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The Health Impact of Early Childhood Programs:
Perspectives from the Brookline
- Early Education Project
Melvin D. Levine and Juclith S. Palfrey
In the evaluation of early childhood programs the
health status of the children enrolled is often a
prominent issue. Planners and policy makers are likely
to ask whether participation in such programs enhances
children's health and, if so, whether the gains are
substantial enough to justify the costs. In early
childhood programs for which improved health is not a
primary objective, program planners may want to know if
the addition of a health-monitoring component would be
cost-effective. As evaluators survey early childhood
programs and their impact on health, they may consider
the possibility of modifying the content of traditional
preventive health care. They may examine the feasibility
of collaborative service models that include the consoli-
dation of early education and preventive pediatrics, so
that communities can shape and upgrade simultaneously the
health care and developmental monitoring of children.
At first glance it might seem that the health of
children is easily amenable to evaluation and measurement.
Accurate numbers, however, are difficult to obtain and are
often misleading. In this paper we outline some salient
clinical and methodological issues that have become appar-
ent to us in working at the Brookline Early Education
Project analyzing the health impact of a comprehensive
early childhood project.
The first section of the paper delineates a number of
critical issues facing evaluators. The second section
discusses the scope of "health" by detailing the various
background and process factors that need to be considered
during evaluation. The third section outlines specific
questions evaluators can ask as they measure the impact
of health. Finally, drawing on our experiences with the
Brookline Early Education Project, the last section
57
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58
reviews seven evaluation prototypes and discusses
matching alternative evaluation strategies to specific
questions.
RELEVANT ISSUES FACING EVALUATORS
Defining Health and Its Borders
Health is more than the absence of disease. It is the
absence of handicap, social and emotional discord, and
environmental stress as well as the presence of resil-
iency, stamina, and homeostasis. There is growing aware-
ness that traditional pediatric health cannot be viewed
apart from psychosocial, behavioral, developmental, and
educational status (Richmond, 197S; Rutter et al., 1970;
Haggerty et al., 1975). Functional health and its
promotion have increasingly become the purview of the
pediatrician working in conjunction with professionals
from other disciplines (Levine, Brooks, and Shonkoff,
1980).
Health issues are likely to involve other areas. For
example, it is essential for those managing children with
musculoskeletal defects to address the functional (i.e.,
gross and fine motor and psychosocial) impacts of such
handicaps. Professionals helping neurologically impaired
children must involve themselves in the assessment of
higher-order cognitive function, self-esteem, behavioral
adjustment, and related family issues. Health maintenance
must include anticipatory guidance and counseling, for
patterns of behavior are as much within the domain of
child health as are infectious diseases and specific
organ disorders. Table 1 samples the broad spectrum of
child health disorders. So many factors are involved
that it is easier to describe what should be included
under the rubric of "health" than to isolate issues
irrelevant to health maintenance.
Describing Health Status
Characterizing the health status of groups of children
is even more difficult than characterizing individual
health. Since universally acceptable scoring and
weighting systems do not exist, the health evaluation of
a cohort enrolled in an early childhood project can be
costly to obtain and difficult to interpret.
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59
TABLE 1 Some Negative Health Outcomes Whose Effects
Early Education Projects Are Intended to Minimize
1. Poor growth and/or nutrition
2. Sensory deficits
3. Chronic illness and symptoms
4. Poor utilization of health services
5. Recurrent trauma
6. Neurological disorders
7. Neurodevelopmental dysfunctions
8. Psychosocial mobility
9. Mental retardation/multiple handicapping conditions
10. Life-threatening diseases
A group's health status cannot be presented as a simple
inventory of existing symptoms and conditions. Evaluators
who wish to characterize the health status of a group of
children need to take into account past medical events,
family history, and current health. In addition, there
must be estimates of vulnerability and resiliency,
descriptions of health practices and knowledge (nutrition,
exercise, and total environment), and accounts of medical
service utilization.
Describing Health Change
After defining the limits of health as a subject
matter and developing the descriptors to characterize
group health status, evaluators must find measures of
health change. This can be particularly challenging in
the preschool child, as the morbidity itself evolves with
age and many of the dysfunctions and disorders are
self-limited or transient.
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60
Sometimes changes in health are more apparent than real
because different measures are used at different ages.
Certain reflexes, for example, can be elicited in children
who are three to six months old but not thereafter.
Hearing and vision are easier to measure after three
years of age than before. ~~~
Some orthopedic dit-ticult~es
may not be evident until a child attempts to walk.
Children may have immunity to certain diseases at
specific ages but not beyond. The descriptors of the
health of children thus depend to some extent on which
window one looks through at what time.
Just as problematic for evaluators is the high
prevalence of self-limited acute or subacute illnesses
and the spontaneous health resiliency of young children
(single, 1964; Miller et al., 1960). This makes it
difficult to study both the occurrence of and recovery
from acute disease. It may be particularly hard to
attribute symptom abatement to treatment effects.
