Vibrant and Healthy Kids

ALIGNING SCIENCE, PRACTICE, AND POLICY
TO ADVANCE HEALTH EQUITY

Committee on Applying Neurobiological and
Socio-Behavioral Sciences from Prenatal Through Early
Childhood Development: A Health Equity Approach

Jennifer E. DeVoe, Amy Geller, and Yamrot Negussie, Editors

Board on Population Health and Public Health Practice

Health and Medicine Division

A Consensus Study Report of

THE NATIONAL ACADEMIES PRESS
Washington, DC
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This activity was supported by a contract between the National Academy of Sciences and the Robert Wood Johnson Foundation (#72444). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-49338-3
International Standard Book Number-10: 0-309-49338-2
Digital Object Identifier: https://doi.org/10.17226/25466
Library of Congress Control Number: 2019948065

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Suggested citation: 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. https://doi.org/10.17226/25466.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

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COMMITTEE ON APPLYING NEUROBIOLOGICAL AND SOCIO-BEHAVIORAL SCIENCES FROM PRENATAL THROUGH EARLY CHILDHOOD DEVELOPMENT: A HEALTH EQUITY APPROACH

JENNIFER E. DeVOE (Chair), Professor and Chair, Department of Family Medicine, Oregon Health & Science University

CYNTHIA GARCÍA COLL, Adjunct Professor, Department of Pediatrics, University of Puerto Rico Medical School; Charles Pitts Robinson and John Palmer Barstow Professor Emerita, Brown University

ELIZABETH E. DAVIS, Professor, Department of Applied Economics, University of Minnesota

NADINE BURKE HARRIS, Surgeon General, State of California (since February 2019); Chief Executive Officer, Center for Youth Wellness, California (until February 2019)

IHEOMA U. IRUKA, Chief Research Innovation Officer, Director, Center for Early Education Evaluation, HighScope Educational Research Foundation

PAT R. LEVITT, Chief Scientific Officer, Vice President, and Director, Saban Research Institute, Simms/Mann Chair in Developmental Neurogenetics, Children’s Hospital Los Angeles; W.M. Keck Provost Professor of Neurogenetics, Keck School of Medicine, University of Southern California

MICHAEL C. LU, Professor and Senior Associate Dean, Academic, Student, and Faculty Affairs, The George Washington University

SUNIYA S. LUTHAR, Foundation Professor of Psychology, Department of Psychology, Arizona State University; Professor Emerita, Teachers College, Columbia University

AMY ROHLING McGEE, President, Health Policy Institute of Ohio

MYRA PARKER, Assistant Professor, Center for the Study of Health and Risk Behaviors, University of Washington

JAMES M. PERRIN, Professor of Pediatrics, Harvard Medical School; Pediatrician, MassGeneral Hospital for Children

NATALIE SLOPEN, Assistant Professor, Epidemiology and Biostatistics, University of Maryland School of Public Health

ALBERT WAT, Senior Policy Director, Alliance for Early Success

BILL J. WRIGHT, Director, Providence Health System, Center for Outcomes Research and Education

National Academy of Medicine Norman F. Gant/American Board of Obstetrics and Gynecology Fellow

EBONY BOYCE CARTER, Assistant Professor, Washington University School of Medicine in St. Louis

Study Staff

AMY GELLER, Study Director

YAMROT NEGUSSIE, Associate Program Officer

SOPHIE YANG, Research Associate

ANNA MARTIN, Administrative Assistant

PAMELA McCRAY, Senior Program Assistant (from April 2019)

ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice

DANIEL BEARSS, Senior Research Librarian

MARY JANE PORZENHEIM, Intern (from June to August 2018)

MISRAK DABI, Financial Associate

TASHA BIGELOW, Editor

Title: Chasing Sunshine
Artist: Stephanie Kohli (Weston, Wisconsin)
Year: 2017
Medium: Mixed Media

Artist statement:

This piece is based off of my daughter running in our garden. Feeding children the best quality food and letting them explore nature in community gardens is a beautiful way to help them shine.

This artwork was submitted as part of the National Academy of Medicine’s Visualize Health Equity Community Art Project nationwide call for art. This call for art encouraged artists of all kinds to illustrate what health equity looks, sounds, and feels like to them. More information on this project can be found at nam.edu/VisualizeHealthEquity.

