School readiness: Why early intervention is key

Pamela C High, MD

Early brain and child development

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5 R's of nurturing brain development

If there is one essential component that influences the trajectory of a life, it is the presence of an engaged and loving adult during early childhood. “A parent or caregiver who is nurturing and invested in their young child is crucial to that child’s cognitive and social-emotional development, and this impact lasts a lifetime,” says Pamela C. High, MD, professor of Pediatrics, Warren Alpert Medical School, Brown University, and director of the Division of Developmental-Behavioral Pediatrics, Rhode Island Hospital, Providence.

In her talk at the 2017 American Academy of Pediatrics (AAP) National Conference and Exhibition titled “School readiness: Beyond the basics,” High emphasized the importance of the early years in an infant’s life as setting the stage for building the capacity and ability to learn.¹ “The science behind early childhood development and the science of education is all the same science,” she says.

Although genetics provide the blueprint for brain development, epigenetics-or the influence of the environment on reading the genetic code-is equally if not potentially more important to brain development, according to High.

“The environment impacts the way the genetic code is read, and it changes the brain structure,” she says. “It changes the physiology of the brain and this impact is present from the earliest moments of development.”

The most active period of brain development is the first 1000 days of life (see “Early brain and child development (EBCD): The first 1000 days”).² As important as this time is, High stressed in her talk that early childhood should be thought of as a “sensitive” period rather than a “critical” one. It is a time of opportunity, when environmental factors most easily influence early brain and child development. However, if positive opportunities are lacking during this “sensitive time,” the developing brain retains some plasticity and is capable of recovery if the environment becomes more supportive. In this way, early experiences shape a child’s life course trajectory.

The rate of achievement of developmental stages during the life course signal if a child is developing as expected or if that development is delayed or restricted.

Along with educating new parents about the important developmental needs of infants and children, pediatricians also play a pivotal role in helping to identify those children for whom early intervention is needed to address any developmental delays.

In her talk, High discussed all these issues as they relate to a child’s readiness for school. As indicated by the title of the talk, she dipped deeper into issues beyond the basics of school readiness to provide pediatricians with a foundational understanding of the influence of early brain development on the life course of a child. After describing the importance of genetics and epigenetics on school readiness and life course trajectories, she summarized the life course perspective underlying school readiness and its implications for maternal and child health. A major focus of her talk was on providing pediatricians with evidence-based strategies to improve a child’s school readiness and life course, describing these strategies as opportunities for pediatricians to engage as advocates for the children in their care.

Life course perspective

A life course perspective for school readiness highlights that there is a typical pattern of development for children that involves acquisition of more knowledge, skills, abilities, and mature behaviors as a child ages. A positive relationship between infant and caregiver is essential for the initiation of healthy development.

The bond formed between mother and child lays the groundwork for all future development, and is not “just touchy-feely stuff,” says High. Building on that essential relationship, a child develops increased language skills and greater capacity for emotional regulation and socialization skills because of the trust and security he or she has experienced. Appropriate development at each stage decreases the likelihood of behavioral problems.

Development is lifelong, and each stage of development provides support for the next, says HIgh. Many factors can hinder a child from moving along this trajectory toward increasing developmental skills, cognition, and emotional regulation. Among these are early experiences that change the brain’s architecture, such as early and prolonged, unmitigated, or toxic stress. These can lead to lifelong problems including poorer health-related quality of life, more depression, and more chronic illness and disability.

Educating mothers and other caregivers on the importance of each developmental stage on the life course trajectory is crucial to help a child reach appropriate development at each stage. For children whose development is delayed, early intervention is crucial.

“For many children, there is a significant opportunity to enhance their development with many interventions so they can achieve their optimal developmental trajectory,” says High. “That is what the life course model is about.”

Evidence-based strategies to improve school readiness

One of the key ways to enhance school readiness for children, particularly those at risk of developmental delays, is to start education early-meaning prekindergarten (pre-K). High cites data from 3 sentinel pre-K programs (HighScope-Perry Preschool Study [Ypsilanti, Michigan]; Abecedarian Project [Chapel Hill, North Carolina]; and Child-Parent Centers [Chicago, Illinois]), all with well-matched control or comparison groups and follow-up for up to 40 years, showing impressive short- and long-term benefits (Table 1).¹ From these data, economists calculate a 15% return on investment for high-quality preschool for at-risk children.

High emphasizes that pediatricians need to understand the importance of early education and to convey this to parents, particularly to those with children at risk of developmental delays.

