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Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity (2019)

Chapter: 1 The Need to Intervene Early to Advance Health Equity for Children and Families

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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Page 41
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 43
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 44
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 45
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 46
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 47
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 48
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 49
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 50
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 51
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 52
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 53
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 54
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 55
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 56
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 57
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 58
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
×
Page 59
Suggested Citation:"1 The Need to Intervene Early to Advance Health Equity for Children and Families." National Academies of Sciences, Engineering, and Medicine. 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press. doi: 10.17226/25466.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

1 The Need to Intervene Early to Advance Health Equity for Children and Families INTRODUCTION Neurobiological and socio-behavioral research indicate that early life conditions, including social supports (e.g., supportive relationships) and adversity (e.g., chronic or severe stress), shape prenatal and early childhood health and development. These experiences have a powerful impact on developing biological systems that impact physical and mental health outcomes throughout life and are further influenced by the social determinants of health (SDOH) (e.g., education, housing, physical and social environment). Despite increasing evidence about what contributes to poor health, these health inequalities have persisted, and for some populations and outcomes, they are worsening. Scientific evidence can be used to better inform efforts to advance health equity; this report uses that evidence to support policy actions, program development, practice changes, systems reform, and research priorities. (See Box 1-1 for a high- level overview of this chapter.) BOX 1-1 Chapter in Brief: The Need to Intervene Early Health disparities during the prenatal through early childhood periods: • Significant, long-standing disparities exist for many health outcomes by education, income, race, ethnicity, geography, gender, neighborhood, disability status, and citizenship status. These disparities put children on a course for poor health outcomes throughout the life-span. • These health disparities include infant and maternal mortality, low birth rate, and chronic childhood diseases (such as diabetes, asthma, obesity, depression, and anxiety). • Clinical care is necessary but not sufficient to address health inequities. To advance health equity, the root causes of poor health and chronic adversity—the social, economic, environmental, and cultural determinants of health—need to be addressed. Scientific advances in the neurobiological and socio-behavioral sciences: • The importance of the environment on biological processes (i.e., the complex interplay of biology and environment), including the impact of early adversity, poverty, and racism on lifelong health outcomes, is now well understood. PREPUBLICATION COPY: UNCORRECTED PROOFS 1-1

1-2 VIBRANT AND HEALTHY KIDS • While more research is needed to develop a better understanding of tailoring interventions to address heterogeneity, research has advanced dramatically to apply new and more effective interventions. • Evidence shows that prevention and early intervention for children on at-risk trajectories works, and it is generally more effective and less costly than intervening later in life. • Negative and positive exposures accumulate over the life course to exert a cumulative effect on health that is probabilistic, not deterministic. That is, the odds of positive or negative health are never fixed; individual exposures, experiences, resilience, and choices help set and adjust these odds over time. The committee’s approach: • This report takes a life course approach, which emphasizes that a temporal and social perspective—looking across an individual’s life experiences or across generations—to gain a better understanding of health outcomes is needed. This approach takes into account an individual’s larger social, economic, and cultural context and that the trajectory of an individual’s life may be changed, negatively or positively, through interactions between the brain, body, and environment throughout the life-span. • Achieving health equity for children will require attention and commitment from a range of sectors. Although there are many barriers, this report identifies many opportunities to make long- lasting reductions in long-standing and persistent health inequities. • Building off 12 core concepts of early development, the committee used scientific evidence to guide its recommendations. • This report provides a range of recommendations for practice, policy, and systems changes, including recommendations that will take time and sustained commitment to dismantle structural barriers and recommendations that could be implemented immediately or in the near term. THE PROBLEM The United States spends much more on health care than any other Organisation for Economic Co-operation and Development (OECD) nation, yet it ranks poorly on most measures of population health (NRC and IOM, 2013; OECD, 2017). Significant, long-standing disparities exist in most health outcomes by education, income, race, ethnicity, geography, gender, neighborhood, disability status, sexual orientation, and citizenship status (NASEM, 2017). Notably, the last few decades have marked a troubling rise in U.S. maternal mortality rates, including black-white disparities, while maternal mortality rates have declined globally (WHO, 2015). Similarly, disparities in infant mortality rates persist where non-Hispanic black, American Indian/Alaska Native (AI/AN), and Hispanic babies experience higher rates of mortality before their first birthdays compared to non-Hispanic white and Asian and Pacific Islander babies (CDC, 2019b). Children in the United States rank behind their peers in most OECD nations in health status and on key determinants of health, and they experience growing disparities on multiple measures of child well-being (OECD, 2009; Seith and Isakson, 2011) (see Box 1-2). For children living in both urban and rural communities, lack of access to critical resources is a major driver of increasing disparities, and this is compounded for economically disadvantaged groups. These disparities put children on a course for poor health outcomes later in life. For more information on maternal and child health disparities, see the sections on Early Childhood Health Disparities and Maternal Health below. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-3 BOX 1-2 United States Compared to Other OECD Countries on Key Health Indicators and Outcomes Compared with other OECD countries, the United States has • Higher infant mortality • Higher child mortality • Higher poverty • Higher gun violence and death • Higher rates of hunger • Higher rates of obesity • Much higher rates of incarceration of young adults • Lower secondary school graduation. SOURCES: Grinshteyn and Hemenway, 2016; OECD, 2014, 2017; Walmsley, n.d. Many families in the United States do not receive health care when needed, receive it too late, and/or experience problems in quality; however, pathways to better health do not depend on health care alone. For example, children in relatively affluent communities, who ostensibly have easy access to the best mental health services, also show elevated distress compared to national norms—as do their low socioeconomic status (SES) counterparts, but due to a very different set of life stressors (Korous et al., 2018). The factors that ultimately contribute to good health (such as nutrition, stress, exposure to environmental toxicants) are on multiple interrelated causal pathways along the life-span (NASEM, 2017). Over the past 100 years, there has been a strong trend toward the conflation of “health” and “health care,” where the health of an individual is considered only through a biomedical lens, not taking into account the multiple social and developmental determinants that drive health (Lantz, 2018). Instead, health has been erroneously equated with health care and health disparities erroneously equated with health care disparities. The result is a narrow policy focus on health care interventions to improve health. More recently, research and practice has shifted away from this prevailing paradigm to one that targets upstream factors that shape health (Hahn, 2019; NASEM, 2017). The 2017 National Academies of Sciences, Engineering and Medicine (The National Academies) report Communities in Action: Pathways to Health Equity reviewed the root causes of health disparities and concluded that health inequity arises from root causes that could be organized in two clusters: 1. Intrapersonal, interpersonal, institutional, and systemic mechanisms (also referred to as “structural inequities”) that organize the distribution of power, and access to critical resources, differentially across lines of race, gender, social class, sexual orientation, gender expression, and other dimensions of individual and group identity, and 2. Unequal allocation of and access to power and resources—including goods, services, and societal attention—which manifests itself in unequal social, economic, and environmental conditions, also called the “determinants of health” (NASEM, 2017, p. 7). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-4 VIBRANT AND HEALTHY KIDS Therefore, health inequities are the result of more than individual choice or random occurrence. They are the result of the historical and ongoing interplay of inequitable structures, policies, and norms that shape lives. Interventions targeting the above factors hold the greatest promise for advancing health equity and promoting positive health outcomes at the population level. Furthermore, the report concluded that Health equity is crucial. Health equity is fundamental to the idea of living a good life and building a vibrant society because of its practical, economic, and civic implications. Promoting health equity could afford considerable economic, national security, social, and other benefits. Yet, recent research demonstrates that worsening social, economic, and environmental factors are affecting the public’s health in serious ways that compromise opportunity for all. Health inequity is costly. Beyond significant costs in direct health care expenditures, health inequity has consequences for the U.S. economy, national security, business viability, and public finances, considering the impact of poor health and disability on one’s ability to participate in the workforce, military service, or society. Addressing health inequities is a critical need that requires this issue to be among our nation's foremost priorities (NASEM, 2017). Given these findings, it is critical to address health disparities (differences in health outcomes) with a comprehensive approach—by treating all the factors that impact individual health, such as education, employment, health systems and services, family, community, housing, income and wealth, physical and social environments, public safety, and transportation (SDOH), in addition to racism, discrimination, segregation, and poverty. To achieve equitable health outcomes in the prenatal through early childhood periods and throughout the life course, all of these contexts need to be addressed. Health inequities are systemic challenges, and chronic childhood adversities have biological implications and effect childhood development, with lifelong impacts on health and well-being. When exposures to key experiences (both positive and negative) differ for specific groups (e.g., black/African American, AI/AN, Hispanic), their odds for good health diverge systematically over time, producing disparities in outcomes. Because the odds of these exposures are impacted by systems, advancing health equity will require more than individual level interventions. It will require systems to change in ways that improve the odds of good experiences and reduce the odds of adverse exposures for specific populations. The focus of this report is on how to best maximize well-being among all young children and families, especially those who are vulnerable at the outset—because life circumstances have rendered them statistically more likely to be on negative adjustment trajectories from early life onward. “Inequities” are operationally defined for the purpose of this report, in part, as the unequal likelihood of thriving or attaining positive adjustment outcomes over time because of differences in opportunity that lead to unfair and avoidable differences in health outcomes. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-5 OPPORTUNITIES Failing to address the context in which children live, grow, and learn undermines the potential of so many children. Evidence shows that prevention and early intervention for children on at-risk trajectories works and is generally more effective and less costly than later intervention. Luckily, a great deal is known about the science of prenatal and childhood development and the biological mechanisms and effects of chronic adversity and adverse childhood experiences (ACES) (see Chapters 2 and 3). Recent advances in science—especially around epigenetics,1 technology and data sharing, and cross-disciplinary collaboration—present an opportunity to systematically apply this knowledge to practice, policy, and systems changes. A large body of research now explicates the mechanisms by which early adversity can change the timing of sensitive periods of brain and other organ systems development, impacting the “plasticity”2 of developmental processes that are driven by experiences in the life of the young child and their family. It is now known that what takes place in early development has lifelong impacts—both positive and negative—on health and well-being. While diseases may appear clinically throughout the life-span, it is known that many diseases originate during early development (Gluckman et al., 2007; Heindel and Vandenberg, 2015). For example, altered nutrition, exposure to environmental chemicals, or stress during specific times of development can lead to functional changes biologically, predisposing individuals to diseases that manifest later in life and affecting physical, mental, and cognitive functions. This report employs the science of early development to inform multidisciplinary and developmentally appropriate systems to support optimal health and well-being for all children throughout their life-spans. The tremendous advances in the theoretical and empirical science in the past 30 years position practitioners and policy makers to take informed action to improve child health outcomes. There is now a firm understanding of the importance of the environment—the constant interplay of nurture–nature, biology–environment—on biological processes, including the impact of early adversity, poverty, and racism on lifelong health outcomes. While there is more to be discovered that will lead to a better understanding of best practices and address challenges of heterogeneity, research has advanced dramatically to apply new and more effective interventions now than ever before. Given these advances and the understanding of how science can be used to advance health equity during early development, the Robert Wood Johnson Foundation (RWJF), as part of its Culture of Health Initiative, asked the Health and Medicine Division of the National Academies to (see Box 1-3 for the full Statement of Task) 1. Provide a brief overview of stressors that affect prenatal through early childhood development and health, 2. Identify promising models and opportunities for translation of the science to action, 3. Identify outcome measures to enable subgroup analyses, 1 The study of how genes are expressed due to changes in the environment and how these biological changes can be passed down from one generation to the next. 2 The process by which neurons within the brain change their gene expression, cellular architecture, connections with other neurons, and function in response to experiences and changes in the environment (i.e., change over time). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-6 VIBRANT AND HEALTHY KIDS 4. Develop a roadmap to apply the science to tailored interventions (i.e., policies, programs, or system changes) based on biological, social, environmental, economic, and cultural needs, and 5. Provide recommendations in these areas, including how systems can better align to advance health equity. To respond to this charge, the Committee on Applying Neurobiological and Socio-Behavioral Sciences from Prenatal Through Early Childhood Development: A Health Equity Approach was formed. The committee applied a health equity frame and builds on the 2017 report Communities in Action: Pathways to Health Equity. As identified in the 2000 NRC and IOM report From Neurons to Neighborhoods, prenatal through early childhood are critical phases of development for the production of health. This report reviews the science that has been developed since From Neurons to Neighborhoods. BOX 1-3 Committee on Applying Neurobiological and Socio-behavioral Sciences from Prenatal Through Early Childhood Development: A Health Equity Approach Statement of Task Building on the science base described in the 2000 NRC and IOM report From Neurons to Neighborhoods: The Science of Early Childhood Development and the concepts in the 2017 National Academies report Communities in Action: Pathways to Health Equity, and drawing upon new insights from 21st-- century science in the neurobiological and socio-behavioral fields in the prenatal to early childhood period, an ad hoc committee will 1. Provide a brief overview of • the key stressors that affect brain development and health outcomes during this period (e.g., structural inequities, income, housing, employment, access to health care, transportation, and others) and • the biological and environmental factors that lead to disparities in health and disease outcomes for subgroups of individuals and the pathways by which biological factors interact with and are influenced by sociocultural factors. 2. Identify promising models and opportunities for translation of the science to action and the intervention points during the prenatal and early childhood periods that will yield the greatest impact, with a focus on practice-based changes and the goal of facilitating broader systems change and alignment based on the science. The committee will draw from international examples as appropriate. 3. Identify the specific outcome measures needed to enable subgroup analyses based on the biological dynamics of the social determinants of health, and identify methods to continuously collect data on both successes and failures to enhance the knowledge base in the future. 4. Based on its review of the evidence and committee expertise, develop a roadmap to systematically apply the science to inform tailored interventions (i.e., policies, programs, or system changes) based on biological, social, environmental, economic, and cultural needs. The roadmap will identify pathways to implement the science in practice and policy. 5. Provide recommendations in the areas above as well as recommendations on how systems can better align to advance health equity and identify specific research needs, as deemed appropriate based on its review of the evidence and its collective expertise. IOM = Institute of Medicine; NRC = National Research Council. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-7 PREPUBLICATION COPY: UNCORRECTED PROOFS

