2

Exploring the Evidence at the Intersection of Early Care and Education with Health

The first panel discussed the importance of early care and education in achieving overall goals for early childhood development, and it explored the evidence concerning effective programs at the intersection of health and early care and education. The opening presentation was given by Judith Carta, the director of the Bridging the Word Gap Research Network, interim director of Juniper Gardens Children’s Project, a senior scientist at the Institute for Lifespan Studies, and a professor of special education at the University of Kansas. Carta described several examples of multi-sector collaboration on early language promotion and closing the word gap. Laurie Brotman, the Bezos Family Foundation Professor of Early Childhood Development in the Department of Population Health at New York University (NYU), discussed family-centered early childhood education as a lever to improve population health and promote health equity. Allison Gertel-Rosenberg, the director of National Prevention and Practice at Nemours, described a collaborative model to bring early care providers together to learn how to change their policies and practices related to healthy eating and physical activity. She also discussed the spread and scale of that collaborative model into a national collaborative. In a joint presentation, Jodie Whiteman, the director of professional development at Zero to Three, and Sarah LeMoine, the director of early childhood workforce innovations at Zero to Three, discussed several examples of professional development programs at the intersection of the health sector and the early care and education sector, including cross-sector core competencies for those working with children prenatal through age 5 and

critical competencies for infant/toddler educators. The session was moderated by Danielle Ewen, a senior policy advisor at EducationCounsel, LLC.

Following the presentations and discussion, participants moved to the adjacent gallery to reflect on the panel discussion with other attendees, and to consider specific questions that were posed on posters around the gallery. Upon reconvening in plenary session, Valora Washington, the chief executive officer of the Council for Professional Recognition, moderated a discussion of the responses to the questions. (Session highlights are presented in Box 2-1.)

CLOSING THE WORD GAP¹

By age 3, a low-income child has typically heard 30 million fewer words than a child from an upper income background (Hart and Risley, 1995). This is known as the word gap, Carta said. Early language exposure has important consequences for vocabulary development, literacy, school success, and life outcomes. Vocabulary by age 3 is an important predictor of reading by third grade, Carta continued, and at age 3 children from higher-income homes have double the vocabulary of those from lower-income homes. Reading in third grade is a critical predictor for later life success and is the most important predictor of high school graduation. Children who cannot read in third grade are four times more likely to drop out of high school and six times more likely to drop out of high school if they are also living in poverty. This discrepancy in language experience between higher- and lower-income children has been known for a long time, Carta said, and it is essentially a health disparity and a life outcome disparity.

There are evidence-based interventions for promoting language in infants and toddlers, including simple behaviors that parents and caregivers can embed in their daily routines to provide a rich language experience to children. The tools for reducing the word gap are available, Carta said, but the importance of talking with young children even before they can speak is not widely known. Closing the word gap will require both prevention and intervention, Carta said. Prevention includes fostering a broader public awareness of the importance of talking to young children and providing a greater variety of programs with training and advice for parents and early educators on ways to promote language. Intervention involves the use of evidence-based strategies that can change how parents, caregivers, and early educators interact with children to promote language.

Bridging the Word Gap Research Network

The Bridging the Word Gap Research Network² was funded by the Health Resources and Services Administration in 2014 to bring together agencies and individuals across sectors who are already working to address the word gap. The goal of the network is to reduce the vocabulary gap of children from lower-income backgrounds by increasing their

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¹ This section is the rapporteur’s synopsis of the presentation by Judith Carta, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

² For more information, see http://www.bwgresnet.res.ku.edu (accessed October 30, 2017).

language learning experiences. The network, Carta explained, is synthesizing the research around prevention and intervention to identify what works to promote children’s language and is sharing the most effective practices with stakeholders across disciplines that can have an impact on children’s language development. The network is also identifying research gaps and developing new studies and innovations for prevention and intervention. In this regard, the network has launched a practice-based research collaborative, which Carta described as a partnership among “hotspots of innovation.” Carta shared several examples of projects from the collaborative.

