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PAPER CONTRIBUTION D

The Healthy Development of Young Children: SES Disparities, Prevention Strategies, and Policy Opportunities

Allison Sidle Fuligni, Ph.D., and Jeanne Brooks-Gunn, Ph.D.1,2

In 1994, the federal government passed the Goals 2000: Educate America Act, which adopted into law six national goals for improving the education system. Foremost on this list was Goal 1: “By the year 2000, all children in America will start school ready to learn” (National Education Goals Panel, 1998). Now that the new millennium has arrived, examination of the status of young children entering school shows that we have fallen short of meeting this goal. In this paper, we explore some reasons that the nation is not appreciably nearer to

1  

Allison Sidle Fuligni, Ph.D., is a research scientist at the Center for Children and Families, Teachers College at Columbia University. Jeanne Brooks-Gunn, Ph.D., is a Virginia and Leonard Marx Professor of Child Development and Education and director at the Center for Children and Families at Teachers College, Columbia University.

2  

We wish to thank Brian Smedley, Marie McCormick, Hortensia Amaro, and the Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public's Health for their support in the writing of this paper. We are grateful for the support of the MacArthur Network on the Family and the Economy, the National Institute of Child Health and Human Development Research Network on Child and Family Well-Being, and the Administration of Children, Youth and Families and National Institute for Mental Health Research Consortium on Mental Health in Head Start. We are also grateful to Penny Hauser-Cram, Amado Padilla, and Deborah L. Coates for their insightful comments on an earlier draft of this paper. Rebecca Fauth provided valuable editorial assistance in the production of the manuscript. Correspondence regarding this paper should be addressed to Allison Sidle Fuligni, Center for Children and Families, Teachers College, Columbia University, Box 39, 525 West 120th Street, New York, NY 10027; asf27@columbia.edu.



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Promoting Health: Intervention Strategies from Social and Behavioral Research PAPER CONTRIBUTION D The Healthy Development of Young Children: SES Disparities, Prevention Strategies, and Policy Opportunities Allison Sidle Fuligni, Ph.D., and Jeanne Brooks-Gunn, Ph.D.1,2 In 1994, the federal government passed the Goals 2000: Educate America Act, which adopted into law six national goals for improving the education system. Foremost on this list was Goal 1: “By the year 2000, all children in America will start school ready to learn” (National Education Goals Panel, 1998). Now that the new millennium has arrived, examination of the status of young children entering school shows that we have fallen short of meeting this goal. In this paper, we explore some reasons that the nation is not appreciably nearer to 1   Allison Sidle Fuligni, Ph.D., is a research scientist at the Center for Children and Families, Teachers College at Columbia University. Jeanne Brooks-Gunn, Ph.D., is a Virginia and Leonard Marx Professor of Child Development and Education and director at the Center for Children and Families at Teachers College, Columbia University. 2   We wish to thank Brian Smedley, Marie McCormick, Hortensia Amaro, and the Institute of Medicine Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public's Health for their support in the writing of this paper. We are grateful for the support of the MacArthur Network on the Family and the Economy, the National Institute of Child Health and Human Development Research Network on Child and Family Well-Being, and the Administration of Children, Youth and Families and National Institute for Mental Health Research Consortium on Mental Health in Head Start. We are also grateful to Penny Hauser-Cram, Amado Padilla, and Deborah L. Coates for their insightful comments on an earlier draft of this paper. Rebecca Fauth provided valuable editorial assistance in the production of the manuscript. Correspondence regarding this paper should be addressed to Allison Sidle Fuligni, Center for Children and Families, Teachers College, Columbia University, Box 39, 525 West 120th Street, New York, NY 10027; asf27@columbia.edu.