1-8 VIBRANT AND HEALTHY KIDS The outcomes the committee seeks to improve across the life course fall into four categories, adapted from a 2016 report Parenting Matters: Supporting Parents of Children Ages 0-8: 1. Physical health and safety, 2. Emotional and behavioral competence, 3. Social competence, and 4. Cognitive competence. See Box 1-4 for definitions of key terms used in this report. BOX 1-4 Key Terms as Used in This Report Early childhood: A time of tremendous physical, emotional, behavioral, social, and cognitive development. For the purpose of this report, early childhood encompasses from birth to approximately 8 years of age. Early development: The period from preconception through early childhood. Child health: The extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments a Health disparities: Differences that exist among specific population groups in the United States in the attainment of full health potential that can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions.bHealth equity: The state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance. c Health inequities: Systematic differences in the opportunities that groups have to achieve optimal health, leading to unfair and avoidable differences in health outcomes. b Social determinants of health: The conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These include education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment (including structures, institutions, and policies), and transportation. c Structural inequities: Personal, interpersonal, institutional, and systemic drivers—such as racism, sexism, classism, ableism, xenophobia, and homophobia—that make those identities salient to the fair distribution of health opportunities and outcomes. For example, policies that foster inequities at all levels (from organization to community to county, state, and nation) are critical drivers of structural inequities. b Toxic stress response: Prolonged activation of the stress response systems that can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years. The toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support.c Toxic stress is the maladaptive and chronically dysregulated stress response that occurs in relation to prolonged or severe early life adversity. For children, the result is the disruption of the development of brain architecture and other organ systems and an increase in lifelong risk for physical and mental disorders. _________________________ aNRC and IOM, 2004. bNASEM, 2017. cCenter on the Developing Child, n.d. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-9 WHY INVEST IN EARLY INTERVENTION AND PREVENTION? There are many reasons to intervene in the prenatal through early childhood periods to prevent and mitigate adverse health outcomes both in early life and over the life course. First, preventing or reducing poor outcomes in the prenatal through early childhood periods generally leads to improved health outcomes later on and therefore can yield health care savings in the long term. For example, in 2007, the IOM reported that the cost associated with premature birth in the United States was $26.2 billion each year (IOM, 2007), and the CDC reports that the United States spends $147 billion in obesity-related health care costs each year (CDC, 2019a). Health care savings are also seen when preventing lead poisoning (Gould, 2009), and some childhood diseases. McLaughlin and Rank (2018) estimate that childhood poverty results in $192.1 billion in aggregate health costs (with another $96.9 billion due to child homelessness and $40.5 billion due to maltreatment). Further, inequity is costly. As noted in Communities in Action (NASEM, 2017), advancing progress toward health equity (across the life course) could produce economic, national security, and other benefits for the nation. The report made the case that beyond the dollar cost of health care services (which itself is significant at $3.5 trillion in 2017, accounting for 17.9 percent of the nation’s GDP [CMS, 2017; Martin, et al., 2018a), health inequities contribute to overall poor health for the nation and therefore have consequences for the U.S. economy, including diminished productivity in the business sector. In 2009, the Urban Institute projected that from 2009 to 2018, racial disparities in health will cost U.S. health insurers approximately $337 billion in total (Waidmann and Urban, 2009). Further, the rising cost of health insurance and medical care for workers cuts into companies’ ability to make a profit and stay competitive (IOM, 2015; Shak et al., 2013). Investing in early development through prevention and early intervention yields cost savings because the investment costs are often less than the downstream costs of poor health and development. For example, investing in high-quality early care and education (ECE) is one way to improve outcomes related to child health. Not only do early childhood intervention programs yield benefits in academic achievement, behavior, educational progression and attainment, and labor market success, among other domains, but well-designed early childhood interventions have been found to generate a return to society (Karoly et al., 2005).4 Garcia et al. (2017) found a 13.7 percent return on investment for comprehensive, high-quality, birth-to-5 early education.5 From a public health perspective, a 2017 systematic review by Masters and colleagues found that national and public health interventions are highly cost-saving for interventions ranging from vaccination to larger determinants of health, though those focusing on the latter had a lower return on investment because they are more complex, resource intensive, and sustained.6 Child maltreatment is costly to the nation as well. The total lifetime economic burden in the United States in 2008 resulting from new cases of fatal and nonfatal child maltreatment was approximately $124 billion (Fang et al., 2012). Further, Bellis and colleagues (2017) found that 4 Studies looking at cost-effectiveness often rely on different underlying assumptions, limiting comparisons across studies and programs. However, overall studies have shown that investments in early childhood appear to save money in the longer term. 5 The study analyzed a wide variety of life outcomes, such as health, crime, income, IQ, schooling, and the increase in a mother’s income after returning to work due to childcare. 6 The review included studies from the UK, Western Europe, the United States, Canada, Japan, Australia, and New Zealand. PREPUBLICATION COPY: UNCORRECTED PROOFS

