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Investing in Children’s Health

In the presentations of their two review papers, Guyer and Bruner discussed the long term effects of early childhood interventions and their effects on later health and healthy child development.

Bernard Guyer of the Johns Hopkins Bloomberg School of Public Health presented the paper, “A Systematic Literature Review and Economic Analysis of Intervention in the Preschool Period,” describing the costs and consequences of interventions available to improve the health of children from birth to age 5, including the prenatal and preconception periods (Guyer et al., 2008). The Partnership for America’s Economic Success, which commissioned the Guyer review, comprises policy makers and business people who have come together to promote early investment in children as a strategy for improved economic success in the United States.

Charles Bruner of the Child and Family Policy Center presented a paper he coauthored with Edward Schor of the Commonwealth Fund entitled “Clinical Practice and Community Building: Addressing Racial Disparities in Healthy Child Development” (Bruner and Schor, 2008) (see Appendix E). The paper describes how clinicians need to focus on total healthy child development, not just the absence of disease. This broad focus affects child clinical health outcomes as well as other healthy development outcomes including education, social development, and justice.



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3 Investing in Children’s Health I n the presentations of their two review papers, Guyer and Bruner dis- cussed the long term effects of early childhood interventions and their effects on later health and healthy child development. Bernard Guyer of the Johns Hopkins Bloomberg School of Public Health presented the paper, “A Systematic Literature Review and Eco- nomic Analysis of Intervention in the Preschool Period,” describing the costs and consequences of interventions available to improve the health of children from birth to age 5, including the prenatal and preconception periods (Guyer et al., 2008). The Partnership for America’s Economic Suc- cess, which commissioned the Guyer review, comprises policy makers and business people who have come together to promote early investment in children as a strategy for improved economic success in the United States. Charles Bruner of the Child and Family Policy Center presented a paper he coauthored with Edward Schor of the Commonwealth Fund entitled “Clinical Practice and Community Building: Addressing Racial Disparities in Healthy Child Development” (Bruner and Schor, 2008) (see Appendix E). The paper describes how clinicians need to focus on total healthy child development, not just the absence of disease. This broad focus affects child clinical health outcomes as well as other healthy development outcomes including education, social development, and justice. 

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 FOCUSING ON CHILDREN’S HEALTH INVESTMENTS TO PROMOTE CHILDREN’S HEALTH: A SYSTEMATIC LITERATURE REVIEW AND ECONOMIC ANALYSIS OF INTERVENTIONS IN THE PRESCHOOL PERIOD Children are our future! Guyer began with a familiar quote, but for many who have worked in children’s health for a long time, he said, this statement is at best, an overused cliché, and at worst, disingenuous. In fact, the level of actual government investment in young children in the United States has declined, and projections through the year 2017 based on cur- rent federal outlays predict a further decline of between 14 and 29 percent in investment in children’s programs, the largest of which are the educa- tional programs (Steuerle et al., 2007). The IOM report, From Neurons to Neighborhoods, emphasized the importance of infant brain development for future development and learning (IOM, 2000). Guyer and colleagues are working to build a parallel argument for the importance of investing in early childhood health, emphasizing the need to integrate a health focus into early childhood development and education. Child health is more than simply the absence of disease and involves more than just providing access to medical care. Health is integrally linked to development and learning, and what happens in early life has implica- tions across the life span. In addition, child health goes beyond the behav- ioral health of individual children. Child health is shaped by multiple determinants including social, environmental, economic, and genetic influ- ences. Investing in early childhood health and development is a community responsibility and a communal investment. Study Objectives and Approach To help build this argument, Guyer and colleagues conducted a system- atic literature review of both the short- and long-term effects of interven- tions in children from birth to 5 years of age, including the prenatal period and the period leading up to the pregnancy. Four areas of preschool child health were selected for study, including tobacco exposure, obesity, unin- tentional injury, and mental health, in part because they were highlighted in the Healthy People 200 and 2000 reports. The primary objective of the review, which covers literature from 1996 to 2007, is to assess both health and cost consequences in the four focus areas across the entire life span. The group focused particularly on economic studies that reported on either cost implications or cost-benefits of interventions. While the team sought randomized clinical trials first, in many cases they have not been done, and well-designed studies, using other kinds of evaluation designs that estimate economic costs, were therefore also assessed. Data from the literature review were adapted to a framework that pro-

