The workshop’s second panel featured three presentations. James Bender, executive director of the Health Information Network of the National Education Association (NEA), spoke about educator-driven, union-led programming for making schools a healthier place for children. Norris Dickard, director of the Healthy Students Group at the U.S. Department of Education’s Office of Safe and Healthy Students, described some of the department’s programs related to student health. Laurie Miller Brotman, director of the Center for Early Childhood Health and Development in the Department of Population Health at the New York University Langone Medical Center, discussed how ParentCorps is attempting to address the socioeconomic adversity that many children experience and to lessen the impact that such adversity has on children’s lifelong health and productivity. A discussion moderated by session chair Holly Hunt, chief of the School Health Branch at the Centers for Disease Control and Prevention (CDC), followed the three presentations. Hunt said that CDC now has two units that focus specifically on school health: her branch, which concentrates on physical activity, nutrition, and the management of chronic conditions in schools, and the division of Adolescent School Health, headed by Captain Stephanie Zaza.
To begin his presentation, Bender explained that the NEA is a member-driven organization and that any program that the NEA runs must
be appealing to its approximately 3 million members who work at 70,000 schools. He noted that the NEA has 51 state affiliates and a huge infrastructure that reaches into every state and almost every municipality in the nation. The nonprofit organization that he works for—the Health Information Network—is affiliated with the NEA and looks for common ground between the concerns of the NEA members and effective public health practices. Among the issues that are on the minds of the NEA’s membership, he said, are the common core standards and high-stakes testing, school funding, meeting individual student’s needs, and professional growth.
When the NEA members were surveyed in 2013 about the health issues that impede student learning, they ranked inattention and hyperactivity as their major concerns. However, despite the negative effects that vision problems can have on learning, as had been described earlier in the workshop by Charles Basch, vision problems ranked only 20th in importance on this survey. This, Bender said, presents a challenge for programs and funders.
Before describing an example of his organization’s efforts, Bender said that one of the great things about working with a union is that unions have an extensive infrastructure that can be used to institutionalize an intervention that works in pilot studies if it effectively taps into educator and school needs. He said that the interventions are science-based and developed with constant feedback from the NEA members to ensure that any intervention links educator priorities with health programming. The first example of such a program, he said, is Breakfast in the Classroom, which has received generous funding from the Walmart Foundation and is being carried out in collaboration with the School Nutrition Foundation, the Food Research and Action Council, and the National Association of Elementary School Principals Foundation. This program is intended to address the fact that schools with a large percentage of students eligible for free lunch often have as many as half of their students coming to school without having had breakfast. Schools in the Breakfast in the Classroom initiative serve breakfast to all the school’s students in the classroom. “Bringing breakfast to the classroom reduces the stigma of having to go to the cafeteria to get breakfast,” Bender explained.
This program has been rolled out to the NEA membership by first targeting local chapter leadership to garner their support, Bender said. Once that has been done, Breakfast in the Classroom staff hold meetings with all of the professionals involved—food service people, custodial staff, and teachers—to get buy-in from these essential stakeholders. This process is challenging, he said, “because you have got to get a lot of people to a lot of meetings and answer all of their questions, but once you get through that, it works [well].” The main complaint that Bender has received from
the NEA relates to teachers who have heard about this initiative and who want their schools to participate. As of 2013, this program had reached 70,000 students, Bender said. He added that Colorado recently passed legislation to offer Breakfast in the Classroom in various school districts across the state that have a high fraction of students receiving free and reduced meals. “That is sustainability,” he said. “That is what we are looking for.”
Bender said that he and his team have learned two important lessons from Breakfast in the Classroom. The first is the need to engage educators. The program succeeded only with complete educator inclusion and by building educator priorities into the training sessions and implementation phases. Developing a sense of shared responsibility leads to smoother implementation and increases the chance that the program will be sustainable, he said. The second lesson is that it is necessary to understand and access the union’s governance and communications infrastructure as a means of aiding the development and implementation of any initiative.
