risk factors for abusing and maltreating children, and outcomes." Even those families who refuse the program after being assessed have their answers to those intrusive questions on the FSC entered into this national database.39

Regardless of their effectiveness, which is not borne out by multiple studies, the constitutional and ethical breaches of this and other home visiting programs need to repaired by the states. Because the federal has no constitutional jurisdiction in the monitoring of family life, these programs should never be considered for expansion and funding by the federal government.
 

Footnotes:

1 Goals 2000 Technology Plan, p. 4.

2 Minnesota Department of Children, Families and Learning, Minnesota Automated Recording Student System Instruction Manual -- System Overview Part 1: List of Software Vendors Certified for MARSS Reporting, (http://CFL.state.mn.tech/marsmnnl.htm   Webmaster's note: This currently seems to be a dead link), p. 4.

3 Goals 2000 Technology Plan, Appendix A, p. 3.

4 Information from TIES Internet site under Student Information Section, (http://ties.k12.mn.us/index.html).

5 ibid.

6 The Cloning of the American Mind: Eradicating Morality Through Education, 1998, Eakman, Huntington House, Lafayette, Louisiana, p. 74

7 Minnesota Department of Children, Families and Learning, Minnesota Automated Recording Student System Instruction Manual, Data Elements and Definitions, (http://cfl.state.mn.us/tech/marsmnl.htm).

8 Minnesota Statutes 1999, 13.32

9 Student Data Handbook for Elementary, Secondary, and Early Childhood Education: 2000 Edition, U.S. Department of Education, Office of Education Research and Improvement, NCES 2000-343, http://www.nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2000343

10 ibid., p. 43-44

11 ibid., p. 50-51

12 ibid., p. 47-48

13 ibid., p.123-140 and Appendix I

14 ibid., p. 132

15 Minnesota Department of Children, Families and Learning, Minnesota Automated Recording Student System Instruction Manual, Data Elements and Definitions, (http://cfl.state.mn.us/tech/marsmnl.htm), p. 25.

16 Dr. Chester M. Pierce, Harvard University, keynote address to the Association for Childhood Education International Denver, Colorado, April, 1972 as quoted in numerous publications, such as, Eakman, op. cit., p. 369

17 ibid., p. 165

18 ibid., p. 28

19 ibid.

20 Brave New Schools, Kjos, 1995, Harvest House Publishers, Eugene Oregon, p. 210

21 Eakman, op. cit., p. 13

22 ibid., p. 76

23 Eakman, op. cit., p. 13

24 Minnesota School-to-Work Initiative, August 30, 1996, p. 7

25 Writing tests flagged for 'crisis,' Shah, May 20, 2000, Minneapolis Star Tribune (http://www.startribune.com/stOnLine/cgi-bin/article?thisSlug=WRIT20)

26 Minnesota Comprehensive Assessments Sample Fifth Grade Writing Prompts, Minnesota Department of Children, Families, and Learning, http://cfl.state.mn.us/GRAD/mcawriting.htm

27 Personal correspondence to this witness, June 14, 2000

28 Shah, op. cit. and Eakman, op.cit., pp. 70-71

29 Eakman, op.cit., p. 82

30 ibid.

31 State leads in classifying kids with emotional disorders, March 28, 1999, Minneapolis Star Tribune

32 Jean Rowe, Medicaid Consultant, October 3, 1996

33 Guidelines for Early Identification of Mental Health Needs in Children and Youth in Minnesota School Health Guide (1997), pp. 14 & 16

34 ibid.

35 Retarding America: The Imprisonment of Potential, Brunner, 1993, Halcyon House, as quoted in Eakman, op. cit., p. 385

36 Minnesota's Profile of Learning: The Radical Mutation of a Good Idea, Summer 1999, Kersten, American Experiment Quarterly, p. 52. This paper is also available at http://www.amexp.org/publications/education/edu16.pdf

37 The Parent Trainers: A Nationwide Study of Home Visitation Programs, Lightfoot and Weed, 1999, Physician's Resource Council of the Alabama Family Alliance, Birmingham, Alabama, p. 46

38 ibid., p. 47

39 ibid., p. 51