Community-Wide Public Awareness

Bringing together multiple agencies and multiple sectors in a community is one way of getting the word out, Carta said. One example of this approach is Too Small to Fail, a joint initiative of the Clinton Foundation and the Opportunity Institute. This public awareness campaign is working with communities to promote recognition of the importance of early brain and language development. The campaign engages community leaders across multiple sectors (e.g., pediatricians, housing, early education, faith-based organizations, community-based organizations, businesses, and others) to provide parents with tools that will help them talk, read, and sing with their young children. The goal, Carta stated, is to get the message out in the places where families go (e.g., laundromats, supermarkets, playgrounds) and to give parents ideas for what they can talk about with their children wherever they spend time together.

Another example provided by Carta is City’s First Readers, an initiative of the New York City Council, which is a multi-sector collaboration fostering early language and literacy through parent engagement workshops, reading opportunities, book distribution, and other activities. The initiative brings together a diverse array of programs from a number of sectors, such as libraries; pediatric settings; the United Way; early childhood education organizations; community-based, literacy-promoting organizations; and home-visiting organizations.

Population-Based Interventions in Pediatric Settings

Another strategy for population-based language interventions, Carta said, is to engage sectors that interact with high numbers of families of young children, such as the pediatric public health sector. Talk With Me Baby is Georgia’s public health sector intervention to bridge the word gap. This public action campaign engages pediatric providers and nutritionists to spread the message that parents are providing “language nutrition”

for their children when they interact and talk with them. Just as children need an adequate amount of food to grow and thrive, so they also need language, Carta said. When parents bring their child for well visits, the providers coach them on age-appropriate activities to promote language development. This initiative is reaching almost all lower-income children within the state of Georgia, she said.

Reach Out and Read is a national program aimed at making literacy a standard part of pediatric primary care. The program has a broad reach and is evidence based, with more than 15 studies supporting its effectiveness. Reach Out and Read is currently reaching 4.5 million children per year, or more than 25 percent of all low-income children ages 6 months to 5 years in the United States, Carta said. At $25 per child per year, this is an example of a low-cost initiative that is being successfully scaled.

Individual Interventions Teaching Parents Language-Promoting Strategies

The final area of intervention discussed by Carta was evidence-based approaches that provide parents with specific training in language-promoting strategies they can use with their children. She described three examples: the Video Interaction Project (which also takes place at pediatric health care visits), which promotes parent–child interaction through one-on-one support; Thirty Million Words, which informs parents about the importance of language and literacy shortly after a child’s birth while they are still in the hospital and then has a home visit to teach simple strategies when the child reaches 6 months; and Tools for Advancing Language in Kids, which is a professional development program for early childhood educators.

Potential Challenges for Future Work

In summary, Carta concluded, multi-sector collaboration to close the word gap is already taking place. Sectors are working together on public awareness campaigns in communities, and agencies are working together across sectors toward the common goals of promoting language and early literacy. Carta noted, however, that multi-sector work is often occurring in parallel—that is, with the various entities working side by side on similar goals—and there is still room to grow in terms of true collaboration and integration across sectors. Such collaboration and integration would include, for example, the sharing of data across sectors and more early screening in pediatric settings, with referrals to more intensive services in early childhood education or home-visiting programs.

Carta noted that through multi-sector collaboration, word gap interventions can be developed and deployed that can strengthen parental

bonds, promote resilience, and give children a stronger language background, which will influence multiple outcomes in their lives (e.g., academic achievement, social and emotional development, health outcomes). Prevention and intervention to address the word gap can help ensure that all children enter kindergarten on track, which will support better health and educational outcomes in the long term.

A participant asked a question about the types of interventions available to support language development in children with hearing impairments. Carta said that the implications of the word gap for children who are hearing impaired are similar to those for children who can hear. She referred participants to the work of Dana Suskind at The University of Chicago. Suskind’s interest in early language experience emerged after learning that among hearing impaired children who had received cochlear implants, language development in children from higher-income areas in Chicago progressed well, but children from the lower-income areas continued to show considerable delay in their language development.