Another program run by the NEA Health Information Network, this one in collaboration with Kaiser Permanente, is intended to improve school employee wellness, which CDC has defined as a key component of a comprehensive approach to a healthy school environment. Health promotion activities have been shown to improve productivity, decrease absenteeism among teachers, and reduce health insurance costs. With the help of Kaiser Permanente, Bender and his colleagues conducted an organizational assessment to determine whether the NEA was ready to work on this issue. This assessment focused on the so-called UniServ staff, the shop stewards who are no longer in the classroom but who spend all of their time dealing with union members and their issues, and it found that 93 percent of these men and women believed the NEA should promote wellness programs. More importantly, although UniServ staff members already had a lot to do, they were willing to take on the promotion of wellness programs to the membership.
Currently, Bender and his team are planning on working with the NEA local affiliates to see how they can set up incentives for promoting wellness activities, disease management, and onsite delivery of health services, including screening, prevention, and stress management. “Stress is a huge problem,” Bender said, adding that teacher stress has increased substantially over the past 5 years and is connected to a corresponding drop in job satisfaction among teachers. Bender concluded his presentation by commenting on the incredible insight that local educators possess. “They know their students and their families,” he said. “They are members of the community. They routinely prioritized students’ needs over all else, and it is very hard to get them to talk about their own needs. But if
you can connect their healthiness state and their productivity to student needs, they are going to go for it. At least that is what we are counting on.” He added, “A project succeeds once it captures the educator’s imagination as they understand how it benefits their student. Union involvement can accelerate the process and can catapult it forward.”
In his brief remarks, Norris Dickard provided an overview of programs that the U.S. Department of Education has in the area of student health. Referring to earlier comments about elevator pitches, Dickard began by describing a hypothetical 30-second elevator talk that he might give to a U.S. senator if asked about key messages of this workshop. Dickard would tell the senator, “Education affects health. Health affects education.” If you dig into the details, it gets more complicated. He also said that after he first joined the U.S. Department of Education in 1993, the department released the National Adult Literacy Survey, and one of the things the survey found was that a significant percentage of the American adult population had low literacy levels and that this had an impact on their ability to understand health and medical information. A subsequent report issued in 2007 found the same situation to be true and noted the effects of low education levels on the ability to navigate a complex health care environment. “That was my first introduction to social disparities in health and the impact of education,” Dickard said.
He cited the 2012 statistics from a recently released CDC School Health Policies and Practices Study, which found that 60 percent of elementary school districts mandated that schools provide recess, while another 32 percent recommended that schools offer recess to their students. This survey found that 12 percent of school districts have at least one school-based health center that offers physical or mental health services. He encouraged the workshop participants to read this report, which is available from the CDC website (http://www.cdc.gov/HealthyYouth/shpps/index.htm [accessed November 3, 2014]).
Turning to the U.S. Department of Education’s programs, Dickard first noted the billion-plus dollars per year investments that the department makes through its 21st Century Learning Center’s program, which is also known as the before school and after school program. In addition to the academic enrichment and remediation activities that take place under that program, the program also expands opportunities for recreation, movement, and fitness activities and drug- and violence-prevention activities. Dickard also mentioned the department’s new Promise Neighborhoods Program, which was based on the model of the Harlem Children’s Zone in New York, which focuses on the critical first 1,000 days of a child’s life
but also has a continuum-of-services component that allows the department to get involved in the health of students (see Box 5-1).
Dickard characterized the Carol White Physical Education Program, which funded some of the Nemours work discussed in the first panel session, as an innovation and demonstration fund. Dickard explained that grantees are encouraged to push the envelope with this infusion of supplemental federal resources that enable schools and districts to really ramp up their fitness and nutrition education and to promote lifelong wellness among both the students and their families. He noted that the department recently awarded a new round of grants under this program.
Dickard then highlighted a new initiative, called Birth to Five, Watch Me Thrive, which the U.S. Department of Education implemented in collaboration with the U.S. Department of Health and Human Services. This program builds on their experience of conducting vision and hearing screening on children by moving into the area of developmental screening. The department is developing tools to help local public health departments, pediatricians, and others get engaged in conducting developmental screening. Dickard also said that CDC would soon release its report on health and academic achievement, which will serve as a resource for local educators and health officials who want to make the case that health is important to the education sector. The report will outline the evidence from the research in plain English, with informational graphics and core messages that can be used by various sectors, showing, for example, that skipping breakfast is associated with decreased cognitive performance and that higher levels of physical education and physical activity are associated with improved cognitive performance. The report also provides concrete actions that can be taken at the local level. Dickard said that while this CDC report focuses on nutrition, movement, and fitness, it provides a useful model for what can be done in other places where health and education intersect.
