Giving children a better start in life: from science to policy and practice

Citation

Axford, J.B.a.N. (2014), "Giving children a better start in life: from science to policy and practice", Journal of Children's Services, Vol. 9 No. 2. https://doi.org/10.1108/JCS-04-2014-0025

Giving children a better start in life: from science to policy and practice

Article Type: Guest editorial From: Journal of Children's Services, Volume 9, Issue 2

Introduction

The Big Lottery Fund (BIG) is investing £165 million over the next 11 years in the Fulfilling Lives: A Better Start (ABS) programme[1]. This investment will facilitate the implementation and testing of different models of early intervention in between three and five disadvantaged areas across England. Alongside government-funded and third-sector providers working collaboratively across health, education and social care, the BIG Lottery investment will allow these areas to make structural changes to the way in which they identify and work with families at risk of poor outcomes. They will also be enabled to introduce a range of preventive interventions focusing on pregnancy and the first three years of life, with the aim of improving children's nutritional, socio-emotional and language/learning outcomes.

The focus on families living in disadvantaged areas is based on an accumulated body of evidence showing that social adversity is a significant predictor of later outcomes (Marmot, 2005; Marmot et al., 2008). In Fair Society: Healthy Lives, Marmot (2010) suggests that giving every child the best start in life is one of the key mechanisms for equalising the life-chances of children and reducing social adversity. The two time-points that are identified as being key to achieving this – pregnancy and the first two years of life – represent “sensitive developmental periods”, during which there is significant “biological embedding of adversities” (Marmot, 2010).

“Sensitive developmental periods” refer to biological time-points during which the effects of experience on the brain are particularly strong, and when certain types of experience need to be present. This input is also described as “experience-expectant” and involves basic sensory and motor functions, including visual and language systems. Although the precise mechanisms by which the experience-expectant development occurs are not yet well known (Twardozs and Lutzker, 2010), it is now accepted that if an infant's development is not functioning normally during this period, it can have long-term implications for the child's later wellbeing (Shonkoff, 2009).

A major Colloquium of the National Academy of Sciences (held on 9-10 December 2011), addressed the ways in which experiences of childhood adversity get ‘under the skin’ and affect physiological and cellular pathways leading to disease susceptibility and how adverse circumstances of children are ‘biologically embedded’ into the molecular, genomic systems that determine expressions of vulnerability and resilience (Boyce et al., 2012, p. 1). The series of papers that emerged from that colloquium presaged a new shape and direction for future research and in particular a developmental neuroscience of early stress and disadvantage (Boyce et al., 2012).

The biological embedding of social adversity refers to the way in which adverse factors, including relationships, nutrition, and the physical/chemical and built environments, can interact with the child's genetic predisposition either during sensitive periods in the development of the brain or other organs, or through the cumulative effects of damage over time (Center on the Developing Child, 2013), resulting in physiological adaptations and disruptions to the functioning of key organs, with significant consequences in terms of later functioning (Center on the Developing Child, 2013).

Shonkoff (2009), in a seminal paper that was published in the Journal of the American Medical Association, summarised the evidence about the ways in which social adversity disrupts developing brain architecture and other organ systems and regulatory functions. He highlighted the long-term consequences of this in terms of children's learning (i.e. linguistic, cognitive and socio-emotional skills), behaviour (adaptive vs maladaptive responses) and physiology (i.e. hyper-responsive/chronically activated stress response). The paper demonstrated the ways in which the latter is associated with stress-related chronic disease, unhealthy lifestyles and widening health disparities (Shonkoff, 2009).

The science of early child development

The papers presented in this special edition of the Journal of Children's Services examine some of these themes in terms of the implications for policy and practice across pregnancy and the first three years of life. The first paper in this edition, by Donkin et al., shows that there is a social gradient such that the lower a family's socio-economic status the greater the likelihood that they have children who are obese or have impaired social-emotional skills or language acquisition. It examines the way in which distal factors such as income and parent education, and proximal factors such as the quality of both early parenting and the home learning environment, can affect later outcomes.