FAMILY-CENTERED EARLY CHILDHOOD EDUCATION³

Poverty, adverse childhood experiences, and racism affect all aspects of child development, Brotman said, including behavioral, physical, cognitive, social, and emotional development. There are many different mechanisms through which poverty and adversity influence these outcomes, she said, but a key mechanism is through the development of self-regulation. During the preschool period, self-regulation skills begin to come together as children hone their ability to pay attention, control impulses, delay gratification, and regulate their emotions, Brotman explained, and these skills are malleable early on. With this evidence in mind, ParentCorps was developed by NYU Langone Health as an enhancement to pre-K programs that supports leaders, teachers, and parents in creating safe, nurturing, and predictable environments for children.⁴

ParentCorps

The goal of ParentCorps, Brotman said, is to promote population health and reduce socioeconomic disparities through a family-centered intervention that is broadly available, engaging, and effective for low-

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³ This section is the rapporteur’s synopsis of the presentation by Laurie Brotman, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

⁴ For more information, see https://med.nyu.edu/pophealth/divisions/cehd/parentcorps (accessed October 30, 2017).

income, culturally diverse families. The program is built on five principles, each based on decades of research and rooted in studies in clinical and developmental psychology. First, ParentCorps was designed to be a universal enhancement to pre-K, in order to achieve maximum reach and acceptability. Second, the program was designed to be embedded in schools and facilitated by school staff, which would foster cost efficiencies and sustainability by building on existing structure and capabilities. Third, the program is timed with the transition to school, at the time when child self-regulation is developing and parents are open to change and motivated to be involved in supporting their children’s learning. Fourth, ParentCorps has multiple components to support the home and classroom environment and also family engagement. Finally, at the core of ParentCorps is a group-based parenting program that places culture at the center in order to build social capital and create a network of empowered parents.

The three main components of ParentCorps are schools, classrooms, and homes, Brotman said. The program influences the school environment through professional learning for leaders, pre-K teachers, mental health professionals in the schools, and family support staff. The home environment is influenced through a 14-session parenting program, which covers topics from goals, routines, and responsibilities to enjoying mealtime together, the power of play, and effective discipline. The program influences classrooms through a program for pre-K students called Friends School. The 14 lessons of the Friends School curriculum span such topics as making friends and sharing; paying attention; saying “please,” “thank you,” “sorry,” and “excuse me;” identifying feelings (happy, sad, mad, scared); taking care of oneself; and celebrating people’s differences. Brotman listed the topics covered during different 2-hour activity sessions, which included free play, the lesson topic, a welcome circle, an activity, physical exercise, food review, calm down techniques, and mealtime with the teacher.

ParentCorps is based on a theory of change that the school, home, and classroom program components come together to create safe, nurturing, and predictable environments; effective family engagement and strong parent–teacher relationships; and social and emotional skills. The result is positive child outcomes in terms of self-regulation, academic achievement, mental health, and physical health (see Figure 2-1).

The theory of change is supported by two decades of evidence from two large randomized controlled trials in New York City in high-poverty schools with pre-K programs, Brotman said. These studies show that this program can lead to short- and long-term changes for children and families. Specifically, replicated evidence shows that the program leads to

• positive parenting practices that lead to safe, nurturing, and predictable environments at home and parental involvement in learning, both at home and in the classroom;
• positive classroom environments that are safe, nurturing, and predictable as well as strong family engagement;
• increased school readiness, both in terms of self-regulation and pre-academic skills (literacy and math); and
• sustained impact (pre-K through second grade thus far) on academic achievement (test scores, teacher ratings), mental health outcomes (behavioral and emotional), and physical health (obesity/body mass index [BMI], healthy behaviors).