The Promise Neighborhoods program focuses on improving the educational and developmental outcomes of children in the nation’s most distressed communities. Programs build a continuum of solutions designed to improve educational outcomes significantly and also support the healthy development and well-being of children. These “solutions” must also include family and community supports, which may include student health programs (e.g., home-visiting programs, programs to improve nutrition and fitness, and programs to create healthier communities).
In providing context for her remarks, Laurie Miller Brotman began by noting that outcomes in a child’s health and development are affected by a wide range of factors and that in the science of early childhood there is not a disconnect between education and health.1 She noted, too, that socioeconomic adversity is an important factor in the development of a child, and she pointed out that nearly half of American children under age 5 live in “poor” or “near poor” families. She also said that poverty and near-poverty are associated with negative outcomes across all key domains of child development—health, learning, social, emotional, and behavioral—and influence the development of self-regulation skills (Blair and Raver, 2012).
Self-regulation, Brotman said, is a key way in which health and academic achievement are linked through what psychologists call the developmental cascade (see Figure 5-1). This cascade starts with socioeconomic adversity, which leads to dysregulation in the child, that is, problems in a child’s ability to regulate his or her own behaviors, including sleep, eating, emotions, and impulsive and aggressive behavior. Data show that a disruptive child in a poor environment is at increased risk of having his or her parenting disrupted, Brotman said, and when parenting is disrupted, it negatively affects the parent’s ability to create a nurturing relationship with the child and makes it more difficult for the parent to engage in effective behavioral management and to be involved in early learning activities. All of these effects in turn disrupt early childhood development in terms of behavior and learning. Disrupted early childhood development may result in lifelong problems, including dropping out of school, antisocial behavior, mental health problems, and obesity. Brotman said there is compelling evidence from longitudinal studies showing that this developmental cascade exists and that with each step down the cascade, it becomes more difficult for a child to get out of it and avoid the worst outcomes.
Given that adversity leads to problems in all of these areas, Brotman said, the question that she as a prevention scientist asks is: How can we impact the developmental cascade? “If we can,” she said, “there is some
1 The science of early childhood development is emerging from the convergence of diverse disciplines such as developmental psychology and epidemiology in longitudinal studies of early childhood interventions. These studies have demonstrated that there are associations between the ecology of childhood with a range of developmental outcomes over a lifespan. In the biological sciences, the mechanisms underlying the associations between social and physical environments and physiological adaptations and disruptions are being illuminated by work in epigenetics, while neuroscience is contributing to understanding how those adaptations and disruptions influence learning, behavior, and well-being (Shonkoff et al., 2012).
FIGURE 5-1 The developmental cascade.
SOURCE: Brotman presentation, June 5, 2014.
hope that we can not only affect one domain but all of these domains.” That idea, she explained, is at the heart of ParentCorps (Brotman et al., 2011), which is as much an approach as it is a program (see Box 5-2). The work that Brotman then discussed was conducted in New York City elementary schools with universal pre-kindergarten programs. She reported findings from a randomized controlled trial conducted in highly disadvantaged minority and immigrant-dense neighborhoods with high school graduation rates of approximately 50 percent and in which half of students in district elementary schools scored below grade level on third-grade tests of reading or math. The trial enrolled nearly 90 percent of the pre-kindergarten population over 4 years in 10 schools. The schools were
ParentCorps is an evidence-based, multi-component intervention for prekindergarten students that promotes high-quality learning environments at home and school, resulting in meaningful educational and health benefits for all children, especially those who are behaviorally dysregulated (e.g., impulsive, inattentive, overactive) in pre-kindergarten. ParentCorps promotes positive parent–child and teacher–child interactions and strong home–school connections through professional development for early childhood teachers and school staff and a 14-week family program.
