An important goal of early childhood education is teaching emotional self-regulation within the context of a safe, stable, nurturing environment. Expulsion of young children ignores underlying emotional and behavioral concerns, disproportionately affects children of color (Black or Hispanic), males, children with disabilities, and socioeconomically disadvantaged populations, and has long-term consequences on educational and life success. Addressing implicit bias and providing child mental health consultation (psychologists, social workers, developmental behavioral pediatricians, child psychiatrists, and child neurologists) to child care providers can prevent expulsion. Pediatricians and other providers within the medical home play an important part in preventing expulsion. However, pediatricians need more training in early childhood mental health and in understanding how systemic racism and implicit bias lead to preschool expulsion in children of color. By identifying children at risk for expulsion because of poverty, racial discrimination, toxic stress, insecure attachment, or history of trauma, the pediatrician can connect families with community resources that may ameliorate these effects. Pediatricians can provide information on social-emotional development in early childhood, promote positive parent-child relationships, and model and discuss age-appropriate and developmentally appropriate behavior management. Pediatricians can also guide parents toward high-quality child care programs that use mental health consultation and developmentally appropriate activities, both of which lessen the chance of child expulsion. Furthermore, behavioral health providers integrated into the medical home can provide consultation to child care providers on managing patients. These recommendations are consistent with our knowledge of early child brain development and support the current tenets of the American Academy of Pediatrics regarding the pediatrician’s role in building resilience and buffering toxic stress to promote optimal child development.
High-quality child care and early education programs provide the positive experiences that nurture social skills, learning, and development. For children from birth through 4 years of age, these programs have the potential to enhance social and cognitive development and readiness for kindergarten.1
Recent studies have found that many adult psychological problems have their roots in early childhood and that many emotional and behavioral problems first emerge in 3- to 5-year-olds. Community-based epidemiologic studies demonstrate prevalence rates of psychiatric diagnoses ranging from 13% to 27% in preschoolers.2–4 Rates of anxiety disorders in preschoolers range from 2% to 20%, rates of oppositional defiant disorder or attention-deficit/hyperactivity disorder range from 2% to 13%, rates of conduct disorder range from 1% to 2%, and rates of depression are less common at 0% to 2%. Even more prevalent are behavioral and parental disciplinary problems that do not rise to the level of a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis but present management challenges. Only 25% of individuals identified with diagnosable problems receive mental health treatment. Treatment received is often inadequate in quality and quantity.5 The actions of some children, particularly those with disruptive behavior, present a challenge to child care settings. Preschool teachers may not have the expertise or the consultative backup to provide optimal care for these children.
Children with developmental disabilities who have behavioral problems are at increased risk for preschool expulsion not only because of their developmental delays but also because of comorbid conditions (eg, eating problems, sleep disorders) that may exist. The overall prevalence of developmental disabilities in 2017 in children 3 to 17 years of age was estimated at 17%, with autism spectrum disorder occurring in about 2.5%, global developmental delay in 1% to 3%, attention-deficit/hyperactivity disorder in about 7% to 9.4% (2.4% in children ages 2–5 years), and speech and language delay in approximately 8% (11% in children ages 3–5 years).6 These children are often prone to behavioral problems because of their inability to effectively communicate, and preschool teachers often misinterpret these behaviors because of lack of specific training with this population and lack of appropriate resources. Preschool teachers need to understand these children’s needs at their developmental level and how best to meet those needs to support their development.
Young children who experience adversity are also at increased risk for preschool expulsion because of behavioral and socioemotional concerns that result from toxic stressors. Trauma impacts early child brain development negatively and causes vulnerability to developmental and behavioral disorders. It is critical that the “why” of these behaviors be acknowledged and treated, not punitively, but with the appropriate supports including safe, stable environments; positive, nurturing relationships; and trauma informed interventions individualized to the child. Preschool teachers and child care providers need to have access to mental health consultation, which supports these goals.7,8
When young children are expelled or suspended from child care or early education settings, they are deprived of both the positive opportunities offered by early care and education and the opportunity for remediation. This policy statement alerts pediatricians to the growing problem of child care and early education expulsion in an effort to foster collaborations that will offer better care to affected children.