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 INVESTING IN CHILDREN’S HEALTH vides a life-course perspective. Interventions and effects from preconception and pregnancy through the preschool and childhood period and adoles- cence were assessed, as well as the effects of early intervention on health in adulthood (interventions in adolescence and adulthood were not assessed). The team looked at the level of intervention, meaning where the interven- tions took place: at the individual level, such as those delivered through a physician; at the family level; in communities, workplaces, or schools; or national or state policy-based interventions. Tobacco There is significant evidence of the link between exposure to tobacco in various settings and adverse health outcomes for young children. Over 10 percent of newborns have prenatal tobacco exposure, which is known to result in low birth weight and other pregnancy outcome complications. Twenty-five to 50 percent of American children are exposed to high levels of environmental tobacco, and teen smoking is a serious concern. The additional costs related to prenatal care and complications of birth that are attributable to maternal smoking amount to approximately $4 billion per year.1 Direct medical costs of pediatric illnesses that are related to parental smoking reach nearly $8 billion per year. Estimates predict that a 15 percent reduction in parental smoking could net a savings of $1 billion per year in direct medical costs. The evidence on tobacco is the most clear as it has been studied for the longest period of time, and there are good interventions with sound study designs presented in the literature. Interventions were identified at all levels, and there was evidence of cost reductions and cost implications across the entire life span (Table 3-1). Obesity The literature shows that among preschoolers, obesity has tripled in the last 20 years, increasing from 5 to 14 percent. More adolescents than ever are obese as well, with 17 to 18 percent of children ages 6 through 18 characterized as overweight. Fifty to 80 percent of overweight children and teens become obese adults with the potential for serious chronic health problems such as type 2 diabetes and cardiovascular disease. The economic impact of obesity is estimated to be $109 billion per year in direct costs, and $75 billion per year in indirect costs. The amount attributable to increased obesity-related hospitalizations for children aged 6 through 17 years increased four-fold between 1979 and 1999, from $44 million annu- 1 All costs in this presentation were standardized to 2006 dollars.

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6 TABLE 3-1 Examples of Reviewed Interventions Intervention Levels Child Health Areas Individual Family Community/neighborhood Society/policy Tobacco Smoking cessation Smoking cessation for Bans/restrictions in Increasing the price of exposure intervention for pregnant pregnant women with workplaces and public tobacco products and women partner support; smoking enforcing age bans cessation for adults living with children Obesity Exercise program; dietary Obesity prevention Healthier food served in and physical activity; education home visits preschools reducing TV watching Unintentional Prenatal home visitation; Community education Changes in baby walker injury home visits that assess combined with giving safety standards; child risks and provide incentives for road passenger safety laws education safety; primary-care- based education; smoke detector distribution Mental health Child-focused skills training; Parent- and child-interaction Preschool-based programs Employer-based work parenting skills training training programs; including academic support through programs collaborative parent tutoring and teacher extensive child care problem solving; training assistance and health supportive consultation care subsidies programs

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7 INVESTING IN CHILDREN’S HEALTH ally to $160 million. Guyer noted that it is very difficult to estimate the overall cost of obesity because these costs have not been followed through- out the entire life span. Far fewer studies are available for obesity than for tobacco (Table 3-1). Guyer and colleagues did not find any studies that met their criteria for interventions in the preconception or pregnancy period that would address obesity during pregnancy, even though it is now known that obesity dur- ing pregnancy is associated with low birth weight and poor pregnancy outcomes. There were several small studies of preschool interventions and parental interventions, but no national or state policy studies on obesity were available at the time of the literature review (although the Robert Wood Johnson Foundation, Nemours Foundation, CDC, and others are discussing studies in this area). Injuries The third focus area was injuries, which are the leading cause of child- hood death, hospitalization, disability, and emergency room visits. For- tunately, there have been some very successful interventions leading to a substantial reduction in injury mortality and morbidity rates in the United States over the last several decades. Reductions in unintentional injuries are the result of interventions such as good environmental engineering, better emergency medical services, and public health education fostering safer behaviors. The framework in Table 3-1 shows the range of interventions. This is the kind of integrated systematic approach that is needed in all of the focus areas, Guyer said. He noted that even though we have employed interventions such as bicycle helmets, gun safety, or home visits, the United States is still not investing at the levels needed to fully address childhood injuries. Mental Health The final area of review was mental health in the preschool period (chil- dren between the ages of 1 and 6). It is estimated that around 20 percent of children have at least mild mental functional impairments. For children between 1 and 6 years old, around 3 to 6 percent exhibit externalizing behaviors, and around 3 to 6 percent have internalizing behaviors. (The review did not include specific diseases, such as autism.) As shown in Table 3-1, there was an array of interventions. Most were clinically based inter- ventions and small intervention studies, with very few done at the systems level. The available cost data was limited, but the estimated cost of treat- ing children aged 1 through 5 years nationwide approached $864 million annually. The argument for better interventions early on to improve mental

