This chapter highlights the main findings and concepts discussed throughout this report and summarizes the report’s recommendations to lay out a roadmap for applying and advancing the science of early development. First, the chapter highlights the key big-picture findings gleaned from this report, followed by briefly reviewing the specific actions to be taken within each sector or area based on the report content.
Key Report Findings
The persistence of disparities between groups of people shows that there is more involved in producing them than individual behavioral choices (see Chapter 1 and NASEM, 2017). The factors that drive health disparities from the preconception period through early childhood are complex, interconnected, and systemic; they result from exposures and experiences that children and families encounter throughout their lives, as well as choices they make. These exposures add up over the life course to exert a cumulative effect on health that is probabilistic, not deterministic. That is, the odds of good health are never fixed; individual exposures, experiences, and choices help set and adjust them over time. While groups of people have varying rates of exposure to key adversities and experiences, their distinct contexts shape their choices and opportunities, and thus they have different odds of experiencing
good or poor health outcomes over time. For any given child, these odds may or may not lead to a particular health outcome. Applied to groups or populations over time, however, they manifest as health disparities.
To understand how certain subsets of U.S. children (e.g., racial/ethnic minority and low-income children) have heightened risk of exposure to the key drivers of poor health outcomes, the systems in which lives are lived and organized need to be examined. If those systems present different opportunity structures and choices to some groups of children and families, intentionally or not, they may generate health disparities upstream (early in life) even as those same systems might be working to address disparities downstream. Reducing health disparities by addressing their systemic roots is foundational to advance health equity; although it is a substantial challenge, it cannot be ignored.
As discussed in Chapter 8, health equity is a systems challenge. Implementing programs aimed at people in crisis alone will not advance health equity—those programs are important for addressing immediate needs, but until the systemic roots of inequity are addressed, there will likely be another set of crises around the corner.
In assessing the state of the evidence on early-life factors that shape health inequities, the committee developed a conceptual model (see Chapter 1, Figure 1-9) that summarizes the complex considerations that need to be addressed to break this cycle. Inherent in the model are three insights that are foundational to an effective health equity strategy targeted at the early-life period (preconception to early childhood).
The Importance of Intervening Early
The preconception through early-life periods are foundational for healthy development across the life course. Biologically, a number of critical systems are developing, and humans have high plasticity during these life stages. Social-psychological and cognitive development are also important leverage points in the early years of life. Biological and social-psychological developmental pathways interact over the entire life course to set the trajectory for positive health outcomes, but the initial trajectories are established in early life. With the opportunity to play out across an entire life course, even small changes in initial health trajectories can result in large differences in long-term outcomes. Additionally, what happens early in life may impact not only initial health trajectories but how responsive those trajectories are to subsequent efforts to change them later in life—“resiliency” in the face of challenging circumstances. It is generally easier to change health trajectories for the better early on.
The Importance of Addressing Systemic and Structural Factors
This is critical because individual experiences, exposures, and choices are nested within and informed by those factors. The likelihood that a child or family will experience positive or adverse exposures is impacted by the systems they move through in their lives, including microsocial systems such as families or immediate social networks, larger institutional systems such as health care or education, and the cultural and historical forces that shape those institutional systems and experiences within them. In addition to affecting exposures to health-positive or health-negative factors, systems also impact how individuals respond to exposures or to interventions designed to mitigate the effects of negative exposures. Individual experiences within systems vary dramatically based on racial, cultural, or other personal characteristics. The effects of these systemic factors are by no means individually deterministic, but they do help set the odds, and when different odds play out over time and across groups of people, they generate systematically different health outcomes. A health equity approach requires systems to change in ways that improve opportunities for good experiences and reduce the odds of adverse exposures for populations that are currently experiencing disparate health outcomes.