Expulsion in Early Education and Child Care Settings: A Failure in Child Behavior Management
In 2005, Gilliam conducted the first national survey of expulsion in early care and education programs.9 He surveyed 52 state-funded programs in over 40 states and reported that 10.4% of teachers expelled at least 1 student in the past year (6.7 of 1000; 3 times as many as in kindergarten through 12th grade), and 22% of those expelled more than 1 child. In March of 2014, the Office of Civil Rights reported that 6% of school districts with preschool programs reported suspending at least 1 child from public preschool.10 Estimates of numbers outside the state-funded system were even higher, with national estimates approaching 12 per 1000 or more than 300 000 preschoolers per year.11 In 1 state, 39% of teachers in early care or education programs reported expelling at least 1 student in the past year, which is 13 times the numbers of students expelled in kindergarten through 12th grade.12 Estimates for private, for-profit, and faith-based schools were higher than for state-funded programs; Head Start rates of expulsion were quite low, especially after new federal guidelines in 2014.13 Even among infants and toddlers, 42% of child care centers in Illinois reported the expulsion of at least 1 child in the past year.13,14 A more recent 2016 national survey of child health involving both public and private programs serving 3- to 4-year-olds showed more than 50 000 children suspended and 17 000 expelled, for a combined rate of 250 children per day involuntarily leaving preschool.15
Clear definitions, criteria, and data for suspension and expulsion are not consistent across states, which vary widely in their policies and offer few formal parameters. It is likely that the data vastly underrepresent actual dismissals from early childhood settings.16 Only public preschools are required to record instances of suspension or expulsion.5 In addition, parents who are asked repeatedly to pick their children up early because of behavior concerns may choose to voluntarily transfer their child without a formal adjudication of suspension or expulsion.
Major disparities exist in who gets expelled. Risk factors for expulsion include being Black, being male, being older, and having a disability. In a 2005 national survey, male preschool students were expelled at 4.5 times the rate of female preschool students, and Black children were expelled at twice the rate of their Hispanic and non-Hispanic white counterparts and over 5 times the rate of Asian American preschoolers.9 In a 2016 report, these discrepancies increased, with Black preschoolers 3.6 times more likely to be expelled than white preschoolers.17 Preschool children with disabilities were 14.5 times more likely to be expelled, and 4-year-olds were twice as likely as 3-year-olds to be expelled. Black boys represent 19% of male preschool enrollment but 47% of preschool children receiving 1 or more out-of-school suspensions; in comparison, white children represent 41% of preschool enrollment but only 28% of suspensions. Hispanic and Black preschool boys represent 46% of those enrolled but 66% of those suspended or expelled.9,10,16–18 Disparities also exist for Black girls who make up 21% of the preschool population but 54% of all female students suspended.19 Studies have demonstrated the role of stereotyping and implicit bias by some preschool teachers who may view developmentally typical behavior in Black male students as “misbehavior.” Teachers may incorrectly assess Black boys to be older than they are and have higher inappropriate expectations for developmentally acceptable behavior. Some preschool teachers responded punitively instead of with empathy, support, and patience.17,20
The reasons for suspension and expulsion include inadequately evaluated and treated behavioral disorders (physical impulsiveness, aggression, biting, throwing chairs, disruptive behavior, defiance, constant tantrums, running away, and inability to function independently).21 Parental stress, adversity, history of trauma, family illness or death, conflict, and divorce are contributing factors that exacerbate the child’s behavior at preschool and present a challenge to the teachers.2 The prevalence of adverse experiences and trauma in this population emphasizes the importance of positive, nurturing, consistent caregiver-child relationships to mitigate toxic stress and promote resilience.22 Preschool teachers need to recognize that behavior is a symptom and try to understand the underlying emotions and thoughts and what traumatic stressors might need remediation. The recent American Academy of Pediatrics (AAP) clinical report on trauma-informed care provides further guidance on management.7
Structural factors associated with child care and early education expulsion include larger class size with lack of space and structure, longer school day, higher child-to-teacher ratios, teacher job stress, low staff wages and poor morale, undiagnosed staff depression, and lack of teacher training on social emotional development.18 As previously mentioned, implicit biases (automatic stereotypes based on structural racism) of some preschool teachers toward children of color play a major role. The most important predictor of adverse outcomes in child care and early education settings was the absence of developmental, behavioral, and early child mental health consultation to teachers, which was associated with twice the rate of expulsion.12,16
What happens on follow-up to children who are suspended or expelled from child care or preschool? The consequences can be quite dire. Once a child is expelled, child care or preschools may no longer provide further education or counseling services to the student or family. Children expelled from preschool or child care are 10 times as likely to drop out of high school, experience academic failure and grade retention, have negative attitudes toward school, and are more likely to face incarceration.23–26 Half of kindergarteners with behavioral health concerns need special education by grade 4. Children with disabilities are less likely to receive the critical special needs services to which they are entitled.