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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ROBERT M. KAPLAN, Stanford University, and BOBBIE BERKOWITZ, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Contents

PREFACE

ACKNOWLEDGMENTS

ACRONYMS AND ABBREVIATIONS

SUMMARY

1 THE NEED TO INTERVENE EARLY TO ADVANCE HEALTH EQUITY FOR CHILDREN AND FAMILIES

Introduction

The Problem

Opportunities

Why Invest in Early Intervention and Prevention?

Current State of Children’s Health

Maternal Health in the United States

Current Environment for Children and Families

Changes in the Economic, Social, and Cultural Environment

About This Report

The Science of Early Development: Core Concepts

Overview of the Study Process and Report

Concluding Observations

References

2 HEALTHY DEVELOPMENT FROM CONCEPTION THROUGH EARLY CHILDHOOD

Introduction to the Science from Prenatal Through Early Childhood

Scientific and Technological Advancements Since From Neurons to Neighborhoods

Biological Mechanisms of Healthy Development

Biological Mechanisms of Stress

Conclusion

References

3 DEVELOPMENT HAPPENS IN CONTEXTS: OVERVIEW OF EARLY LIFE CRITICAL INFLUENCES

Introduction

Family Cohesion and Social Connections

Health Care

Healthy Living Conditions

Economic Security

Nutrition and Food Security

Neighborhood and Community Conditions

Housing

Environmental Exposures

Early Care and Education

Revisiting Crosscutting Elements

Accumulation of Risk

Conclusion

References

4 FOSTERING CAREGIVER WELL-BEING TOWARD HEALTHY CHILD DEVELOPMENT

Introduction

Human Development in the Context of Relationships

Interventions to Promote Relational Supports and Caregiver Well-Being

Synthesizing the Evidence

References

5 LEVERAGING THE HEALTH CARE SYSTEM TO IMPROVE OUTCOMES AND PROMOTE HEALTH EQUITY

Introduction

Background and Current Characteristics of Health Care

Improving Access to Health Care Services

Promoting Quality of Care

Innovative Delivery Models and Financing Care

The Future of Preconception Through Pediatric Care

Conclusion

References

6 CREATING HEALTHY LIVING CONDITIONS FOR EARLY DEVELOPMENT

Meeting Fundamental Needs to Support Prenatal and Early Childhood Development

Economic Stability and Security

Food Security and Nutrition

Housing

Neighborhood Conditions

Environmental Exposures and Exposure to Toxicants

Conclusion

References

7 PROMOTING HEALTH EQUITY THROUGH EARLY CARE AND EDUCATION

Introduction

Direct Links Between ECE and Health Equity

Linkages Between ECE and Health Equity Through Social-Emotional Development

Linkages Between ECE and Health Equity Through Parenting and the Home Environment

Linkages Between ECE and Health Equity Through Supports for the ECE Professional

ECE Conclusions and Recommendations

Conclusion

References

8 A SYSTEMS APPROACH TO ADVANCE EARLY DEVELOPMENT AND HEALTH EQUITY

Introduction

Opportunities to Strengthen a Systems Approach

Conclusion

References

9 A ROADMAP FOR APPLYING THE SCIENCE OF EARLY DEVELOPMENT

Opportunities for Action

References

APPENDIXES

A CRITERIA FOR SELECTING PROMISING MODELS

B PUBLIC MEETING AGENDAS

C COMMITTEE BIOGRAPHICAL SKETCHES

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Preface

All children deserve the opportunity to meet their full health potential and lead fulfilling lives. Our nation’s future depends on it. Yet, there are millions of children in the United States who are not afforded this opportunity today. While spending a record amount of money on health care services, the United States has the worst infant mortality rate among 19 similar wealthy nations, and the U.S. maternal mortality rate in 2018 was our highest since 2000. Although the United States is one of the richest nations in the world, in 2015 more than 9.6 million children lived in families with annual incomes below the poverty line (based on the Supplemental Poverty Measure), with approximately 2.1 million living in deep poverty. The highest rates of poverty were found among Hispanic, African American, and American Indian/Alaska Native families. This is deeply concerning because poverty during pregnancy and childhood is directly tied to poor health and developmental outcomes. Our nation’s health disparities, of which there are many, are directly linked to what happens in early childhood and prenatally (and even earlier). For all children to lead fulfilling lives, we need to first achieve health equity as a nation, and to do so, we must focus on the youngest, and most vulnerable, in our nation. We also need to look beyond health care for solutions; while health care is necessary to improve health outcomes, fixing health care alone will not address health inequities.