In pregnancy, the biological embedding process is referred to as “foetal programming”, and two papers in this special edition examine the adverse factors during pregnancy that are associated with compromised development of the foetus, infant and child. The paper by Glover and Barlow examines maternal exposure at different stages in pregnancy to anxiety, depression and stress from a range of sources (e.g. bereavement, relationship problems, external disasters and war). It examines research showing the impact of such stress on a range of aspects of functioning, including physical (e.g. congenital malformations, reduced birthweight and gestational age), neurodevelopmental, cognitive, and emotional and behavioural (e.g. ADHD, conduct disorder) immediately postdelivery, and in infancy and later childhood. In the paper that follows, Gray et al. examine some of the wider factors that can affect the wellbeing of both pregnant women and their foetus, including maternal age at conception, preexisting physical health and disability, antenatal behaviours such as nutrition, exposure to a range of teratogenic substances(e.g. smoking and substances), intimate partner violence, preterm birth and physical/psychological problems postbirth.

The five papers that focus on the postnatal period address the way in which parenting practices impact on one of the three key outcomes of interest for A Better Start (i.e. nutrition, socio-emotional and learning/language development). At the heart of all papers in this edition is a recognition of the need for sensitive and responsive adult-child interactions and relationships for diverse aspects of children's wellbeing: their healthy nutritional and physical development (Summerbell et al.), their ability to manage stress (National Scientific Council on the Developing Child (NSCDC); Glaser) and to regulate themselves emotionally and develop secure attachments (Van der Voort et al.), their effective language and cognitive development (Mathers et al.), and their ability to move beyond early social disadvantage (Donkin et al.).

Summerbell et al. describe research showing that children's eating and physical activity habits, together with children's weight status, are influenced by a range of eating-related parenting practices. These include feeding styles (i.e. pressure to eat, restriction, monitoring and control of dietary intake), instrumental behaviours (i.e. using food as a reward), availability (i.e. degree to which parents provide a healthy environment), role modelling (i.e. particularly weight-related behaviours) and nutritional knowledge.

Two of the papers in this special edition examine the impact of early stress on the infant's rapidly developing neurological system, and the impact of parent-infant interactions in moderating the impact of such stress. The NSCDC paper examines the impact of “toxic stress”, defined as the strong, frequent or prolonged activation of the body's stress management system. It describes the way in which prolonged elevation of cortisol levels can alter the function of a number of neural systems, suppress the immune response, and change the architecture of regions in the brain (e.g. the Hippocampus) that are essential for learning and memory. It also examines the evidence about the influence of cortisol on epigenetic processes, in which some specific genes are turned “on” and others “off” at particular times and locations in the brain. The authors show that sensitive and responsive caregiving from a parent or a child-care provider (i.e. when it is provided in out-of-home settings) can serve as a powerful buffer against stress hormone exposure.

Glaser's paper also highlights the way in which environmental neglect can impact on brain architecture and functioning, reducing the volume of both white and grey matter. She examines research showing that severe neglect in institutional settings can affect metabolic activity in limbic and paralimbic regions and structural changes in brain connectivity from the amygdala to areas of the prefrontal cortex. Her paper also depicts the way in which children who are exposed to early aggression, such as physical abuse, have an enhanced recognition of angry faces as demonstrated by larger electrical potential recordings in the brain when looking at pictures of angry, rather than happy or fearful, faces, and preferentially discriminating all faces as angry.

Two of the papers in the edition examine the impact of intersubjectivity during the first three years of life in terms of a child's early socio-emotional development (Van der Voort et al.) and their language and learning (Mathers et al.). Van der Voort et al. examine the impact of both maternal sensitivity in the development of secure attachments, and “atypical” parenting behaviours in which the parent is both frightened and frightening (Fr-behaviour), in the development of insecure and disorganised attachements. They show the ways in which both insecure and disorganised attachment can impact on a range of aspects of later development, including neurobiological development, social competence, and risk of later internalising and externalising problems.

Mathers et al. also highlight the importance for children's early learning of early interactions in which young children take the lead. They describe the way in which, in the context of close supportive interactions, babies learn to manage and regulate their emotions and develop a growing sense of self-awareness (i.e. of their own identity and agency) and of social awareness, and the contribution this makes to children's language and cognitive abilities. They also highlight the important role of play for supporting children's development and learning during the early years and beyond.

Implications of the science for policy and practice

The overall aim of the BIG Lottery funding is to improve the long-term life-chances of children who are born into poverty, and the papers in this edition also examine the implications of the evidence described above for policy and practice. The paper by Donkin et al. highlights the fact that poverty can impact on children's wellbeing through both direct (i.e. investment model and the impact of poverty on the ability of parents to give their children access to resources that promote optimal development) and indirect routes (i.e. family stress model and the impact of poverty on parenting stress and the ability to parent well). While most of the papers focus on interventions that are aimed at addressing the second of these two routes, Donkin et al. also highlight some of the measures that can be taken to improve the income of families. These include guaranteeing families a living income through policy measures to ensure that businesses provide a living wage, the development of welfare-to-work reforms designed to promote employment and to make work pay, increases in financial support for children in families through child tax credits, and direct investment in education, social and health services. They also examine some of the US interventions that have been used to increase family income (e.g. programmes such as New Hope, which provides community-based jobs, help with job-searches, monthly income supplements, and health insurance and child-care subsidies).

