Presentation on theme: "Presenter: Dr Rosemary Geddes"— Presentation transcript:
1 Reducing Health Inequality: Early Childhood Interventions to Improve School Readiness in Scotland Presenter:Dr Rosemary GeddesCareer Development Fellow, MRC Human Genetics Unit, Scottish Collaboration for Public Health Research and PolicyContributors:Professor John FrankDirector, Scottish Collaboration for Public Health Research and PolicyProfessor and Chair, Public Health Research and Policy, University of EdinburghSally HawSenior Scientific Adviser, Scottish Collaboration for Public Health Research and Policy
4 Inequalities in Health Outcomes and Risk Factors in Pregnancy, at Birth and Up to 3mths % Least Deprived% Most DeprivedRelative Risk *Risk DifferenceUnplanned pregnancy8394.831Smoked in pregnancy9434.934Planned to bottle feed15463.1Never breast fed21602.838Health OutcomeLow birth weight51.63* Prevalence in most deprived divided by prevalence in least deprivedSource: Bromley & Cunningham-Burley, 2010
5 Inequalities in Health up to 48 months Risk Factors% Least Deprived% Most DeprivedRelative RiskRisk DifferenceMaternal smoking8415.133Eating habits-1.5 – 2.910-26Low physical activity18341.916Health OutcomesFair/bad health 1+ since birth11242.213Behaviour to other children102.314Language development1226Total difficulties (SDQ)7202.7Conduct231.8Hyperactivity272.1Source: Bromley & Cunningham-Burley, 2010
6 Source: Power C, Mathews S Source: Power C, Mathews S. Origins of health inequalities in a national population sample. Lancet 1997: 350:
7 Absolute range: Healthy life expectancy, Males – Scotland 1999- 2006 (Data not available 2003/04) Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities(updated in September, 2009, but very few changes in long-term trends)
8 Absolute range: Healthy life expectancy, Females Scotland 1999-2006 (Data not available 2003/04) Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities
9 Education, Employment, Wealth & Health Source: Fairer Society, Healthy Lives. The Marmot Review.2010.
10 Scotland: Media reports December 2009 “Fifth of Scots have poor literacy”The BBC: “Literacy report shows Russell there really is a crisis in education”The Scotsman:“Zero-tolerance approach to poor literacy needed, experts say”The Herald:
11 Determinants of School Outcomes in Scotland – Why Schools Are Not to Blame “While individuals may defy this trend, no school in a deprived area is able to record a similar level of success to that achieved by almost all schools in the most affluent areas.”¹“...but the gaps between them (schools) are far less important than differences between students. In Scotland, who you are is far more important than what school you attend.”²Literacy Commission. A Vision for Scotland: The Report and Final Recommendations of the Literacy Commission. Scottish Labour, DecemberOECD. Quality and Equity of Schooling in Scotland. Paris: OECD, 2007.
13 `Sensitive periods’ in early brain development The Council for Early Child Development - Putting Science into Action for Children“Pre-school” yearsSchool yearsHigh`Numbers’Peer social skillsSensitivityConceptualizationLanguageHabitual ways of respondingEmotional controlVisionHearingChildren’s early experiences have far-reaching and solidifying effects on the development of their brains and behaviours. This diagram indicates the most sensitive periods of brain development, the foundation for cognitive learning, emotional and social skills, language and expression are laid before children in Canada begin formal schooling.We know there are critical periods of development. For example:Children born with cataracts who don’t have them removed shortly after birth will never have normal sight – the critical period for vision development will have been missed.Children born deaf will unlikely have the same language skills as a child who becomes deaf later in early childhood. The child born deaf will miss the sensitive period of language development.Children exposed to more than one language before the age of 7 months will be able to speak both languages as first languages and more easily acquire additional languages. We know that when we learn a second language later in life we learn it in the memory, rather than the language part of our brain. Our physiology will be unable to form certain sounds and we will likely always have an accent.Children who do not have regular contact with other young children before 4 years old will have underdeveloped social-emotional skills.Trajectories for children with developmental vulnerabilities can be changed but the major effort has to be made in the early years when neural systems are most plastic and compromises or constrictions are most readily overcome. Later interventions are more difficult and less effective.‘Sensitive periods’ in early brain development – this slide is based on the following references:Doherty, G. (1997). Zero to Six: the Basis for School Readiness. Applied Research Branch R-97-3E Ottawa: Human Resources Development Canada.McCain & Mustard (1999). Early Years Study. Toronto, Ontario: Publications Ontario.Shonkoff, Jack (Ed) (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, D.C.: National Academy Press.Low1234567YearsSource: Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.)Created: August 24, 2005
14 Synaptic Density At Birth 6 Years Old 14 Years Old The Council for Early Child Development - Putting Science into Action for ChildrenSynaptic DensityAt Birth6 Years Old14 Years OldDetailed analysis of the patterns of nerve connection that form from birth have been carried out. This slide from the work of Huttenlocher shows the connections amongst the neurons at birth is not intense but by the age of 6 the connection density is considerable. This represents the culmination of all the experiences of the young child, good and bad. By the age of 14 the connection pattern is still greater than at birth but is less intense. The weak pathways, those that have not been intensely used, have been cut out. This process is referred to as the wiring and sculpting of the brain. The wiring of neurons in the brain is hugely influenced by the stimulation and use of these neuron pathways. Thus, as you age, pathways that are not used disappear.Source: Founders’ Network, slide Rethinking the Brain, Families andWork Institute, Rima Shore, 1997.Created: August 24, 2005
15 The gradient worsensEven those ‘optimally born’, if of low socio-economic status, will eventually underperform.Source: Fairer Society, Healthy Lives. The Marmot Review.2010.
