The Intersection of Health and Education to Address School Readiness of All Children

A significant barrier to collaboration between those in ECE and pediatrics is that shared ideas are discussed in different ways. We begin here by defining common concepts. In education, the academic achievement gap is defined as the difference on varying educational measures between subgroups of students (eg, race and/or ethnicity or socioeconomic status), allowing for disparities in the academic achievement of students across academic areas (eg, math, early reading ability, and third-grade reading levels) and nonacademic skills (eg, self-control) to be described.^39,–42 The term is further broken down into the “income achievement gap” (disparities in academic achievement between low-income and high-income students) and “racial and/or ethnic achievement gap,” including the "black-white achievement gap” (disparities in academic achievement between black and white students) and “Hispanic-white achievement gap” (disparities in academic achievement between Hispanic and white students). In this review, we default to the most specific terms possible to ensure clarity.

Multiple studies led to recognition of the academic achievement gap,^39,–42 with crucial contribution from the Early Childhood Longitudinal Study of a kindergarten class from 1998 into adulthood (Table 1).^43,44 The Early Childhood Longitudinal Study revealed racial and/or ethnic and income achievement gaps in math and early reading for black and white students, for Hispanic and white students, and for low- and high-income students.^24,45,46 

Racial and/or ethnic and income gaps in early childhood development exist before school entry and are referred to as the SR gap. Pediatrics and ECE generally overlap, and those in the fields define SR as a child’s optimal development in 5 similar domains^2,50,51 (Table 2) when compared with education researchers, who often assess 1 domain (eg, cognition) and less frequently consider SR as a whole.^52,–56 Finally, international public health fields include children’s SR and the parents’ and communities’ readiness for school.⁵⁷ As a result, there is no common language for defining, measuring, and discussing SR in collaborative work. On the basis of current definitions in the literature, we reconciled SR definitions and for the purpose of this review refer to SR as a child’s development across 5 domains: (1) cognitive development, (2) physical development, (3) language development, (4) social-emotional development, and (5) approaches to learning (Table 2).^2,50,51 

Studies reveal income SR gaps in approaches to learning such as self-control between low- and high-income children⁴ and racial and/or ethnic SR gaps in language and cognitive development between Hispanic and white students.^47,–49 SR gaps are consequential given that early academic skills are strong predictors of future academic success even when adjusting for ability and behavior,¹⁶ and SR gaps that are evident in kindergarten tend to persist throughout school.^58,–62 Some estimate that the black-white test score gap at the end of high school could be reduced by at least half if the gap were eliminated at school entry.⁶³ 

Although academic achievement and SR gaps are striking, improvements are also evident. Some academic achievement gaps narrowed.²⁴ For example, from 1998 to 2010, the black-white, Hispanic-white, and income achievement gaps in math declined despite recent increases in income inequality.²⁴ These changes correspond with improvements in early childhood experiences and alterations in parenting behaviors, particularly for lower-income children, with increases in books and reading in the home, access to educational games on computers, and interactions between parents and children during this period.⁶⁴ 

High-quality preschool programs help narrow the SR gap. Participation in preschool has increased over time because of substantial public investment through federal and state preschool programs, such as Head Start (HS).^65,–68 Although preschool enrollment increased for all groups from 1970 to 2010, a sizable gap remains between high- and low-income families in the percentage of children who are enrolled.⁶⁹ Today, only 54% of 3- and 4-year-old US children are enrolled in preschool,^70,71 and ∼2.5 million 4-year-old children lack access to publicly funded preschool programs.⁶⁷ Pediatricians must work with those in ECE and local communities to close that gap and provide parenting support to maximize early child development.^34,36 

There is limited research on how acute and chronic diseases impact young children’s early development and to what extent poverty further undermines development. In a 2005 review, Currie³⁸ summarized the existing evidence collected by researchers who explored how poor child health contributes to racial and/or ethnic and income SR gaps. In this section, we provide an update on the impact that neonatal and chronic illnesses have on early development, which is essential to the shared definition of SR (Table 3).

