Reducing Health Inequality: Early Childhood Interventions to Improve School Readiness in Scotland Presenter: Dr Rosemary Geddes Career Development Fellow, MRC Human Genetics Unit, Scottish Collaboration for Public Health Research and Policy Contributors: Professor John Frank Director, Scottish Collaboration for Public Health Research and Policy Professor and Chair, Public Health Research and Policy, University of Edinburgh Sally Haw Senior Scientific Adviser, Scottish Collaboration for Public Health Research and Policy

WHAT IS THE PROBLEM?

UNICEF Children Well-being across the OECD

Inequalities in Health Outcomes and Risk Factors in Pregnancy, at Birth and Up to 3mths % Least Deprived % Most Deprived Relative Risk * Risk Difference Unplanned pregnancy 8 39 4.8 31 Smoked in pregnancy 9 43 4.9 34 Planned to bottle feed 15 46 3.1 Never breast fed 21 60 2.8 38 Health Outcome Low birth weight 5 1.6 3 * Prevalence in most deprived divided by prevalence in least deprived Source: Bromley & Cunningham-Burley, 2010

Inequalities in Health up to 48 months Risk Factors % Least Deprived % Most Deprived Relative Risk Risk Difference Maternal smoking 8 41 5.1 33 Eating habits - 1.5 – 2.9 10-26 Low physical activity 18 34 1.9 16 Health Outcomes Fair/bad health 1+ since birth 11 24 2.2 13 Behaviour to other children 10 2.3 14 Language development 12 26 Total difficulties (SDQ) 7 20 2.7 Conduct 23 1.8 Hyperactivity 27 2.1 Source: Bromley & Cunningham-Burley, 2010

Source: Power C, Mathews S Source: Power C, Mathews S. Origins of health inequalities in a national population sample. Lancet 1997: 350:1584-89.

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)

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

Education, Employment, Wealth & Health Source: Fairer Society, Healthy Lives. The Marmot Review.2010.

Scotland: Media reports December 2009 “Fifth of Scots have poor literacy” The BBC:  http://news.bbc.co.uk/1/hi/scotland/8393805.stm “Literacy report shows Russell there really is a crisis in education” The Scotsman: http://news.scotsman.com/opinion/Literacy-report--shows-Russell.5883656.jp “Zero-tolerance approach to poor literacy needed, experts say” The Herald: http://www.heraldscotland.com/news/education/zero-tolerance-approach-to-poor-literacy-needed-experts-say-1.989347

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.”² Literacy Commission. A Vision for Scotland: The Report and Final Recommendations of the Literacy Commission. Scottish Labour, December 2009. http://www.scottishlabour.org.uk/literacy OECD. Quality and Equity of Schooling in Scotland. Paris: OECD, 2007.

WHAT DETERMINES THESE OUTCOMES?

`Sensitive periods’ in early brain development The Council for Early Child Development - Putting Science into Action for Children “Pre-school” years School years High `Numbers’ Peer social skills Sensitivity Conceptualization Language Habitual ways of responding Emotional control Vision Hearing Children’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. Low 1 2 3 4 5 6 7 Years Source: Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.) Created: August 24, 2005

Synaptic Density At Birth 6 Years Old 14 Years Old The Council for Early Child Development - Putting Science into Action for Children Synaptic Density At Birth 6 Years Old 14 Years Old Detailed 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 03-012. Rethinking the Brain, Families and Work Institute, Rima Shore, 1997. Created: August 24, 2005

The gradient worsens Even those ‘optimally born’, if of low socio-economic status, will eventually underperform. Source: Fairer Society, Healthy Lives. The Marmot Review.2010.

Life Course Problems Related to Early Life 2nd Decade 3rd/4th Decade 5th/6th Decade Old Age School Failure Teen Pregnancy Criminality Obesity Elevated Blood Pressure Depression Addictions Coronary Heart Disease Diabetes Premature Aging Memory Loss Source: Clyde Hertzman, Early Child Development: A powerful equalizer.

How can this be influenced?

WHAT WORKS?