Behavioral and developmental disorders of early child-
hood reveal considerable instability over time as well.
Although some researchers (Thomas and Chess, 1975; Taft,
1978) have suggested that behavioral characteristics may
be maintained from infancy through childhood, others
(Bell et al., 1971; Carey et al., 1977) have demonstrated
that children who have "behavior problems" at age two or
three may not be the same children who have difficulty in
school.
It may be impossible to identify precise endpoints of
health change. For example, one may not be able to
determine whether a child has had one prolonged episode
of otitis media that never really healed or multiple ear
infections (Giebink and Quie, 1978). This difficulty
impedes any precise accounting of numbers of acute
illness episodes during a given period.
The measurement of health change is complicated for
three reasons: (1) the actual content of health and
morbidity evolves with age, (2) many conditions undergo
spontaneous remission, and (3) some disorders are closely
associated with others and are therefore indistinguishable
from one another. Therefore, before looking at the impact
of a program on health, evaluators should develop appro-
priate methods of characterizing change: The health (of
a group or individual) may vary depending on the period
of time under scrutiny. The measures of health should
therefore be dynamic, depending on the age and development
of the children in a program. The measurement of health
"progression" must somehow be differentiated from normal
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61
chronological change. To document enhancement, evaluators
must show that a particular child or group of children at
the end of two years improved in overall health character-
istics. As difficult as this may be, such documentation
stands as a critical requisite for the evaluation of
health as a progressive phenomenon.
Dealing With Low Prevalence Rates
in Pediatric Morbidity
Pediatric illness differs fundamentally from its adult
counterpart. In the latter, a relatively small number of
major illnesses (e.g., hypertension, obesity, coronary
heart disease, cancer, and diabetes) are likely to be
highly prevalent within a population. Evaluators of
adult health programs may be able to measure the impact
of a program on these distinct entities and thereby
generalize about health status and program-induced change.
In contrast, there is no single chronic organic condition
of childhood common enough to scrutinize in such a fashion
without a very large sample. Therefore, in studying
chronic medical conditions in a service program for chil-
dren, it is often necessary to employ aggregate ratings
that "lump" children with such disparate conditions as
congenital heart disease, juvenile rheumatoid arthritis,
nephrotic syndrome, recurrent urinary tract infection,
and asthma for purposes of analysis. The alternative is
to use samples that are too large for most early childhood
projects.
Resiliency in childhood also differentiates child
health from adult health. Most child health setbacks are
likely to be acute and self-limited, leaving no scars or
aftereffects. Cataloging of such events shows that in a
single year most children have been ~sick" as many as
four or five times (single, 1966). For children such
morbidity is par for the course, developmentally appro-
priate, perhaps immunologically necessary, and ultimately
inconsequential (Mortimer, 1968). Evaluators thus need
to weight acute self-limited disease very differently in
children.
Absence of Data on Normalcy
In assaying pediatric health status, we are hampered
by a paucity of data on normalcy and normal variation.
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62
While information does exist regarding the prevalence of
specific chronic diseases or congenital anomalies and the
incidence of some acute illnesses, this information tends
to reflect major social class differences (Morris, 1979),
serious problems with reporting (Brewer and Kakalik,
1979; Bureau of Education for the Handicapped, 1979), and
inadequacies in many of the measuring techniques (Balinsky
and Berger, 1975). ~
-
This distortion makes it especially
difficult to determine if the health status of a partic-
ular group of children is below or beyond what ordinarily
might be expected. Normative data are even more deficient
in assessing developmental status, behavior, family
functioning, and health care utilization patterns. Much
of traditional medical research has had the benefit of
normative data. For example, it is possible to study the
effects of a medication on a patient's glucose level,
since norms for blood sugar are available. For many of
the aggregate measures of community child health, however,
no such norms exist (Starfield, 1974). What is "normal"
or "to be expected" for a particular population must
almost always be reestablished in undertaking evaluation
research. In many instances this requires the use of
comparison groups or control populations.
Selecting Outcome Measures
In documenting program effects on health, one critical
issue is the precise outcomes to be measured at designated
outcome points. One might be tempted to consider only
the prevalence of morbidity as an outcome measure. This,
of course, leaves out such issues as parental health
knowledge, patterns of use, and children's health stamina.
Furthermore, it is unlikely that the straightforward
rendering of morbidity statistics constitutes an adequate
reflection of project effectiveness. An early support
project may be beneficial without diminishing the
prevalence of a disorder. For example, one would not
expect a program to lessen the occurrence of myopia, yet
an effective effort might result in a reduction of
previously undetected or untreated nearsightedness. In
fact, an early childhood project may exert its greatest
effects not on prevalence figures but on awareness,
management, coping, and the prevention of complications.