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Promoting Health: Intervention Strategies from Social and Behavioral Research achieving this laudatory outcome and offer research and policy strategies that may help move the nation in this direction. The Goal 1 Technical Planning Group (1993, p. 1) also highlighted three objectives for families and communities necessary to support school readiness: Objective 1. All children will have access to high quality and developmentally appropriate preschool programs that help prepare children for school; Objective 2. Every parent in America will be a child's first teacher and devote time each day helping his or her preschool child learn; parents will have access to the training and support they need; and Objective 3. Children will receive the nutrition and health care needed to arrive at school with healthy minds and bodies, and the number of low-birthweight babies will be significantly reduced through enhanced prenatal health systems. Clearly, the interplay of all of these objectives is necessary to ensure that young children are in the optimal state of physical, emotional, and intellectual well-being when they enter school. DEFINING HEALTHY DEVELOPMENT FOR YOUNG CHILDREN The dimensions of school readiness outlined by the Goal 1 Technical Planning Group (1993) include aspects of physical health, as well as social, emotional, and cognitive development. These five dimensions are listed below (from Love et al., 1994, pp. 4–5): Physical well-being and motor development Physical development (rate of growth and physical fitness) Physical abilities (gross motor skills, fine motor skills, oral motor skills, and functional performance) Background and contextual conditions of [physical] development (vulnerabilities, such as prenatal alcohol exposure; environmental risks, such as harmful aspects of the community environment; health care utilization; and adverse conditions, such as disease and disability) Social and emotional development Emotional development (feeling states regarding self and others, including self-concept; emotions, such as joy, fear, anger, grief, disgust, delight, horror, shame, pride, and guilt; and the ability to express feelings appropriately, including empathy and sensitivity to the feelings of others) Social development (ability to form and sustain social relationships with adults and friends, and social skills necessary to cooperate with peers; ability to

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Promoting Health: Intervention Strategies from Social and Behavioral Research form and sustain reciprocal relationships; understanding the rights of others; ability to treat others equitably and to avoid being overly submissive or directive; ability to distinguish between incidental and intentional actions; willingness to give and receive support; ability to balance one's own needs against those of others; creating opportunities for affection and companionship; ability to solicit and listen to others' points of view; being emotionally secure with parents and teachers; being open to approaching others with expectations of positive and prosocial interactions, or trust) Approaches toward learning Predisposition (gender, temperament, and cultural patterns and values) Learning styles (openness to and curiosity about new tasks and challenges, task persistence and attentiveness, tendency toward reflection and interpretation, and imagination and invention) Language usage Verbal language (listening, speaking, social uses of language, vocabulary and meaning, questioning, and creative uses of language) Emerging literacy (literature awareness, print awareness, story sense, and writing process) Cognition and general knowledge Knowledge (physical knowledge, logicomathematical knowledge, and social-conventional knowledge) Cognitive competencies (representational thought, problem solving, mathematical knowledge, and social knowledge). Domains of child well-being could be conceived somewhat differently. For instance, health is sometimes divided into four broad categories: (1) physical health, (2) emotional well-being and behavioral competence, (3) cognitive and linguistic development, and (4) social competencies (McCormick and Brooks-Gunn, 1989). Starfield (1992a) describes a “profile of health” encompassing five domains: (1) physical activity and physical fitness, (2) physical and emotional symptoms, (3) self-perceptions of health and satisfaction with health, (4) achievement of developmental and social relationship milestones, and (5) “resilience” (presence of characteristics influencing future good health). Brooks-Gunn and Duncan (1997) list four domains of well-being that are applicable to young children: (1) physical health (including birthweight, growth, and conditions such as blood-lead levels); (2) cognitive ability (measured by intelligence, verbal ability, and achievement test scores); (3) school achievement; and (4) emotional and behavioral outcomes. Each of these conceptualizations emphasizes the importance of considering multiple domains of functioning when assessing health and well-being. It is noteworthy that scholars and policy makers