Children who are born prematurely or with prenatal and early life insults, including neonatal encephalopathy, cerebral palsy, and intrauterine drug exposure, are more likely to experience impairment in cognition, attention, and difficulty with learning later in life.^{38,72,–81,92,–94} Although specific developmental impairment varies by gestational age and neonatal conditions (Table 3), the most striking finding across conditions is that preterm and term children living in poverty are less likely to be ready for kindergarten, have less access to preschool, and receive less elementary school support than more advantaged peers who are born prematurely.⁷⁵ Despite factors such as respiratory distress syndrome, chronic lung disease, or intraventricular hemorrhage, the most important factor when determining if late-preterm, premature, low birth weight or very low birth weight infants are ready for school is if they live in poverty.^74,93,95 The evidence strongly suggests that intensive care coordination of developmental services, universal access to preschool, future school support, and antipoverty efforts can significantly close the SR gap in premature infants of low socioeconomic status,^38,73,75,93 and researchers articulate these as an arena of potential collaboration between the ECE and pediatric communities.

Children with chronic illnesses are at risk for poor social-emotional and cognitive development⁹⁶; conversely, our search revealed limited evidence that acute illness impacts early child development for SR. Many common chronic illnesses, such as obstructive sleep apnea, dental caries, allergies, asthma, sickle cell anemia, attention-deficit/hyperactivity disorder, malnutrition, and obesity, can impact a child’s early development across multiple SR domains (eg, social-emotional, cognitive, and language), leading to decreased early SR and long-term implications for academic achievement (Table 3).^{38,84,–91,97} In particular, chronic otitis media and chronic respiratory disease put children at higher odds of being developmentally vulnerable across multiple developmental domains at school entry.^82,–85 Urban preschool children with “asthma that limits daily activity” have lower SR scores, and parents are more likely to report that their children need help in school.⁸⁵ Pediatricians who care for children with chronic illness are responsible for more than their physical development because these conditions appear to impact multiple domains of development that are crucial to SR.

During our review of the child health literature, an important theme emerged: child poverty is independent and additive because it consistently undermines early child development. Children living in poverty face “double jeopardy” because poverty is a risk factor for poor SR,² and being poor increases the likelihood of chronic health problems.^20,38 Chronic illnesses, such as lead poisoning, asthma, dental caries, and malnutrition, continue to disproportionately impact poor children despite improved access to health care.^20,38,98 The interactions between poverty, chronic illness, and child development require further transdisciplinary research.

Early childhood experiences differ across income groups. For example, for children aged 0 to 2 years, those who are not poor are more likely than children who are poor to experience warm parenting practices (hugging) than punitive parenting practices (spanking).⁹⁹ Children who are not poor from birth to 2 years old also have greater access to children’s books and are more likely to be read to than their poor counterparts.^99,–101 In their well-known study, Hart and Risley¹⁰² found that young children of parents who receive public assistance heard fewer than one-third as many words per hour as higher-income children, and the words were more likely to be negative.^{18,100,102,–107} 

Similarly, substantial differences exist in spending on child care, preschool participation, and access to educational resources, such as a home computer.¹⁰⁸ It is important to note that lower-income families value SR^18,109,110 but face innumerable financial, informational, and cultural barriers that limit access to high-quality child care, education,¹¹¹ and preschool.¹¹² For example, in 2010, ∼80% of 4-year-olds from families in the top one-fifth of the income distribution attended preschool compared with ∼60% of those in in the bottom one-fifth.⁶⁹ These early childhood differences have significant consequences because children who experience responsive and stimulating care tend to score higher on assessments of physical, social-emotional, and cognitive development (literacy and numeracy) than those who do not.^99,113,114 

Gaps in early childhood development and SR stem from multiple sources. Researchers in both education and pediatric literature report positive relationships between child development and a range of early childhood experiences, such as breastfeeding,¹¹⁵ rich language environments,¹¹⁶ access to educational resources such as books,¹¹⁷ and book reading.^118,119 There is extensive evidence that the quality of verbal interactions between parents and children during play, reading, and daily routines improves child development for SR.^{100,102,104,–107,120,121} Maternal depression, stress,^122,–124 and harsh parenting¹²⁵ are associated with negative child outcomes. Although parenting programs have had mixed results,¹²⁶ some interventions (including nurse home-visitation programs,^11,14,15 family literacy courses offered by child care centers and elementary schools,^127,128 and text-messaging programs¹²⁹) have improved parenting practices and led to improved child outcomes.