Another issue in selecting outcome measures is the
need for a method of weighting. Health outcomes can be
measured in terms of their severity, their impact (on
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63
function, on families, on society), and their relevance,
so that composite morbidity may be subdivided into
significance for treatment (prescriptive implications)
and potential for impairment of future health or function
(predictive weight). Even a low prevalence of disorders
that are likely to thwart academic function or behavioral
adjustment may be more important than a high occurrence
of such disorders as flat feet. Evaluators might also
want to select outcome measures that have significant
implications for treatment. A project should be judged
more harshly if it missed problems that were treatable
than if it overlooked those for which no therapy was
available.
Outcome measures should not be too global, particularly
with regard to developmental and behavioral assessments.
A project that uses IQ as an outcome measure will not be
pinpointing the prevalence of problems with attention,
language, or other isolated information-processing
deficits that can seriously impair function (Levine,
Brooks, and Shonkoff, 1980). Similarly, the results of a
developmental screening test by themselves are unlikely
to be sufficient to describe a project's impact on
children's development (Meter, 1973; Meissels, 1978). A
more comprehensive picture would include parental reports
of function, direct observations of behavior, or specific
teacher accounts of skills, abilities, and interest.
One challenge for those evaluating early childhood
projects is the identification of measures that can be
used to provide an in-depth assessment of function to
determine whether the program has diminished or minimized
the effects of so-called low-severity, high-prevalence
dysfunctions of childhood, which include specific learning
disabilities, primary attention deficits, and various
forms of psychosocial maladaptation during the school
years.
In delineating outcome measures, evaluators should
consider the objectives of the project under scrutiny.
For instance, if health is a high priority of a given
project and if assurance of primary care is an explicit
goal, then it is appropriate to determine if the project
has met that goal by assessing patterns of health care
utilization of the enrolled children. This approach may
be less relevant in projects that have had only an
incidental commitment to health.
Finally, within a given population uniformity of
outcome measurement may be unrealistic and inappropriate,
especially in programs emphasizing the individualization
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64
of services. To measure gains, evaluators may need to
specify "target subgroups. n For a subgroup with hearing
deficits, incremental growth in vocabulary may be a better
measure of program effectiveness than mean developmental
scores at age five. Evaluators can identify areas in
which they would expect or hope to see progress for
particular children.
_ _ _ They might also weigh expectations
against accomplishments. For example, a project may not
be able to diminish the prevalence of problems with
short-term memory in children, but it might be able to
achieve a generalized improvement in the reading
proficiency of children with short-term memory problems,
a gain that would surpass what would be expected for
nonparticipating children with this developmental
dysfunction. Thus, although a project may not diminish
the severity or prevalence of short-term memory problems,
it may manage to have "better Hopers," more competent
readers, and perhaps happier children within this target
subgroup. In some cases a project may want to evaluate
only specific target groups to demonstrate program
effects. When an evaluation becomes this focused,
however, either large numbers or elegant small sample
designs are needed to demonstrate that intervention has
been successful.
-
Assessing the Cost-Effectiveness
of a Health Program Evaluation
A major challenge exists in the calculation of a
cost-benefit ratio for health program evaluations. There
is constant pressure to balance the expense and difficulty
of acquiring a particular set of data against its ultimate
value for children and its relevance to the objectives of
a project. It may be simple to determine immunization
rates for a particular population, but if the project is
located in a town where most children are well immunized
anyway, despite its economy this will not be a useful way
of measuring program impact. On the other hand, if a
service model is likely to improve a family's ability to
. . . . . .
cope with behavior problems, a series of expensive
measures of behavior and parenting may be most relevant
(Haggerty et al., 1975; Roghmann et al., 1973; Haggerty,
1965). There can be no one set of criteria for
evaluating all projects. Those aspects of health chosen
for evaluation will depend largely on the nature of the
community, the objectives of the program, the
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65
availability of evaluation funds, and current public
policy questions.
Identifying The Evaluation Consumer
In designing an evaluation of health outcome, it is
essential to understand the needs and priorities of those
for whom the evaluation is intended. The content of an
analysis depends largely on its intended audience. It
can be argued, however, that all evaluations should be
able to undergo some degree of rigorous scrutiny, even if
intended primarily for nonacademics. Purely anecdotal
reports and testimonials are inadequate measures of health
care provision under any circumstances; highly esoteric
statistical analyses, on the other hand, may have little
impact on school committee decision making or on the
deliberations of legislators. Often evaluations must
apply several formats, each designed for a unique
constitutuency.
Timing and Staging
A critical issue for evaluation is timing. The health
effectiveness of a program can be documented while it is
in progress. Alternatively, one could consider assessment
of its impact at the end of a project or at a short or
long interval following termination. Decisions about
timing must consider what is being measured and demon-
strated. If a major goal is to minimize morbidity and
suffering and to cushion the traumatic impact of daily
events and environments, then it is crucial to offer
evaluations while the project is in progress. If the
goal is to look at the long-range effects of intervention
or general service, postintervention analyses are needed.