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Promoting Health: Intervention Strategies from Social and Behavioral Research from a variety of disciplines have converged on broadening their definitions of child well-being: educators have recently added physical and emotional health; health scholars now include emotional health, communication, and relationships; economists also focus on these factors in addition to human capital indicators; and psychologists include more than cognitive, social, and emotional aspects of development. However, these broad constructs are subsumed under a variety of rubrics —health, development, healthy development, well-being, and of most significance here, school readiness. In using such domains to define school readiness for young children, we wish to emphasize several points. First, broad conceptualizations include domains that are usually considered under the rubric of health, defined by the World Health Organization (WHO, 1978) as: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” In addition to physical health, other competencies are required under this definition. Second, under such definitions, competencies as well as liabilities or dysfunction are emphasized. Hence, healthy development can be considered to include more than simply the absence of disease. Third, competencies with social cognitive components are included, such as engagement, motivation, and curiosity. On the other hand, we must not limit ourselves to observing only competencies, because many conditions—such as asthma, limitations on daily activities, or low literacy—have important effects on children's abilities to engage in family, school, and peer activities. Thus, there is clearly a need for a balanced view of health and development that encompasses the absence of conditions that limit children's lives as well as the presence of factors and features that enhance their lives. Fourth, many definitions of health do not consider the comorbidity or co-occurrence of various conditions or features. We know that limitations often co-occur. For instance, a child with poor self-regulation will often also exhibit aggressive behavior; low levels of literacy often co-occur with attentional difficulties; and a fussy or irritable temperament may be associated with less responsive relationships between the child and the mother. Physical health problems also tend to co-occur: during a span of several years, children who experience one type of medical condition are significantly more likely to also experience other types of illnesses or psychosocial conditions (Starfield, 1992a). In addition, physical conditions have associations with emotional and behavioral outcomes and abilities. For instance, high blood-lead levels are associated with hyperactivity, impulsivity, being easily frustrated, and having difficulty following directions (Loeber, 1990). Children who are in poor health are more likely to experience limitations in their abilities to engage in age-appropriate activities, which may have consequences for their development of peer relationships (Starfield, 1992a; Klebanov et al., 1994). Although a detailed examination of comorbidity of health and developmental conditions is beyond the scope of this chapter, we wish to underscore the

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Promoting Health: Intervention Strategies from Social and Behavioral Research importance of considering patterns of limitations and abilities within individual children. In addition to the burdens of co-occurrence of multiple limiting factors for some children, patterns in which children experience limitations in combination with positive competencies will result in quite different outcomes. For example, a child with a chronic health condition such as asthma, but with very high literacy and language abilities, will be in a very different position in terms of establishing relationships with peers and succeeding in school than a child with similar health conditions but poor communication skills or poor emotional self-regulation. Based on these considerations, we believe that in order for children to be considered ready to learn they must be healthy in all of the domains discussed above. They should be free from physically limiting conditions and be on a normal trajectory of development in physical, social, emotional, and cognitive domains. (It is important to note, however, that there remains a longstanding debate regarding what constitutes “normal development” and what the relevant cutoff points would be). With this vision of the health and development of the whole child in place, we return to assessment of the nation's progress on the first education goal—that of school readiness. Although definite strides have been made toward improving the health and well-being of young children, the basic objectives of Goal 1 have not been met for all children, leaving many unprepared physically, mentally, and/or socially for learning in school. The National Education Goals Panel has measured progress on Goal 1, in part by assessing indicators including health risks at birth, full immunization rates at various ages, regularity of reading to children by parents, and preschool participation. (1) From 1994 to 1996, the rate of infants being born with one or more health risks decreased, but only to 34%. (2) Rates of full immunization of 2-year-olds increased from 1994 to 1997, but only to 78%. (3) Rates of regular parental reading to preschoolers increased from 1993 to 1996, but only to 72%. (4) Rates of preschool participation increased, but no change in the disparity of preschool participation rates between children from high- and low-income families occurred from 1991 to 1996 (National Education Goals Panel, 1998). In an innovative exploration of teacher and parent perceptions of school readiness, Lewit and Baker (1995) compared the responses from three different studies of kindergarten teachers and families to estimate rates of school readiness. In the first, teachers rated the most important characteristics of school readiness; these were physical health, communication skills, enthusiasm, taking turns, and the ability to sit and pay attention. In a second study, a sample of 7,000 kindergarten teachers estimated that only 65% of their students in the fall of 1990 were ready for school. The third study used the most important characteristics of school readiness identified by teachers above and found that in a sample of 2,126 parents of kindergartners, only 63% reported that their children had been rated highly by their teacher in all five of the characteristics listed