1-10 VIBRANT AND HEALTHY KIDS disproportionate health expenditure in later life might be reduced through childhood interventions to prevent ACEs, showing the long-lasting costs of early adversity. While the primary beneficiaries of prevention and early intervention efforts are children and their families, the nation as a whole also benefits through cost savings, a healthier and more productive workforce, and strengthened national security (NASEM, 2017). CURRENT STATE OF CHILDREN’S HEALTH Overall Well-Being of Children and Families in the United States This section begins with a broad overview of the current state of child health in the United States, followed by a summary of key health disparities in child and maternal health in the country. Child health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments (NRC and IOM, 2004). Children in the United States are generally perceived to be healthier now than in the past because they are much less likely to encounter the major infections or debilitating diseases of past generations and are typically able to recover fully from “acute” childhood illnesses. However, ailments of the past have been replaced with chronic conditions (such as diabetes, asthma, obesity, depression, and anxiety), with large segments of U.S. children facing barriers to good health and well-being as a result of poverty, food insecurity, unsafe or unstable housing, and substantial adversity (such as ACEs) in the first few years of life. Children who are born and raised in poverty are at particularly high risk for poor health outcomes, more problems in early development (e.g., lack of readiness for school at age 5, diagnoses of developmental delays and/or disorders), and higher rates of most childhood chronic conditions. Early adverse experiences have intermediate effects on physical and/or mental well- being and contribute to chronic disease and poor functioning in adulthood (Hughes et al., 2017; Shonkoff et al., 2012). In fact, these impacts are cumulative, and adults who experience adversity in childhood have substantially higher rates of heart disease, lung disease, metabolic syndrome, and other costly health conditions (see Chapters 2 and 3 for more information). Many of these health disparities are rooted in historical practices and policies (such as segregation and redlining), and this historical legacy continues to shape the development of children today. (See Chapter 3 for a discussion on historical trauma and NASEM (2017) for an overview of historical injustices that impact health outcomes.) Early Childhood and Maternal Health Disparities in the United States This section provides a brief overview of child and maternal health disparities and indicators of health in the United States. It is not a comprehensive overview but rather highlights some of the key health disparities. The most recent data available are presented. Chapter 3 provides a detailed overview of health disparities and critical influences or factors that can either promote or hinder healthy development, with a focus on factors that shape inequities at the child/family level and the community and population levels. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-11 Infant Mortality Rates In 2015, infant mortality rates per 1,000 live births by race and ethnicity were as follows: non-Hispanic black (11.3), AI/AN (8.3), Hispanic (5.0), non-Hispanic white (4.9), and Asian/Pacific Islander (4.2) (CDC, 2019b) (see Figure 1-2). In 2014, infant mortality in rural counties was 6.55 deaths per 1,000 births, 6 percent higher than in small and medium urban counties and 20 percent higher than in large urban counties (Ely et al., 2017). Neonatal mortality was 8 percent higher in both rural (4.11 per 1,000 births) and small and medium urban counties compared with large urban counties (Ely et al., 2017). Mortality for infants of non-Hispanic white mothers in rural counties (5.95 per 1,000) was 41 percent higher than in large urban counties and 13 percent higher than in small and medium urban counties (Ely et al., 2017). For infants of non-Hispanic black mothers, mortality was 15 percent higher in small and medium urban counties and 16 percent higher in rural counties (12.08) compared with large urban counties (Ely et al., 2017). FIGURE 1-2 Infant mortality rates by race and ethnicity, 2015 SOURCE: CDC, 2019b. Low Birth Weight Low birth weight (LBW; less than 5.5 pounds at birth) babies are more at risk for many short- and long-term health problems, such as infections, delayed motor and social development, and learning disabilities (CDC, 2016). Causes of LBW include maternal smoking, use of alcohol, or lack of weight gain and social and economic factors, such as low income, low parental educational level, maternal stress, and domestic violence or other abuse (CDC, 2016). LBW levels among race and Hispanic-origin groups in 2016 ranged from 6.97 percent for births to non-Hispanic white women to 13.68 percent for births to non-Hispanic black women. Rates among Hispanic subgroups ranged from 6.90 percent for births to Mexican women to 9.5 percent for births to Puerto Rican women (Martin et al., 2018b). In 2016, 14 percent of black infants were LBW, compared with 8 percent of Asian and Pacific Islander, 8 percent of AI/AN, 7.0 percent of white, and 7 percent of Hispanic infants. Among those of Hispanic origin in 2016, Puerto Rican infants were the most likely to be LBW (9 percent) (Child Trends, 2018b). In 2013, the most recent year that information for Asian and Pacific Islander subgroups was available, Asian Indian infants were the most likely to be LBW (11 percent), followed by Filipinos (9 percent). Black infants are also more than twice as likely as other infants to be very LBW—less than 3 pounds 5 ounces—at 2.9 percent in 2016, compared with between 1.1 and 1.2 percent for white and Hispanic infants, respectively (Child Trends, 2016b). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-12 VIBRANT AND HEALTHY KIDS Chronic Childhood Diseases Conditions that rarely lead to death in children and youth are now more prevalent: obesity, asthma, mental health conditions (especially Attention-deficit/hyperactivity disorder, depression, and anxiety), and neurodevelopmental conditions (including autism spectrum disorders [ASDs]) (Perrin et al., 2007, 2014; Van Cleave et al., 2010). For example, in children less than 18 years of age, asthma was prevalent among 8.1 percent of white non-Hispanic children, 12.6 percent of black non-Hispanic children, 8.2 percent of other non-Hispanic children, and 7.7 percent of Hispanic children. Among Hispanic children, 11.3 percent of Puerto Rican children and 6.2 percent of Mexican/Mexican American children had asthma (CDC, 2019c). During 2016, asthma affected children living in families with incomes of less than 100 percent of the federal poverty level (FPL) (10.5 percent) more than those living in families with incomes of ≥250 percent of the FPL (250 to <450 percent FPL: 6.9 percent; ≥450 percent FPL: 6.7 percent) (Zahran et al., 2018). Mental and Behavioral Conditions Particularly noteworthy is the growth of mental and behavioral conditions among children and youth. Recent work has documented their a) high prevalence, b) major impact on youth well-being and functioning, c) common association with other chronic conditions, d) high costs, and e) complication of the course, treatment, and outcomes of most other conditions (Ghandour et al., 2012; Houtrow et al., 2014; Perrin et al., 2018). Importantly, most of these high-prevalence conditions occur at higher rates and usually higher severity among low-income children, even though the rate of growth has increased in all SES levels (Houtrow et al., 2014). Although all of these conditions have genetic components, they also often reflect the consequences of early childhood experiences and their influence through epigenetics and other physiologic mechanisms. Furthermore, less than optimal access to and use of health care in early years can negatively affect these conditions over time. Early Life Adversity The impacts of early life adversity and disparities are discussed in detail in Chapters 2 and 3; however, a highlight of a few disparities is provided here. ACEs (including physical, emotional and sexual abuse, physical and emotional neglect, and household stressors, including parental mental illness, substance use or incarceration, parental separation or divorce, and domestic violence) are highly prevalent in all racial and socioeconomic groups. Almost 50 percent of children and adolescents (age 0-17) have experienced at least one category of ACEs, according to national population-based studies (Bethell et al., 2014), and black, Hispanic, and poorer children are exposed to more ACEs relative to white or wealthier children (Slopen et al., 2016).7 Foster care children are at between 1.5 and 7 times greater odds of having experienced any 1 of the 10 traditional ACEs compared to children not placed in foster care, even after controlling for race and ethnicity, parent education and employment, welfare services, and poverty status (Turney and Wildeman, 2017). 7 ACEs are discussed in detail in Chapter 3. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-13 School Readiness School readiness8 is an important indicator for future child well-being, and there are deep disparities across race and ethnicity (see Chapter 7 for a detailed overview of the importance of ECE). Figure 1-3 provides examples of important measures of school readiness by race and Hispanic origin. Using 2016 National Survey of Children’s Health data, Ghandour et al. (2018) found that only 41.8 percent of 3- to 5-year-olds in the United States were estimated to be on track in all four domains of school readiness. Overall, Hispanic children are less likely to show cognitive/literacy readiness skills than are white, black, or Asian/Pacific Islander children. FIGURE 1-3 Percentage of children ages 3 to 6 with selected school readiness skills, by race and Hispanic origin, 2012 SOURCE: Child Trends, 2015. NOTES: Data represent parent reports of specific cognitive and literacy skills. Data are sourced from Child Trends’ analysis of the National Household Education Survey. In 2012, 27 percent of Hispanic 3- to 6-year-olds could recognize all 26 letters of the alphabet, compared with 41 and 44 percent, respectively, of white and black children. Asian/Pacific Islander children had the highest rate of recognizing all the letters, at 58 percent. A similar pattern in the ability to count to 20 and write their name was seen by race, although Asian and Pacific Islander children were similar to their white and black counterparts (Child Trends, 2015). Young pre-K children living in poverty are much less likely to have cognitive and early literacy readiness skills than are children living above the poverty threshold. Disparities in all measures of early school readiness by income level were greatest in 1999, but these narrowed in 2007 (Child Trends, 2015). 8 That is, children possessing the skills, knowledge, and attitudes necessary for success in school and for later learning and life. The concept of “school readiness” is broader than cognitive or pre-academic skills, such early literacy and math. However, comparable data across communities or states are limited mostly to such outcomes, which are what is presented here. All states have developed some form of school readiness assessments, and most of them focus on children’s social-emotional development, approaches to learning, and physical health and development, as well as cognitive abilities (Daily et al., 2010). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-14 VIBRANT AND HEALTHY KIDS Poverty Poverty affects large numbers of U.S. children. A recent National Academies report, A Roadmap to Reducing Child Poverty, estimated that in 2015, more than 9.6 million children under 18 years of age lived in poverty, as measured by the Supplemental Poverty Measure (SPM) (NASEM, 2019). Thus, 13 percent of the child population lived in households with annual incomes ranging from $22,000 to $26,000 for a family of four. Moreover, of those 9.6 million children, 2.1 million lived in “deep poverty,” defined as having family resources below half the poverty line—$11,000 to $13,000 annual income. An additional 22 percent of U.S. children live in “near poverty” households, defined as between 100 and 150 percent of the SPM poverty line. These 16.7 million children live in households that frequently pay more in taxes than they receive in tax credits, reducing their net incomes (NASEM, 2019). Many U.S. families with children face persistent problems related to poverty, including inadequate housing, clothing, and food for their children, and health problems accompany those deficits. Health Insurance Coverage From 2008 to 2016, the rate of uninsured children steadily decreased from 9.7 to 4.7 percent. However, the percentage of uninsured children increased to 5.0 percent in 2017 (Alker and Pham, 2018). See Figure 1-4 for the rate of uninsured children from 2008 through 2017. FIGURE 1-4 Rate of uninsured children, 2008–2017. SOURCE: Alker and Pham, 2018. For the percentage breakdown of the number of uninsured children by race and ethnicity in 2016 and 2017, see Figure 1-5. As the figure shows, for black, white, Asian/Native Hawaiian/Pacific Islander, and Hispanic children, the rate of children without insurance increased from 2016 to 2017. In the same 2-year period, the rate of children without insurance decreased for AI/AN children by 0.2 percent. However, the rate of children without insurance for this group is far higher than for other racial and ethnic groups at 12.8 percent in 2016 and 12.6 percent in 2017 (Alker and Pham, 2018). In 2017, 27 states and Washington DC, had significantly lower rates of children without insurance than the national rate of 5.0 percent, and 11 states had no statistically significant difference from the national rate. However, 12 states had significantly higher rates, with the highest rates of children without insurance in Texas (10.7 percent), Alaska (9.6 percent), and Wyoming (9.5 percent). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-15 FIGURE 1-5 Children’s uninsured rate by race and ethnicity, 2016–2017 SOURCE: Alker and Pham, 2018. MATERNAL HEALTH IN THE UNITED STATES Women in other high-income countries fare better in terms of access to health care and health status than women in the United States. U.S. women in have the highest rate of maternal mortality because of complications from pregnancy or childbirth and among the highest rates of cesarean sections, and maternal mortality rates are rising for them while declining in other countries (see Figure 1-6). For the past six decades, black women have died at a rate that ranges from three to four times that of white women, with 38.9 deaths per 100,000 live births among black women versus 12 deaths per 100,000 live births among white women as of 2010 (Creanga et al., 2015; MHTF, n.d.). AI/AN women also fare worse than white women, with approximately twice as many pregnancy-related deaths per 100,000 live births. Some researchers point to structural drivers of maternal mortality disparities in the United States, such as racism and discrimination (ACOG, n.d.) and adverse changes in chronic diseases and insufficient health care access (Nelson et al., 2018). See Chapter 5 for a detailed overview of preconception through postpartum care. Prenatal Care Access to prenatal care varies across race and ethnicity groups. In 2016, about 77 percent of women who gave birth initiated prenatal care in the first trimester. However, only 66.5 percent of black, 72 percent of Hispanic, 63.0 of AI/AN, and 55.9 percent of Native Hawaiian or other Pacific Islander women received it, whereas 82.3 percent of non-Hispanic white women did (Osterman and Martin, 2018). People of color are much more likely to be affected by late initiation of prenatal care, which is most common in Pacific Islanders at 18.4, with non-Hispanic white women at 3.3 percent. AI/AN women have a 9.2 percent chance of late prenatal care initiation, and black women have a 7 percent chance (Osterman and Martin, 2018). (See Chapter 5 for more statistics and information on prenatal care.) PREPUBLICATION COPY: UNCORRECTED PROOFS

