Abridged Version
Starting Points
Meeting the Needs of Our Youngest Children

Ensure Good Health and Protection

ew social programs offer greater long-term benefits for American society than guaranteeing good health care for all infants and toddlers. We realize the return on that investment when fewer children suffer from preventable illnesses and disabilities, when fewer parents bear the burden of caring for sick children and paying their medical bills, when more healthy children and adolescents succeed in school and, in time, form a more productive workforce and become better parents. We don't have to guess about the benefits of early health care; indeed, in no other area of social policy can costs and benefits be calculated so precisely. For example, every dollar spent on childhood immunizations saves ten dollars in later medical costs.

Being healthy also means being safe. At present, many infants and toddlers are not safe. Some grow up in neighborhoods where a walk to the grocery store or an afternoon in the playground may be fraught with danger. Some spend long stretches, while their parents work, in substandard child care, under the supervision of underpaid, distracted babysitters, or in the care of brothers or sisters who themselves need more adult attention. And too many are at risk even when cared for by their own parents: some may suffer neglect or outright abuse; others may have parents who do not realize that their practices, or the setting they've provided, are unsafe.

To ensure good health and protection to our youngest children, this nation must

Provide needed health care services for all infants and toddlers

Protect infants and toddlers from injury and promote their health

Create safe environments for infants and toddlers

Provide Needed Health Care Services for All Infants and Toddlers

Unfortunately, not all young children now receive adequate health care. The American Academy of Pediatrics recommends nine well-child visits by age two, but fewer than 50 percent of all two-year-olds have visited the pediatrician that often. Immunization remains haphazard, with predictable consequences. In 1992, more than 60 percent of children in most states had not received a complete sequence of recommended immunizations by age two.

The supply of health professionals and the quality of child health care vary significantly by community: the most inadequate prenatal and child health services are found in low-income, minority, and transient communities. As a result, our poorest communities are plagued by high rates of infant mortality, low-birthweight babies, communicable childhood diseases, and child abuse. Children growing up in poverty suffer from higher rates of malnutrition and anemia than do other children. Many of the tragedies represented by these statistics are preventable.

Children in poverty are not alone in receiving inadequate health care; nearly 13 percent of America's children do not have access to the health care services they need to grow up healthy. In 1992, 8.4 million children lacked access to health care services because they had no insurance, and millions more were insured for only part of the year. Most children rely on working parents for health care coverage, yet nearly 80 percent of uninsured children are dependents of working parents.

In 1979, the Select Panel for the Promotion of Child Health--a federal group composed of leading health care professionals--undertook a thorough review of children's health care. Fifteen years later, the task force agrees with the panel's conclusions:

Health care services for all children must be comprehensive, preventive, and primary.

The 10 percent of children who have chronic or disabling conditions need, in addition, specially designed services and support.

Comprehensive services include parental education and counseling.

Access to health care must be ensured through services such as transportation to health facilities and translators who can speak with parents and children in their own language.

The task force identified two elements that would go farthest toward ensuring that children under three receive needed health care services. First, pregnant women, infants, and toddlers must be explicitly included in health care reform. Second, home visiting services should be available as part of comprehensive health services.

Reform Health Care. Health care reform should result in comprehensive health care services for all our nation's children. The task force recommends that pregnant women and all children under three be the first to be included in a universal system. Moreover, the task force agrees that the health care needs of infants and toddlers call for services that are broader in scope than those designed for older children and adults, and in certain instances they must be of greater intensity and duration than would be possible under a more general standard.

Young children need comprehensive health care because their needs differ markedly from those of older children and adults. Infants' and toddlers' unique needs arise from their developmental vulnerability and the degree to which they are dependent on others--on their parents and on social and governmental institutions--for their health care.

Attempts at cost control may have unintended adverse effects on the quality of health care. The design or revision of a benefits package must take into account not only budgetary considerations and national priorities, but also scientific criteria for adequate health and medical care. Meaningful grievance procedures must enable consumers and providers to protest unfair practices or unintended consequences. To achieve this, consumers and clinicians must work with policymakers in defining what constitutes a child health care service.