The Interconnected Nature of Health Disparities
The systems that influence developmental and health trajectories are profoundly interconnected. The microsocial environment of children’s daily lives—families and immediate social networks—is nested within and impacted by the key institutional systems that form the framework of society, and those institutional systems are nested within and impacted by cultural and historical forces that have shaped their essential character. The impact of any one of these systems will inevitably ripple across and shape what happens in others. In terms of the early-life drivers of health inequities, this means that there is no one-sector solution: the root causes are crosscutting, and improving outcomes in one sector is often interdependent on what happens in another. Poor outcomes in the early learning system may have roots in the family environment, which may in turn be shaped by the family’s economic circumstances, and may also mean that the family is unable to access needed services in health care or other systems. Complex and interconnected root causes call for comprehensive and crosscutting solutions; one-dimensional strategies are not enough.
What Works?: The Key Elements of a Successful Strategy
The above insights are not meant to suggest that the work being done to improve health outcomes within individual settings is unimportant or somehow reflects inadequate thinking. In fact, a tremendous amount
has been learned about what works and what actions need to be taken—enough to identify the key building blocks of a successful strategy for addressing health equity. In this report, the committee examined the evidence to identify “what works” in a number of different critical contexts.
What Works in the Family Environment (Chapter 4)
Supporting the well-being of children starts with supporting the wellbeing of their caregivers, and strategies designed to reduce children’s potential exposure to maltreatment are particularly important. Strategies built to harness existing social resources within a family’s environment or community are both cost effective and able to improve the continuity of support systems for caregivers. Context is important: culturally specific or experience-specific processes need to be considered to best respond to families’ unique needs in ways that are most likely to engage them, and tiered approaches that recognize the different degrees of risk that families face and offer appropriate resources based on that assessment are more likely to succeed than a one-size-fits-all approach.
What Works in the Health Care System (Chapter 5)
Health care practice, especially in the preconception, prenatal, and pediatric arenas, has not yet caught up to the current science to encompass key advances, such as the life course perspective, the role of adversity, trauma, and the toxic stress response, and the integration of the social determinants of health (SDOH), to transform health care for young families into a system designed to facilitate health production. However, strengthening the content of health care alone will not advance health equity—access to health-enhancing services for all populations by expanding public coverage and addressing nonfinancial barriers to participation will be critical. Furthermore, holding health systems accountable for this shift through changes in equity-focused quality measures and aligned incentives that more comprehensively address health and the risks of poor health will be required. Other necessary actions include transforming the organization, payment, and delivery of health care services to allow for the adoption of integrated, whole-person care models that emphasize a life course approach and address upstream causes of poor health; facilitating the spread of multidisciplinary team-based care; developing trauma-informed systems that can respond effectively when a child is exposed to early-life adversity; and supporting cross-sector partnerships that intentionally connect health care services to the work of partners outside of the health system that are taking the lead to address the SDOH.
What Works in the Early Living Environment (Chapter 6)
It is critically important to provide predictability and security in the lives of children and their families by reducing childhood poverty, ensuring economic stability, and establishing a healthy and safe living environment. Money matters—having resources available to meet basic needs can improve health and reduce health and developmental disparities in early childhood, and public programs that provide resources to those families represent critical investments that “pay off” in the form of better outcomes for children as they enter school healthy and ready to learn and later move into adulthood. However, hinging these benefits on employment or earned income requirements that take caregivers from the home may be counterproductive for families if those requirements increase caregiver stress or hinder opportunities for developing healthy family relations, attachment between mother and child, or breastfeeding. Finally, the critical role of safe, stable, and affordable housing and food security are key determinants of childhood health, as are efforts to prevent and mitigate the impact of exposure to environmental toxicants during the preconception and early childhood periods.
What Works in Early Childhood Education (Chapter 7)
Early childhood education programs play a critical role in ensuring that children are healthy and ready for school life and beyond. It is necessary to incorporate health outcomes and health equity into a comprehensive approach to school readiness, including integrating it into the preparation and training of teachers. Educators—who are critically important caregivers to the children they work with—need adequate compensation and supports for their own health and well-being to ensure their effectiveness in the classroom or learning environment. Family support programs based in the home environment can provide valuable support when aligned with existing early childhood education systems. Last, there is a critical need to address access and affordability of promising models in early childhood education, especially for populations who have historically experienced health inequities.