ParentCorps is a universal program, offered to all families of young children, and it aims to promote foundational skills for students as they make the critical transition to school. ParentCorps engages diverse parents as partners and creates networks of knowledgeable, motivated, and empowered parents throughout the school community. It builds on the strengths of culturally diverse students and families and includes tailored proactive strategies to address the needs of students who are behaviorally dysregulated. The ParentCorps approach incorporates best practices from mental health, education, and professional learning in order to provide supportive, safe, and inspiring spaces for educators and parents to work together on their shared goal of helping young children to succeed. It supports sustainable school-based programming for parents and students and evidence-based teacher practice that synergistically combine to ensure early and equal opportunities for every student.
randomly assigned to receive ParentCorps or education as usual, and children were studied prospectively from pre-kindergarten through second grade. By second grade, relative to children in control schools, children in schools with ParentCorps had higher reading and math test scores, improved teacher ratings of academic performance, and fewer emotional and behavioral problems. In addition, children who had dysregulated behavior when they entered pre-kindergarten had lower rates of obesity (Brotman et al., 2012, 2013).
Replicating and extending findings from a smaller trial (Brotman et al., 2011), this trial with more than 1,000 Afro-Caribbean, African American, and Latino low-income families found substantial benefits for parents across several domains (see Figure 5-2). Approximately 60 percent of families participated in the family program during early evening hours. Based on intent-to-treat analyses (including all parents whether or not they participated), parents in schools with ParentCorps were more knowledgeable about evidence-based practices, reported using more strategies to support positive child behavior, and, according to teachers, were more involved in education. One interesting finding, Brotman said, was that even parents
FIGURE 5-2 ParentCorps impact on parenting that is sustained from prekindergarten through kindergarten.
NOTES: Impact for parents of all pre-kindergarten students regardless of program participation (intent-to-treat). Green indicates high risk.
SOURCE: Brotman presentation, June 5, 2014.
who did not come to the after-school intervention but whose children were in a ParentCorps school were somewhat more involved in their children’s education, according to teacher reports. She attributed this finding to the fact that the professional development training is giving teachers the skills to better engage families. The data also showed that parents with behaviorally dysregulated children in pre-kindergarten benefited in terms of decreasing their use of harsh and inconsistent parenting (Dawson-McClure et al., 2014).
As an example of the type of gains that ParentCorps is producing, Brotman reviewed the program’s impact on reading achievement (see Figure 5-3). The data show that relative to education as usual, children in schools with ParentCorps had greater reading achievement test scores in kindergarten, and this effect was still apparent in second grade. Children who were in pre-kindergarten in schools that had been implementing ParentCorps for several years showed much greater effects, as more parents participated and teachers were more proactive at engaging families and promoting children’s social and behavioral competencies. The more sessions that the parents attended, the better the child’s reading achieve-
FIGURE 5-3 The impact of ParentCorps on reading achievement.
NOTE: Red line indicates size of black-white reading achievement gap.
SOURCE: Brotman presentation, June 5, 2014.
ment. Children who were in the ParentCorps school during the fourth year of implementation and whose parents participated in five or more group sessions had the largest gains, which suggests that ParentCorps has the potential to close the achievement gap for poor and minority children (Brotman et al., 2013). Gains were also seen in teacher-rated mental health problems (see Figure 5-4) and in obesity among children with behavior regulation problems in pre-kindergarten (see Figure 5-5; Brotman et al., 2012). Brotman said that, taken together, these data point to the importance of self-regulation as an important risk factor for achievement outcomes, health outcomes, and mental health outcomes as well as to the ability of parents and teachers to support all children, especially those with regulation problems, as a strategy for improving population health.
In closing, Brotman said that she and her colleagues are now thinking about ParentCorps “as a population-level approach to buffer the adverse effects of poverty on early childhood health and development by engaging and supporting both parents and teachers of young children.” They
FIGURE 5-4 ParentCorps impact on teacher-rated mental health problems.
SOURCE: Brotman presentation, June 5, 2014.
FIGURE 5-5 ParentCorps impact on obesity at age 8.
NOTE: BMI = body mass index; NYC = New York City.
SOURCE: Brotman presentation, June 5, 2014.
have added various elements to all aspects of the program and have developed supports for the schools that implement the program. She said that the newest and potentially most important feature for dissemination is “leadership consultation,” which refers to working with principals, not only to implement the program well, but to really change school policies
and practices in order to increase opportunities for all children, especially those kids who have problems with self-regulation or who do not have the foundational skills that are necessary for school success.
