We Need a Comprehensive Psychosocial Care System for Preschool Children

Every country should rethink its strategy for the care of preschool children, particularly those aged under three. Recent learning from developmental psychology and neuroscience, as well as the need to make workplaces productive and economies successful, all demand a fresh look at family supports from pregnancy onwards.

The contemporary ad hoc approach to developing preschool children has been rendered obsolete by recognition that the first three years of life witness a never-to-be-repeated explosion in brain development. As a result, what happens in these first years determines, to a considerable extent, infants’ future social relationships, experiences, personalities, behaviours and outcomes.

The preschool years are vital not only for individuals but for nations, their economies and their societies. Yet current public policy continues to reflect an outdated assumption that mothers are financially able to stay home and are willing and sufficiently skilled to provide all the care and stimulation needed to make the most of this early period of dramatic development.

This false premise helps explain the hotchpotch of inadequate or, often, nonexistent provision for preschool children almost everywhere – with the United States well down the league table. This approach should be replaced by a well thought-out system of psychosocial care for our youngest children, mirroring the commitment of schools to provide a wide range of services and universal availability for older children.

Cost of poor care for preschool children

The losses caused by existing preschool strategies are considerable. In the US, despite economic growth over the past 40 years, we have seen population-level declines, albeit modest, in children’s health, well-being and social relationships, according to the Duke Child Well-Being Index. Educational attainment has been flat. Children’s kindergarten readiness skills have increased only modestly over the past 25 years. In the past two decades, the rate at which infants are born underweight has actually increased.

These failures have been compounded by inadequate progress for preschool children living in poverty, which has led not only to underdevelopment of their potential, but also to increasing disparities with children from better-off backgrounds. These better-off children are getting much more of what they need when they can benefit most from it – in those crucial early years. The differential outcomes for poor children often change, and disadvantage, their lives forever.

Some countries, notably in Scandinavia, as well as New Zealand and the Netherlands, have an approach to preschool support that is more coherent for fostering child development from infancy. They support parents being at home and access to high-quality childcare and education. But the US has only pockets of preschool programs that hint at the possibilities of a more systematic approach: typically Head Start, home-visiting programs that serve only a fraction of young children in a community, maybe a food bank, prekindergarten for some children, and perhaps a church-based program directed toward the most vulnerable families. The resulting preschool menu might look good on paper, but the kitchen runs out of food before parents know what to order.

Too little is spent on preschool children

We spend many more tax dollars per person as children get older, despite scientific certainty that neuronal development and brain plasticity reach their peak in early life during the preschool years – as does the likelihood of intervention success. Ask any parent when in their child’s life they need money most, and they will say the earliest years, when parents’ income is lowest. In the US, we spend $12,401 annually on each school-aged child, but only $2,566 per year on each child from birth to age five, according to the 2018 study ‘Cradle to kindergarten: A new plan to combat inequality’ by Ajay Chaudry et al.

We know how to tackle the problem: we could create a preschool system for this youngest group that is both universal and comprehensive. After all, the US has the best-regarded and accessible higher education system in the world, and it established the world’s first universal public school system 200 years ago. However, this system didn’t —and still doesn’t — recognise what we now know: namely, that the most crucial years have already passed by age five.

Our public school system offers a guide for reformers of preschool care in its provision of wide-ranging services. Children receive more than education for literacy. Children in need are given free nutritional support. When counselling is required, it can be provided. A school nurse is usually on hand. If a child is being abused, a social worker has been trained to detect it. So schools are good examples of how to focus on the whole child and how to address a breadth of needs.

Piloting a pre-school psychosocial system

Of course, we don’t want to replicate public schools for one-year-olds. But we have learned that we need a two-barrelled approach for preschool care that provides both investment in community resources from the top down and ways for every family to access the resources it needs from the bottom up.

We have tested two key ingredients that would be essential in developing a psychosocial preschool care system from pregnancy and infancy up to school age. The system would require, first, an expansion in the capacities of evidence-based community resources. Second, there would have to be a way for all parents and children to navigate these resources to ensure access to the help they need.

Some communities are creating innovative, experimental models of universal preschool psychosocial care. The Family Connects program in Durham, North Carolina, for example, has developed an infrastructure of community agencies that are committed to supporting families during their children’s preschool years.

From the top down, the community has aligned itself through an electronic directory that includes 400 professional, paraprofessional and volunteer agencies providing preschool support to families. From the bottom up, a trained nurse greets every mother in the birthing hospital to welcome the family into the community and to communicate that every child and parent can be successful but everyone needs some help.

“We know how to create a pre-school care system for this younger group that could be both universal and comprehensive.”

From there on, the program is entirely voluntary. The nurse makes one to three home visits to listen to the family and determine exactly what the family needs and what resources could help them. The assessments cover healthcare, family safety, financial stability, parenting and parental mental health. In about half of the cases, the nurse works with the family to figure out how to meet their needs. In other cases, the nurse connects the family to community resources that can help tackle problems such as maternal substance abuse, financial crises and depression. In all cases, the nurse links the record to the family’s paediatrician for continuing care.

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Four independent evaluations have shown that the preschool intervention is associated with parent satisfaction, improved outcomes for infants at six months, better connections to community resources, more positive parenting, increased father involvement, lower maternal anxiety and enhanced home safety.

The first randomized controlled trial showed that at age five, a significantly lower rate of child-abuse-investigated cases and emergency department visits had been recorded for the Family Connects group of children than for a control group. Each evaluation has shown promising results, but each has also found areas where the program could improve. Evaluations need to continue so that Family Connects 2.0 will be even better than the current version.

Better data on preschool children

A lack of effective data systems for young children can create a barrier to connecting families with community agencies. Imagine healthcare today without your electronic health record. We are designing a digital, family-level information system that could become a child’s cumulative psychosocial record of screenings, interventions and assessments. This record could be the psychosocial equivalent of an electronic health record, an invaluable tool for focusing supports for each child’s preschool care.

The tool also enables aggregation of measures to chart population-wide improvement. If we create such records for every consenting child in a community, we will have a comprehensive assessment of family needs. If we compare that assessment with a map of available community resources, our leaders can identify community-specific gaps in resources so that we can deploy public resources in a more economically-efficient manner. The result would be a 21st-century system of preschool care for young children.