With a successful, evidence-based program in place, the next step was to take ParentCorps to scale in New York City, Brotman said. As of September 2017, ParentCorps was in place in 35 high-poverty schools and centers in five boroughs, with plans for further expansion in 2018, she said. Working with partners in the Department of Education, Brotman said, a three-tiered model for spreading ParentCorps’s evidence-based practices to two other initiatives was developed. New York has invested in Pre-K for All, a program to give all children in New York City an opportunity to engage in full-day pre-K, and in NYC Pre-K Thrive, a component of ThriveNYC, a mayoral initiative to support mental health. The ParentCorps program is

1. providing universal supports to all 1,870 Pre-K for All programs, which serve 70,000 children annually;
2. spreading evidence-based practices through intensive professional learning in 350 Pre-K for All programs; and
3. continuing to deliver ParentCorps in 55 Pre-K for All programs.

Furthermore, an evaluation plan has been developed in partnership with the Department of Education; the plan includes three randomized controlled trials to assess implementation and effectiveness and to rigorously evaluate the scale-up initiative.

Potential Opportunities, Challenges, and Future Directions

The opportunities to partner with education providers and leaders to implement health promotion programs are enormous, Brotman concluded. The greatest challenge, she said, will be moving from the efficacy data and the promise of these interventions to actually implementing, evaluating, and improving at scale. Moving forward, Brotman said, will depend on relationships, partnerships, and trust.

LEARNING COLLABORATIVES

Nemours has been working at the intersection of early care and education and health for some time, Gertel-Rosenberg said. The company first worked with partners in the state of Delaware to change regulations affecting early care and education so that they better reflected best practices in healthy eating and physical activity. Those changes affected the 54,000 children in Delaware who were in early care and education settings on a regular basis, she said.

Nemours has also had success at the practice level, establishing a collaborative model that brought early care providers in Delaware together in groups to learn together how to change their policies and practices related to healthy eating and physical activity. Nemours engaged early care providers who were serving about 2,700 children in Delaware. Gertel-Rosenberg said that 100 percent of the providers made changes in either healthy eating or physical activity and that 81 percent of them made changes in both. Nemours found that early care providers were eager for this type of information, including actionable steps—a pattern that continued with the launch of Let’s Move! Child Care in 2011. A decision was made to try to spread and scale the early care and education learning collaborative model beyond Delaware.

National Early Care and Education Learning Collaborative

With a 5-year cooperative agreement with the Centers for Disease Control and Prevention (CDC), Nemours was able to leverage and expand the collaborative work that had been successful in Delaware, and in 2012 the national Early Care & Education Learning Collaborative (ECELC) was launched.⁵ The ECELC has now been implemented in 10 states (Alabama, Arizona, California, Florida, Indiana, Kansas, Kentucky, Missouri, New Jersey, and Virginia). More than 2,200 early care and education programs serving more than 191,000 children have taken part in 106 collaboratives across the country. Evaluation shows that these providers are making significant changes in practices related to nutrition, physical activity, breastfeeding, screen time, and other areas, Gertel-Rosenberg said.

The ECELC has two main parts. A practice component offers early care providers the tools and technical assistance to change the practices in their care centers or family child care homes. There are best practices for physical activity, screen time, breastfeeding, and other areas. A systems change component helps to foster sustainability. This work is done via state or local plans that are developed by state partners in coordination

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⁵ For more information, see www.healthykidshealthyfuture.org (accessed October 30, 2017).

with other partners in the state. States and localities are provided with technical assistance and peer support from other states that have gone through similar sustainability and integration opportunities.

Lessons Learned

Gertel-Rosenberg shared four key lessons from the scale-up of the ECELC. Be responsive to the needs of partners and early care and education providers, she said. State and local partners know their geography and their communities, and they can help with uptake in their areas. The curriculum is customizable, and the implementation is reflective of what is needed in the states and communities. For example, the curriculum has been translated into Spanish, and there is now a family child care curriculum. In Arizona the ECELC was aligned with and supported the goals of the state’s existing Empower initiative to help children grow up healthy.

