f t 9 !

Fostering Lifelong Health Begins at Birth

Dr. Paula Braverman
By Dr. Paula Braverman

Too Small to Fail advisory council member Paula Braveman, MD, MPH, is a professor at the University of California, San Francisco School of Medicine.  She is the Director of the Center on Social Disparities in Health, and an expert on how social factors influence health, particularly maternal and infant health.

What happens in the first few years of life can shape a lifetime.  For some time we have known about this in relation to education: School readiness predicts school performance, which predicts educational attainment.

And now we have evidence that this also applies to health:  One of the most powerful influences on health across one’s entire life is what happens from birth to age five.  Research has shown that children’s mental, emotional and physical development in early childhood is strongly influenced by their early experiences. And that, in turn, influences their health throughout their lives. Where and how children live, learn and play — at home, in their neighborhoods, childcare settings and schools — is crucial; many people will probably be surprised to learn that medical care plays a relatively minor role in early childhood development, in most cases.

Healthy communities begin with thriving children

As research director for the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, I have spent several years listening to educators, child development experts, urban planners, experts on work, business leaders and others, as well as reviewing the scientific research.  In researching ways to improve the health of all Americans, the Commission heard compelling evidence of the importance of non-medical factors — the so-called “social determinants of health.”  And it issued recommendations, both in 2009 and this year, identifying factors beyond medical care that can improve health and reduce health disparities.

The Commissioners heard such strong evidence on the importance of early childhood development for health throughout life that they highlighted the need to create conditions in early childhood that will foster lifelong health.  They recommended making high-quality early childhood development programs — those proven to promote cognitive, emotional and physical development — accessible to all children, particularly low-income children, for whom it makes the most difference. 

The business and finance sectors have realized this for some time.  The case for early childhood development as a wise business investment has been so strong that organizations such as the Committee for Economic Development, PNC Financial Services Group, the Business Roundtable and prominent economists have called for universal preschool programs.

What works:  talking and reading narrows the “word gap”

Sometimes when we study health problems, we have limited evidence of what concrete solutions will work — or the solutions may not appear within reach.  But early childhood development is an area where we know a great deal about what works.  There is much we need to learn, and we should keep looking for the most effective and efficient approaches.  But we know enough now to be confident that when we invest in well-tested strategies for promoting young children’s development, we are investing in both the health and the economic future of our whole society.

We know that high-quality center-based early childhood programs (such as the best Early Head Start programs) can help close the word gap.  By the age of 4, children of affluent parents have heard more than 30 million more words than children in poor families.  And the word gap is accompanied by a large gap in school readiness, with lifelong consequences. Closing the word gap can give low-income kids a fighting chance to succeed in school, which is crucial for their –and our society’s — health and economic futures.

The gaps develop very early. Researchers at Stanford have identified a language processing gap among babies that correlates with social class and appears in the earliest months of life. And we have learned the importance of the words a baby hears.  Even if a child doesn’t understand the words initially, just hearing them seems important, as well as the tone in which they are said. Not only do babies of low-income parents hear far fewer words, but they are much more likely to hear negative words and discouragement than babies of affluent parents. The latter are more likely to hear praise and words of encouragement, which significantly affects children’s behavior and learning. The word gap is not just about the quantity of words heard, but also the quality of that verbal interaction.

Our knowledge of brain development has taken great leaps in the past two decades. During the first five years of life, the brain is developing at an amazingly fast rate — almost like no other period in life. Researchers have observed differences in young children’s brain architecture and brain circuitry that can have serious consequences for their health later in life — for example, altering their response to stress, including their immune response — corresponding to whether they have experienced chronic poverty. We now know that child poverty can change children’s biology, even affecting whether favorable or unfavorable genes are expressed or suppressed.

We now know that by intervening during the earliest years, it is possible to have a powerful impact.  We also know that those interventions will not only determine whether a child has a chance to succeed economically, by preparing her or him for school, but also can lessen the child’s likelihood of developing diabetes, heart disease, or depression in adulthoodA growing body of research has tied health outcomes in adulthood to experiences in childhood, particularly in the earliest years.

Pre-school services are not enough.  To succeed in giving all children a chance to develop their potential, we also need to support parents so they can interact with children in a way that promotes brain development.  We need initiatives that will help parents provide a secure, nurturing and stimulating atmosphere at home.  The 2014 Robert Wood Johnson Foundation Commission’s recommendations included the need to “help parents who struggle to provide healthy, nurturing experiences for their children,” also addressed in the 2009 recommendations. 

Supporting caregivers means addressing poverty and illiteracy

We need to encourage parents to talk to and read to their children. Young children spend more time at home than at center-based services.  So children’s interactions with parents and other caregivers are very important. 

But many parents are struggling with poverty; providing shelter and food for their children may be their most immediately pressing priorities.  More than one out of five U.S. children lives in povertyOne in every 6 U.S. households with children is food insecure, often not knowing whether they will have their next meal because of lack of money.

Financial hardship creates stresses for parents and children with serious consequences.  The current minimum wage does not lift a one-wage-earner family (or some two-wage-earner families with multiple dependents) out of poverty. We need to think long and hard as a society about how we can help children living in families that are desperate economically.  It seems unrealistic to expect that parents who are in desperate economic conditions will be able to read to their children on a regular basis, or to be as nurturing and encouraging as they want to be.  Recognizing the lifelong impact of childhood poverty on health and well-being, other affluent nations have created and sustained social policies that have drastically reduced child poverty.  These nations have healthier populations than we do, and that may be related, at least in part, to how they protect young children.

And some parents are unable to read to their children because they themselves cannot read.  The United States has one of the lowest rates of adult literacy among affluent countries.  One in seven adult Americans is not literate. And that understates the problem, because many more have limited literacy.

Finally, we also need policies that can reduce caregivers’ work-family conflicts. A non-livable minimum wage can require parents to work multiple jobs, increasing stress for them and their children.  And lack of affordable childcare threatens many parents’ ability to keep a job.

We must promote universal pre-school, and encourage all parents to read and talk to their children and interact supportively with them.  But that will not be enough, particularly for parents who are struggling to keep a roof over their children’s heads and put food on the table.  We also must address child poverty and adult illiteracy, and we need policies to reduce serious conflicts between work and family. 

We need a broad approach to stimulating early childhood development that includes, but goes beyond, promoting early childhood programs like Early Head Start. Let’s urge parents to read to and encourage their children. But current evidence tells us that to have large and sustained effects, we need to address broader issues of poverty and the inadequate safety net for those who are raising our next generation.