Mar 10, 2015 - nurturing support system envelopes and inspires all children throughout ..... in neighborhoods and school
AAP Headquarters 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019 Phone: 847/434-4000 Fax: 847/434-8000 E-mail:
[email protected] www.aap.org Reply to Department of Federal Affairs Homer Building, Suite 400 N 601 13th St NW Washington, DC 20005 Phone: 202/347-8600 Fax: 202/393-6137 E-mail:
[email protected]
Executive Committee President Sandra G. Hassink, MD, FAAP President-Elect Benard P. Dreyer, MD, FAAP Immediate Past President James M. Perrin, MD, FAAP Executive Director/CEO Errol R. Alden, MD, FAAP Board of Directors District I Carole E. Allen, MD, FAAP Arlington, MA District II Danielle Laraque, MD, FAAP Brooklyn, NY District III David I. Bromberg, MD, FAAP Frederick, MD District IV Jane M. Foy, MD, FAAP Winston Salem, NC District V Richard H. Tuck, MD, FAAP Zanesville, OH
March 10, 2015 Dear Senator: The American Academy of Pediatrics (AAP) is a non-profit professional organization of 62,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults. As children’s health experts and advocates, we are writing to address what we believe to be the key issues facing children’s education and health today. The Academy hopes to inform your ongoing efforts to promote learning through policies that promote child health and development so that our nation’s youth may experience lifelong health and become the future leaders of America. As the 114th Congress gets underway, we appreciate the opportunity you have to reauthorize the Elementary and Secondary Education (ESEA) Act. These next two years offers a tremendous opportunity to ensure that current and future generations of America’s children grow into healthy, productive members of society. As pediatricians, we know that children start learning from the day they are born and that it is crucial that they receive the proper health care, social supports, stimulation, nutrition, exercise and nurturing environments to ensure proper brain development that leads to academic success. We support our nation’s youth from the cradle to college to career. We know the importance of an educational emphasis across the lifespan is heightened in the context of new research showing that adverse childhood experiences are linked with “toxic stress,” a complex biologic phenomenon associated with significant and irreversible changes in children’s brains and lifelong effects on learning and communication. It is only with comprehensive and longitudinal approaches to education and health policy that we will raise the next generation of productive, healthy, and active citizens to lead our country to a better future. It is vital that education policies consider children from birth to college as more than half of all public schools include early learning programs from infancy to school age.
District VI Pamela K. Shaw, MD, FAAP Kansas City, KS District VII Anthony D. Johnson, MD, FAAP Little Rock, AR District VIII Kyle Yasuda, MD, FAAP Seattle, WA District IX Stuart A. Cohen, MD, MPH, FAAP San Diego, CA District X Sara H. Goza, MD, FAAP Fayetteville, GA
Child health begins before birth Healthy families make healthy babies. The health of a child begins before birth; a pregnant mother’s health and wellness have profound implications for the health of her developing fetus. Supporting policies that recognize the power of prevention, including tobacco cessation and drug abuse counseling, nutrition and mental health services, and a full panel of recommended screening tests and procedures, will reduce pre-term births, low birth weight infants, and numerous other causes of physical and
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cognitive delays. Studies have shown that chronic stress in mothers, even while pregnant, can negatively and irrevocably impact the subsequent brain development of the child, causing emotional and behavioral disturbances as well as learning difficulties.1 Preventive health programs play an essential role in supporting mothers before, during, and after their pregnancies to create a healthy platform from which to build the health and development of their young children. Although schools and child care play a major role in children’s health and development, engaging families and communities is necessary to ensure long-term success. Schools actively should engage parents in their children’s education to ensure that behavioral and developmental achievements in school can be continued at home and across the generations. In addition, the provision of home visiting services during the first years of life further reinforces best practices and addresses deficiencies in the home setting. Finally, as an equal partner with the educational system, the medical home is paramount to improving physical, emotional, social, and cognitive health indicators across all demographic groups. Improved linkages between schools and a child’s medical home means that pediatricians can help with the dissemination of health materials, early literacy materials, and more. Emphasis on such broad community involvement – from teachers and parents to neighborhood leaders and pediatricians – ensures that a holistic, nurturing support system envelopes and inspires all children throughout their lives. Emotional stressors in early childhood impact children for life. Success in school is strongly linked to physical, mental, and emotional health. Just as routine medical visits and screenings, vaccinations, quality nutrition, and physical activity are essential in a child’s growth and development, so too is the quality of social and emotional support. A comprehensive and