Existing Efforts to Prevent Preschool Expulsion
In December 2014, the US Departments of Education and Health and Human Services issued a joint “policy statement with recommendations and resources to assist states and their public and private local early childhood programs in preventing and severely limiting expulsions and suspensions in early learning settings.”27 The aims included administering policies free of bias and discrimination; setting goals and using data to monitor progress; highlighting workforce competencies, evidence-based interventions, and early childhood mental health consultation; encouraging behavioral screening and follow-up; and identifying free resources for families. In 2015, Head Start proposed rule changes, severely limiting suspensions and prohibiting expulsions and required programs to engage a mental health consultant.15
Evidence is emerging that early childhood mental health services can reduce behaviors leading to expulsion.25 Two randomized trials of Connecticut’s early childhood consultation program produced significant decreases in teacher-rated challenging behaviors and a reduction in challenging behaviors in toddlers in infant and toddler child care centers.19,26,28 Gilliam measured implicit bias in a video experiment and demonstrated that the race of the teacher plays a role in the outcome in misidentifying misbehavior in Black male students and suggested that video interventions with child care staff can improve awareness and reduce implicit bias.29,30 RECAST (Racial Encounter Coping Appraisal and Socialization Theory) is a specific training program that provides racial literacy education and coping strategies for white teachers working with children of color in a number of large urban school systems in the United States.31 Other strategies include professional development with antiracism training and improved racial diversity of the staff.29 Gilliam has published family narratives that document (1) the need for teachers to understand the impact of trauma and adversity on the parents of young males of color; and (2) the need to support these families and not inappropriately stigmatize, label these students as problems, and expel them.21 Systemic racism unfairly targets these young black male students.
Efforts at Remediation at the Federal and State Levels
Given the detrimental effects of preschool expulsion, recommendations for remediation of this problem have been proposed. These recommendations have come from a variety of organizations, including federal agencies such as the US Department of Health and Human Services. Federal support has primarily come in the form of policy statements, federal grants, and technical assistance programs to states. The recommendations from federal agencies target not only early childhood programs but also state policies and practices. For instance, under the Child Care and Development Block Grant Act of 2014, states were required to meet new eligibility requirements that included funds for implementation of effective behavior management strategies and positive behavior interventions and to disseminate educational materials on these positive behavioral interventions and supports to providers and the public.32 Additionally, the Office of Special Education and Rehabilitative Services issued a “Dear Colleague” letter in 2016 that emphasized the requirement for behavioral supports to preschool students and students with disabilities who need them.33 A Dear Colleague letter is official correspondence used to inform members of the Congress or Senate and/or make statements on policy.
The US Departments of Education and Health and Human Services have funded Technical Assistance Centers in some states to implement the Pyramid Model for Promoting the Social Emotional Competence of Infants and Young Children. Funding was provided by the Preschool Development Grant at the University of Oregon in partnership with the University of South Florida and the University of Colorado Denver.32,34 Randomized trials have demonstrated that use of this model is associated with improvement in children’s social skills and challenging behaviors.35
Perhaps the most powerful federal response was the initial US Department of Health and Human Services policy statement on expulsions in early childhood settings.27 This statement encouraged early childhood programs to (1) develop and clearly communicate preventive guidance and discipline practices; (2) develop and clearly communicate expulsion and suspension policies; (3) access technical assistance in workforce development to prevent expulsion and suspension; (4) set goals and analyze data to assess progress in reducing expulsions; and (5) make use of free resources to enhance staff training and strengthen family partnerships. The US Department of Health and Human Services followed up their initial 2014 statement on preschool expulsion with a 2016 Spotlighting Progress in Policy and Supports statement that recommended the following:
States, schools, and early childhood programs should establish developmentally appropriate expulsion and suspension policies and implement these without bias.
Programs should invest in teacher and caregiver training to build skills and knowledge that would prevent preschool expulsion.
Staff should have access to support from specialists, such as early childhood mental health consultants and developmental-behavioral pediatricians.
Partnerships between teachers and families should be fostered.
Universal developmental and behavioral screening programs should be implemented.