Clearly, money is the main barrier between America's young children and the health services they require; but other nonfinancial barriers must also be surmounted. These include

Capacity shortages. Many communities do not have enough providers, especially pediatricians, family practitioners, and nurse practitioners.

Unfriendly services. Even parents who are motivated to seek out health services sometimes find them unfriendly and hard to access.

Undervaluing of preventive services. Many parents who obtain health care when their children are sick are unlikely to use preventive services like well-child visits or immunizations, particularly when these services are not easily available.

Lack of continuity. Many young children do not have a primary health care provider.

Other barriers include the violence, drugs, and social isolation found in some impoverished inner-city neighborhoods--conditions associated with low levels of health care. Expectant mothers in these neighborhoods are far less likely to receive adequate prenatal care than those in more affluent locales; and preschool immunization rates are also low in these areas. Already overstressed, these children and their families should not have to add inadequate health care to their list of everyday life problems.

Provide Home Visiting. One promising way of improving health outcomes among families with young children is home visiting. For more than a century, home visiting has existed in the United States as a strategy for delivering health care, information, and support services to pregnant woman and families with young children. Today, home visiting services are drawing attention as a promising preventive strategy. [See Healthy Families America sidebar.]

The current practice of early hospital discharge after the birth of the newborn makes home visiting an attractive strategy during the first six weeks of life. In addition to providing education and advice, the home visitor can be an important link between the family and community services and supports. Some states now offer voluntary home visiting services to all new parents and provide more intensive services to at-risk families with young children.

Especially effective are comprehensive prenatal and infant services, in which trained nurses or paraprofessionals visit unmarried, adolescent, uneducated, or low-income mothers and their children. These programs have successfully encouraged expectant mothers to stop smoking, eat a balanced diet, use the WIC nutrition supplementation program, and seek childbirth education. In families that have been visited, the incidence of low-birthweight babies, child abuse and neglect, and childhood injuries has decreased. Home visiting programs are also cost-effective. In one study, by the time the children had reached the age of four, the government had saved $1,722 per child for the entire sample and $3,488 per child for low-income families.

The task force recommends that home visiting services be offered on a voluntary basis as part of comprehensive health services to all first-time parents and their newborns. More intensive home visiting services would have the greatest benefit if offered to all families in communities with high rates of poverty and large numbers of single, young mothers. These voluntary services could help those most likely to benefit without singling out any particular mother or child in the neighborhood.

Protect Young Children from Injury and Promote Their Health

Unintentional injuries remain the leading cause of death among children aged one to four. Children growing up in poverty are more likely to die from an unintentional injury than children from better-off families. While many childhood injuries do not result in death, they may result in disability or disfigurement and may compromise a child's future development, well-being, and achievement. Because most of these injuries are preventable, the task force recommends new public strategies to reduce the incidence of unintentional injuries to young children. These strategies must include broad-based community efforts to encourage the use of child safety seats, fire alarms, window guards, and flame-retardant sleepwear, and to reduce the temperature of tap water in homes and child care settings.

Promoting young children's health is a responsibility shared by parents, other caregivers, educators, the community, and health officials at all levels of government. But how can we best support parents' own efforts to promote their children's health? First, community leaders can identify what needs to be known by parents and others in the community. Second, programs to teach health-promoting behaviors to parents can be started in accessible settings at convenient hours. Third, religious, civic, business, and other community organizations can communicate information about children's health, setting as their highest priority the good health of every neighborhood child. [See Safeguarding Children sidebar.]

Create Safe Environments for Young Children

Although most research and public debate about violence have focused on school-aged children and adolescents, violence also affects pregnant women, infants, and toddlers. Women face the highest risk of violence by a male partner during their childbearing years, and most particularly during pregnancy. The abuse of pregnant women leads to serious risks for the infant, including low birthweight, birth defects, prematurity, and even such grave consequences as stillbirths and infant mortality.

Very young children are also victims of abuse. Of the two million children who experience physical abuse or neglect each year, more than a third are infants under one year of age. In 1990, almost 90 percent of those children who died as a result of abuse were under the age of five; 53 percent were less than a year old.