The remaining papers examine ways of addressing the indirect impact of poverty on children's outcomes. The NSCDC highlights the significant gap between science and policy in terms of the development and implementation of strategies to prevent or reduce significant stressors that affect children and families every day. They highlight, for example, limitations in terms of: the availability of maternity/paternity leave following pregnancy/adoption; convenient, affordable, high-quality early care and education; efforts to reduce high job turnover in child-care programmes; and access to clinical expertise in mental health for very young children. They also criticise the overuse of stimulants and anti-depressants to manage children's emotional and behavioural problems.

Two papers describe some of the evidence-based methods of addressing the indirect impact of poverty during pregnancy through the provision of interventions that can improve health-related behaviours (Gray et al.) or severe stress and depression during pregnancy (Glover and Barlow). A number of the papers describe evidence-based methods of working to improve outcomes during the postnatal period – diet and nutrition (Summerbell et al.), children's socio-emotional development (Van der Voort et al.; NSCDC; Glaser) and children's early learning (Mathers et al.) – by improving the interactions between primary caregivers and their infants/toddlers. The papers by Summerbell et al. and Mathers et al. extend the evidence to caregivers and caregiving outside the home, identifying a range of methods of working with children in early years settings that can improve their nutrition, and language and cognition.

There have been varying degrees of success in improving outcomes for young children through the provision of such early preventive intervention. Compare, for example, the diverse benefits identified by the early US High-Scope Perry Preschool initiative (Schweinhart, 2005) with the more limited benefits of the UK Sure Start initiative (Belsky et al., 2007). Problems in demonstrating benefits are not evidence, as some have argued (e.g. Lee et al., 2014), of the weakness of the research about the importance of early parenting. Rather, they reflect a continuing lack of the type of nuanced information about what works, for whom, under what circumstances (Pawson and Tilley, 1997) that is necessary to ensure that services are effective in meeting the needs of parents experiencing significant adversity. The lack of success in changing outcomes also highlights the need for better use of the rapidly developing “implementation science” that enables both practitioners and policy makers to deliver services with integrity, and in ways that match parents’ needs and their readiness for change (e.g. Halle et al., 2013).

All of the papers in this special edition represent the views of experts who were invited to present the case for early preventive intervention during pregnancy and the first three years of a child's life, and who have drawn on a range of sources to do this, many of which are rigorous systematic reviews, and all of which are scientific studies of one type of another. None of the evidence presented suggests that the events that occur to a child during this period are consistent with what has been described as “parental determinism”[2] (Furedi, 2008) or “infant determinism”[3] (Wastell and White, 2012; Lee et al., 2014), and none of the interventions recommended by the papers in this edition involve “blaming” parents. Rather, such interventions have been informed by a highly rigorous and substantial body of evidence about the biological embedding of social adversity during sensitive developmental periods, and the related financial benefits of investing during this period relative to later timepoints (www.heckmanequation.org), alongside an economic case for such investment in disadvantaged children (Heckman, 2006). They also represent examples of strengths-based methods of supporting parents who are experiencing multiple sources of adversity, and have evidence that they are effective or are promising in terms of improving the wellbeing of children who would otherwise be disadvantaged as a result of their early life circumstances.

Next steps

A Better Start has been designed to address the problems that were highlighted by earlier area-based initiates of this sort (e.g. Sure Start), and has involved significant investment in terms of the selection and implementation of the services being provided – including our own contributions in terms of providing an underpinning evidence base (Axford and Barlow, 2013a, b). The large-scale evaluation of A Better Start that is planned, to be led by the first author, is aimed not only at assessing its impact in the short and medium term (i.e. up to children being nine years of age), but also at providing much needed evidence about some of the potential mechanisms that have been identified by this collection of papers.

Jane Barlow and Nick Axford

Notes

1. http://www.biglotteryfund.org.uk/betterstart

2. Parental determinism’ claims that this scientific literature is used to create discourses that locate the everyday activities of parents as being responsible for the later problems of children and thereby wider society (Lee et al., 2014).