Roadmap to Advance Health Equity Across the Life Course
In this report, the committee identified knowledge gaps that can be closed with greater investment in biological, behavioral, psychological, intervention, and implementation research. Each of these areas is equally important for addressing the gaps, and the committee recommends multidisciplinary research efforts to bring fresh, new ideas and practical
approaches (such as innovative measurements and research methodologies) to advance efforts in tackling head on the serious challenges of health disparities to achieve health equity. The committee emphasized, however, that the great advances in knowledge since the release of From Neurons to Neighborhoods (NRC and IOM, 2000) make it very clear that policy makers, health providers, business leaders, and others in the public and private sectors do not need to wait any longer to take action. As the report brings to the fore, there are important opportunities to harness the many promising and evidence-based approaches that have come from advances in the understanding of how to address the neurobiological and socio-behavioral determinants of health disparities. In brief, the roadmap the committee has put forth includes the following key strategies (see Table 9-1):
- Intervene early: In most cases, early intervention programs are easier to implement, more effective, and less costly.
- Support caregivers: This includes both primary caregivers and caregivers in systems who frequently interact with children and their families.
- Reform health care system services to promote healthy development: Redesign the content of preconception, prenatal, postpartum, and pediatric care while ensuring ongoing access, quality, and coordination.
Create supportive and stable early living conditions:
- Reduce child poverty and address economic and food security,
- Provide stable and safe housing, and
- Eliminate exposure to environmental toxicants.
- Maximize the potential of early care and education to promote health outcomes.
- Implement initiatives across systems to support children, families, other caregivers, and communities: Ensure trauma-informed systems, build a diverse and supported workforce, and align strategies that work across sectors.
- Integrate and coordinate resources across the education, social services, criminal justice, and health care systems, and make them available to translate science to action.
It is the committee’s hope that this roadmap will catalyze the steps that need to be taken across systems to close the health equity gap and improve the lives of the nation’s children.
TABLE 9-1 Roadmap to Apply the Science of Early Developmenta
|Intervene early||Implement programs that ensure families have access to high-quality, cost-effective community programs, including interventions to foster strong attachments and group-based supports in communities (Recommendation 4-4)||Federal, state, tribal, territorial, and local policy makers; philanthropic organizations|
|Routinely track levels of risk among mothers and children over time using periodic assessments (Recommendation 4-5)||Health care providers|
|Support caregivers||Strengthen and expand evidence-based home visiting programs (Recommendation 4-3)||Federal policy makers; HRSA; ACF; federal, state, territorial, tribal, and local agencies overseeing program implementation|
|Implement paid parental leave (Recommendation 6-1)||Federal, state, tribal, territorial, and local policy makers|
|Reform health care system services to promote healthy development||Increase access to preconception, prenatal, postpartum, and pediatric health care (Recommendation 5-1)||HHS; Medicaid agencies; public and private payers; federal, state, local, tribal, and territorial policy makers|
|Expand accountability and improve quality of preconception, prenatal, postpartum, and pediatric care (Recommendation 5-2)||Public and private payers; HRSA, CDC, CMS, perinatal and pediatric quality collaboratives, and health care–related workforce development entities|
|Adopt policies and practices that improve the organization and integration of care systems from preconception through pediatric care and that focus on the caregiver and child together as the unit of care (Recommendation 5-3)||HHS; state Medicaid agencies; health systems leaders; federal, state, tribal, and territorial policy makers|
|Transform preconception, prenatal, postpartum, and pediatric health care to address the root causes of poor health and well-being (Recommendation 5-4)||HHS; public and private payers; medical accreditation bodies; WPSI, Bright Futures, ACOG, AAP, AAFP, and others|
Create supportive and stable early living conditions
||Reduce barriers to participation to WIC and SNAP benefits; do not tie these benefits to parent employment for families with young children or for pregnant women (Recommendation 6-2)||Federal, state, tribal, territorial, and local policy makers|
|Increase the supply of high-quality affordable housing that is available to families (Recommendation 6-3)||Federal, state, tribal, territorial, and local agencies|