ECE programs affect child development: preschool experiences have positive effects on children’s cognitive development.^130,131 In contrast, informal care (provided by family and friends) tends to be lower in quality and lead to lower SR.¹³² The most famous preschool intervention study, the HighScope Perry Preschool study,¹³³ had positive effects even well into adulthood. Researchers in a meta-analysis of studies between 1967 and 2007 estimate a treatment effect for preschools on achievement outcomes of approximately one-third of an SD.¹³⁴ Preschool effects appear to be particularly strong for children from underserved backgrounds.¹³⁵ 

Developmental surveillance and screening is an important part of routine pediatric care, and although related, it is distinct from SR screening in schools and clinics.^2,35 The American Academy of Pediatrics and Bright Futures outline universal developmental surveillance for each well-child check in language and gross and fine motor domains with supplemental screening tools at certain ages (9 months, 18 months, and 2.5 years) to identify delays.² Tools commonly used for general development include the Ages and Stages Questionnaires, the Parents’ Evaluation of Developmental Status, and The Survey of Well-being of Young Children; tools used for autism spectrum disorder include the Modified Checklist for Autism in Toddlers, Revised, with Follow-up (known as M-CHAT-R/F); and for psychosocial screening, the Survey of Well-being of Young Children, the Parents’ Evaluation of Developmental Status, and the Ages and Stages Questionnaires are used from 0 to 5 years of age.² The goal in early delay identification is to connect children and families with community-based services, such as early intervention programs, home visitation programs, HS, and school-based special education programs, as soon as possible to maximize each child’s learning potential.^2,35,136 Using a single developmental screener for diagnosis, special education placement, or delaying school entry runs the risk of misclassification. Using multiple screeners reduces this risk.^136,137 

Although it is clear that children enter kindergarten with a range of SR skills, many school systems do not track incoming skills or skill development. Questions remain about how schools should assess students at kindergarten entry¹³⁸ and how these Kindergarten Entry Assessments (KEAs) can be used to inform school, clinic, and community initiatives to improve SR gaps. States and school districts employ a wide range of KEAs, from parent intake forms to informal teacher observations or checklists and formative assessments.¹³⁹ In 2014, >29 states were engaged in the development and implementation of various KEAs through federal grant programs, such as Race to the Top–Early Learning Challenge. The decentralized data present challenges because they do not allow for comparison across localities nor evaluation of programs or practices. Moreover, they are rarely available for community partners, such as the pediatric system, because of privacy restrictions.¹⁴⁰ Although the evaluation of KEAs are underway to determine the long-term benefits for students, teachers, school districts, and states, there is no overarching effort to share data across the fields.

Like school system KEAs, efforts to assess SR in pediatric clinics have been underway for decades,^141,–145 yet no single SR screener has emerged as a comprehensive, validated, culturally sensitive tool. Common tools range from simple methods (the “Draw-a-Person” test¹⁴⁶) to more complex screeners, such as the Kaufman Assessment Battery for Children test, McCarthy Scales of Children’s Abilities, Preschool Readiness Experimental Screening Scale, and the Bracken School Readiness Assessment.^{141,147,–149} Many are heavily focused on cognitive and motor skills (eg, counting, and drawing a circle) rather than social emotional skills, which are equal if not better predictors of a child’s kindergarten success.^2,150,–152 Barriers to office screening include a lack of validated multidomain tools available in multiple languages; time for administration and scoring; a structured clinic system to provide parents with feedback and activate requisite referrals; and attendant reimbursement structures. Accurate SR assessment requires the integration of screening tools with parent perspectives, preschool teachers, and the child’s social situation to best capture the child’s strengths and areas in which to intervene.^2,35,141 Although pediatricians are integral to this work, it requires a strong partnership with community-based early childhood systems. Recent national efforts, such as Help Me Grow, provide states with a model to leverage existing resources to ensure that communities identify vulnerable children, link families to community-based services, and empower families to support healthy child development.^153,–155 Overall, although both schools and clinics have a long history of using a wide range of assessments of children’s social emotional and cognitive development at kindergarten entry, a standard of practice and structural changes are needed in both settings.

