Optimizing the Health and Development of Children

The progress that US society has made in health promotion is evident in the almost doubling of life expectancy in the 20th century, the compression of morbidity, and the increased functional capacity. Much of the improvement in health and functional ability at the end of life is influenced by what happens much earlier in life.¹ The idea that health "develops" during childhood is evident from emerging studies tying early health and developmental potential to later educational attainment, disease burden, and disability.^{1 - 2} As innovative strategies focus on promoting "health for all," optimizing the healthy development of all children will require greater attention.^{2 - 3}

Children's health and health care delivery are defined by those same characteristics that distinguish children from adults: their developmental vulnerability, their dependency on adult caregivers, and the determinants and distribution of morbidity and disability.^{4 - 5} Unlike care for adults, the emphasis of care for children is not just on staying healthy or maintaining health status but instead on actively promoting health and well-being.

A growing evidence base is drawing the attention of policymakers and clinicians to this critical need of not just maintaining but actually optimizing the health of children. Several decades of brain research document the role of early experience in determining lifelong learning, emotional well-being, and social attainment; longitudinal epidemiologic studies identify early childhood origins of adult disease and provide evidence of predisease pathways that start in early childhood; and demographic analyses show that many health and social disparities that have their origins in early childhood are compounded as children grow into adolescence and adulthood.^{2 ,6 - 8} The National Academy of Sciences' landmark report From Neurons to Neighborhoods documented that early experiences, especially early relationships, play an important role in cognitive, social, and emotional development.⁶ Early intervention research shows that intensive, comprehensive early intervention and education programs can alter developmental "trajectories" and substantially improve health, educational, and social outcomes from middle childhood through adulthood.^{9 - 10} Economic analyses also show that investments in early childhood create substantial social wealth.¹¹

This research is all the more compelling given the current status of young children in the United States. Many children are exposed to preventable risks, such as parental drug use, mental health problems, and poverty. It is estimated that 20% of all parents who are primary caregivers experience clinical symptoms of depression that may preclude optimal parenting.¹² Longitudinal studies show that high school achievement is highly correlated with capacities early in childhood, yet many low-income children start school 1 year behind children from higher-income families and continue to lag behind, even when given access to the best schools.^{13 - 14} Racial/ethnic disparities also abound; a 1996 national survey of families with young children found that 37% of white children had 1 or more risk factors for adverse outcomes, with higher rates among African American (66%) and Latino (72%) children.¹⁵

From Neurons to Neighborhoods suggests that pediatric clinicians are well positioned to improve child health and developmental outcomes, yet are not fulfilling this important role. Nearly half of parents have concerns about their young child's behavior (48%), speech (45%), or social development (42%).¹⁶ These concerns are important to address, given that previous studies suggest that about 70% of children with developmental problems at kindergarten entry could have been identified earlier, but were not.¹⁷ The National Survey of Early Childhood Health (NSECH) shows that in 2001, fewer than half of parents ever recalled their child's development being assessed by the health care provider, although professional guidelines call for assessments at most visits.^{16 ,18} The NSECH also shows that many parents are not being counseled on key recommended developmental issues, although parents express interest in this information to help them in their parenting.^{16 ,19}

Given the health and health care deficits that young children experience, several initiatives are focusing on improving the organization, financing, and delivery of early childhood health services. In this issue of THE JOURNAL, Minkovitz and colleagues²⁰ report on a national trial using an experimental design, the Healthy Steps for Young Children Program.²¹ Healthy Steps changes the structure of pediatric primary care by adding a trained developmental specialist to the pediatric primary health care team. In the study by Minkovitz et al, the developmental specialist not only provided developmental services but also was encouraged to build a closer relationship with parents to enhance their knowledge, skills, and parenting behaviors. This was accomplished through changes in the process of care delivery: upgrading well-child visits, increasing consistency in the type and nature of contacts and interactions, improving the quality of child development assessments, and focusing on family and psychosocial issues. In addition, Healthy Steps provided other enhanced services, including greater connections between the health care team and family through telephone conversations and home visits timed to correspond with critical developmental transitions in the child's life when the parent-child relationship is most likely to be stressed. Healthy Steps also strengthened linkages between primary care practices and other community-based services and resources.