Findings inevitably reflect the timing of an evaluation,
and the implications can be great, especially for issues
of cost-effectiveness. Because of the instability of
health conditions in childhood and the high degree of
resiliency, the timing of evaluations significantly
influences the attribution of program effects, which can
be misleading from a public policy viewpoint. For
example, if children in a particular program have less
difficulty adjusting to the first weeks of kindergarten
than nonparticipants, evaluators may feel that they have
documented a measurable effect. It may turn out, however,
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66
that the two groups are virtually indistinguishable if
they are evaluated in mid-February of the kindergarten
year. Allocators of resources would wonder if great
expenditures to promote "educational readiness" were
really worthwhile if their effects were demonstrable only
during the earliest months of kindergarten and thereafter
washed-out.
Traditional health issues follow a similar pattern.
If a child's flat feet are detected in an early childhood
project, but the child has no pain or functional limita-
tion and it is documented that the finding would otherwise
not have emerged until the first or second grade, what
has been gained? In any event, by the time the child is
eight or nine, the parents are likely to be aware of the
condition. In that case, what is the value of early
detection? Assuming that the condition is discovered
early and the child given corrective shoes, does it
really make a difference (Bleck, 1971; Cowell, 1977)? In
some cases it may be better not to diagnose a problem
that is going to resolve itself or that may not cause
symptoms or require treatment for several years.
It may be that years after a program ends there is
little difference in the prevalence of previously
undiagnosed findings. One might argue that ultimately
the important problems will be detected. There is a
danger that early detection may obligate programmers to
unnecessary expenditures for interventions, especially
for conditions that are likely to remit spontaneously.
Once again, it is important to review the objectives of a
project. The timing of an evaluation of program effects
should relate to the objectives. In stating objectives
there should be some consideration of the anticipated or
desired duration of effects. Outcome measures can then
be timed to assess these accordingly.
Having delineated these issues for the evaluation of
program effects on health, we now turn to a more detailed
examination of the measurement of health status. The next
section describes this as a necessary step in demon-
strating the influence of a specific program on health.
THE SCOPE OF CHILD HEALTH
As early childhood programming expands, the literature
from education (e.g., U.S. General Accounting Office,
1979; Lazar, 1977; Bronfenbrenner, 1975; White, 1975;
Zigler and Valentine, 1979) and pediatrics (e.g.,
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67
Richmond, 1975; Thomas and Chess, 1975; Taft, 1978; Carey
et al., 1977; Roghmann et al., 1973; Klaus and Kennell,
1976; Morris et al., 1976; Badger et al., 1976) makes it
clear that the scope of child health that can be addressed
is very wide. Clearly, evaluators should focus on those
aspects of a health program that are most likely to
reveal efficacy. In our work at the Brookline Early
Education Project (Pierson, 1974) and the school clinics
at Children's Hospital Medical Center in Boston (Levine,
1979), we have found it most helpful to define (1) the
background health characteristics of the children, (2)
the ongoing health and developmental processes at home
and in the program, and (3) the outcomes that the program
intends to achieve. Only with these areas clearly
defined does it become possible to address specific
questions regarding program impact.
Background Variables
From the intrauterine period onward, the experiences
of children vary significantly. Some endure prenatal and
postnatal trauma, some are born into impoverished and
disorganized families, some inherit genetic disorders,
and some fail to receive adequate nurturance. Others,
because of their constitutional makeup, never adjust
optimally to their milieu and continually hunger for
greater satisfaction from it. Still others arrive with
ease, cope readily, and manifest little or no disability
in dealing with the external world.
Programs dealing with young children generally take
these variations into account for staffing and pro-
grammatic reasons. To do so for outcome measurement is
equally critical. Children who are more "at risk" will
require greater levels of service; their outcomes may
turn out to be excellent, but they differ from children
not at risk. For instance, the most pertinent outcome
ma F^' ~ mid ~-~1 ~= serf child might be ease with
611 ~ ~ ~ ~ ~ =- ~ ~ ~ ale ~ ~
-
.
a hearing aid, skill in using a total communication
system, and ability to attend a normal school for at
least some of the day. On the other hand, outcome
measures for a normally hearing child from a socio-
economically depressed and disorganized home might be
assurance of primary health care, money for food, and an
adequate after-school, supervised program.
Because the health needs of children are so varied,
programmers, monitors, and policy makers should keep
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98
the needs of public policy makers and investigators,
cross-fertilization between disciplines is likely to
accelerate the process. We will have achieved a great
deal if this paper can help foster such collaboration.
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Representative terms from entire chapter:
education project