16 Life Course Problems Related to Early Life 2nd Decade3rd/4th Decade5th/6thDecadeOld AgeSchool FailureTeen PregnancyCriminalityObesityElevated BloodPressureDepressionAddictionsCoronary HeartDiseaseDiabetesPrematureAgingMemory LossSource: Clyde Hertzman, Early Child Development: A powerful equalizer.
19 Main findings of a rapid literature review Early childhood intervention programmes can help to reduce disadvantage due to social and environmental factorsImprovements in all domains of child development, school achievement, delinquency & crime prevention, & life successSuccessful interventions utilize a mixed (centre & home-based), two-generation (child & parents) approachGreatest effects are seen in those at highest social riskHigh quality preschool can help to reduce disadvantage & can raise early language, pre-reading & maths skills with the most deprived children displaying the strongest gainsHome learning environment of more importance for intellectual & social development than parental occupation, education or incomeActivities influence children’s cognitive development & can moderate, but not eradicate, effect of socio-demographic disadvantageSource: Geddes et al. Interventions for promoting early child development for health: an environmental scan with special reference to Scotland. April 2010.
20 Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional & Cognitive Development based on evidence of promising interventionsDeliveryPopulationCONTINUUM OF CAREPregnancy0-12 months12-36 monthsmonthsHighest risk of develop-mental and/or attachment disorderMedium riskUniversalChildrenEnrichment of home environment e.g.Nurturing of holistic child developmentChildren’s centres with use of multi-agency integrated servicesFull- or half-day child care at high quality child development centre (higher risk - higher number of hours up to a max. 30 hrs/wk) Enrichment of home environmentFull-day* high quality preschool Enrichment of home environment Child training e.g. Incredible YearsSpecialist input as requiredParent-ChildIntensive midwifery supportNFPAttachment-based interventions to improve parent sensitivity§Intensive midwifery & home visiting supportIntensive home visiting supportPositive Parenting e.g. Triple P, Parents As TeachersParentsMaternal education & literacy Parenting preparationSupport for addictionsTraining to understand stages of child development & how to nurtureParenting/child management support e.g. Incredible Years More intensive support in accessing services, problem solving, adult education for high school completion, job/employment support, accessing benefits, addiction management etcChildren’s centresHalf-day preschoolPromotion of sensitive parenting with provision of support as neededSupport for behaviour changeAntenatal care according to medical riskSupport for breastfeeding initiation & maintenanceSupport in accessing services Problem solving techniques Adult education for high school completion, job/employment supportChildren’s centres e.g. drop-in centres, toy & book librariesResources e.g. Bookstart#Enrichment of home environmentAccess to information on positive, sensitive parentingStandard antenatal care. Promotion of healthy diet, physical activity, breastfeeding & smoking cessation.Ready Steady Baby#Information on healthy child developmentInformation on available child, parent & family servicesCore child health promotion programme with routine child development reviewsSPECTRUM OF RISKAt any level of risk, the child/family receives services proportionate to their risk + any services below that level; NFP=Nurse-Family Partnership. §Interventions for attachment disorder fall out with the scope of this review but are mentioned here for completeness. #Universal book resources: Ready Steady Baby is for all pregnant women; Bookstart provides free books at 2 months, 18 months & 3 years, & information for parents *There is a debate about full vs. half-day: British EPPE study says full=half; US National Center for Educational Statistics says full-day for high risk and half-day for medium & low risk children.Source: Scottish Collaboration for Public Health Research & Policy
21 This scan did not have as an objective a cost-benefit analysis of programmes but brief slide included just to illustrate the types of returns one could expect from Early Childhood Intervention programmes; In each of these 4 programmes the initial investment (which varied from about $6,000 to >$30,000 per child/family) resulted in returns of >$3 for every dollar invested. Returns from reductions in government spending as result of reduced use of special education services, reduced involvement in juvenile delinquency, reduced welfare & dependency costs, reduced criminal justice costs, and increases in tax contributionsSource: Seven things legislators need to know about school readiness. US State Early Childhood Policy Technical Assistance Network. March 2003.