A multitude of factors, from the macro to the micro levels, contribute to the divergent health trajectories that children experience. A child’s health ecosystem is influenced by social, economic, cultural, and

environmental factors that impact healthy development and well-being. These influences start before birth and have an impact throughout an individual’s life and across generations. Exposure to positive influences consistently and longitudinally increases the likelihood of health production, while exposure to negative influences decreases opportunities to be healthy. The timing of these exposures in life also matters—the prenatal to early childhood period is one of the most sensitive times for children to get on the right track to meet their full health potential. Lifelong and multigenerational health disparities are a result of children in this critical age group lacking access to positive opportunities (such as high-quality early care and education, stable and safe housing, and healthy foods) that promote health combined with a preponderance of negative influences that harm health trajectories. Children’s health is inextricably linked to family health and community health. For many communities, population health disparity gaps are widening. Persistent, additive disadvantages and early adversity are significant contributors to the widening gaps. Past historical injustices, such as segregated schooling laws, redlining, and assimilation policies, continue to impact children due to structural injustices put in place in the past that persevere today and continue to create barriers to health for those who live in contexts that undermine their opportunity to reach their health potential. This has led to persistent childhood (and lifelong) health disparities. Communities of color have much higher rates of preterm birth, infant mortality, chronic disease (e.g., diabetes), and exposure to adverse childhood experiences, to name just a few.

In preparing this report, the committee took seriously its charge to review the ways in which early life stress affects health, the pathways by which health disparities develop and persist, and the roadmap needed to get all children on positive health trajectories. Scientific discoveries have built a solid base of evidence about what impacts children’s health trajectories positively and negatively—now is the time to apply and advance science to chart a course of action to get all children back on track for health. During the committee’s time reviewing the scientific evidence for how to translate the best science into action to positively impact health during early childhood, we strove to close the disconnect between evidence and practice in the nation today. While some scientific evidence has laid the groundwork for actionable practice, policy, and systems solutions, other emerging scientific findings are ripe for further research and inquiry. The committee also acknowledged that achieving and sustaining health equity is a long-term goal with many interrelated strategies and tactics. Thus, we included some recommendations that can be feasibly implemented more quickly by a focused group of actions, while other recommendations may take longer and will require broad support from many different actors at all levels of society.

This report details the latest scientific information about factors impacting health and how to achieve equitable promotion of health for all children. Multilevel and multipronged strategies focused on prevention, early detection and referral, and mitigation are needed to gain momentum toward achieving health equity. These strategies involve intervening at the policy, system, and program levels—this will ultimately require a concerted effort from the nation to distribute resources where they are needed and change policies to better align with the science and evidence. With this in mind, where possible, the committee sought to leverage existing resources or systems that serve children as platforms by which to improve and scale services for children. Furthermore, intentional strategies to understand and reduce inequitable outcomes, access, and experiences across communities of different races, linguistic backgrounds, income groups, genders, and geography are needed. Taking action requires a life course lens, multisector collaboration, and ongoing measurement of outcomes that can be assessed longitudinally and across multiple generations. What science teaches us about sensitive periods and the plasticity of the brain and body provides a clear path for action—if we follow that path regarding prevention and mitigation of adversity during this crucial life period, we can turn the tide for our nation’s children. This report provides a roadmap for doing so.

The committee is grateful to the Robert Wood Johnson Foundation for appreciating the need for this work and for supporting putting science into action. The committee welcomed this unique opportunity to shine a brighter spotlight on cutting-edge developmental science about how children develop and grow. Furthermore, we appreciated the opportunity to deepen our understanding about how the key principles and tenets of this critical scientific evidence base on optimal development can be made more accessible to prime the public, practitioners, and policy makers for action. It is the committee’s hope that this report’s bold recommendations will move our nation to practices and policies that center this science, hand in hand with equity, to advance health and well-being for all.