coordinated approach to children’s health and wellness ensures that young children are prepared for the classroom and beyond. Policy of the American Academy of Pediatrics recognizes that a child exposed to constant, or “toxic,” stress in utero, infancy, and toddlerhood experiences profound and irreversible changes in brain anatomy and chemistry that lead to lifelong challenges in learning, emotionality, and responses to stress and adversity. Toxic stress may take the form of a lack of basic biological needs such as food or stable housing; family dysfunction; abuse and neglect; or many other adverse childhood experiences. While limited and appropriate quantities of stress are biologically advantageous, children who are exposed to toxic stress instead develop unhealthy developmental responses. Toxic stress experiences are built into the children’s brains and increase the likelihood for the development of health-threatening behaviors and chronic, stress-related diseases later in life. The Centers for Disease Control and Prevention has found that as the number of adverse childhood experiences increases, the risk for health problems including depression, heart disease, and liver disease also increases.2 Children affected by toxic stress are at higher risk for impaired American Academy of Pediatrics. Technical Report: “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics, 2011. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663 2 Centers for Disease Control and Prevention, Adverse Childhood Experiences webpage: http://www.cdc.gov/ace/findings.htm Last visited April 20, 2012. 1
American Academy of Pediatrics Page 3 memory and mood control, heightened anxiety, a limited capacity for contextual learning, and difficulty differentiating safety and fear in ways that are similar to patients with Post-Traumatic Stress Disorder (PTSD). Toxic stress is implicated in the development of medical complications including drug use, obesity, and altered immune function and inflammation. Adults who suffered such adverse childhood experiences are more likely to have experienced school failure, gang membership, unemployment, violent crime, and incarceration.3,4 Finally, toxic stress is associated with the intergenerational transmission of health and educational disparities. A focus on this ecobiodevelopmental model, as well as a response to the reality of toxic stress and its long-term effects on our children, are imperative in the success of education policy. Literacy promotion is essential for brain development and school readiness. As pediatricians, we know that reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development. We encourage parents and other caregivers to read aloud to children in their infancy and preschool years because we know it is one of the most effective ways to expose them to enriched language and to encourage specific early literacy skills needed to promote school readiness. In fact, early, regular parent-child reading may be an epigenetic factor associated with later reading success.5 Unfortunately, we also know that every year more than 1 in 3 American children start kindergarten without the language skills they need to learn to read. Children from low-income families hear fewer words in early childhood and know fewer words by age 3 than do children who live in higher-income families. As such, AAP encourages federal and state support for programs like Reach Out and Read and others that provide books to families with young children, either through their pediatricians’ office, library, school or other entity, that allows more books to be read to children thus expanding their exposure to the printed word and resulting in increased literacy skills. High quality early education yields positive effects that persist through adulthood. Early education includes all of a child’s experience at home, in child care, and in other preschool settings. Approximately two of every three children in the United States under the age of six attend out-of-home childcare during a period when early brain development is at its peak. The quality and quantity of early education provided, therefore, has profound and long-lasting implications for the cognitive development of young children. In the short term, children who are unprepared for kindergarten are unlikely to catch up; studies have shown that the achievement gap among children entering kindergarten only widens after third grade for children with poverty- and family-related risk factors. Inferior-quality care, at home or outside the home, can have harmful effects on language, social development, and school performance that are more difficult to ameliorate, especially for children in schools with fewer resources.6 3
AAP Technical Report on Toxic Stress: www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663 American Academy of Pediatrics. Policy Statement: “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health.” Pediatrics, 2011. www.pediatrics/org/cgi/doi/10.1542/peds.2011-2662 5 American Academy of Pediatrics. Policy Statement: “Literacy Promotion: An Essential Component of Primary Care Pediatric Practice.” Pediatrics, 2014. 6 Policy Statement: “Quality Early Education and Child Care from Birth to Kindergarten.” Pediatrics, 2005. 4