22 MonitoringData to monitor children’s development and functioning in the Scottish population, and the effectiveness of related programmes, are lacking.More early-stage measures are needed as well as better late-stage measures, which would require data linkage.Data need to be collated and analysed centrally to reveal patterns of “unmet need” in child development by geographic, ethnic and socioeconomic position.
24 What is the EDI?The EDI is teacher-completed (20 minutes) checklist that assesses children’s school readiness when they enter school.It measures the outcomes of children’s pre-school (0-5 years) experiences as they influence their readiness to learn at school.As a result, the EDI is able to predict how children will do in primary school.The EDI is designed to be interpreted at the group level & does not provide diagnostic information on individual children.
26 1) Physical Health and Well-Being Physical readiness for school day- e.g., arriving to school hungryPhysical independence- e.g., having well-coordinated movementsGross and fine motor skills- e.g., being able to manipulate objects
27 turity 2) Social Competence 3) Emotional Maturity Overall social competence- e.g., ability to get along with other childrenResponsibility and respect- e.g., accept responsibility for actionsApproaches to learning- e.g., working independentlyReadiness to explore new things- e.g., eager to explore new itemsturity3) Emotional Maturity3) Emotional MaturityPro-social and helping behaviour- e.g., helps other children in distressAnxious and fearful behaviour- e.g., appears unhappy or sadAggressive behaviour- e.g., gets into physical fightsHyperactivity and inattention- e.g., is restless
28 4) Language & Cognitive Development Basic literacy- e.g., able to write own nameInterest in literacy/numeracy and memory- e.g., interested in games involving numbersAdvanced literacy- e.g., able to read sentencesBasic numeracy- e.g., able to count to 20
29 5) Communication Skills and General Knowledge (No subdomains)- Ability to clearly communicate one’s own needs and understand others- Clear articulation- Active participation in story-telling (not necessarily with good grammar and syntax)- Interest in general knowledge about the world
30 Trajectories Established Early - Vulnerability on EDI and Grade 6 outcomes N of domainswith low scores:Percentage of Grade 6 students not meeting provincial standards inrelation to number of vulnerabilities in Kindergarten (EDI)Source: TDSB, 2007
31 Maps show us: Large local area differences in the proportion of developmentally vulnerable children; The high proportion of avoidable vulnerability; The degree to which socioeconomic context explains and does not explain variations in early development; Which communities are doing better or worse than predicted…….to set up the study of ‘why’; Change over time
34 International Early Development Instrument implementations
35 Translating School Readiness into Community Actions School readiness assessment provides communities with the opportunity to better understand how they can allocate resources & concentrate their efforts to work towards improving outcomes for children. The Early Years SOA is already set up for LAs to do this!EDI: brought stakeholders together; encouraged, established a forum for community mobilisation; developed & cemented inter-sectoral coalitionsNumerous community initiatives resulted from the process – parenting programmes & resources; nutrition & dental interventions; literacy projects
36 Year 2003 2006 Floreat 47.22% 14.3% Wembley 47.11% 11.8% Decrease in the % of vulnerable children as a result of improved ECD in Western AustraliaYearFloreat % 14.3%Wembley 47.11% %AEDI
37 Useful websites & references Offord Centre for Child StudiesAustralian Early Development Index - click on AEDIBritish Columbia ECD mapping portalHertzman C, Williams R. Making early childhood count. CMAJ Jan 6;180(1):68-71.Lloyd JEV, Hertzman C. From Kindergarten readiness to fourth-grade assessment: Longitudinal analysis with linked population data. Social Science & Medicine. 2009;68(1):Hertzman C. Tackling inequality: get them while they’re young. BMJ 2010; 340:346-8Marmot M. Fair Society, Healthy Lives. London: University College London; 2010.Contact details: