Interventions for Promoting Early Child Development for Health An

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					                       Reducing Health Inequality:
                Early Childhood Interventions to Improve
                      School Readiness in Scotland
Dr Rosemary Geddes
Career Development Fellow, MRC Human Genetics Unit, Scottish Collaboration for Public Health Research and Policy

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
UNICEF Children Well-being across the OECD
      Inequalities in Health Outcomes and Risk
    Factors in Pregnancy, at Birth and Up to 3mths
     Risk Factors             % Least           % Most         Relative Risk *   Risk Difference
                             Deprived          Deprived
Unplanned pregnancy              8                 39                4.8               31
Smoked in pregnancy              9                 43                4.9               34
Planned to bottle feed          15                 46                3.1               31
Never breast fed                21                 60                2.8               38
   Health Outcome
Low birth weight                 5                 8                 1.6               3

  * Prevalence in most deprived divided by prevalence in least deprived

 Source: Bromley & Cunningham-Burley, 2010
       Inequalities in Health up to 48
Risk Factors                   % Least    % Most    Relative Risk   Risk Difference
                              Deprived   Deprived
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        11          24          2.2               13
Behaviour to other children     10          24          2.3               14
Language development            12          26          2.2               14
Total difficulties (SDQ)         7          20          2.7               13
Conduct                         23          41          1.8               18
Hyperactivity                   13          27          2.1               14

Source: Bromley & Cunningham-Burley, 2010
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:

“Literacy report shows Russell there really is a
  crisis in education”
•   The Scotsman:

“Zero-tolerance approach to poor literacy
  needed, experts say”
•   The Herald:
         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

1.    Literacy Commission. A Vision for Scotland: The Report and Final Recommendations of the Literacy Commission.
      Scottish Labour, December 2009.
2.    OECD. Quality and Equity of Schooling in Scotland. Paris: OECD, 2007.
       `Sensitive periods’ in early brain development

High                “Pre-school” years                                School years

                                                                    Peer social skills

                                                 Conceptualization               Language
                                                  Habitual ways of responding
                                                    Emotional control

       0          1           2           3          4           5           6           7
Source: Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years
Study, 1999; Shonkoff, 2000.)
                            Synaptic Density
                     At Birth          6 Years Old         14 Years Old

Source: Founders’ Network, slide 03-012. Rethinking the Brain, Families and
Work Institute, Rima Shore, 1997.
                   The gradient worsens

Source: Fairer Society, Healthy Lives. The Marmot Review.2010.
 Life Course Problems Related to Early Life

     2nd                   3rd/4th                  5th/6th
                                                                            Old Age
   Decade                 Decade                   Decade

• School Failure       • Obesity               • Coronary Heart •Premature
                                                 Disease         Aging
• Teen Pregnancy • Elevated Blood
                   Pressure       • Diabetes                              • Memory Loss
• Criminality
                 • Depression

                       • Addictions
 Source: Clyde Hertzman, Early Child Development: A powerful equalizer.
How can this be influenced?
      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
   • Activities influence children’s cognitive development & can
     moderate, but not eradicate, effect of socio-demographic
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   Children                                Enrichment of home environment e.g.       Full- or half-day child care at high    Full-day* high
                   of develop-                                            Play@home                                 quality child development centre        quality preschool
                   mental                                                 Nurturing of holistic child development   (higher risk - higher number of hours   Enrichment of
                                                                          Children’s centres with use of multi-     up to a max. 30 hrs/wk)                 home environment
                                                                          agency integrated services                Enrichment of home environment          Child training e.g.
                                                                                                                                                            Incredible Years
                   disorder                                                                                                                                 Specialist input as
                                  Parent-Child Intensive midwifery        Attachment-based interventions to         Intensive home visiting support         Positive Parenting
                                               support                    improve parent sensitivity§               NFP                                     e.g. Triple P,
                                               NFP                        Intensive midwifery & home visiting                                               Parents As Teachers
                                                                          support                                                                           Specialist input as
                                                                          NFP                                                                               required

                                  Parents       Maternal education &      Training to understand stages of child development & how to nurture
                                                literacy                  Parenting/child management support e.g. Incredible Years
                                                Parenting preparation     More intensive support in accessing services, problem solving,
                                                Support for addictions    adult education for high school completion, job/employment support, accessing benefits, addiction
                   Medium risk                                            management etc
                                  Children                                Enrichment of home environment e.g. Play@home                                  Half-day preschool
                                                                          Nurturing of holistic child development
                                                                          Children’s centres
                                  Parent-Child Promotion of sensitive parenting with provision of support as needed

                                  Parents      Support for behaviour     Support for breastfeeding initiation &      Support in accessing services
                                               change                    maintenance                                 Problem solving techniques
                                               Antenatal care according                                              Adult education for high school completion,
                   Universal                   to medical risk                                                       job/employment support
                                  Children                               Children’s centres e.g. drop-in centres, toy & book libraries                      Half-day preschool
                                                                         Resources e.g. Bookstart#
                                                                         Enrichment of home environment
                                  Parent-Child Access to information on positive, sensitive parenting

                                  Parents       Standard antenatal care. Information on healthy child development
                                                Promotion of healthy     Information on available child, parent & family services
                                                diet, physical activity, Core child health promotion programme with routine child development reviews
                                                breastfeeding & smoking
                                                                               Source: Scottish Collaboration for Public Health Research & Policy. 2010.
                                                Ready Steady Baby#
Source: Seven things legislators need to know about school readiness. US State Early Childhood Policy Technical
Assistance Network. March 2003.
• 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

Gross and fine motor skills
- e.g., being able to manipulate
2) Social Competence
Overall social competence
- e.g., ability to get along with other
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

                                            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
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

      60                                                       N of domains
      50                                                       with low scores:
      40                                                       0
      30                                                       1
                                                               2 or more
             Reading         Writing         Math

Percentage of Grade 6 students not meeting provincial standards in
relation to number of vulnerabilities in Kindergarten (EDI)     Source: TDSB, 2007
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
Decrease in the % of vulnerable children as a
result of improved ECD in Western Australia

                 2003           2006

Floreat         47.22%          14.3%

Wembley         47.11%          11.8%

      Useful websites & references
• Offord Centre for Child Studies
• Australian Early Development Index - click on AEDI
• British Columbia ECD mapping portal
• 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.
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