Another lesson is that incentives foster engagement. This is not limited to financial incentives, Gertel-Rosenberg said, and she emphasized opportunities to think outside the box. One incentive that brought people to the table, for example, was ensuring that the learning sessions and the action periods in between were eligible for continuing education hours or clock hours.

Leverage the initial investment with additional investment, Gertel-Rosenberg said. Nemours was able to increase the spread of ECELC and provide additional enhancements beyond what was initially funded by CDC by partnering with private foundations to meet shared needs. These partners wanted to have collaboratives in additional places, for example, or they wanted to provide durable goods to help providers implement the best practices (e.g., family-style dining, physical activity), or they wanted to pilot innovations on such topics as parent engagement, centralized kitchens for child care centers, or variations on the implementation of the model. Nemours also worked with the states to determine how their funding could best be leveraged. In Florida, for example, funding from CDC’s 1305 program⁶ was used to spread the learning collaboratives to additional sites in the state.

Finally, Gertel-Rosenberg advised participants to think about integration and sustainability at the beginning, middle, end, and every point in between. They could consider, for instance, integrating into existing systems, especially other child-serving systems. Each state provides examples of how to integrate and embed the content and demonstrate

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⁶ State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (DP13-1305). See https://www.cdc.gov/chronicdisease/about/state-public-health-actions.htm (accessed October 30, 2017).

value, she said. In Orange County, Florida, for example, a quality rating and improvement system pilot awards points for healthy eating and physical activity, which creates an additional incentive for early care and education programs to ensure that this content is embedded. A preschool in Jefferson County, Kentucky, highlighted the impact of implementing family-style dining at snack time. They noticed significant changes in food behaviors as well as increased independence that carried over to other activities (e.g., students setting up their own cots or initiating other self-care activities without adult prompts). As the ECELC project has ended in some states, those states have chosen to continue funding the project coordinators and the work.

THE PROVEN POWER OF EARLY CONNECTIONS⁷

Since 1977, LeMoine said, Zero to Three has been translating research on how the youngest children think, learn, and interact with the important adults in their lives into helpful tools, services, and practical resources for parents, policy makers, and professionals.⁸ The mission of Zero to Three is to ensure that all babies and toddlers have a strong start in life. Zero to Three envisions a society that has the knowledge and the will to support all infants and toddlers in reaching their full potential. LeMoine emphasized the urgency of that mission, and she shared a quote from the Institute of Medicine and the National Research Council (IOM and NRC) consensus report Transforming the Workforce for Children Birth Through Age 8: A Unifying Foundation:

Zero to Three: Professional Development Initiatives

Whiteman noted the variety of different professionals who touch the lives of very young children and families. She discussed several examples of the work that Zero to Three is doing at the intersection of the health sector and the early care and education sector, spanning physical health,

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⁷ This section is the rapporteur’s synopsis of the presentation by Sarah LeMoine and Jody Whiteman, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

⁸ See https://www.zerotothree.org (accessed October 30, 2017).

mental health, child welfare, and social services; early identification and intervention; and early care and education.

One such example, Knowledge and Know-How: Nurturing Child Well-Being, is a program of eight online 1-hour lessons for professionals. Whitman said that the simple theory of change model is based on the integration of cross-sector professionals as well as the integration of health, well-being, mental health, early intervention,⁹ and the opportunity to share language. Immediate outcomes include knowledge gains, strengthened parent–provider relationships, and the promotion of cross-sector collaboration. Longer-term outcomes include increased support for families, optimal development for infants and toddlers, and a reduced risk of child maltreatment.

Whiteman also described Cross-Sector Core Competencies for the Prenatal Through Age Five Field, a program funded by First Five LA. This professional development resource covers eight competency areas: early childhood development; family-centered practice; relationship-based practice; health and developmental protective and risk factors; cultural and linguistic responsiveness; leadership; professional and ethical practices; and service planning, coordination, and collaboration. These competencies build on and are aligned with related professional criteria, and they are intended to enhance cross-sector collaboration and foster shared language.