The combination of high trust^{31,–33,156,157} and near-universal access to 0- to 5-year-old children gives pediatricians an opportunity to address threats to optimal early childhood development (presented in Section 1), particularly in the most disenfranchised communities.^103,104,158 On review of existing clinic-based SR interventions, we found interventions target the early educational gaps summarized in Section 1: parenting practices, verbal interaction, book sharing, and preschool access. In this section, we highlight the lessons learned from current interventions and provide an update on emerging models.

Review of existing evidence-based SR interventions (fully or partially clinic-based) targeted 3 distinct outcomes that are essential to SR (defined in Table 2): parent-child interactions, social-emotional development, and language development. Parent coaching improves parent-child interactions (Video Interaction Project [VIP], Building Blocks, and HealthySteps), behavioral parent training improves social-emotional development (the Triple P Positive Parenting Program, Incredible Years, and Help Me Grow), and early literacy promotion improves language development, daily reading, and access to books at home (Reach Out and Read [ROR], Little by Little School Readiness Program, Book Start, Let’s Read, City’s First Readers, and Bright Beginnings). Because in-depth descriptions of these programs exist elsewhere,¹⁵⁹ we summarize the key component(s) below.

Although distinct in design, both the VIP and HealthySteps provide longitudinal, individualized 1:1 interactions between the parent(s) and a nonclinician provider to enrich parent-child interactions, such as reading, discipline, and daily parenting practices.^158,160 After recurring, guided parent-child interactions in the clinic, VIP improved infant stimulation and parent reading,¹⁵⁸ whereas HealthySteps improved positive parenting practices around discipline and sleep and increased access to services.¹⁶⁰ The 1:1 interaction appears to be essential because Building Blocks, which mailed home developmental materials and toys, had less impact on infant stimulation and parenting stress than did VIP.^158,161 Overall, in-person parent interactions with a nonclinician provider are an important feature for future interventions aimed at modifying parent-child interactions.

Recent meta-analyses reveal that 2 community-based behavioral parent training programs, the Positive Parenting Program and Incredible Years, improve child behaviors and parenting skills,^162,163 which in turn improves social-emotional development. The Incredible Years Series uses group visits with video reflection, whereas the Positive Parenting Program stratifies group visit size on the basis of parent need (eg, serious problem behaviors requiring individualized sessions). When these programs occur within a pediatric clinic, it allows health providers to refer, communicate, and support serious behaviors or family needs.¹⁵⁹ 

The evidence-based clinic intervention with the most widespread dissemination to promote early literacy is ROR, in which pediatric clinicians provide books and model developmentally appropriate reading practices to low-income patients.^164,–166 Evidence strongly supports that ROR increases parent and child book sharing, supports reading as a favorite activity, increases daily reading, increases the number of books at home, and promotes language development across English, Spanish, and non–English-speaking low-income children.^166,–169 Since 2000, there have been multiple calls to incorporate ROR into all high-risk clinics.^5,35,166 The key components of ROR have been successfully adapted in many settings: the Special Supplemental Nutrition Program for Women, Infants, and Children centers housing Little by Little; home visits with Book Start and 10 Books a Home; and community-wide campaigns to promote early literacy with City’s First Readers in New York City and Talk, Read, Sing across multiple communities (Oakland, CA, Tulsa, OK, Minneapolis, MN, and Miami, FL).^{159,170,–172} 