1-16 VIBRANT AND HEALTHY KIDS FIGURE 1-6 Global, regional, and national levels of maternal mortality, 1990–2015 NOTE: Data from GBD 2015 Maternal Mortality Collaborators, 2016. SOURCE: Martin and Montagne, 2017 courtesy of Propublica. THE CURRENT ENVIRONMENT FOR CHILDREN AND FAMILIES In the past 20 years, much has changed in the landscape in which prenatal to childhood development takes place in the policy and funding environment and the social, economic, and cultural context. The following section outlines some of these important changes. Changes in the Funding and Policy Environment Federal spending (not including tax reductions) on children under 18 increased from $210 billion in 2000 to $375 billion in 2017, driven largely by increased health spending on Medicaid, which nearly tripled between 2000 and 2017, and the Children’s Health Insurance Program (CHIP; Table 1-1) (Isaacs et al., 2018). Federal spending on nutrition, income security, ECE, and housing also increased substantially between 2000 and 2010, though many programs have seen a decline in federal support since 2010. Approximately 61 percent of federal expenditures in 2017 served children in low-income families through means-tested programs and tax provisions (Isaacs et al., 2018). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-17 TABLE 1-1: Federal Expenditures on Children by Program, Selected Years 1960–2017 NOTE: Numbers in billions of 2017 U.S. dollars. SOURCE: Isaacs et al., 2018 Altogether, federal spending on children in 2017 accounted for 9.4 percent of total federal outlays (Figure 1-7), and it is projected to fall to 6.9 percent. In contrast, federal spending on adults through Social Security, Medicare, and Medicaid accounted for 45 percent of total federal outlays, which is projected to grow to 50 percent by 2028 (Isaacs et al., 2018). It should also be noted that federal spending on children (which accounted for 34 percent of total public spending on children) in 2017 represented only 2 percent of GDP in the United States, which is well below that of other developed nations. An international comparison of public spending on children from 1985 to 2000 ranked U.S. spending (2.4 percent of GDP) the second lowest among 20 OECD countries, much less than the 9.6 percent median across OECD countries (Lynch, 2006). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-18 VIBRANT AND HEALTHY KIDS FIGURE 1-7: Share of federal budget outlays on children and other items, selected years, 1960– 2028 NOTES: Authors’ estimates based primarily on Congressional Budget Office, The Budget and Economic Outlook: 2018 to 2028 and Office of Management and Budget, Budget of the United States Government, Fiscal Year 2019 and past years. (Republished with permission of Urban Institute, from Kid's Share 2018, Isaacs et al., 2018; permission conveyed through Copyright Clearance Center, Inc.). SOURCE: Isaacs et. al., 2018. One of the most important changes in the policy landscape over the past 20 years has been the Patient Protection and Affordable Care Act (ACA), which expanded health care access for children and families through a combination of Medicaid expansions, private insurance reforms, and premium tax credits (Kaiser Family Foundation, 2019). The uninsured rate among women ages 19-34 decreased from 25 percent in 2010 to 14 percent in 2016 (Gunja et al., 2017), which has significant implications for preconception and prenatal health. The ACA requires coverage for women’s preventive services at no cost-sharing, including well-woman visits, and eliminates exclusions for preexisting conditions (for example, pregnancy and depression), which improves access for women with chronic conditions (Gunja et al., 2017). The ACA mandates coverage for essential health benefits (EHBs), which include maternity care and mental health services. For children, The ACA requires coverage for preventive services at no cost-sharing and EHBs, eliminated exclusions for preexisting conditions, and prohibits lifetime dollar limits, which improves access for children with special health care needs (National MCH Workforce Development Center, 2015). Even though the ACA did not substantially increase children’s eligibility for Medicaid (or CHIP), the process of parents’ seeking enrollment in Medicaid or exchange plans led to their learning of their children’s eligibility, which increased child enrollment substantially. Presently, it is unclear how recent policy changes to deregulate consumer protections under the ACA and to restrict eligibility, enrollment, and benefits through Medicaid waiver will impact health care access and equity for children and families. (See Chapter 5 for more about the ACA.) PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-19 Federal funding for ECE has steadily increased over the last 10 years; however, total spending on ECE in the United States remains limited. Only 0.5 percent of U.S. GDP is spent on ECE, whereas other peer nations spend 1 percent or more (OECD, 2019). Recent increases include lawmakers approving an $890 million increase for Early Head Start and Head Start, including $170 million for Early Head Start—Child Care Partnerships, from Fiscal Year 2016 levels to FY2019 levels (FFYF, 2018; see Chapter 7 for more on these programs). In addition, in response to decades of early childhood and brain development research, policy makers, advocates, program administrators, and other leaders in the child care community have advanced a number of policies and initiatives that recognize child care programs as opportunities to improve children’s development, rather than solely as work-support programs. As a result, for example, the most recent reauthorization of Child Care Development Block Grant (CCDBG)9 provides for more continuity of care by allowing parents to receive subsidies for a year, even if their income, work, or education status changes during that period. There has also been more attention paid to increased compensation for the workforce. For example, states and local communities have developed a number of strategies to enhance compensation for early childhood educators, including tax credits, wage supplements (often tied to attaining higher education or credentials), targeted increases for child care subsidy rates, salary scales, provision of benefits, and parity with K–12 teachers. More recently, there has been greater recognition from policy makers, advocates, and ECE practitioners of the importance of ECE program leaders (including elementary school principals). CHANGES IN THE ECONOMIC, SOCIAL AND CULTURAL ENVIRONMENT Income inequality has been growing—the income gap between higher- and lower-income individuals has increased substantially over the past 30 years (NASEM, 2017).10 Those with incomes in the top 10 percent average 9 times the income of those in the bottom 90 percent, and those with incomes in the top 0.1 percent have more than 188 times the income of the bottom 90 percent (Inequality.org, n.d.). Lasting effects of the 2008 recession include displacement of vulnerable populations, which exacerbated the impact on both their health and their economic well-being and resulted in greater income inequality and wealth inequality (Smeeding, 2012). People of color continue to face structural barriers when it comes to securing quality housing, health care, employment, and education (NASEM, 2017; Pager and Shepherd, 2008). For example, data suggest that schools are becoming increasingly segregated by poverty and race, which has implications for which communities have access to high-quality, well-funded education (Boschma and Brownstein, 2016; Darling-Hammond, 1998). Racism also continues to be a pressing problem, and it is built into systems, as seen by racial profiling by law enforcement officers, disproportionate suspension and expulsion rates of young boys of color (see Chapter 7), and the difficulty that some subgroups have in breaking the cycle of poverty (see Chapter 6). 9 See, https://www.acf.hhs.gov/occ/ccdf-reauthorization. 10 There are several different ways to measure income inequality, including the use of different data sets, that lead to different results (with no single source that illustrates all of the major trends in inequality) (CBPP, 2018). However, regardless of the method or data used, results consistently show an increase in income inequality in the last three decades. See a draft paper by Auten and Splinter (2018) for additional analysis that argues that income inequality has not grown as much as others have estimated. PREPUBLICATION COPY: UNCORRECTED PROOFS