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Promoting Health: Intervention Strategies from Social and Behavioral Research above. Although the estimation techniques used here are not the most straightforward, they suggest that as many as one-third of kindergartners may not be considered by their teachers to be ready for school. It is also interesting to note that teachers often emphasize the importance of the physical health of children as well as the children's social-emotional skills (including sitting still and taking turns). Contrary to expectations, teachers are less concerned about traditional academics as evidenced by their lack of concentration on the cognitive abilities of children. Rather, teachers focus on the children's communication skills, which include verbal, cognitive, and social-emotional aspects. In a recent study using a nationally representative sample of 3,595 kindergarten teachers, rates of readiness are reported somewhat differently (Rirnm-Kaufman et al., in press). Teachers reported that 16% of children experienced serious difficulties upon entering kindergarten, and more than one-third of teachers reported that specific problems were experienced by about half the class or more. This study highlighted the specific arenas in which children are perceived as having difficulty upon school entry. For instance, 46% of teachers reported that a majority of their class had difficulty following directions, 34% had a majority with difficulty working independently, 20% said a majority of the class had problems with social skills, and 14% reported that half or more of the class had communication or language problems. In the remainder of this chapter, we explore the health and development of young children in the context of optimizing healthy development and school readiness. We first discuss socioeconomic disparities in health and development. Next, we describe possible mechanisms or pathways through which socioeconomic status may operate to affect child health and development. Third, we present links between this conceptual work on processes and existing strategies for prevention of poor developmental outcomes in young children. We conclude with discussion of future directions for policy-oriented research and intervention. SOCIOECONOMIC DISPARITIES IN HEALTH AND DEVELOPMENTAL OUTCOMES Socioeconomic status (SES) accounts for large differences in physical and emotional health outcomes for adult populations. These differences appear across the income distribution and cannot be explained by the differential access to health care (Marmot et al., 1984, 1991; Marmot and Shipley, 1996), or educational attainment (Adler et al., 1994) of different SES groups (Brooks-Gunn et al., 1999). Among children, SES is also a strong predictor of health and development (e.g., Brooks-Gunn and Duncan, 1997; Duncan and Brooks-Gunn, 1997). In this section, we present SES disparities in young children's outcomes, including cognitive and language development, emotional health, and physical health, and discuss the relative importance of separate factors of SES (e.g., parental education and family income) for each.

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Promoting Health: Intervention Strategies from Social and Behavioral Research Questions to Be Addressed Several questions are addressed in terms of SES disparities in the health and development of young children. First, we must ask whether young children are more or less ready for school as a function of SES. If the answer is yes, then the problem of SES disparities goes beyond a simple equity issue because it affects children's ability to do well in school academically, emotionally, and socially. Second, if we do find associations between SES and school readiness, we want to know which aspects of SES are responsible for the associations, in order to make policy decisions for raising the competencies of low-SES children. For instance, different programs might be designed depending on whether parental education or family income is more important for child outcomes. If maternal education seems to be more highly related, we might want to emphasize programs that increase mothers' human capital, such as GED completion programs, dropout prevention, or literacy programs. On the other hand, if family income is more predictive, then economic policies may be more beneficial, such as increasing the Earned Income Tax Credit, the minimum wage, or housing subsidies. If both aspects of SES are important, then programs should combine these approaches, and of course, if neither is particularly relevant, we should be looking elsewhere for ways to reduce SES disparities in child outcomes. Strategies may focus on the parent, the family, or the child, or some combination. For instance, to affect some outcomes, we might want to alter parental behavior toward the child by teaching parenting skills and reducing the emotional distress of the parent, or we might want to enhance the human capital or wages of the parents themselves through training and education programs. For other outcomes, family living conditions may be the target, through reducing environmental toxins in the household or neighborhood. Or services may be targeted directly to the child, as in high-quality child care programs. All of these approaches require the support and involvement of the parent, through either direct participation or enabling the child to participate by bringing the child to the intervention program site. Third, if we do find SES differences, what are the outcomes that are most affected? Again, this bears on the types of remedies that should be proposed. If language and literacy are strongly related to SES, then prevention might focus on literacy programs in the home and/or academically oriented child care. If emotional problems are more prevalent among low-SES children, intervention might focus on impulse control and self-regulation through parenting skills training, a child care program, or reduction of lead exposure in the living quarters. If health problems such as asthma are disproportionally present in lower-SES groups, yet another set of programs should be designed to reduce the disparities, such as improving parent knowledge for identifying and treating health problems; removing roaches, dust, and other allergens from the living environment; and/or improving access to medical treatment.

