Optimizing the Health and Development of Children
Authors: Neal Halfon
Journal: JAMA (2003)

THE PROGRESS THAT US SOCIETY HAS MADE IN HEALTH promotion is evident in the almost doubling of life expectancy in the 20th century, the compression of morbidity, and the increased functional capacity. Much of the improvement in health and functional ability at the end of life is influenced by what happens much earlier in life. The idea that health “develops” during childhood is evident from emerging studies tying early health and developmental potential to later educational attainment, disease burden, and disability. As innovative strategies focus on promoting “health for all,” optimizing the healthy development of all children will require greater attention. Children’s health and health care delivery are defined by those same characteristics that distinguish children from adults: their developmental vulnerability, their dependency on adult caregivers, and the determinants and distribution of morbidity and disability. Unlike care for adults, the emphasis of care for children is not just on staying healthy or maintaining health status but instead on actively promoting health and well-being. A growing evidence base is drawing the attention of policymakers and clinicians to this critical need of not just maintaining but actually optimizing the health of children. Several decades of brain research document the role of early experience in determining lifelong learning, emotional wellbeing, and social attainment; longitudinal epidemiologic studies identify early childhood origins of adult disease and provide evidence of predisease pathways that start in early childhood; and demographic analyses show that many health and social disparities that have their origins in early childhood are compounded as children grow into adolescence and adulthood. The National Academy of Sciences’ landmark report From Neurons to Neighborhoods documented that early experiences, especially early relationships, play an important role in cognitive, social, and emotional development. Early intervention research shows that intensive, comprehensive early intervention and education programs can alter developmental “trajectories” and substantially improve health, educational, and social outcomes from middle childhood through adulthood. Economic analyses also show that investments in early childhood create substantial social wealth. This research is all the more compelling given the current status of young children in the United States. Many children are exposed to preventable risks, such as parental drug use, mental health problems, and poverty. It is estimated that 20% of all parents who are primary caregivers experience clinical symptoms of depression that may preclude optimal parenting. Longitudinal studies show that high school achievement is highly correlated with capacities early in childhood, yet many low-income children start school 1 year behind children from higher-income families and continue to lag behind, even when given access to the best schools. Racial/ethnic disparities also abound; a 1996 national survey of families with young children found that 37% of white children had 1 or more risk factors for adverse outcomes, with higher rates among African American (66%) and Latino (72%) children. From Neurons to Neighborhoods suggests that pediatric clinicians are well positioned to improve child health and developmental outcomes, yet are not fulfilling this important role. Nearly half of parents have concerns about their young child’s behavior (48%), speech (45%), or social development (42%). These concerns are important to address, given that previous studies suggest that about 70% of children with developmental problems at kindergarten entry could have been identified earlier, but were not. The National Survey of Early Childhood Health (NSECH) shows that in 2001, fewer than half of parents ever recalled their child’s development being assessed by the health care provider, although professional guidelines call for assessments at most visits. The NSECH also shows that many parents are not being counseled on key recommended developmental issues, although parents express interest in this information to help them in their parenting.