Specific goals should be set to reduce and eventually eliminate preschool expulsion with appropriate tracking of data.36
Opportunities for Remediation in Early Childhood Programs
Gilliam has proposed that rather than expelling young children, programs should assess the behavioral supports necessary for these children or transition them to more appropriate programs.12 He proposed that early childhood teachers should have regular access to early childhood mental health consultation. In addition, he addressed the working conditions of preschool and child care providers, suggesting that early childhood programs enforce student-to-teacher ratios of no more than 10 to 1 and that teachers work reasonable hours with breaks away from children to decrease job stress. In another study, Gilliam noted the need for mental health consultation not only for children but also for teachers.16
The importance of early childhood mental health consultation is the focus of a statement published by Zero to Three in 2011.37 The Center on Enhancing Early Learning Outcomes recommended expanding early childhood mental health services, in addition to providing professional development and training resources for teachers, promoting children’s social and emotional development, assisting with effective classroom management, and developing consistent data collections systems on preschool expulsion and suspension.38 The Center for American Progress has proposed the following recommendations: prohibiting suspension and expulsions in early childhood settings, developing alternatives that proactively address children’s emotional and behavioral needs, investing in teacher professional development, empowering teachers with tools to fight implicit bias, and promoting meaningful family engagement.39
In summary, there seems to be agreement that clear policies on preschool suspension and expulsion should be developed with subsequent tracking of data and the goal of eventually eliminating these practices. In addition, training of teachers and child care providers is essential to managing behavior, recognizing implicit bias, and promoting social emotional regulation in preschoolers. Supports for teachers in the form of early childhood mental health consultants and improved working conditions are also needed. Family and caregiver partnerships are critical in developing alternatives to preschool expulsion and accessing appropriate resources.
Pediatricians have a role in preventing preschool expulsion. Many of the strategies used by pediatricians to promote school readiness are also ones that help avoid preschool expulsion.40 By the nature of their relationships with families, pediatricians encourage positive parent-child interactions from an early age. They can inform parents and preschool teachers about the role of relationships and experiences in early child brain development and serve as models for appropriate caregiver and child interactions. Pediatricians can identify differences in temperament that could be potentially problematic and encourage enjoyable parent and child activities such as reading and playing together. Pediatricians often serve as guides for disciplinary strategies that are positive rather than punitive, and they provide resources and supports for parents who face challenges finding quality child care and managing their child’s difficult behaviors. Pediatricians identify through surveillance and screening children who have developmental and behavioral concerns and who may be at increased risk for preschool expulsion; these children can then be referred to early intervention services or for diagnostic evaluations by mental health providers including developmental-behavioral pediatricians. For children with developmental disabilities, pediatricians can provide guidance in interpreting the child’s behavior in the context of the child’s communication and adaptive abilities and address any physical concerns that may be contributing to negative behavior and help provide resources; for example, a care plan with daily routines may help the family and child communicate with child care providers. Pediatricians can also screen for toxic stressors and social determinants that may predispose children to behavior and emotional problems if not addressed (mental illness in a parent, food insecurity, history of trauma, etc). Pediatricians can also provide guidance in selecting early childhood programs and encourage communication and collaboration between parents and child care providers and educators. They may be able to consult with child care providers regarding at-risk child behaviors and suggest appropriate mental health resources to the preschool teachers. Recent studies have shown that integrated health care in primary care settings can be effective in developing strategies that prevent early childhood expulsion.41 Pediatricians often serve as health care consultants to child care programs. Public and private insurance should pay pediatricians for appropriate screenings, integration of behavioral health services, and management and consultation to early childhood programs.
In addition, pediatricians can advocate for safe and nurturing communities and quality child care and early education programs. They need to be aware of resources in their community that will help support children and families. Pediatricians can become involved in efforts to reduce the impact of poverty and racial and cultural bias by supporting programs such as visiting nurses, universal preschool, income support, antibias training, and widespread access to health care. Pediatricians can collaborate with others at a community, state, and national level to support initiatives that will prevent preschool expulsion, recognizing that this phenomenon represents much larger concerns of inequity in early childhood opportunities and the need to address social emotional regulation and development effectively.
The recommendations below provide guidance to pediatricians and community organizations and outline policies to advocate for at local, state, and federal levels.
For Pediatricians at the Practice Level
Assist families in fostering positive parent child relationships and help promote a developmental approach to behavior management.
Screen for socioeconomic determinants and adverse events that put children at risk for developmental and behavioral dysregulation and provide resources for prevention.
Offer and encourage parent or caregiver education on social emotional development and the adverse effects of insecure attachment, toxic stress, and trauma on early brain development.
Partner with families to create developmentally appropriate plans that will address behavioral and emotional issues.
Partner with families of children with developmental disabilities to develop care plans which will assist preschool teachers’ understanding of the child’s specific needs, preferences, communication abilities, and daily routines.