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Promoting Health: Intervention Strategies from Social and Behavioral Research Fourth, we must address the issue of which children and families should be served by such interventions. If intervention programs are not universal, the feasibility of targeting services should be considered in order to provide appropriate services to the families that are most likely to benefit. For instance, programs that are most highly associated with gains in literacy skills for mothers with low literacy skills might use maternal education to define eligibility, whereas a program that has been shown to have the strongest consequences for low-birthweight rather than normal-birthweight infants would be targeted to that population. Fifth, are there any implications of early SES disparities for later health and development, even after the entrance to school? Some work suggests that this is the case. In a sample of more than 11,000 British adults, inequalities in health status at age 33 were linked to several causes early in life, including SES at birth for the whole sample and poor housing during childhood for the women (Power et al., 1998). Such findings indicate the importance of reducing differences in material resources early in life for reducing lifelong health disadvantages. Research on Education and Income as Indicators of SES Let us begin this discussion by reviewing what is known from the research about SES and child development. There are three main lines of research addressing this topic. First, effects of parental education have been examined by developmentalists from a human capital standpoint. Second, a focus on family income considers the importance of material resources to health and development (Wachs and Gruen, 1982; Hoff-Ginsberg and Tardiff, 1995). Both of these categories are often subsumed under the broad domain of SES (with the addition of parent's occupational status, which has not received much attention in the literature on young children). Within the category of family income, the literature has addressed issues of depth of poverty, persistence of poverty, and timing of poverty since all provide a richer exploration of the effect of money (or lack of it) on child development. The third topic is neighborhood income. Neighborhood characteristics are receiving increased attention in the literature on young children (Brooks-Gunn et al., 1997a,b; Leventhal and Brooks-Gunn, 2000). We focus here on neighborhood income, recognizing, however, that other structural features of neighborhoods might be important. In much of the research, it is nearly impossible to separate the association between neighborhood income and other features, such as the percentage of unemployed adult males, percentage of single mothers, percentage of families receiving welfare, or percentage of adults with a college education. All of these features overlap with income, resulting in multicolinearity when all variables are included together in a regression (Brooks-Gunn et al., 1997b; Sampson et al., 1997).

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Promoting Health: Intervention Strategies from Social and Behavioral Research Associations Between SES and Child Outcomes In the following sections, we briefly review research showing the relationships between these three components of SES on three domains of child outcomes: (1) cognitive, language, and early schooling; (2) emotional and behavioral development; and (3) physical health. In the findings reported below, other important factors are statistically controlled, including family structure, ethnicity, and maternal age. When reporting effects of family income, maternal education is controlled, and vice versa, so that wherever possible we are reporting the independent effects of the SES indicator in question. Cognitive, Linguistic, and Early Schooling Outcomes The number of years of schooling of the mother has been shown to have a consistently significant effect on child outcomes. In two large samples (the Children of the National Longitudinal Survey of Youth [NLSY] and the Infant Health and Development Program [IHDP]), effects of mother's education on child language, achievement, and IQ scores ranged from .10 to .29, for children from 2 to 8 years of age. Even after controlling for family income, effects ranged from .07 to .18 (Duncan et al., 1994; Smith et al., 1997). Although many studies of SES effects on early cognitive abilities have not examined family income separately from other SES indicators, recent analyses have shown that income does affect cognitive outcomes at a young age. In the National Longitudinal Study of Youth-Child Supplement (NLSY-CS) and the IHDP, effects were found on several different cognitive indicators, using several different measures of income (Smith et al., 1997). Total family income was positively associated with verbal scores and achievement test scores as well as intelligence test scores for children ranging in age from 3 to 8 years (Duncan et al., 1994; Smith et al., 1997; Klebanov et al., 1998). Effect sizes for family income ranged from .20 to .32, even after controlling for mothers' education. For families that experienced persistent poverty (below the poverty level at four different time points), children's cognitive scores averaged 6 to 9 points lower than those of children who had never lived in poverty. Living in poverty for only some but not all of the early years was associated with smaller differences compared to children who had never lived in poverty (Smith et al., 1997). The effects of family income are nonlinear. Children whose family incomes were below 50% of the poverty level had scores 7 to 12 points lower than children who were near-poor (just over the poverty level); whereas those who were slightly less poor (50–100% of the poverty level) had scores ranging from 4 to 7 points lower than the near-poor group (Smith et al., 1997). Although the timing of poverty did not show a significant relationship with early measures of IQ, verbal ability, or achievement scores in the NLSY or IHDP data (Duncan et al., 1994; Smith et al., 1997), analysis from the Panel Study of Income Dynamics

