Changing the Narrative for Early Childhood Investment

Advances in the biological and social sciences tell us that the period from conception to school entry is a time of both significant opportunity and considerable risk.Multiple interventionsduring theseearlyyears have been designed to address the rootsof lifelongdisparities in learning, behavior, and health, and half a century of program evaluation has documented positive impacts on a variety of outcomes. That said, the quality of program implementation has been highly variable and the magnitudeof the impactshas remained fairly stableduring the past several decades, consistently falling within the small to moderate effect-size range. The time has now come for a different approach to early childhood investment that catalyzes innovation, seeks far greater impacts, and views best practices as a baseline, not a solution.1,2 The cumulative knowledgebase constructedby the architects of theNurse-Family Partnership (NFP) during 3 decades hasclearlyearnedhighrankingonthe listofbestpractices.This highly disciplined group of investigators has designed, refined, and scaled the most extensively studied intervention model in the prenatal and early childhood arena—and demonstrated a range of impacts on perinatal health, child wellbeing, and maternal life-course outcomes.3 The most recent NFP report adds new data on postinterventionmeasures of childdevelopment at ages 6 and9years.4 Nurse-delivered services produced amixed picture of behavioral benefits (in contrast to negligible effects from paraprofessionals), but no significant impacts on school achievementwere foundateither age.Thesedataunderscore theneed for a deeper understanding of the adult capabilities that are strengthened by the NFP, the causal mechanisms that explainprogrameffectsonchildren, and the reasonswhy trained nurses achieve greater impacts than paraprofessionals. These findings also present a sober picture for decision makers seeking more effective strategies to strengthen the foundations of school success at a time when gaps in educational attainment associatedwith racehavenarrowedbutdisparities linked to family income have been growing and social mobility diminishing.5 Moreover, while advances in biomedical research have produced dramatic progress in the treatment of childrenwith cancer, cystic fibrosis, and human immunodeficiencyvirus/AIDS,persistent racial/ethnic and income disparities in key health indices have eluded solution. In this context, the limited extent to which new discoveries inneuroscience,molecularbiology, andepigeneticshavecatalyzed more effective strategies to reduce the biological embedding of early adversity presents an indefensible contrast.6 Growing evidence of the extent to which toxic stress can disrupt developing brain circuits, other maturing organs, and metabolic regulatory systems underscores the need for new interventions focused on reducing or mitigating the consequences of significant adversity.7,8 Three iconic intervention models that have been evaluated through randomized trials—the Perry Preschool Project, the Abecedarian Project, and the NFP—dominate the debate onearlychildhood investment.The1960sPerryPreschoolProject randomized trial (n = 123) studied 1 to 2 years of centerbased preschool for 3to 4-year-olds, linked to weekly home visiting that included parent coaching by a highly trained teacher.9 The 1970s Abecedarian Project randomized trial (n = 111) studied 5 years of center-based child care beginning in early infancy and delivered by highly skilled staff, without an obligatory parent component.10 The NFP, which has been studied in thousands of families in multiple sites, provides structured home visiting by trained nurses from the prenatal period to age 2 years. All 3 studies demonstrate that programs staffedbywell-trainedprofessionalscanproducemultiplechild and parent impacts but their service models are not comparable, their target populations differ, and theirmeasured outcomes vary. The Perry Preschool Project and theAbecedarian Projectproducedshort-termeffectsoncognitivemeasuresand long-term impacts on high school graduation, economic selfsufficiency, and (for the Perry Preschool Project only) reduced incarceration. Public discourse on the economic benefits of early childhood intervention is based almost entirely on the Perry Preschool Project data, but few of the thousands of programs provided in the United States today are replications of thatmodel. Likewise, advocacy for homevisiting services typically cites the impacts of the NFP, but most programs do not meet its rigorous standards. The time is long overdue for the scientific community to clarify the evidence base for early childhood investment. Generic statements about program impacts that do not link specific interventions to specific outcomes have limited meaning. Effects onparent behavior are not the sameas impacts on children, andchanges in childbehavior arenotproxies for academic achievement. Significant progress will require the disciplineddevelopmentof enhanced theories of change that are grounded in science and drive the design of explicit strategies focusedon specific causalmechanisms toproducebreakthrough gains on important outcomes. The fundamental challenge is not just the inability to produce larger impacts but also the absence of a research anddevelopment enterprise to encourage thedevelopment and testing of innovative strategies. Funding that is restricted solely Author Audio Interview at jamapediatrics.com