Help coordinate care of children with developmental and behavioral problems and seek appropriate subspecialist consultation (developmental behavioral pediatrics, child neurology, child and adolescent psychiatry, etc); these subspecialists may then also liaison with preschool teachers.
Use the pediatric medical home team (care coordinator, integrated behavioral health provider) to consult with families whose children are at risk for expulsion and work with their child care provider to find more supportive and therapeutic alternatives.
Identify children with developmental and behavioral problems in a timely fashion through both screening and surveillance and refer for evidence-based treatments.
For Pediatricians at the Community Level
Publicly address implicit bias within preschool and child care settings through specific trainings in collaboration with antiracism resources in the community.
Provide consultation to child care providers about at-risk child behavior. Use integrated behavioral health providers to expand the health care consultant role with child care centers.
Identify available resources for children and families locally and regionally (parent support groups, early child mental health providers) and facilitate access to these services.
Encourage collaboration among community partners to develop programs and environments that promote childhood resilience (opportunities for library reading groups, playful learning, safe playgrounds and parks, parenting groups, etc).
For Pediatricians at the Regional and National Advocacy Level
Advocate for national quality regulations for early childhood programs that replicate the 2015 Head Start federal guidelines that prohibit preschool expulsion.
Advocate for quality early childhood programs and early childhood mental health services, including antiracism training to prevent implicit bias and structural racism.42
Support initiatives to end systemic racism and efforts to provide behavioral health and educational programs that will equalize the playing field for children of color. The iceberg model is a systems thinking theory of change model that can provide guidance for multiple levels of intervention.43
Participate in antiracist or implicit bias sessions, including those offered by the AAP, to increase self-awareness and facilitate understanding of the behavior of others.
Advocate for appropriate payment codes that will compensate pediatricians for their consultation and advocacy services.
Work with payers for adequate payment of integrated behavioral health care, care coordination, early child care mental health consultation, and health care consultation to child care programs and acknowledge the need for shared communication between providers.
Develop appropriate billing codes that recognize behavioral precursors to specific Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnoses and provide payment to pediatricians for early intervention and preventive measures.
P. Gail Williams, MD, FAAP
Michael Yogman, MD, FAAP
Walter Gilliam, PhD
Council on Early Childhood Executive Committee, 2019–2020
Jill Sells, MD, FAAP, Chairperson
Sherri Alderman, MD, FAAP
Nerissa Bauer, MD, FAAP
Andrew Hashikawa, MD, FAAP
James Guevara, MD, FAAP
Dipesh Navsaria, MPH, MSLIS, MD, FAAP
Bergen Nelson, MD, FAAP
Georgina Peacock, MD, FAAP
Amy Shriver, MD, FAAP
Jennifer Takagishi, MD, FAAP
Douglas Vanderbilt, MD, FAAP
Katiana Garagozlo, MD – AAP Section on Pediatric Trainees
Ami Gadhia – Child Care Aware
Dina Lieser, MD, FAAP – Maternal and Child Health Bureau
Lucy Recio – NAEYC
Zero to Three
Florence Rivera, MPH, CAE
Committee on Psychosocial Aspects of Child and Family Health, 2019–2020
Arthur Lavin, MD, FAAP, Chairperson
George LaMonte Askew, MD, FAAP
Nerissa S. Bauer, MD, MPH
Evelyn Berger-Jenkins, MD, FAAP
Thresia B. Gambon, MD, MBA, MPH, FAAP
Tiffani Jenae Johnson, MD, FAAP
Douglas P. Jutte, MD, MPH, FAAP
Arwa Abdulhaq Nasir, MBBS, MSc, MPH, FAAP
Rachel Shana Segal, MD, FAAP
Lawrence S. Wissow, MD MPH, FAAP
Rebecca A. Baum, MD – AAP Section on Developmental and Behavioral Pediatrics
Sharon Berry, PhD, LP – Society of Pediatric Psychology
Edward R. Christophersen, PhD, FAAP – Society of Pediatric Psychology
Kathleen Hobson Davis – Family Liaison
Norah L. Johnson, PhD, RN, CPNP-BC – National Association of Pediatric Nurse Practitioners
Abigail Boden Schlesinger, MD – American Academy of Child and Adolescent Psychiatry
Amy Starin, PhD, LCSW – National Association of Social Workers
Carolyn McCarty, PhD
Robyn Wheatley, MPH
Drs Williams and Yogman both conceptualized the statement and drafted revisions, revised the initial manuscript, approved the final manuscript, and agree to be accountable for all aspects of the work. Contributor: Walter S. Gilliam, PhD.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.