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Promoting Health: Intervention Strategies from Social and Behavioral Research (PSID) showed that family income in the early childhood years is more strongly related to the ultimate years of schooling the child completes than is family income at any other period in the child 's life (Duncan et al., 1998). Links between neighborhood income, defined in terms of structural characteristics of neighborhoods at the census-tract level, and child cognitive outcomes have been documented starting at age 3 and continuing through age 6. Residing in an affluent neighborhood (defined as the proportion of residents with incomes over $30,000) was positively associated with intelligence test scores at age 3 for children in the IHDP (Brooks-Gunn et al., 1993; Chase-Lansdale et al., 1997). Similarly, at ages 5 and 6, residing in a high-SES neighborhood was associated with higher IQ, verbal ability, and reading achievement scores, after controlling for family and individual characteristics (Chase-Lansdale and Gordon, 1996; Chase-Lansdale et al., 1997 Duncan et al., 1994). It is the presence of high-income neighbors relative to middle income ($10,000 to $30,000 per year) that makes a difference in these cognitive and achievement outcomes, not the presence or absence of low-income neighbors. We will return to possible reasons for such findings in the next section. Emotional Health Outcomes Studies of the prevalence of emotional health or behavior problems tend to find that overall, approximately one-quarter of all preschoolers have reported behavior problems (e.g., Richman et al., 1975); however, higher rates are often associated with low SES. Again using data from IHDP and NLSY, effects of maternal education on emotional health are found. In both samples, maternal education is related to fewer internalizing problems, and maternal education is associated with fewer externalizing problems in the IHDP sample only (Brooks-Gunn et al., 1997; Chase-Lansdale et al., 1997). Links between family poverty and child behavioral problems have also been noted in the research. Among children ages 3 to 17 years in the 1988 National Health Interview Survey Child Health Supplement, parents of poor children were more likely to report that they had had an emotional or behavioral problem lasting 3 months or more (Brooks-Gunn and Duncan, 1997). Higher family income-to-needs ratio is associated with lower levels of externalizing problems in the IHDP and NLSY samples at ages 3 through 6 (Brooks-Gunn et al., 1993; Chase-Lansdale et al., 1997). Findings are less strong for neighborhood income effects on emotional and behavioral outcomes in young children. However, there are links between externalizing behaviors and the presence of low-income neighbors as opposed to middle-income neighbors (Duncan et al., 1994; Chase-Lansdale et al., 1997).