1-20 VIBRANT AND HEALTHY KIDS Chapter 3 expands on these issues and the impact they have on the health of children and families. FIGURE 1-8: For children, growing diversity in family living arrangements. SOURCE: Pew Research Center, 2015b In terms of family structure, American families have changed, with a PEW Research Center (2015b) survey finding that there is no longer one dominant family type in the United States today (as compared to 1980, where 61 percent of children were living with married parents in their first marriage—today, that number is 46 percent) (see Figure 1-8). PEW also found, for example, that two-parent households are no longer the norm, as rates of divorce, remarriage, and cohabitation have increased. This decline has been offset by an almost threefold increase in those living with just one parent—typically the mother (10.5 percent of children age 18 or younger lived with only a mother in 2018, compared to 2.4 percent living with the father only [U.S. Census, 2018]). Women who are single or living with a nonmarital partner account for 4 in 10 births in the United States. Single-parent families are more than 4 times more likely to be poor than are two-parent families (Pascoe et al., 2016), and this can affect their ability to invest time and resources in their children, which would have longer-term implications for the persistence of poverty across generations. More mothers (of children 18 or younger) have also entered the workforce—70 percent, with 40 percent of them being the primary earner (Pew Research Center, 2015a). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-21 The makeup of children in the United States has changed as well. In 2000, 61 percent of all U.S. children were non-Hispanic white; in 2016 that number was 51 percent, with the proportion of children with Hispanic origins growing from 17 to 25 percent between 2000 and 2016. The percentage of non-Hispanic black children has stayed relatively constant since 1980 (14–15 percent) (Child Trends, 2018c). From 1994 to 2017, the population of children of immigrants11 grew by 51 percent, from 18 to 27 percent (Child Trends, 2018a). These children are mainly second-generation immigrants (16.7 million), with first-generation immigrants making up a much smaller number (2.9 million, which is 3–5 percent of all children). In 2016, 33 percent of U.S. children lived in a household where more than one language is spoken (dual- language learners [DLLs]), with Spanish being the most common other language for these children (Child Trends, 2016a). Evidence shows that populations from immigrant backgrounds and ethnic and racial enclaves might bring or develop particular child-rearing practices that lead to strengths and weaknesses in their children’s adaptations and success in other environments. For example, Galindo and Fuller (2010) have shown that Latino children have higher social-emotional skills in preschool but some of the academic skills of low-income Latino children lag beyond other groups. School success as measured by grades is associated with different family constellations and practices in immigrant populations, such as Cambodian, Dominican, and Portuguese populations (Garcia Coll and Kerivan Marks, 2009). When examining cultural variation, no particular parenting or household composition is associated with success across all domains of child outcomes, aside from preventing extreme neglect, abuse, or lack of stimulation. A more general cultural shift has been the increase in personal-use technology (e.g., computers, tablets, mobile phones), which has advanced at a rapid pace in the last 20 years. The divide in access to digital devices has decreased significantly, with more families having access to smartphones across socioeconomic lines. Access to other devices, however, continues to create a digital divide that children in non-mainstream populations have to surpass. School districts across the country are integrating technology into the classroom. The health care field has advanced in the area of telehealth, providing greater remote access to health care providers. This access can have positive and negative effects, and it can even increase inequities when not used properly. ABOUT THIS REPORT Report Conceptual Model The committee’s conceptual model (Figure 1-9) served as a unifying framework for the committee’s approach to the report, aiming to improve prenatal through early childhood development with a health equity approach. The model adapts elements and concepts from the World Health Organization (WHO) Commission on Social Determinants of Health conceptual framework (WHO, 2010), the closed-ecological model (Bronfenbrenner, 1979; McLeroy et al., 1988; NASEM, 2017; Velez-Agosto et al., 2017), a model of children’s health and its influences (NRC and IOM, 2004), and the life course health development model (Halfon et al., 2014). Building on the life course model, this figure shows early development within the context of the life course stages, beginning with preconception and ending with adulthood along the bottom. It 11 Immigrant children are defined here as those who have at least one foreign-born parent. PREPUBLICATION COPY: UNCORRECTED PROOFS