3. Infant determinism’ is described as a discourse that “attributes lifelong outcomes to infant experience” (Lee et al., 2014).

References

Axford, N. and Barlow, J. (2013a), “The science within: what matters for child outcomes in the early years”, report for the Big Lottery A Better Start initiative, available at: http://betterstart.dartington.org.uk/resources/evidence-reviews/science-within/ (accessed 24 April 2014)

Axford, N. and Barlow, J. (2013b), “What works: an overview of the best available evidence on giving children a better start”, report for the Big Lottery A Better Start initiative, available at: http://betterstart.dartington.org.uk/resources/evidence-reviews/what-works/ (accessed 24 April 2014)

Belsky, J., Barnes, J. and Melhuish, E. (2007), The National Evaluation of Sure Start: Does Area-Based Early Intervention Work?, Policy Press, Bristol

Boyce, T.W., Sokolowski, M.B. and Robinson, G.E. (2012), “Toward a new biology of social adversity”, PNAS, Vol. 109 No. 2, pp. 17143-48

Center on the Developing Child (2013), How Early Experiences get into the Body: A Biodevelopmental Framework, Center on the Developing Child, Harvard, available at: http://developingchild.harvard.edu/resources/multimedia/interactive_features/biodevelopmental-framework/ (accessed May 14, 2014).

Furedi, F (2008), Paranoid Parenting: Why ignoring the experts may be bet for your child, 2nd ed., Continuum, London and New York, NY

Halle, T, Metz, A and Martinez-Beck, I (2013), Applying Implementation Science in Early Childhood Programs and Systems, Paul H Brookes Pub Co, Baltimore, Maryland

Heckman, J.J. (2006), “Skill formation and the economics of investing in disadvantaged children”, Science, Vol. 312 No. 5782, pp. 1900-2

Lee, E., Bristow, J., Faircloth, C. and Macvarish, J. (2014), Parenting Culture Studies, Palgrave Macmillan, Basingstoke

Marmot, M. (2005), “Social determinants of health inequalities”, Lancet, Vol. 365 No. 9464, pp. 1099-104

Marmot, M (2010), Fair Society: Healthy Lives: The Marmot Review, University College, London

Marmot, M., Friel, S., Bell, R., Houweling, T.A. and Taylor, S. (2008), “Commission on social determinants of health. Closing the gap in a generation: health equity through action on the social determinants of health”, Lancet, Vol. 372 No. 9650, pp. 1661-9

Pawson, R. and Tilley, N. (1997), Realistic Evaluation, Sage, London

Schweinhart, L.J. (2005), Lifetime Effects: The High-Scope Perry Preschool Study Through Age 40, High/Scope Press, Ypsilanti, MI

Shonkoff, J. (2009), “Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention”, JAMA, Vol. 301 No. 21, pp. 2252-9

Twardozs, S. and Lutzker, J.R. (2010), “Child maltreatment and the developing brain: a review of neuroscience perspectives”, Aggression and Violent Behavior, Vol. 10 No. 15, pp. 59-68

Wastell, D. and White, S. (2012), “Blinded by neuroscience: social policy, the family and the infant brain”, Families, Relationships and Societies, Vol. 1 No. 3, pp. 397-414

About the Guest Editor

Jane Barlow was appointed Professor of Public Health in the Early Years at the University of Warwick in October 2007. Her main research interest is the role of early parenting in the aetiology of mental health problems, and in particular the evaluation of early interventions aimed at supporting the parent-infant relationship during pregnancy and the postnatal period. She is the Director of the newly established Warwick Infant and Family Wellbeing Unit (WIFWu), which provides training and research in innovative evidence-based methods of supporting parenting during pregnancy and the early years to a wide range of early years and primary care practitioners. She has also researched extensively on the effectiveness of interventions aimed at preventing and treating abuse and is a strong advocate of a public health approach to child protection. She is leading the evaluation of A Better Start. Professor Barlow is the corresponding author and can be contacted at: mailto:jane.barlow@warwick.ac.uk

About the Editor

Nick Axford is a Senior Researcher at the Social Research Unit, Dartington. He leads the Unit's work on identifying “what works” as regards improving children's wellbeing. This includes the Investing in Children web site (http://www.investinginchildren.eu), a project for the European Commission on interventions tested and found effective in Europe, and reviews of the evidence in a given field – most recently for the Big Lottery A Better Start initiative and the Healthy Child Programme 0-5 years (both with Jane Barlow).