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8 FOCUSING ON CHILDREN’S HEALTH health for mothers and young children is something that clearly needs to be developed further, Guyer said. Conclusions Health problems of early childhood are antecedent to many of the health disparities and chronic diseases of adulthood. Health and economic consequences are high when followed across the entire life span. There is a body of evidence emerging that shows that something can be done about these problems by intervening early. Programs have been developed but have not been brought up to full scale, and systems are lacking. Effective pro- grams and policies must be based on broad public health approaches, rather than relying on individual control or medical interventions alone. There are multiple societal determinants, necessitating multifaceted approaches, and there is a societal cost of failing to intervene. As discussed earlier, much research has been done regarding tobacco exposure, and there is a great deal of ongoing research into childhood obe- sity. But mental health is an area that needs greater focus, and injury pre- vention is an area where advances have been made in the past, but renewed attention is needed. Guyer noted that literature on the effect of interven- tions early in life relative to reducing health disparities is also lacking. More high-quality intervention studies are needed to demonstrate long- term effects and to convince policy makers to direct resources toward the early period of life. This is a “societal investment,” promoting early child- hood health both for the sake of the child and for the sake of promoting the health of the entire population. CLINICAL PRACTICE AND COMMUNITY BUILDING: ADDRESSING RACIAL DISPARITIES IN HEALTHY CHILD DEVELOPMENT How can we make well-child pediatric practice address all of children’s needs for healthy development, Bruner asked, and what specifically around clinical health care practice can be done that also leads to community build- ing? How do we address the determinants of good health that require non- medical interventions, such as exposure to lead paint and other toxins? Common Factors and Consequences There are common factors that lead to racial and ethnic disparities in health: family factors such as poverty or stress; environmental factors such as safety or exposure to toxic substances; social factors including racism; and service factors including access, use, and quality of services such as

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9 INVESTING IN CHILDREN’S HEALTH clinical health services. All of these factors affect health outcomes, but, Bruner pointed out, they also affect education, social, and justice system outcomes. Together, they present a confluence of risk factors that produce a confluence of very poor child outcomes. The good news is that clinical health services are not alone in trying to affect all of these factors. To the extent we can affect child health, we can also affect other outcomes. But the clinical health services community does need to change its practice to be broader and to recognize that it has a partnering role with other institu- tions and organizations. Figure 3-1 compares white non-Hispanic, black non-Hispanic, and Hispanic populations in terms of various selected health outcomes, health service access, education outcomes, and several other outcomes and condi- tions. For example, the percentage of children aged 6 to 11 years who are overweight is nearly double for black non-Hispanic children, and more than double among Hispanic children, compared to white non-Hispanic children. Some of the health disparities relate to the lack of a regular source of health care. Incomplete immunization rates in minority populations are also a concern. Lack of 4th-grade reading proficiency, 8th-grade math proficiency, and high school dropout rates are more than double in these minority communities. Other outcomes, for example, the incidence of 20- to 24-year-old males in prison, is significantly higher for African Americans. White N H Black N H Hispanic Health Outcomes Low Birth Weight 7. 2 % 13.4 % 6.8 % KEY: Elevated Blood Lead Levels ( 0-5 ) 2.6 % 4.3 % 3.1 % 6-11 Over weight 11.8 % 19.2 % 23.7 % Italic s: lower than White, non- Health S ervic e Access Hispanic 24 .1 % Lack of Regular Source of Care 3.3 % 5.8 % Underlined : more than Incomplete Immunizations (19-35 mo) 16.7 % 25.5 % 21.3 % 2x rate for White, Education Outcomes non- Hispanic Below Basic 4 th Grad e Readin g 22 % 54 % 50 % Bolded : more Below Basic 8 th Grad e Math 18 % 53 % 45 % than 5x rate Non- completion of High School 21.4 % 48.8 % 46.8 % for White, non- Hispanic Other Outcomes Foster Care / 1,00 0 4.9 15.8 6.5 63.4 (20-24 year-olds) Male Prison / 1,00 0 9.5 24.9 Conditions Children in Povert y 11 % 36 % 29 % Children in Single Parent Families 23 % 65 % 36 % 20.3 % 25.3 % Pop. in High Vulnerabilit y Trac ts 1.7 % FIGURE 3-1 Comparison of selected disparities. SOURCE: Bruner and Schor, 2008. Figure 3-1.eps