1-22 VIBRANT AND HEALTHY KIDS is important to note that risk and protective factors can be transferred intergenerationally, which makes the parent or primary caregiver and/or the parent–child dyad a central focus of intervention. With the necessary supports and conditions, healthy biological, socio-emotional, cognitive, and socio-behavioral development increase across the life course. Within the context of the life course, the diagram’s nested circles illustrate the complex sociocultural environment that shapes development at the individual level and the opportunities for interventions to improve individual health and developmental outcomes and population health, well-being, and health equity. The context and conditions here continue to play an important role in health and well-being throughout the life course. Individual social and biological mechanisms operate and interact within and across the three levels. The outer level, “socioeconomic and political drivers,” is adapted from the WHO social determinants framework and represents the level at which structural inequities operate. These structural inequities are deeply embedded into policies, laws, governance, and culture; they organize the distribution of power and resources differentially across characteristics of identity (i.e., race, ethnicity, gender, class, sexual orientation, and others) (NASEM, 2017; WHO, 2010). The next level represents social, economic, and environmental conditions (i.e., the SDOH): education, employment, health systems and services, housing, income and wealth, physical environment, transportation, public safety, and social environment. In the model, these nine interdependent factors are grouped into three domains that the committee has identified, based on the available evidence and existing resources, as important for targeting prenatal and early childhood interventions: healthy living conditions, ECE, and health systems and services. These domains in the gray and light blue circles are the primary foci of Chapters 5–7, and each is discussed in terms of evidence-based solutions, opportunities for intervention, barriers, promising models, and research needs. The next level represents the factors that most directly and proximally shape children’s daily experiences and routine patterns; these include caregiver well-being and support and attachment and family cohesion, which affect social connections in early life. Culture, according to Velez-Agosto and colleagues (2017), operates at various levels, including all the levels in the committee’s conceptual model. Systems, such as ECE and health care, have cultures and also enact in their daily operations ways of conceptualizing the child’s development, how to promote it, and what resources have to be accessed in order to correct illness and developmental problems. Cultures can also be sources of strength, providing support for coping with life demands and toxic stress (Garcia Coll et al., 1996). Families and communities also have cultures that are similarly enacted in daily routines and in developmental goals and expectations. Inequities might arise from lack of understanding of normative cultural frameworks between any of these levels, lack of respect and acceptance for different ways of being that are considered normative in other settings, and lack of access to critical resources, such as high-quality ECE and health care, due to racism and discrimination (Garcia Coll et al., 1996). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-23 FIGURE 1-9: Leveraging early opportunities to achieve health equity across the life course: A conceptual framework NOTE: The elements and systems included in the nested circles impact every stage of the life course. Types of Interventions The committee deployed lessons from the latest insights in neurobiological and closed- behavioral sciences that define how early childhood experiences translate into health outcomes and inequities across the life course in order to offer promising practices or transformational levers that might help move the needle in a positive direction. In its Statement of Task (see Box 1-3), the committee was asked to look at interventions defined as policies, programs, or system changes. What is meant by each of these is briefly described below (see Box 1-5 for examples). Systems Systems are a collection of interacting, interdependent parts that function as a whole. For the purposes of this report, most of the systems are social constructs and are organized around a key functional area (education, health care, criminal justice). Systems have existing patterns and structures that define how people tend to move through them. A few essential features that define a system include PREPUBLICATION COPY: UNCORRECTED PROOFS

1-24 VIBRANT AND HEALTHY KIDS • Structures: The essential organizational components of a system, including how it is governed. • Flows: How information, money, or people move through and are configured in relation to each other. • Goals: The actions the system is trying to accomplish—its purpose or function. • Rules and Norms: How a system is organized and what can and cannot happen within it. • Paradigms: Assumptions that system makes that inform how things are organized and flow within it. These features could be thought about in the context of a single system or considered through a social ecosystem lens and applied to how systems interact with each other. Programs A program is a targeted or specialized pathway by which a specific group of people move through a system or between a set of systems—a change in the system’s structures or flows for certain kinds of clients. It is often driven by a recognition that the standard approaches are not achieving the system’s goals for some people. Programs usually do not change the goals or rules or the system itself; rather, they generally offer a new way to achieve improved outcomes within the current system’s structures (such as a support group for new mothers offered in a primary care setting). Policy Policy is a shift in the overarching legal or regulatory structure that governs how systems operate or interact with one another. Policies usually set the rules, goals, norms, or paradigms within which systems establish structures and flows, and they may also set the limits on the types of exceptions or changes that systems can put in place. Some policies can impact large swathes of the population, such as laws, regulations, court rulings, administrative rules, or executive orders, and often have consequences when not followed. Some policies have a smaller scope, such as guidelines issued by professional organizations, recommendations of expert panels, or local programs. In general, policies, systems, and programs can be thought of as nested within each other. The impact profile of efforts at any given level may be constrained by what is happening in the others—promising programs that do not consider the potential limitations that the policy environment places on potential adoption and spread will not be as useful as those that do. BOX 1-5 Example of Systems, Policy, and Programmatic Changes Conceptual Example: How do we build more integrated care that helps support people in both the clinical and social drivers of poor health outcomes? Systems Change: Altering the basic or fundamental structures or patterns by which information, money, people, or other resources flow through or between systems. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-25 • Example: A health care system implements standardized social determinants screening (for example, asking questions at medical appointments about housing and food security) for all patients and builds out a standard referral system to community agencies. Policy Change: Altering the overarching legal or regulatory structure that governs how systems operate or interact with each other. • Example: Data and privacy regulations are changed to allow partners in other sectors to see and share important information on their mutual clientele. Programmatic Change: Creating specific alternative structures or patterns that alter the default experience for targeted subsets of a population. • Example: A system builds an enhanced model of intensive case management for its clients with the most intensive needs. These clients receive extra supports, but the experiences of others remain mostly unchanged. Committee’s Methodology As discussed above, an intervention could consist of policies, programs, or system changes or a combination of those approaches. The literature on the effectiveness and applicability of interventions provides important information for assessing which interventions are most effective and suitable for a general or more specific population. However, many interventions have not been adequately evaluated for their effectiveness—in general, for a specific outcome, or when brought to scale. In addition, studies vary in dimensions such as appropriateness of design and setting, quality of execution, interactions with other interventions, and consideration of economic consequences. With the above in mind, the committee examined the available literature, conducting a comprehensive review from the peer-reviewed and gray literature. 12 This entailed a systematic search of academic and governmental databases and websites for studies that evaluated or assessed the effects of interventions. Where possible, the committee relied on existing systematic reviews and meta-analyses with strong methodologies and existing comprehensive reviews. Comparisons across studies are needed to better assess intervention opportunities; however, such comparisons are often not available or difficult to interpret due to methodological strengths and limitations relating to the nature of the study design and the data collected. For example, what is considered the gold standard research design to show that a program does in fact lead to the results it is trying to achieve—the randomized controlled trial (RCT)—may not always be feasible. This is because RCTs are not appropriate in all settings, particularly not to study community-level interventions, and for some interventions, randomization can be considered ethically objectionable if it denies a service or treatment known to be beneficial (Center on the Developing Child, 2016). While large-scale, multiyear RCTs will continue to be important to demonstrate program impacts, there is also an important role for short-term, flexible study methodologies to test program components and subgroup variability and allow for mid- course corrections and enhancements (such corrections are not possible in traditional RCTs) (Center on the Developing Child, 2016). While there is nothing fundamental in the design of an 12 The date range for the search was 2013–2019. Search terms included the following categories: prenatal and early childhood, neurobiological, socio-behavioral, biology/biomarkers, health indicators/outcomes, structural inequities, social determinants of health, and model/intervention. PREPUBLICATION COPY: UNCORRECTED PROOFS