Bender started the discussion by commenting that he was fascinated to see that the ParentCorps intervention showed an impact on obesity without any specific content related to obesity. It illustrates how addressing some of the underlying factors related to health issues can produce a measurable difference, he said.
Session moderator Holly Hunt commented that it is not easy working across the health and education sectors and asked the panelists if they had any ideas on what the health sector could do more efficiently or take on in order to work better with schools and educators. Dickard replied that many of the topics discussed at the workshop, including vision screening and asthma management, are matters of state law rather than federal mandates and that this might be a place for education and health to work together. For example, approximately 30 states currently require vision screening of school children, and the nation’s optometrists, through their professional society, are working to encourage the remaining states to mandate vision screening for all students. Similarly, allergists have been involved in passing state laws on emergency response to anaphylactic shock. Activism on the part of physicians and other health care specialists at the state and local levels was instrumental in the passage of these laws, Dickard said. He added that physicians are in the position at the local level to help make the case from a scientific and medical perspective that health contributes to positive academic achievements.
Robert Kaplan of the Agency for Healthcare Research and Quality commented that mandating screening could drain resources from other needed areas and that caution should be exercised unless a careful evidence-based review shows that screening is effective on a population basis. Mary Pittman of the Public Health Institute wondered if dental screening should also be considered, given the connection between dental cavities, mouth pain, and nutrition. Bender said that he did not think the NEA or teachers would object to that even though that is not currently on their list of concerns. He added that if dental issues are important, there needs to be an effort to educate teachers why they should be concerned about their students’ dental health.
Brotman said that there are incredible opportunities for taking action, particularly in the early childhood setting, given that the science shows it is important to take action at an early age in order to have the biggest
impact and that the federal government, philanthropy, and the business community all seem ready to invest in the early childhood years. “I think the energy and the momentum is there, and that this is one place where the different sectors can really come together,” Brotman said. She added that the best opportunities she sees lie in creating new approaches that involve both the health and education communities rather than trying to undo systems that are already in place. Brotman said that children with behavioral and emotional problems and with problems in other heath areas discussed at the workshop account for a large proportion of special education dollars and that about 20 to 25 percent of children in a disadvantaged urban area start their first day of pre-kindergarten or kindergarten with these problems.
Pamela Russo from the Robert Wood Johnson Foundation asked Bender if he could provide advice on how to approach local NEA affiliates to help connect with schools. Bender replied that it is best done on a one-to-one basis. “You have to establish a relationship and build trust,” he said, and one should not expect a yes or a no answer on the first meeting. “You have to establish a relationship over time and really listen to what they are dealing with and what is important to them and then connect what you need to do with what they need,” he added. He did note that there is no public directory of union locals associated with specific schools. One approach he recommended is to contact the state NEA affiliates, which are listed on the NEA website, and ask for their help in contacting local affiliates.
Marthe Gold from the City College of New York asked about the time and effort required of the parents enrolled in ParentCorps and about the type of professionals involved in the program. She also asked Brotman if she had any idea on the per capita cost of implementing this type of program. The parent program, Brotman responded, consists of 14 2-hour sessions, and she said that in the last trial, 60 percent of the parents had come to at least 1 session and 40 percent had come to 5 or more, with an average attendance of 10 sessions. The program’s goal is to have parents attend 10 or more sessions in order to get the biggest impact at the population level, and she and her colleagues have been working over the past 6 to 7 years on ways of marketing the program to parents. ParentCorps has developed a 14-month start-up model to help schools build capacity for sustainable implementation.
Regarding the professionals involved, Brotman said that in the trial, school-based mental health professionals and teachers delivered the program to parents. The members of her staff are mostly psychologists and social workers. She added that the program now focuses on training schools to run the program on their own, with technical support from ParentCorps staff. One reason that the program is getting bigger effects
over time, she said, is that teachers are participating in the program, which not only helps the teachers but also increases interaction time with parents.
Speaking about the cost of the program, Brotman said that once the program is in place in a school, its cost is less than $500 per family, and the ParentCorps team is working to reduce costs further. Brotman and her colleagues are also in the process of finishing a cost–benefit analysis for ParentCorps. Brotman said that their preliminary analysis clearly shows that ParentCorps improves quality of life and saves money in the long run.