Several examples of child health systems in which families are directly linked to early education and education services exist. The first, a randomized trial in an urban pediatric clinic, improved HS enrollment via a computer-generated enrollment packet sent directly to HS (referral letter from a physician, physical examination, and immunization records) compared with providing parents with a list of HS phone numbers.¹⁷³ This approach resulted in higher HS attendance, a higher likelihood of being on a waitlist, and increased direct contact of families by HS.¹⁷⁴ This exemplifies how the clinic can bridge families and existing community resources. However, the reality of inadequate HS spots reduces this intervention’s impact. Second, library card distribution via clinic “prescriptions” are in the early stages of exploration.¹⁷⁵ The strength here resides in parents’ reporting libraries as a frequented SR community resource,^176,177 and library card ownership and use increase reading aloud by parents.¹⁷⁸ A feasibility study revealed library card distribution by pediatric providers to be easy to incorporate into the workflow¹⁷⁹; however, the link between card distribution and increasing library visits is not yet established. Third, a brief SR clinic appointment with a community health worker increased parent storytelling and library visits but needs further evaluation for generalizability.^30,180 Last, low-cost evidence-based text-messaging programs¹²⁹ empower preschool parents to promote SR, a “vaccine for SR,” so to speak. Once validated in a clinic setting, there is potential for widespread dissemination given the rapid and widespread adoption of text messaging from clinics to patients for other applications, such as appointment reminders.¹⁸¹ 

The near-universal, repeated, and trusted access to even the most disconnected families provides the scaffolding for pediatrics to elevate its role in supporting the early childhood system by putting forward a comprehensive framework, such as an “SR Clinic” designation. This echoes previous efforts to create change within medicine, such as the Baby-Friendly designation, which >500 hospitals carry.¹⁸² This voluntary accreditation would convey a type of practice that is focused on early childhood learning. Such a designation could be earned by (1) providing a range of evidence-based 0-to-5 educational interventions in the clinic (ROR, HealthySteps, and VIP) and (2) achieving high, population-based SR rates.

A second opportunity lies in leveraging technological advances: options that are scalable and sustainable include automatic HealthySteps referrals, library card distribution, and text-messaging systems. The ubiquity of HS and libraries, in addition to the rapid adoption of electronic health records, makes such an effort not a technological challenge but one of priorities. SR is foundational for educational success, and significant gaps in SR exist for our low-income families, contributing to the cycle of poverty. Pediatricians are well positioned and thus should move quickly to adopt best practices to give all kids the best chance to succeed.

A third innovation opportunity takes advantage of novel data capacity generated by using KEAs, allowing for linkages between the health and education sectors. Data from KEAs and educational outcomes could be used to drive and inform clinic, school, and community SR efforts on a hyperlocal level as well as align ECE interventions in both fields with shared outcome metrics. Important privacy concerns are governed independently through the Family Educational Rights and Privacy Act in education and the Health Insurance Portability and Accountability Act in medicine, requiring data sharing between the health and education systems to be thoughtful; nevertheless, the interoperability of data is an area of promise and rapid growth.¹⁸³ We suggest that these challenges are, again, not technologically insurmountable but require leadership and vision to overcome.

Finally, the promise in transdisciplinary work between the fields of education and pediatrics is fundamentally hindered by siloed funding. There are notable and visionary exceptions,^184,–186 but traditionally, extramural funding agencies and foundations solicit proposals from either the education or medicine field; thus, few opportunities exist to support innovative, transdisciplinary work. Ultimately, the sustainability challenge is health care financing, which cannot currently be used to reimburse providers for educational outcomes, although mechanisms to address this are being tried.^187,188 

In this review, we attempt to bridge the education and pediatric literature to describe the challenges of addressing SR, catalog current evidence-based solutions, and highlight the value of integrative work compared with a health or education perspective alone. In challenges, we found that a lack of shared language across the fields drives inconsistency in how SR gaps are addressed in practice and in research. In solutions, we see that clinics are implementing SR interventions that complement, but do not replace, the known effects of high-quality preschool on a child’s overall development. Finally, we share new opportunities for collaboration to scale and increase the impact of SR interventions, such as an SR Clinic designation linked to school performance, but identify privacy restrictions, limited data sharing across fields, and restricted funding as implementation obstacles.

The evidence from both education and pediatrics is clear: low-income children start school farther behind than their advantaged peers. There is great opportunity for transdisciplinary work between those in education and pediatrics to drive the implementation of evidence-based solutions and ultimately improve the lives of young children.

ECE

early childhood education

HS

Head Start

KEA

Kindergarten Entry Assessment

ROR

Reach Out and Read

SR

school readiness

VIP

Video Interaction Project

We acknowledge the Stanford University librarians, Nicole Capdarest-Arest and Christopher Stave, for their incredible help with the literature review.