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20 FOCUSING ON CHILDREN’S HEALTH These are young men who may need to assume parenting roles for young children. The rate of children living in single-parent families is three times higher in the African American community. Clearly, serious disparities in health co-occur with other disparities around education, social develop- ment, and justice system involvement. The Role of Clinical Practice in Addressing Disparities Child health care practitioners cannot fulfill their role in child health without addressing more than clinical health conditions, Bruner said. They must focus on total healthy child development, which is not just the absence of disease. This broader approach affects clinical health outcomes, but it also affects other health and development outcomes including education, social development, and justice. Figure 3-2 highlights some of the outcomes sought in well-child care for birth through age 5, related to physical health and development, child emotional, social and cognitive development, and family capacity and func- tioning. These are consistent with the most recent American Academy of Pediatrics (AAP) Bright Futures Guidelines, which provide a comprehensive and broad view of what a clinical practice can accomplish (Hagan et al., 2008). Not all of these are the responsibility of the clinical practitioner, but practitioners can contribute significantly to these outcomes through antici- patory guidance. For example, patterns of eating and exercise begin very young. The USDA’s Women, Infants, and Children (WIC) nutrition program does a very good job educating those that receive WIC assistance about the importance of good nutritional habits. But there are still baby bottles filled with soda or juice because many parents simply don’t know enough about good nutrition. The health practitioner can be that point of change. At the family level, parents need to be knowledgeable about a child’s physical health status and needs, and clinicians need to be alert to any warning signs of child abuse and neglect. But the health practitioner can also identify maternal depression, stress, and family violence. Although clinicians can’t address all of these issues alone, they are a point of contact, and they need to help ensure support is provided. The Importance and Prevalence of Place Bruner and his staff at the Child and Family Policy Center conducted an analysis of all 65,000 census tracts in the United States and ranked them by the prevalence of 10 select factors related to “child vulnerability” such as single parents, poor families, aged 25 or older without high school comple- tion, head of household on public assistance, and other similar situations. They then ranked the census tracts by the number of risk factors each had.

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Outcomes of Well -Child Care During the First Five Years of Life Domain of Well-Child Care Outcome at School Entry • All vision problems detected and corrected optimally • All hearing problems detected and managed • Management plans in place for all chronic health problems • Immunizatio n complete for age • All congenital anomalies/ birth defects detected Child Physical Health and Development • All lead poisoning detected • All children free from exposure to tobacco smoke • Good nutritional habits and no obesity; attained appropriate growth and good health • All dental caries treated • Live and travel in physical ly safe environments • All developmental delays recognized and treated (emotional, social, cognitive, communication) • Child has good self-esteem Child Emotional, Social, and Cognitive Development • Child re cognizes relationship between letters and sounds • Child has adaptive skills and positive social behaviors with peers and adults • Parents knowledgeable about child’s physical health status and needs • Warning signs of child abuse and neglect detected • Parents feel valued and suppor ted as their child’s primar y caregiver and function in partnership with the child health care provider • Maternal depression, family violence, and family substance abuse detected and referral initiated Family Capacity and Functioning • Parents understand and are able to fully use well-child care services • Parents read regularly to the child • Parents knowledgeable and skilled to anticipate and meet a child’s developmental needs • Parents have ac cess to consistent sources of emotional support • Parents linked to all appropriate community services c Note : regular font bullets are those outcomes for which child health are providers should be held ac countable for achieving. Italicized bullets are those outcomes to which child health care providers should contribute by educating parents, identifying potent ial strengths and problems and making appropriate referrals, but for which they are not independently responsible. FIGURE 3-2 Outcomes of well-child care. Figure 3-2.eps SOURCE: Bruner and Schor, 2008. landscape 2