Main findings of a rapid literature review Early childhood intervention programmes can help to reduce disadvantage due to social and environmental factors Improvements in all domains of child development, school achievement, delinquency & crime prevention, & life success Successful interventions utilize a mixed (centre & home-based), two-generation (child & parents) approach Greatest effects are seen in those at highest social risk High quality preschool can help to reduce disadvantage & can raise early language, pre-reading & maths skills with the most deprived children displaying the strongest gains Home learning environment of more importance for intellectual & social development than parental occupation, education or income Activities influence children’s cognitive development & can moderate, but not eradicate, effect of socio-demographic disadvantage Source: Geddes et al. Interventions for promoting early child development for health: an environmental scan with special reference to Scotland. April 2010.

Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional & Cognitive Development based on evidence of promising interventions Delivery Population CONTINUUM OF CARE Pregnancy 0-12 months 12-36 months 36-48+ months Highest risk of develop-mental and/or attachment disorder Medium risk Universal Children Enrichment of home environment e.g. Play@home Nurturing of holistic child development Children’s centres with use of multi-agency integrated services Full- 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 environment Full-day* high quality preschool Enrichment of home environment Child training e.g. Incredible Years Specialist input as required Parent-Child Intensive midwifery support NFP Attachment-based interventions to improve parent sensitivity§ Intensive midwifery & home visiting support Intensive home visiting support Positive Parenting e.g. Triple P, Parents As Teachers Parents Maternal education & literacy Parenting preparation Support for addictions Training to understand stages of child development & how to nurture Parenting/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 etc Children’s centres Half-day preschool Promotion of sensitive parenting with provision of support as needed Support for behaviour change Antenatal care according to medical risk Support for breastfeeding initiation & maintenance Support in accessing services Problem solving techniques Adult education for high school completion, job/employment support Children’s centres e.g. drop-in centres, toy & book libraries Resources e.g. Bookstart# Enrichment of home environment Access to information on positive, sensitive parenting Standard antenatal care. Promotion of healthy diet, physical activity, breastfeeding & smoking cessation. Ready Steady Baby# Information on healthy child development Information on available child, parent & family services Core child health promotion programme with routine child development reviews   SPECTRUM OF RISK At 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. 2010.

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 contributions Source: Seven things legislators need to know about school readiness. US State Early Childhood Policy Technical Assistance Network. March 2003.

Monitoring Data 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.

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.

What Does the EDI Measure?

1) Physical Health and Well-Being Physical readiness for school day - e.g., arriving to school hungry Physical independence - e.g., having well-coordinated movements Gross and fine motor skills - e.g., being able to manipulate objects

turity 2) Social Competence 3) Emotional Maturity Overall social competence - e.g., ability to get along with other children Responsibility and respect - e.g., accept responsibility for actions Approaches to learning - e.g., working independently Readiness to explore new things - e.g., eager to explore new items turity 3) Emotional Maturity 3) Emotional Maturity Pro-social and helping behaviour - e.g., helps other children in distress Anxious and fearful behaviour - e.g., appears unhappy or sad Aggressive behaviour - e.g., gets into physical fights Hyperactivity and inattention - e.g., is restless

4) Language & Cognitive Development Basic literacy - e.g., able to write own name Interest in literacy/numeracy and memory - e.g., interested in games involving numbers Advanced literacy - e.g., able to read sentences Basic numeracy - e.g., able to count to 20

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

Trajectories Established Early - Vulnerability on EDI and Grade 6 outcomes N of domains with low scores: Percentage of Grade 6 students not meeting provincial standards in relation to number of vulnerabilities in Kindergarten (EDI) Source: TDSB, 2007

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

International Early Development Instrument implementations

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 coalitions Numerous community initiatives resulted from the process – parenting programmes & resources; nutrition & dental interventions; literacy projects

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 Australia Year 2003 2006 Floreat 47.22% 14.3% Wembley 47.11% 11.8% AEDI

Useful websites & references Offord Centre for Child Studies http://www.offordcentre.com/index.html Australian Early Development Index - click on AEDI http://www.rch.org.au/ccch/index.cfm?doc_id=10556 British Columbia ECD mapping portal http://www.ecdportal.help.ubc.ca/archive/faq.htm Hertzman C, Williams R. Making early childhood count. CMAJ. 2009 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):111-23. Hertzman C. Tackling inequality: get them while they’re young. BMJ 2010; 340:346-8 Marmot M. Fair Society, Healthy Lives. London: University College London; 2010. Contact details: Rosemary.Geddes@hgu.mrc.ac.uk