LeMoine described a related example focused on Critical Competencies for Infant-Toddler Educators. This resource builds on the cross-sector collaborative foundation. Caring for infants and toddlers requires a holistic approach, she said, and educators play a key role in supporting and nurturing all aspects of infant/toddler learning and development. In the best-case scenario, LeMoine said, educators partner with families and with other sectors and disciplines to create a comprehensive environment that protects, engages, and nurtures children. In considering its decades of work with numerous partners, Zero to Three identified a persistent gap found in the daily interactions between infants-toddlers and their educators. These educators often receive workforce training geared intentionally toward the pre-K age group and then return to work to care for, say, a 6-month-old, unclear on how to transfer their new knowledge to their very young charges. To address this, Zero to Three developed specialized competencies that include sector-, discipline-, role-, and age-specific skills. In implementing these competencies, Zero to Three is supplementing and building on what already exists in the states. There is training for the pro-

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⁹ “Early intervention” generally refers to services defined in Part C of the Individuals with Disabilities Education and Improvement Act (IDEA). For more information, see http://idea.ed.gov/part-c/search/new.html (accessed January 23, 2018).

fessional development providers who train early care educators as well as support and training for the educators themselves to reflect on and positively impact their daily practices with infants and toddlers. LeMoine said that Zero to Three applies a diversity, fairness, and equity lens to each of the practices that are included in the critical competencies, not only because educators work with a diverse population but also because educators themselves are diverse. The critical competencies also address working with vulnerable populations and multi-language learners.

Sometimes children need more than what even the most skilled educator can provide, LeMoine said, and Zero to Three also emphasizes a multi-disciplinary approach to help educators connect with families in meaningful ways and understand where their role might end and where other partners and support services can step in (e.g., identification of children who may need additional specialized services, coordination with medical partners, referring for mental health evaluation).

DISCUSSION

To start the discussion, Ewen listed some of the topics raised in the presentations, including specific health and development issues such as vocabulary gaps, nutrition, executive function,¹⁰ and self-regulation; the importance of taking equity into account; and the need to engage and share information with the many diverse stakeholders involved in some way in children’s health, including parents and caregivers, pediatricians, mental health providers, community service providers, social service providers, and others. Speakers also emphasized the importance of cross-sector collaboration and partnerships; the integration of programs and services to foster sustainability; and evidence to support spread and scale of programs. The discussion centered on metrics and measurements—in particular, on assessing the impact of programs on equity and on metrics of mental and physical health outcomes in young children.

Assessing Equity

Phillip Alberti of the Association of American Medical Colleges acknowledged the attention to equity in the programs discussed and

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¹⁰ Harvard University’s Center on the Developing Child provides the following definition: “Executive function and self-regulation skills are the mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully. Just as an air traffic control system at a busy airport safely manages the arrivals and departures of many aircraft on multiple runways, the brain needs this skill set to filter distractions, prioritize tasks, set and achieve goals, and control impulses,” see https://developingchild.harvard.edu/science/key-concepts/executive-function (accessed January 22, 2018).

asked whether disparities-focused metrics or equity-sensitive metrics were assessed in order to understand how the programs were affecting the gaps. He raised the need for implementation science, noting that one size will not fit all in every program, school, or community, and he asked whether anyone was studying the types of adaptations that might be needed to ensure that all communities benefit equally.

LeMoine responded that the Harris Foundation’s Infant Mental Health Tenets, which are diversity informed, were applied as overarching principles in developing Zero to Three’s critical competencies. There are also measures tied into state systems that are used to assess how well diversity, fairness, and equity are being applied in each of the competency areas. Reflection tools tied to specific competency areas are used at the individual practice level. At the systems level, Zero to Three is conducting pilot studies with data fields. There is also attention to implementation science, LeMoine said. For example, teams are required to come together for direct service training. This is a significant commitment, she added, and there is a readiness-for-change component to the program, where the teams reflect beforehand.

Brotman reiterated that ParentCorps is focused both on promoting population health and on reducing disparities. Since its inception, the program has been careful to look at how it affects different subgroups, paying attention to gender, race/ethnicity, and children who come to pre-K with low self-regulation skills. ParentCorps has also been deeply engaged in racial equity work at all levels and is working with the Pacific Education Group consulting firm, Brotman added. There is a tremendous amount of work to do, she said, in order to understand what it means to apply a racial equity lens to all of the components of a program (e.g., the population as well as workforce diversity, including diversity of the implementation team, coaches, trainers, researchers) and to tie that together with prevention science, developmental science, implementation science, and improvement science.

Measuring Mental and Physical Health Outcomes

Aly Richards of the Permanent Fund for Vermont’s Children noted the challenges of identifying the right metrics to use for child mental health and physical health outcomes, especially metrics that translate to health and mental health partners. She asked specifically about the teacher ratings used by ParentCorps and also about whether ParentCorps has been able to leverage those metrics and outcomes to secure funding. Brotman replied that the randomized controlled trials of the ParentCorps model used the Behavior Assessment System for Children, which includes teacher ratings and parent ratings. Moving forward, ParentCorps is work-

ing in partnership with the Department of Education on existing assessments for quality and outcomes. The quality discussion is somewhat easier to have, she said, even though the topic is complicated. Discussions about measuring children’s behavior and mental health face numerous complexities. In New York City there is systematic, annual measurement of BMI, and ways to measure academic outcomes in school-age children, but there is no systematic way yet to measure mental health outcomes.

Terry Allan of the Cuyahoga County Health Department in greater Cleveland asked about the durability over time of health outcomes associated with the ParentCorps program. Brotman responded that there are replicated findings from one study that followed children through early adolescence and from another that has thus far followed the children through second grade. In the latter, the children will continue to be followed as they transition to middle school, while those in the earliest cohorts will be followed as they transition to high school. There are very clear patterns of separation, very early on in pre-K, Brotman said, as the children without intervention escalate on the obesity scale, and that separation continues to grow over time.

GALLERY WALK REFLECTIONS

Following the panel discussion, participants moved to the gallery to consider the following questions:

• How can the field better apply what is known at the interface of early care and education and health (e.g., screening for developmental milestones)?
• What are the gaps that need to be prioritized?
• What new insights can be offered?

Upon reconvening, Washington summarized individual participants’ responses to the questions posed in the gallery and moderated the discussion. Health outcomes are among the most well-documented benefits of programs that serve young children, Washington said, and she emphasized the need to consider how best to leverage this fact. She observed that there were many diverse comments shared by individual participants during the gallery walk, and she framed the comments in terms of four principles:

• Respect. Many of the individual comments focused on how best to respect families in this work and on the importance of asking parents what they want.
• Competence. There were many comments concerning how this work will actually be done. Questions were posted regarding infra-

• structure, how sectors work together, and whether there is a common language that enables communication across these sectors, for example.

• Strengths. Participant comments also raised the issue of how best to build on the current knowledge base and not “reinvent the wheel.” This work has been going on for a long time, Washington said, and participants highlighted the need to build upon existing strengths and leverage the prior work. Questions were raised about the need for public campaigns to advertise and promote these strengths.
• Equity. Washington noted that there were only a few comments posted about equity, and she prompted participants to consider the issue further, including where equity ranks in the work on the intersection between early childhood care and health.