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Children in high-quality early childhood programs, however, show remarkable improvement in school readiness. Studies have shown that children who attend high-quality early childhood programs demonstrate better math and language skills, better cognition and social skills, better interpersonal relationships, and better behavioral self-regulation than do children in lowerquality care. It has also been shown that low-income preschoolers participating in Early Head Start and Head Start demonstrate improved scores in vocabulary, early writing, and early mathematics. Long-term follow-up studies comparing children in Head Start against their control peers show remarkable improvements in social and behavioral outcomes, including rates of educational attainment, home ownership, employment, and avoidance of incarceration. Such long-term outcomes produce significant cost savings; one study in California showed a return of $2.62 for every $1.00 invested in a one-year, high-quality preschool education, with an annual return rate of ten percent over 60 years.7 However, increasing capacity and access for low-income children in early education is essential to ensure success, as studies have shown that many eligible children do not participate in high quality early education and child care programs. Improving the quality and accountability of the early childhood workforce is equally imperative, with provisions for data collection and analysis to determine efficacy of programs and interventions. The American Academy of Pediatrics, in partnership with other early childhood advocacy groups and with the support of the Head Start grant program, has outlined some of these key provisions in the development of publicallyavailable early childhood resources and research in the Healthy Child Care America initiative. Such a comprehensive focus on early education, with emphasis on universal access to developmentally-appropriate activities led by qualified educators, will ensure that all children are prepared for kindergarten and beyond.
School readiness and health Healthy children are better prepared to learn and thrive in school. Academic achievement is strongly linked with a child’s health and well-being. Children experiencing hunger, illness, or violence cannot fully focus on school performance. Schools are in a unique position to help address many of the barriers to learning students often face. Not enough children in elementary and secondary education are performing at grade level in essential subjects of math and reading, and the achievement gap among children of color is unacceptable. In order for students to reach their maximum potential, rigorous academic standards must be provided in conjunction with comprehensive student support services, which focus on children’s emotional, social, behavioral, and mental health. Acceptable accommodations must be provided for students with physical and mental illness, including medical and counseling services and individualized academic supports. Practical life skills such as conflict resolution, problem solving, responsible decision-making and relationship-building should be taught at all schools and not just the most poorly-performing. For younger children, schools should consult with American Academy of Pediatrics. Technical Report: “School Readiness.” Pediatrics, 2008. www.pediatrics/org/cgi/doi/10.1542/peds.2008-0079 7
American Academy of Pediatrics Page 5 health professionals in order to prevent harm and to promote health for infants, toddlers, and preschool age children enrolled in early education. In collaboration with a child’s medical home, schools should work to provide mental health resources to children and families that need assessments and special interventions. For example, for preschool-aged children, rather than expelling these young children for challenging behavior, schools should instead connect families with resources for mental health consultation. Elementary and secondary education that emphasizes academic rigor along with social and emotional learning will enable children to become healthy and productive citizens prepared for success in college, technical schools, the military, and the workforce. Schools must accommodate children with disabilities and provide them a rigorous education. It is also important to remember that all students are general education students first. Whether children receive special education or related services under the Individuals with Disabilities Education Act (IDEA) or accommodations under Section 504 of the Rehabilitation Act of 1973, all children are entitled to receive an appropriate education from the nation’s public school system. Pediatricians work every day with families and children with disabilities to ensure that these children get the early intervention they need to prepare them for school, and then work with the families throughout the child’s school career to shape Individual Education Plans (IEPs) to help students receive the education they deserve, graduate from high school and move on to college.8 Students with disabilities need to be held as much as possible to the same rigorous academic standards as the general student population and there should be as minimal alternative assessments and academic alternative standards given to students with disabilities as possible. Early childhood education should be supported in including children with disabilities and provide them with the same high quality early education that their peers receive. Children are better prepared to succeed in school when they follow healthy sleeping patterns. State and local education agencies can also play a role in ensuring that students health needs are met by establishing school start times that encourage healthy sleeping patterns in children, particularly adolescents. The Academy recognizes insufficient sleep in adolescents as an important public health issue that significantly affects the health and safety, as well as the academic success, of middle school and high school students. Many middle