1-26 VIBRANT AND HEALTHY KIDS RCT that precludes investigating heterogeneous effects in different populations, to do so requires careful consideration of the sample size and identification of subgroups of interest prior to the randomization. As a result, many RCTs have not been able to answer important questions about variability in effects across subpopulations or which components of an intervention are driving the results. While RCTs can be used to study the effect of separate program components, it is difficult to use RCTs to examine complex programs with multiple dimensions (or for community-level interventions). RCTs remain a critical tool for studying the effectiveness of programs, but it is important to note their limitations as well. (See Chapter 8 for a research recommendation on this topic.) Because of the limitations of RCTs in some contexts, and limitations of observational studies that are correlational in nature, researchers have increasingly used “natural experiments” to estimate causal effects. Such studies harness changes in state and local policies that generate plausibly random or quasi-random variation in exposure to a given service or treatment to estimate its causal effect on outcomes of interest (see Angrist and Pischke, 2009) for an overview of these methods). Despite the limitations of estimation based on observational data, careful use of observational data has many advantages. First, it is very useful for identifying associations that can be more rigorously studied using other approaches. Second, in some cases, careful use of natural experiments or other research designs can minimize the bias from confounding. Finally, some questions are, by their nature, not amenable to randomized trials and so can only be studied using observational data. The way data is gathered across study designs also varies, as data collection may occur for different outcomes at different points in time, so the data may be incomplete and therefore hard to compare. When reviewing the science on a certain intervention/policy, there may be cases with strong evidence for one or more important outcomes and weaker (or mixed, or null) evidence for one or more other outcomes. This does not mean that the intervention/policy should not be considered or implemented. If there is a strong theoretical basis for making the change (for example, from a biological pathway or development standpoint) and strong evidence for one or more salient health outcomes that is being targeted and has a large population health impact, the intervention/policy could be deemed appropriate despite its limitations. This is true for several interventions and policies recommended in this report. About the Report Recommendations The committee provides a range of recommendations for practice, policy, and systems change, including recommendations that will take time and sustained commitment to achieve and recommendations that could be implemented immediately or in the near term. Some of the committee’s recommendations will be difficult to implement; however, the degree of difficulty in implementing any given recommendation does not mean it is not worth pursuing. Achieving health equity for children will require attention and commitment from a range of sectors. For example, in Chapter 8, the committee discusses the need for better alignment among the many children- and family-serving sectors in the United States. Although there are many barriers to achieving alignment, there is also great opportunity to make long-lasting reductions in long- standing and persistent inequities. Furthermore, inequities that originate at the system and institutional levels will require solutions that target policy and structures. Given this understanding, the committee provides the recommendations with the long-term outcomes in mind and the goal of both improving the current state and making strides today to establish systems where inequities will no longer be the status quo. Where possible, the committee also PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-27 recommends or highlights ways to leverage existing programs that either embrace the core scientific principles laid out in this report (see the Core Principles below and Chapter 2) or have a strong basic structure from which to build (for example, Home Visiting). Therefore, the committee makes some recommendations for improving programs that are not optimally or extensively implemented but have the potential to be updated, scaled, or better used to promote related services that advance health equity. Given the fragmented nature of many systems in the United States (for example, the health care system has both public and private payers and multiple entities that set guidelines for care and accountability), many of the committee’s recommendations are directed to multiple actors with varying roles and responsibilities, each of whom is important to advancing child and family outcomes. Further, as a matter of jurisdiction, some recommendations are better targeted to varying levels of government (e.g., local, state, tribal, and territorial). To address deeply rooted inequities, which play out across multiple sectors, some recommendations entail a comprehensive approach that requires partnerships across sectors and levels of government—this is consistent with Communities in Action (NASEM, 2017), which identifies cross-sector collaboration as a key element for promoting health equity in communities. Resources Resources will be needed to implement many of the recommendations in this report. The root causes of structural inequities are found in differential access by virtue of race or ethnicity to resources for some groups, due in part to certain laws and policies (NASEM, 2017; see also Chapter 3). Calling for change of any kind to advance health equity will require changes to laws, policies, and other sources of inequity so as not to perpetuate structural racism and discrimination. Decision makers and leaders can coordinate, integrate services, and educate on all of these issues, but if the resources are not there to back the needed changes, the change likely will not occur. The committee was asked by RWJF to identify what practice, policy, and systems changes need to be implemented, based on what is known from developmental science; however, the committee was not tasked to identify the sources or mechanisms for funding those changes. In a few instances, the committee was able to provide estimates of the potential costs for implementing its recommendations using existing estimates. Doing so, however, was complicated when those estimates did not include cost savings from improved health outcomes resulting from the intervention, producing a one-sided picture. Although the committee was not asked to identify the mechanisms and sources for implementing the report recommendations, there are many extant mechanisms and proposals for funding various public or population health activities. For example, taxes on tobacco, alcohol, and other products (such as sugary beverages) have been used to channel resources and shape economic incentives (NASEM, 2018b). An IOM (2012) committee proposed establishing a tax on medical care transactions to provide a long-term financing structure to cover public health services. Other mechanisms—both within and outside the health sector—include federal or state Wellness Trusts (Prevention Institute, 2015), hospital community benefit expenditures (Rosenbaum et al., 2015), community wealth-building (including the role of anchor institutions, see Porter et al., 2019), and Children’s Services Councils13. (A 2018b National Academies proceedings provides an overview of several of these options and others.) Each of these financing mechanisms has advantages and disadvantages that would need to be weighed for the specific intervention or program for which it is considered. 13 See, for example, http://flchildrenscouncil.org/about-cscs/overview (accessed June 17, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

1-28 VIBRANT AND HEALTHY KIDS Promising Models In its statement of task, the committee was asked to identify promising examples of models that apply the science of early development to health equity. The committee adapted the selection criteria used in the Communities in Action: Pathways to Health Equity (NASEM, 2017) report to guide this process.14 The committee used the three sets of criteria from the National Academies 2017 report (see Appendix A for a list of all of the selection criteria), which were informed by research and practice-based evidence and the expertise of the committee members. The committee made a few additions based on the focus of this report (the prenatal through early childhood period) and removed those not relevant to this study. The first set consists of six core criteria, which need to be met by all the promising models. These core criteria assure that the examples chosen are substantively significant. The committee used these promising models as examples throughout the report to highlight bright spots that have been able to use what is known from the science to advance health equity in the preconception through early childhood periods. Furthermore, “promising” does not imply that the model is new but rather that it is a program or intervention that met the committee’s core criteria, and each promising model has a unique approach and is at a different phase of development: some have been around for more than 30 years and have changed based on evaluations or input from users, while others have emerged in the past few years. In Chapters 4–7, three promising models were identified for each chapter (each model is summarized in a box). These examples are not blueprints, and exact replicas might not work with all populations or locations; however, the lessons learned and approaches used prove valuable to those working to create positive change toward health equity during the preconception through early childhood periods. Note that throughout the report, the committee cites many other examples of current practices and programs that illustrate the topic being discussed; however, those examples may not meet all of the committee’s criteria (and are not labeled as promising models). The first core criterion requires that the model’s main focus be during the prenatal and/or early childhood period, as that is the focus of this report; this inevitably involves the mother (or other primary caregiver). The second notes that the intervention is informed by findings from the neurobiological, socio-behavioral, and/or biological sciences—also a focus of this report. The third core criterion is that the model addresses at least one (preferably more) of the nine SDOH identified by the NASEM 2017 report: education, employment, health systems and services, housing, income and wealth, the physical environment, public safety, the social environment, and transportation. “This criterion was informed by the wealth of literature suggesting the importance of targeting the social and economic conditions that affect health, especially at the community level” (Bradley et al., 2016; Galea et al., 2011; Heiman and Artiga, 2015; Hood et al., 2016; NASEM, 2017; Wenger, 2012). Furthermore, this criterion is basic to the committee’s charge, which posits that the SDOH need to be addressed to reduce health inequities. The fourth criterion is that the model is designed to have or has evidence of having an impact on a group or population that experiences health inequities. The fifth core criterion “states that the solution needs to be multisectoral, meaning that it engages one or more sectors” (ideally, at least one “nontraditional” sector, meaning other than public health or health care). Multisector collaboration is a powerful lever for addressing health 14 The original criteria from the National Academies (2017) report are available at https://www.nap.edu/read/24624/chapter/7#323. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-29 inequities and building a culture of health (APHA, 2015; Danaher, 2011; Davis et al., 2016; Kottke et al., 2016; Mattessich and Rausch, 2014). Engaging stakeholders across multiple sectors provides the opportunity for innovative and cost-effective methods to sustain solutions at the community level (NASEM, 2017). The sixth core criterion requires the solution to be evidence informed. “This entails an assessment of evidence or the best available information to identify a problem and develop a solution that has a measurable outcome. Here, there is considerable flexibility in terms of the type of evidence that will qualify. This flexibility is based on the understanding that low- resource communities that suffer from health inequities often do not have the infrastructure, personnel, or financial resources to provide the highest standard of evidence” (NASEM, 2017, p. 326). The sixth core criterion is that there needs to be an evaluation plan with identified outcome measures to track the impact of the intervention. The second set of criteria—aspirational criteria—reflects the elements, processes, and outcomes of interventions that the committee identified as valuable for promoting health equity. This set of criteria highlights important features of interventions, such as nontraditional partners or nonhealth domains (e.g., community organizers, public libraries, Parent Teacher Association groups) and an intervention being interdisciplinary and/or multilevel (the intervention has multiple levels of influence, such as individual, family, organizational/institutional, or governmental). THE SCIENCE OF EARLY DEVELOPMENT: CORE CONCEPTS Based on its review of the science, the committee updated the core concepts from the 2000 report From Neurons to Neighborhoods and identified 12 core concepts of early development, with a focus on equity. The evidence behind these concepts is described in Chapters 2–4, and this evidence guided the committee in developing recommendations that are responsive to the science of early development. 1. Biology–environment interaction impacts health and development: Human long-term social, emotional, behavioral, cognitive, and physical health is shaped by genetic, epigenetic, and environmental factors that integrate biological information at the level of molecular, cellular, and organ systems with the family, neighborhood, and culture in which the individual is embedded. These developmental processes start before conception through a dynamic and continuous interaction between biology and aspects of the environment and extend throughout the life-span. 2. Brain development proceeds in well-defined but continuous steps: Human developmental processes are now conceptualized as continuous, rather than occurring in discrete stages as was originally thought. A sequence of temporally well-defined sensitive periods (sometimes referred to as “critical periods”) of brain maturation—in tandem with environmental influences—lead to the acquisition of social, emotional, and cognitive skills. During these sensitive periods, early adverse experiences influence brain development and can alter the trajectories of development in each of these functional domains, impacting long-term well-being. 3. Major physiological systems develop rapidly in pregnancy and early childhood: It is now known that physiological systems other than the brain, such as the immune system, microbiome, and endocrine system, can also be influenced preconceptionally. Like the PREPUBLICATION COPY: UNCORRECTED PROOFS