In addition, she underscores the importance of formal, validated developmental and autism screening, recommended by the AAP since 2003, to identify children with developmental challenges who quality for early intervention.

Early intervention is for children aged 3 years and younger who show significant delays in cognition, hearing/visual abilities, communication skills, adaptive skills, and social-emotional skills. According to High, 2.95% of children in the United States in 2015 were enrolled in services that provided early intervention either in the home or in the community.

Table 2 lists a number of evidence-based early childhood intervention services offered in the home. Relatively new, home-based programs, often referred to as Maternal Infant Early Childhood Home Visiting programs, exist in every state, says High, although not in every town, and all can benefit child development.³

For example, she said that the Nurse-Family Partnership program, designed for first-time mothers who are enrolled by the 28th week of their pregnancy and continue in the program until their child is aged 2 years, has shown strong effectiveness in reducing child abuse and neglect by 48%, reducing visits to the emergency department for accidents and poisonings by 56%, and reducing behavioral and intellectual problems by 67%.⁴

Other evidence-based parenting programs designed to promote social and emotional competence and prevent behavioral problems include Incredible Years, Family Check-Up, Triple P, and Parent Child Interactive Therapy (PCIT).

These training programs begin by promoting healthy parent-child relationships, often including teaching parents how to participate in child-directed play and “times in.” As described by the Incredible Years Parenting Pyramid (Figure 1), the next steps involve coaching the child around social-emotional expression and persistence at task to improve their language and social-emotional regulation. Parents are also taught how to use praise effectively and how to provide spontaneous rewards and incentives. Children learn trust and security through maintenance of consistent routines and appropriate limit setting.

To address behavioral problems, parents are taught how to use ignoring and redirection first, and then limited time-out for the child to calm and regain composure. Most of these skills are taught with groups of parents who view videos and practice these techniques at home before reporting back to their peers. Table 3 lists websites providing more information on these programs.

Along with educating parents on the importance of pre-K schooling and early intervention programs, pediatricians also can offer guidance on how parents can help their children reach specific developmental stages. Figure 2 shows strategies to support and improve developmental trajectories in young children stratified by their risk for delay. All children benefit from access to high-quality healthcare.

Table 4 provides a list of behaviors parents should be encouraged to engage in with their children. High underscores the need to enjoy talking, singing, and reading with young children every day and to limit access to digital media. As indicated at the end of the table, this is because of the adverse effects of too much screen time on the developing brain, including its association with obesity, sleep problems, attention-deficit/hyperactivity disorder (ADHD), and aggression.¹ Too much screen time also takes away from talking and building relationships, High says.

Another evidence-based model that High encourages pediatricians to employ is the Reach Out and Read model that promotes early literacy by enhancing early language skills and nurturing early relationships.^5,6 “It is an ‘essential component’ of pediatric primary care according to the AAP,” she says. (For more information, see the AAP website Books Build Connections Toolkit at www.aap.org/en-us/literacy/Pages/default.aspx.)

In addition, High encourages pediatricians to educate parents on the availability of free educational tools available via websites, smartphones, and apps (Table 5).

Finally, High refers pediatricians to a simple guide for parents about habits they can cultivate to help nurture their child’s brain (see “5 R's of nurturing brain development”).⁷

References:

1. High P. School readiness: Beyond the basics. F3005. Presented at: American Academy of Pediatrics National Conference and Exhibition; September 16-19, 2017; Chicago, IL.

2. American Academy of Pediatrics. The First 1,000 Days: Bright Futures Examples for Promoting EBCD. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/EBCD/Documents/EBCD_Well_Child_Grid.pdf. Accessed June 29, 2018

3. US Health Resources and Services Administration. Maternal and child health: Home visiting. Available at: https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview. Accessed June 29, 2018.

4. Nelson, CA. Nurse-Family Partnership. In: Committee on Integrating the Science of Early Childhood Development; Shankoof JP, Phillips DA, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academies Press; 2000. Available at: https://www.nursefamilypartnership.org/wp-content/uploads/2017/07/NFP_Overview.pdf. Accessed June 29, 2018.

5. Council on Early Childhood, High PC, Klass P. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):404-409. Available at: http://pediatrics.aappublications.org/content/pediatrics/early/2014/06/19/peds.2014-1384.full.pdf. Accessed June 29, 2018.

6. Reach Out and Read. Mission and model. Available at: http://www.reachoutandread.org/about-us/mission-and-model/. Accessed June 29, 2018.

7. American Academy of Pediatrics. Early education-The 5 R’s. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/EBCD/Pages/Five.aspx. Accessed June 29, 2018.