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Promoting Health: Intervention Strategies from Social and Behavioral Research Physical Health Outcomes Patterns of physical health problems and conditions reveal higher rates of illness among poor children (Starfield, 1992a; Brooks-Gunn and Duncan, 1997). For instance, parents of poor children are nearly twice as likely as those of nonpoor children to report that their children are in fair to poor health; blood-lead levels are three times more likely to be dangerously high among poor children; childhood immunization is three times more likely to be delayed for poor children, and the percentage of children with conditions limiting school activity is two to three times higher among poor children (Starfield, 1992a; Brooks-Gunn and Duncan, 1997). Growth stunting and short-stay hospital episodes are also twice as common among poor children (Brooks-Gunn and Duncan, 1997), and duration of poverty is strongly related to growth stunting (Korenman and Miller, 1997). It is difficult to estimate the effect of neighborhood income on health outcomes for young children. We do know that in addition to the direct effects of poverty on nutrition and access to preventive health care, the higher rates of health problems among poor children are partially due to hazardous and unsafe living conditions of poor housing and dangerous neighborhoods (Starfield, 1992b). However, since most studies do not control for family-level indicators of poverty or human capital, it is impossible to distinguish between neighborhood and family-level indicators of physical health. This research tends to look at the prevalence of child health indicators by health district using aggregate data only, without individual-level data. Some research on disparities in low-birthweight births has combined neighborhood-level and individual-level data, and concluded that residence in low-income neighborhood has an independent association with lower rates of prenatal health care and higher incidence of low-birthweight births (Gould and LeRoy, 1988; Collins and David, 1990; O'Campo et al., 1997). Summary We find that maternal education, family income, and neighborhood income each have independent effects on child cognitive, emotional, and physical outcomes. Maternal education tends to be strongly associated with all types of cognitive assessments (cognitive, verbal, and school achievement measures), but more strongly associated with internalizing than externalizing behavior problems. Family income also affects cognitive assessments and is more predictive of externalizing problems. When other aspects of family poverty are assessed, such as persistence and extreme poverty, stronger effects are seen. Finally, a few links between neighborhood poverty and early childhood outcomes have been documented, net of family-level influences. In particular, the presence of affluent neighbors has been associated with cognitive and school achievement out-

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Promoting Health: Intervention Strategies from Social and Behavioral Research to see movement in this direction with the introduction of universal pre-kindergarten programs in many states, and home-visiting programs for all babies born in some counties and states. Universal services, then, are converging, with newborns and 4-year-olds currently being served in many areas. Policymakers should consider whether early childhood and family services should be made available to all families consistently from birth, or at least starting at age 3. Projects will need to tailor both core and support services to be responsive (and relevant) to the needs of working parents by scheduling them on off-hours, providing more home-based services, and providing supports such as transportation, child care, and meals to help remove barriers to participation. Since working parents have less time, coordination of services will be important, so that more services, such as child care and parenting education, are offered at the same site. While these issues are important for all parents, the problems will be even more serious when programs include parents who are moving from welfare to work. Consistent with this recommendation, programs have to consider the changing needs of poor parents, especially in light of welfare reform. Concluding Remarks The study of early childhood interventions is not a new topic. In fact, some of the conclusions are strikingly similar to those made by Urie Bronfenbrenner more than 25 years ago in a review of the effects of early intervention (Bronfenbrenner, 1974). We conclude, as did Bronfenbrenner, that high-quality early childhood programs can have significant effects on cognitive outcomes for children, especially when the children are from low-income families and especially when the programs provide both child and family services. What has changed in the more than 30 years since the programs that began in the 1960s and 1970s were first evaluated is a change from deficit models to models focusing on the strengths of families. Families are considered to be at risk due to the inequities of opportunities and differential obstacles faced by low-income families. The field has broadened its focus to consider the multiple contexts in which children develop and consider the interrelationships among parents, program staff, and neighborhood providers, all of whom jointly provide opportunities for growth. With the increased numbers of mothers of young children in the workforce, we have learned more about the difficulties families have managing family and work responsibilities, and the limited choices that families often have in procuring high-quality child care. We have made strides in addressing questions about who ought to be targeted in early intervention efforts, how to successfully integrate services, how programs affect outcomes for mothers and other family members, what effects programs have on outcomes other than child IQ, and how staff and family perceptions influence program processes and outcomes. At the same time, some of Bronfenbrenner's statements have stood the test of time over a quarter of a century. Parents need supports in multiple arenas of

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