Jennifer E. DeVoe, Chair
Committee on Applying Neurobiological and Socio-Behavioral
Sciences from Prenatal Through Early Childhood Development:
A Health Equity Approach

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Acknowledgments

The committee wishes to thank and acknowledge the many individuals and organizations that contributed to the study process and development of this report. To begin, the committee would like to thank the Robert Wood Johnson Foundation—the study sponsor—for its support of this work.

The committee found the perspectives of multiple individuals and groups immensely helpful in informing its deliberations through presentations and discussions that took place at the committee’s public meetings. Speakers provided presentations on the state of the science in several domains and offered promising models for action, which informed the committee’s work; these include (in order of appearance) Dwayne Proctor, Paula Braveman, Fernando Martinez, Phil Fisher, Sarah Barclay Hoffman, Robert Kahn, Suzanne C. Brundage, Megan Smith, Lee Beers, Neal Halfon, Milton Kotelchuck, Ron Haskins, Greg Miller, Greg Duncan, Jessica Pizarek, Helena Sabala, Anne Mauricio, and Elisa Nicholas. The committee also heard policy perspectives from state Representative Ruth Kagi, state Senator Elizabeth Steiner Hayward, Bobby Cagle, and state Senator David Wilson—the committee greatly appreciates the perspectives they brought to the discussions.

The committee’s work was enhanced by the technical expertise and support provided by Marisa Gerstein Pineau, Petra Jerman, and Nat Kendall-Taylor, who served as consultants. The committee expresses its gratitude to Angela Diaz, who shared her time as a liaison from the Committee on the Neurobiological and Socio-Behavioral Science of Adolescent Development and Its Applications.

Importantly, the committee heard from a number of caregivers who shared their personal stories and experiences with the committee. These discussions helped ground the committee in the lived experiences of the complex issues that the committee needed to tackle in this report, and the committee is incredibly grateful for their bravery in sharing their experiences in a public forum. Thank you to Abraham Gomez, Shalice Gosey, Lori Hernandez, Ana De Jesus, Yesenia Manzo-Meda, Maria Rodgers, and discussants Alexa Bach, Jennifer Eich, Patricia McKenna, and Reggie Van Appelen.

The committee thanks the National Academies of Sciences, Engineering, and Medicine staff who contributed to the production of this report, including study staff Amy Geller, Yamrot Negussie, Sophie Yang, Anna Martin, Pamela McCray, and Rose Marie Martinez. Thanks go to Mary Jane Porzenheim, summer intern, and other staff in the Health and Medicine Division who provided additional support, including Carla Alvarado, Alina Baciu, Aimee Mead, Andrew Merluzzi, Cyndi Trang, Alexis Wojtowicz, and Hayat Yusuf. The committee thanks the Health and Medicine Division communications staff, including Jeanay Butler, Greta Gorman, Nicole Joy, Sarah Kelley, and Tina Seliber. This project received valuable assistance from Stephanie Miceli (Office of News and Public Information); Misrak Dabi (Office of Financial Administration); and Clyde Behney, Lauren Shern, and Taryn Young (Health and Medicine Division Executive Office). The committee also appreciated the collaboration with the study staff for the concurrent study on adolescence; thanks to Emily Backes, Dara Shefska, and Liz Townsend. Appreciation also goes to the National Academy of Medicine (NAM) Culture of Health Program team for their collaboration and support: Charlee Alexander, Kyra Cappelucci, and Ivory Clarke. The committee was also fortunate to have support from Ebony Carter (NAM Norman F. Gant/American Board of Obstetrics and Gynecology Fellow), who contributed her time and expertise throughout the report’s development.

The committee received valuable research assistance from Daniel Bearss, Senior Research Librarian (National Academies Research Center). At the end of the report process, Daniel Bearss passed away. Daniel was a dedicated, meticulous, and respected colleague, and he will be missed by the study team, who are incredibly grateful for his contributions to this report and the National Academies.

Finally, the National Academies staff offers additional thanks to the executive assistants and support staff of committee members, without whom scheduling the multiple committee meetings and conference calls would have been nearly impossible: Iris An, Gatanya Arnic, Mai Castillo, Saúl Cruz, Dhiana Dhahrulsalam, Justin Farmer, Lynne Lathbury, Suzanne Lee, Lauren Oujiri, Kathy Rentie, Katie Rivers, and Lorena Segarra.

Acronyms and Abbreviations