The evaluation included both randomized and quasi-experimental groups and evaluated children for the first 3 years of life. It demonstrated that the children and families in the Healthy Steps group received more services, information, anticipatory guidance, timely visits, and appropriate care than did families in the control group. The evaluation also showed that parents adopted behaviors that decreased their child's exposure to risks and increased their use of optimal child-rearing practices. While there were some differences between the randomized and the quasi-experimental practice comparisons, most effect sizes showed at least a 2-fold difference. In addition, quality measurement for children cannot simply be based on the health care that is provided within the pediatric practice, but also must account for the quality of connections that clinicians make with resources in their community.²² While not directly measured by the Healthy Steps evaluation, the results are consistent with this idea.

Healthy Steps is an important innovation that is part of a wave of new initiatives designed to improve the quality of early childhood health services. The National Initiative for Children's Healthcare Quality (NICHQ) recently launched an improvement initiative in the states of Vermont and North Carolina to accomplish many of the same goals as Healthy Steps using the Breakthrough Series collaborative improvement methodology.²³ Several other states have used the Foundation for Accountability's "Promoting Healthy Development" survey to measure the quality of pediatric health and developmental services, and subsequently instituted a range of improvements in reimbursement, contracting arrangements, and practice-level monitoring and feedback.

Healthy Steps and other initiatives for quality improvement are also taking place in the context of major population-based initiatives seeking to optimize all aspects of early childhood health, development, and well-being. First 5 California, one of more than 30 statewide initiatives being launched in the United States, allocates more than $500 million to improving services and reengineering systems for young children. Smart Start in North Carolina is another example of an initiative that is adopting a comprehensive approach. More recently the federal Maternal and Child Health Bureau launched the State Early Childhood Comprehensive Systems (SECCS) initiative to provide planning grants and implementation funds to states to support the improvement of early childhood health, developmental, and family support services.

What is important about Healthy Steps, and why many of these new, multisector, comprehensive early childhood initiatives must take note, is that it provides important evidence that by changing the structure and process of pediatric care, performance in the delivery of pediatric developmental services can be improved significantly. While it has always been difficult to link changes in the process of pediatric care to outcomes, the use of an experimental design and randomization for part of the population supports the validity of the Healthy Steps results. Healthy Steps is also important because it not only focuses on processes within the pediatric practice, but it changes the connections of the pediatric practice to parents outside of the office and reduces important barriers to the provision of certain services.

What will it take to convince payers, both private and governmental, to reimburse Healthy Steps services as part of regular preventive and developmental care? Unfortunately, in the current health care climate, diffusing the Healthy Steps model may require meeting a cost-benefit threshold based on preventing adverse outcomes, such as developmental disabilities and behavioral problems. That will be difficult, as the very developmental sensitivity that identifies early childhood as an unparalleled period for optimizing development is also an Achilles heel. Child outcomes are influenced by many aspects of the child's environment. Since there will always be multiple influences (both positive and negative) impacting the lives of young children, no single intervention or change in service delivery is likely to produce a large, sustained effect. Perhaps if health plans were held accountable not only for whether their members stay healthy but also for whether they are able to demonstrate that they are optimizing health, there would be new incentives to improve and reimburse these kinds of services. In the end, it will come down to a question of whether investing in higher-quality developmental health services produces benefits in which society is willing to invest.

Unfortunately for children, there is another "catch-22." Many potential benefits of developmental services provided to young children do not accrue for many years. Tracking and attributing the impact of these investments is difficult, if not impossible. In addition, potential benefits may not accrue to the health system or a particular health plan in the short run and instead may become manifest in decreased use of remedial services such as special education, mental health, and juvenile justice services as well as greater educational attainment. This dispersion of potential savings across sectors reduces the ability of the health sector to capture the full return on its investment and thus reduces the incentives to invest.

The ethical, scientific, social, and economic imperatives of promoting optimal health and development in the early years, and its bearing on the future health and well-being of the population as a whole, argue that early childhood health policy is more than a health care issue. Improving the health, development, and education of young children requires transformations in the health system, such as Healthy Steps has done, but also requires improvements in education, family support, and the neighborhoods in which children grow up. Given the promising results of the Healthy Steps evaluation and the emergence of other complementary interventions and approaches to improvement, it is important to consider a more integrated and population-based strategy to improving early childhood health.²⁴ With many early childhood initiatives at the state level and with the SECCS initiative, the improvement goals at the state, national, local, and practice levels are aligned, and this should be exploited. Several other industrialized nations already have moved in this direction, and there is no reason the United States cannot follow suit. The tradeoffs in health care expenditures between early childhood and end of life will become even more acute and significant as the baby boom generation ages and consumes increasing proportions of the health care dollar. Investing in early childhood health care is a policy priority that we cannot neglect.