There is no doubt that repeated exposure to violence threatens children's healthy physical, intellectual, and emotional development. Parents, too, are affected by a climate of violence; they often lose confidence and are so traumatized that they find it difficult to be emotionally responsive to their children. The task force concludes that this nation must make a clear commitment to the right of all young children to grow up in safe homes and neighborhoods. Parents would benefit from family-centered approaches to help them understand the profound effects of violence in the home and in the community on young children. Energy and resources must be directed toward preventing violence in children's lives and dealing with the damage that has already occurred. The task force recommends these interventions:

Adopt family-centered approaches. The strongest buffer for young children living in dangerous environments is a supportive relationship with parents. Parent education and family support programs can help parents understand their critical role in the lives of their children. Parents should have access to proven programs that prevent child abuse and neglect and must be taught skills in nonviolent conflict resolution. Supportive networks and individual counseling should be available to parents when necessary.

Initiate community-based efforts. Increased funding must be made available for community programs that address violence prevention, such as partnerships between child and family services and law enforcement agencies. For maximum effectiveness programs must be implemented locally. Such efforts convey to families that they are not alone--that society is committed to addressing violence in their communities.

Control access to guns. Ridding our communities of violence requires nothing less than the removal of all guns, except those lawfully registered under stringent controls. Parents must be made to understand that possession of a gun for protection actually increases the chances of their children being injured or killed. Clearly, however, before parents can accept this understanding and act on it, they must be confident that their communities are safe.

Part II Chapter 3 Sidebars

Healthy Families America

In 1992, more than 2.9 million cases of suspected child abuse were reported, many of them among children from birth to three years of age. Research indicates that the best way to promote healthy child development, to strengthen families, and to prevent child abuse is to provide parents with education and support beginning with the birth of their first baby, ideally by means of a voluntary program of home visits. Hawaii's Healthy Start Program is an effective model. This initiative provides an initial home visit and assessment of all families with newborns. "At-risk" families are identified and provided with family support, family crisis resolution strategies, and mental health services. Based on Healthy Start, Healthy Families America was launched in 1992 to lay the foundation for a nationwide neonatal home visiting program. Initiated by the National Committee to Prevent Child Abuse,

in partnership with the Ronald McDonald Children's Charities, Healthy Families proposes to establish intensive home visitor programs in areas where parents lack education and support programs and to build onto existing programs wherever possible. The need for such programs is particularly great where children are at greatest risk for abuse or neglect (that is, in communities with high percentages of low-birthweight babies, births to unmarried adolescents, and children living in poverty). Community-based parent education and support programs exist in the United States, but few are statewide, comprehensive, and well-coordinated with other federal, state, and local programs. Healthy Families America intends to improve this situation. Efforts are under way in all fifty states to build a Healthy Families America system, and eleven states are operating small pilot programs.

Safeguarding Children

A napping baby sprawled on the back seat of a car; a toddler who picks at the paint on the kitchen wall and then eats it; an infant teething on a sharp-edged toy--they're all in danger. Many young children risk injury or illness all day long without venturing far from their normal routines. The good news is that concerted efforts to childproof homes and reduce risks in the car and the neighborhood do work. Risk reduction requires parent education, so that new mothers and fathers (and other caregivers) can learn to spot possible hazards and prevent injuries; at the same time, policymakers, manufacturers, and community groups, must take a proactive approach to safeguarding children. One effort to create injury-free environments for children is Communities for Child Safety, a program administered by the National 4-H Council. This program defines injury broadly to include intentional, unintentional, physical, and emotional harm. It brings together people who work in injury control and those who work in child abuse and neglect.

Begun in 1987 in Chicago, Communities for Child Safety sends two-person teams into neighborhoods to collect information on hazards, to develop networks with key organizations and support groups, to educate local residents, and to persuade local government and organizations to change their policies and approaches. Teams urge communities to hold child safety fairs, to assess home safety, to offer infant/child CPR classes for parents, to educate parents in child safety, to establish fire safety programs, to work to prevent child abuse and neglect, and to clean up vacant lots and playgrounds. The goal is a community injury prevention plan.