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22 FOCUSING ON CHILDREN’S HEALTH Those with six or more vulnerability factors have child vulnerability rates at two and half to nine times the level of others on these 10 indicators (Figure 3-3). Imagine, Bruner said, living in a community with no vulnerability factors, where half of America lives, versus living where there are six or more vulnerability factors, where opportunities, resources, and support are limited or not available. When the neighborhood census tracts are broken down by race and ethnicity (see Figure 3-4), that data show that 83 percent of those with no vulnerability factors are white. Around 83 percent of those with six or more vulnerability factors are nonwhite. Of all white non-Hispanics, 1.7 percent live in census tracks with six or more vulnerability factors, compared with 20 percent all blacks and 25 percent of all Hispanics. About 7 percent of the white population and 50 percent of the Hispanic and the black popula- tions live in communities with three or more vulnerability factors. If we do not have interventions and strategies that are focused on and appropriate to these neighborhoods where the children of color are living, Bruner said, we are not going to be able to affect those health disparities. Place has an independent effect on health outcomes. Environmental factors, family cir- cumstances, and access to health services are factors, but it is also that this is the place where the children are, so how do we develop strategies that work in these neighborhoods? No Six or More Vulnerability Vulnerability Factors Factors % Single Parents 20% 53% % Poor Families with Children 7% 41% % 25 + No HS Completion 13% 48% % 25 + BA or Higher 27% 7% % HoH on Public Assistance 5% 25% % HoH with Wage Income 81% 69% % HoH with Savings, Dividend Income 42% 11% % Owner-Occupied Housing 71% 29% % 18 + Limited English 2% 18% % 16-19 not School /Work 3% 15% FIGURE 3-3 Child-raising vulnerability factors, 2000 Census data. NOTE: BA = bachelor degree; HoH = head of household; HS = high school. SOURCE: Bruner, 2007. Figure 3-3.eps

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2 INVESTING IN CHILDREN’S HEALTH 83.2 % 6. 2% 6.1% 4.5% No Vulnerability Factors 17.6 % 38.0 % 39.4% 5.0% Six or More Vulnerability Factors White, Non-Hispanic Black Hispanic Other FIGURE 3-4 The importance/prevalence of -place and race: Racial composition of Figure 3 4.eps census tracts by child-raising vulnerability, 2000 census data. SOURCE: Bruner, 2007. Help Me Grow: A Model for Clinical Practice Bruner described the “Help Me Grow” initiative, a publicly funded program of the state of Connecticut Children’s Trust Fund (Dworkin et al., 2006). It provides comprehensive well-child assessments and effective refer- rals to both clinical and nonclinical services. The program has strengthened and integrated community resources and has helped identify specific gaps in services. A primary component of Help Me Grow is physician education and training of health care providers in developmental surveillance, provid- ing guidance on what screening should be done during well-child visits and how to elicit feedback from parents. Providers can refer parents, confident that there will be effective follow-up, as telephone care coordinators then contact the family to schedule the recommended appointments. Community health liaisons in the field identify resources and support that are available in the community and facilitate coordination (see Figure 3-5). Bruner emphasized that the role of clinical practice in reducing health disparities extends beyond strictly medical interventions. As shown in Fig- ure 3-5, some of the referrals are to programs under part C of the Infants and Toddlers with Disabilities Act (IDEA) or to professional clinical mental health services. But data from the model program shows that about one quarter of the issues identified for referral relate to parenting stress, lack of knowledge about child development, challenging child behaviors, and dis- cipline issues around which parents feel a lack of control. Correspondingly, about one quarter of their referrals and actual scheduling of appointments relate to community-based parent support groups, church-related activi- ties, community-based parenting education classes, and interventions that reduce the isolation and separation that parents often experience. There is clearly a role that pediatric practitioners can play in reaching out beyond strictly medical issues.