and high school students are at risk for adverse consequences of insufficient sleep, including higher anxiety levels and impairments of mood, attention, memory, behavioral control, executive function and quality of life. Insufficient sleep also takes a toll on academic performance.9 Although there are a number of factors that negatively impact the amount of sleep that adolescents get each night, including biological changes in sleep associated with puberty, lifestyle choices and academic demands, evidence strongly suggests that earlier school start times (i.e., before 8:30am) are a key contributor to insufficient sleep, as well as circadian rhythm disruption, in this population. Furthermore, a substantial body of research has demonstrated that delaying school start times is an effective countermeasure to chronic sleep loss in the adolescent population. As such, the AAP
American Academy of Pediatrics. Clinical Report: “Early Intervention, IDEA Part C Services, and the Medical Home: Collaboration for Best Practice and Best Outcomes.” Pediatrics, 2013. www.pediatrics.org/cgi/doi/10.1542/peds.2013-2305 9 American Academy of Pediatrics. Policy Statement: “School Start Times for Adolescents.” Pediatrics, 2014. www.pediatrics.org/cgi/doi/10.1542/peds.2014-1697 8
American Academy of Pediatrics Page 6 strongly supports efforts of school districts to optimize sleep in students and urges middle schools and high schools by delaying school start times until 8:30am or after. Safe schools are successful schools. Preventing bullying, harassment, and violence in schools is of the utmost importance. Victims of such behaviors demonstrate poorer school performance, increased absenteeism, and decreased confidence and coping skills. It is imperative that all students are protected against bullying, regardless of their real or perceived race, ethnicity, age, sex, class, national origin, ability, sexual orientation, gender identity, disability, or religion. In an age in which even young children are increasingly using technology, schools must realize that prevention of bullying includes not only verbal and physical bullying in schools, but also harassment via forms of electronic communication, such as cell phones or social networking sites, known as “cyber bullying.”10 Students also need to be safe from extreme forms of discipline from school employees. The Academy believes that behavioral interventions that compromise health and safety should not be utilized in schools, including the use of restraint and seclusion in non-emergencies that do not threaten physical safety. Schools need to protect all students from physical and mental abuse. In addition, schools should consider utilizing in-school suspensions in place of out-of-school suspensions when such discipline is warranted. Healthy environments are vital for positive school outcomes. More than twenty percent of children now live in poverty—up from seventeen percent in 2007. Children who lack basic necessities, including a safe and nurturing home environment, food, or clothing, have difficulty concentrating and learning in school. For many of these children, schools provide resources that they otherwise would not be able to access including nutritious meals, access to healthcare, and numerous other services. All of these resources provide children with a better opportunity to succeed as adults. It is crucial to our nation’s poor children that they are provided with a comprehensive education that provides them with opportunities for their future careers or further education. All of our nation’s children deserve these basic supports, but for children living in poverty, it is imperative that we use schools as a way to provide opportunities to which they may not have access. Focusing attention on these poverty-related hindrances to school success is essential in closing the achievement gap and making possible a trajectory of upward mobility for all children and families. Focus on the built environment in neighborhoods and schools, including tobacco-free zones, safe playgrounds and indoor play areas, and well-lit public spaces, allows children to explore their community in safe and developmentally appropriate ways. In addition, school environments should promote healthy eating, and all foods sold in schools should contribute to a healthy diet for children at their different ages and developmental stages. Physical activity and recess is important for student readiness. Attention also must be placed on the importance of exercise and free play. Physical activity is essential because of its association not only with decreased rates of obesity, but also with increased social and emotional American Academy of Pediatrics. Policy Statement: “Role of the Pediatrician in Youth Violence Prevention.” Pediatrics, 2009. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;124/1/393 10