In response to a question from George Isham of HealthPartners about how to set priorities for action, Brotman said that the top priority should be to engage families and understand the family perspective. “If we are going to make change over the long run,” she said, “it is going to be at least in part through the parents and through the family.” She also expanded on the complex approach that ParentCorps takes to get its program integrated into schools. The first step is to work with a school’s principal to establish policies and practices for that specific school. Next comes working on the classroom and thinking about what actually takes place in the classroom when it comes to combining health and education. The third step is rolling out the evidence-based program for families. “I think that if we really want to influence children’s trajectories for health, as well as education,” she added, “we have to get much more serious about really appreciating the complexities of what it means to change an environment at home and in the classroom and in school.”
Pittman asked the panel for ideas on how to deal with the fact that many children are not engaged in any academic pursuits during summer break and may also be experiencing inadequate nutrition, given that they are not getting the free breakfast or lunch that they receive during the school year. California, she noted, has some summer meal programs that it runs through the public library that combine education, public health, and nutrition. Dickard responded that the U.S. Department of Agriculture has a program to promote summer meals in order to overcome that nutrition deficit and also that many school districts offer summer reading programs to keep children engaged in learning activities. Bender added that there has been a spontaneous effort among teachers, working together with local food banks, to provide students with weekend backpacks filled with non-perishable food so they have something to eat over the weekend, an idea that could perhaps be carried over to summer break. Such efforts get complicated rather quickly, though, without the logistics of a formal school meal program. “When you get into these other areas where kids aren’t normally congregating during the summer,” Bender said, “you have to find out where they are and figure out how you make the food program work there.”
Debbie Chang from Nemours asked Bender and Brotman about the sustainability of their programs. Bender said that the Breakfast in the Classroom program is the most sustainable because of the U.S. Department of Agriculture regulations and reimbursement policies. The main challenge is getting start-up funds because the program pays for itself once it is running. Based on the results of pilot programs, some state legislatures have stepped up and provided start-up funding for high-need districts. Bender added that the key to sustainability is to take time to ensure that a program fits into local priorities and to customize it to fit the needs of the school district and its employees. Then, making a value proposition becomes easier, and the program becomes sustainable. “For us,” he said, “it’s that engagement piece, that customization piece, that is so important.”
Brotman said that most of the ParentCorps program was funded by grants from the Institute of Education Sciences and the National Institute of Mental Health. However, the program has relied upon generous—and critical—funding from philanthropic organizations to pay for the research trials, innovations, and the development of best practices. Over the past couple of years New York State’s Office of Mental Health has provided funding for implementation and the cost–benefit analyses because the office recognizes the value of preventive intervention, social-emotional development, and families. Brotman’s team is working with schools and principals to learn more about how to repurpose existing funds to cover costs of this evidence-based program. She noted that the expensive part of ParentCorps is the after-school component, which requires funds for meals and stipends for school staff. Her team is working on a cost-efficient model that offers the less expensive school-day version and reserves the more expensive after-school version for families who need it. Brotman added that her team is undertaking a strategic planning process to guide ParentCorps growth in New York City and in other urban centers across the country.
Regarding national scale-up, Brotman said that there are both opportunities and challenges related to ParentCorps implementation in large urban school systems and Head Start. She said that the Head Start system has workforce issues that are different from those in schools. “If we move too quickly into different systems and with different people, we are going to lose all of the effects,” she said. “We are sure about that.” As a result, ParentCorps is for the moment keeping its focus on the prekindergarten and kindergarten populations in urban schools, but Brotman added that there are incredible opportunities for others to develop similar programs for daycare settings, primary care practices, and other community settings.
Terry Allan from the National Association of County and City Health
Officials and the Cuyahoga County Board of Health asked Bender if schools ever complain about the time needed to apply for grants to bring the type of programs discussed in this session into their schools. Yes, Bender said, and the problem is that principals and teachers are not grant writers. His team’s approach has been to prescreen schools with the help of the NEA state affiliates to identify those with the greatest chances of success and then motivate that select group to complete the application process. “Our solution to the problem is to try to reduce the number of rejections and frustration because it does hurt the program long term.”