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2 Telephone Care Pediatric Practitioner Coordination Training /Developmental 1. 2. Schedule Appointments Surveillance • follow-up assessment • professional services “Do you have concerns about how • community suppor ts your child is learning, behaving, or Provide Feedback and developing? ” Follow-up Community Child Health Liaison • identif y and update resources for 3. care coordination • investigate and follow p with care -u coordinator for specific families • develop networks across provider s and communit y resources Child Parenting Domestic Home Head Part C Mental Educa- Violence Visiting Star t Health tion Shelter Peer Parent of Church Suppor t Hispanic Parents Children Family Group for Resource Anony- with Night Grand- Center mous ADHD Program parents Group Hartford, Connecticut. FIGURE 3-5 A model for clinical practice: Help Me Grow inFigure 3-5.eps SOURCE: Bruner and Schor, 2008. landscape

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2 INVESTING IN CHILDREN’S HEALTH Implications for Practice and Research We don’t have all the answers, Bruner said, but we do know enough to take action. There are some promising programs in place, but there needs to be diffusion of innovative strategies and incentives for moving these activities from exemplary programs to routine practice, including fis- cal incentives, technical assistance, and recognition. Methodological rigor must be applied in assessing effects both around clinical child health, and then more broadly, in healthy child development. Randomized controlled trials are appropriate for some aspects of this work but are not applicable when assessing the success of building social support systems within the community. The clinical health community needs to keep its focus on the clini- cal practitioner’s role. Although there is a need for community develop- ment, for poverty reduction, and for a whole array of policies necessary to improve child health, these are not factors that the health practitioner can always control. A child health practitioner should not try to fill all the roles of child development specialist, family therapist, community resource, or community organizer. The health practitioner must provide the neces- sary clinical resources and use clinical expertise wisely. But it is not enough to simply advocate for others to intensify their own community-building efforts. There must also be changes within clinical practice. Bright Futures is an excellent model for a starting point. Practitioners need stronger links to community resources and can offer additional insight into resource needs for healthy child development. We need to know what preventive strategies work, Bruner said, for example what obesity prevention approaches are effective in the early years, or what types of practices can further reduce tobacco exposure through anticipatory guidance. The current research base on preventive primary pediatric practice is quite limited compared to the available research base on other clinical practices. OPEN DISCUSSION The open discussion that followed the presentation of the papers focused primarily on tobacco exposure. Bruner remarked that from a reimburse- ment perspective, smoking cessation programs should be covered by health insurance and Medicaid and ought to be actively promoted. He also noted the need for research demonstration programs on effective ways to limit children’s exposure to tobacco smoke, as well as for encouraging parents to ensure a smoke-free environment for their children (e.g., by not smoking around their children or by quitting altogether). Satcher said restrictions on smoking in public places results in more people quitting smoking. Nicole Lurie commented that there is evidence from around the country that the

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26 FOCUSING ON CHILDREN’S HEALTH tobacco industry has been targeting cigarette marketing at young black women with promotions such as two-for-one sales in their communities. She noted that this needs to be further investigated and addressed from a community perspective. REFERENCES Bruner, C., and E. Schor. 2008. Clinical practice and community building: Addressing racial disparities in healthy child deelopment. Working paper. Des Moines, IA: National Cen- ter for Service Integration. Bruner, C., M. S. Wright, and S. N. Tirmizi. 2007. Village building and school readiness: Clos- ing opportunity gaps in a dierse society. Resource brief. Des Moines, IA: State Early Childhood Policy Technical Assistance Network. Dworkin, P., J. Bogin, M. Carey, and L. Honigfeld. 2006. How to deelop a statewide system to link families with community resources: A manual based on Connecticut’s “Help Me Grow” initiatie. http://www.commonwealthfund.org/publications/publications_show. htm?doc_id=462069 (accessed January 5, 2009). Guyer, B., S. Ma, H. Grason, K. Frick, D. Perry, A. Wigton, and J. McIntosh. 2008. In- estments to promote children’s health: A systematic literature reiew and economic analysis of interentions in the preschool period. http://www.partnershipforsuccess.org/ uploads/20081118_HopkinsPaperFINAL.pdf (accessed January 5, 2009). Hagan, J. F., Jr., J. S. Shaw, and P. Duncan, Eds. 2008. Bright Futures guidelines for health superision of infants, children, and adolescents (3rd ed). Elk Grove Village, IL: American Academy of Pediatrics. IOM (Institute of Medicine). 2000. From neurons to neighborhoods: The science of early childhood deelopment. Washington, DC: National Academy Press. Steuerle, C. E., G. Reynolds, and A. Carasso. 2007. Inesting in children. http://www.partner shipforsuccess.org/uploads/200801_UrbanPaperFINAL.pdf (accessed January 5, 2009).