|Develop a comprehensive plan to ensure access to stable, affordable, and safe housing in the prenatal through early childhood periods (Recommendation 6-4)||Secretary of the HHS in collaboration with HUD and other relevant agencies|
|Test new Medicaid payment models that engage providers and other community organizations in addressing housing safety concerns, especially those focused on young children (Recommendation 6-5)||Center for Medicare & Medicaid Innovation|
|Address the critical gaps between family resources and family needs through a combination of benefits that have the best evidence of advancing health equity, such as SNAP benefits, increased housing assistance, and a basic allowance for young children (Recommendation 6-6)||Federal, state, tribal, and territorial policy makers|
|Support and enforce efforts to prevent and mitigate the impact of environmental toxicants during the preconception through early childhood periods (Recommendations 6-7, 6-8, and 6-9)||Federal, state, territorial, tribal, and local governments; CDC, EPA, FDA, the U.S. Consumer Product Safety Commission; health care providers|
|Maximize the potential of ECE to promote health outcomes||Develop a comprehensive approach to school readiness that explicitly incorporates health outcomes and leverages ECE systems and programs, including home visiting (Recommendation 7-1)||Federal, state, local, tribal, and territorial governments and other public agencies (e.g., school districts, city governments, public–private partnerships); Office of Child Care and Office of Head Start; health and human service entities, the federal Early Learning Interagency Policy Board, state Early Childhood Advisory Councils, and federal, state, local, tribal, and territorial agencies; HHS; OPRE; ED|
|Develop and strengthen coursework or practicums that focus on competencies of educators, principals, and ECE program directors that are critical to children’s health, school readiness, and life success (Recommendation 7-2)||Degree granting institutions, professional preparation programs, providers of ongoing professional learning opportunities|
|Develop and implement a strategic plan to (1) improve the quality of ECE programs by adopting health-promoting standards and (2) expand access to comprehensive, high-quality, and affordable ECE programs across multiple settings (Recommendation 7-3)||Federal, state, tribal, and territorial policy makers in coordination with HHS, the Office of Head Start, and Office of Child Care|
|Implement initiatives across systems to support children, families, and other caregivers||Develop cross-sector initiatives that align strategies to address barriers to data sharing and integration, cross-sector financing, and other challenges to cross-sector collaboration (Recommendation 8-1)||For all actions in this section: policy makers and leaders in the health care, public health, social service, criminal justice, ECE/education, and other sectors who frequently interact with children and their families|
|Enhance detection of early-life adversity and improve response systems (Recommendation 8-2)|
|Develop trauma-informed systems (Recommendation 8-3)|
|Build a diverse, culturally informed workforce in all relevant systems (Recommendation 8-4)|
|Improve access to programs and policies across systems that provide parental or caregiver supports and help build or promote family attachments and functioning. For families with intensive support needs, develop programs or initiatives designed to provide comprehensive wraparound services (Recommendation 8-5)|
|Integrate care and services across the health continuum, including the adoption of models that provide comprehensive support for the whole person by leveraging and connecting existing community resources (Recommendation 8-6)|
|Resources need to be integrated and coordinated to translate science to action||Support payment reform to allow for upstream investment (Recommendation 8-7)||Policy makers and leaders in the health care, public health, social service, criminal justice, ECE/education, and other sectors who frequently interact with children and their families|
NOTE: AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; ACF = Administration for Children and Families; ACOG = American College of Obstetricians and Gynecologists; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare & Medicaid Services; ECE = early care and education; ED = U.S. Department of Education; EPA = U.S. Environmental Protection Agency; FDA = U.S. Food and Drug Administration; HHS = U.S. Department of Health and Human Services; HRSA = Health Resources and Services Administration; HUD = U.S. Department of Housing and Urban Development; OPRE = Office of Planning, Research & Evaluation; SNAP = Supplemental Nutrition Assistance Program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children; WPSI = Women’s Preventative Services Initiative.
a Some of these actions fit in more than one category but are only listed once; this table does not include recommendations from this report that are solely research based.
NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press.
NRC and IOM (National Research Council and Institute of Medicine). 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.