1-30 VIBRANT AND HEALTHY KIDS brain, these systems begin to develop prenatally, with early sensitive pre- and postnatal periods that can be disrupted by early adversity. These early influences can have long- term consequences for mental and physical health. 4. The early caregiving environment is crucial for long-term development: The family and community caregiving professionals have a central role in early childhood development, indicating the need for a multigenerational approach to assuring optimal growth and development. The child thrives in healthy relationships throughout childhood, but relationships with parents are the building blocks for subsequent relationships and child outcomes. For example, maternal–child interactions impact the well-being of both mother and child, where a positive mother–child relationship rests on good maternal well-being (whereas prolonged maternal distress impairs parenting and the quality of attachment). 5. The developing child plays an important role in interactions and development: Children are active participants in their own development, reflecting the intrinsic human drive to explore and master one’s environment. Early experiences create biological structures, and shape psychological and behavioral adjustment, in ways that influence how the child will react and act in response to later environmental demands. 6. The development of executive functions15 is a key aspect of early childhood development: The emergence and maturation of executive functions (inhibitory control, mental flexibility, and working memory) are a cornerstone of early childhood development. Executive function maturation continues through early adulthood and contributes to the health, well-being, and productivity of adults. 7. Trajectories—positive or negative—are not immutable: The developing child remains vulnerable to risks and open to protective influences through adolescence and young adulthood, although early life represents the stage at which interventions are most effective in positively influencing a child’s development. 8. There is variability of individual and group development: Individual children demonstrate significant variability in these sensitive periods of brain development and in response to interventions. This variability often makes it difficult to distinguish among typical development, maturational delays, transient disorders, and persistent impairments or to predict response to treatment. Understanding this heterogeneity of development and individual differences in access and responsiveness to interventions is a major goal. 9. Experiences across environmental contexts play a significant role in early development: Children can be more or less sensitive to experiences due in part to their biological makeup, but this is impacted powerfully by multiple family and community factors. These include family interactions and adversity, accessibility to community programs and interventions, and environmental factors, such as quality and stability of housing, toxic environmental exposures, food accessibility, early childhood education, family support, and culture. Effective interventions can alter the course of development 15 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” (Center for the Developing Child at Harvard University, see https://developingchild.harvard.edu/science/key-concepts/executive-function/, accessed June 17, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NEED TO INTERVENE EARLY 1-31 throughout childhood by changing the balance between risk and protective processes, leading to more adaptive outcomes. 10. Disparities in access to critical resources matter: Disparities in health and developmental outcomes result from not only health care disparities but also disparities and inequities in family and community factors. Achieving equity in health and developmental outcomes in young children requires addressing health care disparities and also assuring those family and neighborhood conditions in which all children and families can be healthy and thriving. 11. Health outcomes are the result of experiences across the life course: Birth and early developmental outcomes are influenced by the health of the mother and father not only during pregnancy but also before and between pregnancies and across the life course, starting with their own prenatal and early life experiences. Disparities in the child’s birth and early developmental outcomes are therefore the consequences of not only differential exposures during pregnancy and early childhood but of differential parental life course trajectories set forth by early programming mechanisms and influenced by cumulative life adversity. 12. Early interventions matter and are generally more cost effective than later ones: Family-based interventions that consider both risk and resilience and are informed by or sensitive to the mores and values of the target population can potentially positively change developmental pathways. The integration of various levels of services that are community based and have supportive policies in place tends to be more effective. OVERVIEW OF THE STUDY PROCESS AND REPORT To address its charge, the committee gathered information through a variety of means. It held two information-gathering meetings that were webcast live, in August and October 2018 (the meeting agendas are listed in Appendix B). The committee also held deliberative meetings throughout the study process. The committee received public submissions of materials for its consideration throughout the course of the study.16 The committee’s online activity page provided information to the public about its work and facilitated communication with the public.17 Throughout this report, the committee provides conclusions and recommendations. Chapter 2 provides an overview of healthy development from conception through early childhood, including what is new in the science of development since the publication of From Neurons to Neighborhoods (NRC and IOM, 2000). It aims to demystify the “black box” of development for the public, practitioners that work with children, and policy makers and to convey that we know enough about early development to act now to advance health equity for children and families. Chapter 3 provides an overview of the critical influences or factors that can either promote or hinder healthy development, with a focus on factors that shape inequities at the child/family level and the community and population levels across the SDOH. Chapter 4 focuses on how to best foster children’s healthy psychosocial development, emotional adjustment, and physical health using what science has shown about risk and resilience and the importance of healthy relationships among children and families in high-risk contexts. Chapter 5 16 Public access materials can be requested from paro@nas.edu. 17 See nationalacademies.org/earlydevelopment. PREPUBLICATION COPY: UNCORRECTED PROOFS

1-32 VIBRANT AND HEALTHY KIDS explores the role of the health care system in advancing health equity and what the system would need to look like from preconception through early childhood to meet the developmental needs of children. Chapter 6 provides recommendations on how to better meet the fundamental needs of families and children through economic security, stable and safe housing, and protection from environmental toxicants. Chapter 7 discusses the critical role of ECE and how it can serve as a platform for advancing health equity for children and families. Chapter 8 addresses needed systems changes and summarizes the opportunities to overcome barriers to strengthen a systems approach, the key stakeholders who need to be involved, and necessary alignment, measures, and research based on the committee’s assessment of the literature in Chapters 2–7. Finally, Chapter 9 highlights the main findings and concepts discussed throughout this report and summarizes the report recommendations, laying out a roadmap for applying and advancing the science of early development. CONCLUDING OBSERVATIONS The science of early development is clear. Long-term physical health and emotional, behavioral, social, and cognitive competence is shaped by genetic, epigenetic, and environmental factors, including their interactions, before conception and through the life-span. There are risk factors that necessitate action at the practice, policy, and systems levels that take into account the full range of factors that impact health and well-being. These actions need to be taken before insults to early development occur; however, the science of plasticity indicates that it is never too late to intervene. These actions need to take a life course, multigenerational approach to make progress on health inequity, because the well-being of a child depends on the well-being of a parent/caregiver. Multipronged, cross-sector interventions, focused on prevention, early detection, and mitigation and working at the policy, system, and program levels, are needed to move toward health equity. REFERENCES ACOG (American College of Obstetricians and Gynecologists). n.d. Racial disparities in maternal mortality in the United States: The postpartum period is a missed opportunity for action. https://www.acog.org/-/media/Departments/Toolkits-for-Health-Care-Providers/Postpartum- Toolkit/ppt-racial.pdf?dmc=1&ts=20190716T2208336641 (accessed July 16, 2019). Alker, J., and O. Pham. 2018. Nation's progress on children's health coverage reverses course. Washington, DC: Georgetown University Health Policy Institute, Center for Children and Families. Angrist, J. D., and Pischke J., 2009. Mostly harmless econometrics: An empiricist's companion. Princeton, NJ: Princeton University Press. APHA (American Public Health Association). 2015. Opportunities for health collaboration: Leveraging community development investments to improve health in low-income neighborhoods. Washington, DC: American Public Health Association. Auten, G., and D. Splinter. 2018. Income inequality in the United States: Using tax data to measure long- term trends. Bellis, M., K. Hughes, K. Hardcastle, K. Ashton, K. Ford, Z. Quigg, and A. Davies. 2017. The impact of adverse childhood experiences on health service use across the life course using a retrospective cohort study. Journal of Health Services Research & Policy 22(3):168–177. PREPUBLICATION COPY: UNCORRECTED PROOFS

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Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity Get This Book
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Children are the foundation of the United States, and supporting them is a key component of building a successful future. However, millions of children face health inequities that compromise their development, well-being, and long-term outcomes, despite substantial scientific evidence about how those adversities contribute to poor health. Advancements in neurobiological and socio-behavioral science show that critical biological systems develop in the prenatal through early childhood periods, and neurobiological development is extremely responsive to environmental influences during these stages. Consequently, social, economic, cultural, and environmental factors significantly affect a child’s health ecosystem and ability to thrive throughout adulthood.

Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity builds upon and updates research from Communities in Action: Pathways to Health Equity (2017) and From Neurons to Neighborhoods: The Science of Early Childhood Development (2000). This report provides a brief overview of stressors that affect childhood development and health, a framework for applying current brain and development science to the real world, a roadmap for implementing tailored interventions, and recommendations about improving systems to better align with our understanding of the significant impact of health equity.

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