Prevention of Disparities: Spreading and Scaling Programs That Work

In considering gaps to be prioritized, Alan Mendelsohn of NYU suggested that greater focus is needed on the role that the health care system can play in the prevention of disparities in early child development and school readiness. He referred to the examples provided by Carta and other panelists and emphasized the importance of this role of the health care system as a focus, rather than an afterthought, in policy conversations. He observed that the pediatric platform is quite good at screening and identifying families with emergent problems (e.g., parent–child challenges; developmental statuses that require referral for early intervention or other services). He suggested that a prime opportunity to engage families during the critical birth to age 3 period is during the many pediatric primary care visits that occur during this time frame (at least seven in the first year of life). Parents come with an interest in knowing about their children’s development and behavior. The Reach Out and Read program, which incorporates books into pediatric care (discussed by Carta), is an example of working to prevent child development disparities before they occur, he said. These programs have been shown to be effective, and some, he added, are being effectively scaled (as discussed by Carta, Reach Out and Read is currently reaching more than 25 percent of low-income children in the United States from age 6 months to 5 years).

Isham said it would be important to understand what factors or characteristics of the Reach Out and Read program led to the broad reach that it has achieved thus far. Understanding how such programs are spread will also be important to efforts to reduce disparity, he added. For example, if a program is covered or incentivized by insurance, that would limit spread to the population that has the relevant insurance coverage.

Alan Mendelsohn said that one reason it is possible to reach that 25 percent of low-income families through health care is because many are covered by Medicaid and come in for the many early childhood pediatric visits for vaccines, screenings, and other services. With regard to dissemination and implementation across practices, he referred participants to the work of Perri Klass and his colleagues at NYU (for example, see Klass et al., 2009). The model includes, for example, grassroots efforts, making literacy promotion part of the pediatric training in residency programs, and developing regional organizations and infrastructure to allow for central and local support for the implementation of the program.

Whiteman said that Zero to Three is the home of Healthy Steps, a program that trains and houses Healthy Steps specialists in pediatric offices to work with families on all aspects of behavioral health. Zero to Three is now working on taking this program to scale. Whiteman noted that Zero to Three is currently advocating at the federal and state policy levels and working with health maintenance organizations and Medicaid to address reimbursement issues for these services. For example, billing and reimbursement may depend on the specific license a Healthy Steps specialist has.

Bonnie Kerker of the NYU Department of Population Health agreed with Mendelsohn and said that it will be critical to expand the focus of the pediatric visit to include, in addition to developmental programs, mental health and social aspects of the family environment. These areas also have tremendous impact on both immediate and longer-term outcomes for children and thus need greater attention. She also suggested that there is a need to start before the pediatrics office—in the obstetrician/gynecologists office—as data show that in order to ensure positive outcomes for children, social, emotional, and other aspects of child health need to be addressed even before a woman becomes pregnant.

Washington noted that prevention is often tied to funding (i.e., funding decisions based on whether prevention is done). Larry Pasti of the Forum for Youth Investment said that many family insurance plans now incentivize prevention for adults—for example, by offering discounts on gym memberships or other incentives—but such incentives have not yet benefited children or infants. He suggested that insurance companies help fund preventive initiatives that can have long-term health benefits for children, such as the types of reading programs discussed.

Funding, Financing, and Reimbursement

Paula Lantz of the Gerald R. Ford School of Public Policy at the University of Michigan suggested that there is a need to add funding and financing to the principles listed by Washington. It is important to

include a cost component in evaluations in order to better understand both the costs and the value of interventions and to demonstrate the costs and value to policy makers and other funders. She also spoke of the need to consider different funding models, especially as they relate to different kinds of communities. For example, how can high-quality pre-K be funded so that inequities will not become reinforced and widened? Washington agreed that the issue of funding is applicable to all of the principles she listed.

A participant pointed to the ongoing struggle between reimbursement methodology and the movement toward value-based payment. In New York, for example, there are more than 2 million children in managed care, which is rapidly transitioning to value-based payment models. New York State recently released a value-based payment model for pediatrics that is focused on achieving population health–level impacts. The model addresses the need to transition to yet-to-be-developed common metrics between the early education sector and pediatrics. These are ambitious measures, she added. She urged the National Academies to elevate the conversation about expanding quality measures from not just whether a well-child visit is done, to whether that well-child visit includes a population health primary prevention focus and whether it could eventually align goals with early care and education.

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