American Academy of Pediatrics Page 7 development and improved behavioral and academic outcomes in the classroom. There has been a growing trend toward reallocating time in school to emphasize the more traditional academic subjects like math, reading and science. These are important subjects that every student needs to master, but cutting back on physical activity to spend more time on these subjects puts this important part of a student’s school day at risk. Physical activity should be incorporated daily in school, both formally in physical education and informally on playgrounds during recess and in extracurricular activities. It is also important to understand that recess is a unique form of activity and it should serve as a complement to, rather than a replacement of traditional physical education. Recess represents an essential, planned respite from rigorous cognitive tasks. Recess gives students an opportunity to rest, play, imagine, think, move around and socialize.11After recess, students are often more attentive and better able to perform cognitively. Recess also helps young children to develop social skills that are otherwise not acquired in a more structured classroom environment. Thus, both physical education and recess need to be included in the daily schedule at school for children, and they need to complement each other, not replace one for the other. Returning to play and returning to the classroom are key in promoting student well-being. Through participation in physical education, school athletics, and outside-of-school sports and activities, students may suffer injuries ranging from cuts, bruises and muscle strains, to more serious injuries like concussions that can affect the ability of a student to concentrate and perform on both the athletic field and in the classroom. It is imperative that there are proper safeguards in place and medical personnel on hand at school-sponsored functions and that there is effective communication between students, parents, teachers, administrators and medical providers on steps that need to take place for a full recovery for students. While the majority of the focus on concussions has been centered on the timing of safe return to play, little attention has been given to academics and learning and how a concussion may affect the young student learner. As such, it is important to recognize that students with a concussion may need academic adjustments in school to help minimize a worsening of symptoms. Most concussions resolve within 3 weeks of the injury, but for those that last longer, it may be beneficial for a more detailed assessment by a concussion specialist (licensed physician, such as a pediatrician, neurologist, primary care sports medicine specialist, or neurosurgeon with expanded knowledge and experience in pediatric concussion management) and recommendations specific to the educational environment may be needed. In addition, considerations should also be given to developing a 504 plan or, subsequently, but unlikely, an IEP, in the student with a lengthy recovery period. Students should be performing at their academic “baseline” before returning to sports, full physical activity, or other extracurricular activities following a concussion.12
Health across the lifespan
American Academy of Pediatrics. Policy Statement: “The Crucial Role of Recess in School.” Pediatrics, 2013. www.pediatrics.org/cgi/doi/10.1542/peds.2012-2993 12 American Academy of Pediatrics. Clinical Report: “Returning to Learning Following a Concussion.” Pediatrics, 2013; 132; 948. www.pediatrics.org/cgi/doi/10.1542/peds.2013-2867. 11
American Academy of Pediatrics Page 8 Prevention of adult disease begins early in childhood. School-based health promotion and education can help prevent children from developing obesity, heart disease, substance use, and other chronic conditions that plague many children and adults today. Young people who make regular visits to a medical home or school-based health center (SBHC) and have access to all preventive health care services, screenings, and vaccinations highlighted in AAP’s Bright Futures guidelines show significantly improved overall health. They are more likely to have received recommended vaccines, report healthier behaviors and higher satisfaction with their health status, and have significantly lower rates of chronic disease, resulting in less school and work absenteeism and billions of dollars in direct and indirect healthcare cost savings across the lifespan.13 Across the nation, schools play an integral role in expanding access and improving the availability of medical care to children, particularly the millions of children who are uninsured or living in areas lacking adequate medical services. Coordinated school health programs, through the collaboration of school nurses and physicians, provide primary physical and mental health services to children who do not have ready access to health care, while assisting families in securing health care in a permanent medical home. Schools are an important source of regular health care for children with special needs, while also offering screenings and intervention services for children with a variety of concerns, including mental health issues, family dysfunction, violence prevention, and substance use disorders. In collaboration with the medical home and school-based health centers, health education in schools is among the most efficient and cost-effective ways of improving child health. These programs reinforce healthy habits and reduce risky behaviors. Comprehensive, scientifically accurate, age-appropriate, and culturally relevant health education in all areas of health, including sexuality and reproductive health, can encourage positive behaviors by developing knowledge and addressing the physical, emotional, intellectual, social, and ethical dimensions of life-long healthy living. Emphasis on data collection and quality assurance will improve outcomes across the lifespan. Increasing infrastructure for the collection and interpretation of individual, school-, community-, and state-wide data on the educational climate and school health delivery systems will ensure that limited resources are not duplicative but instead target gaps in existing services. Powerful examples of the successes in such research metrics are found in the examples of school bullying prevention programs, which have significantly decreased school violence and improved emotional health and academic outcomes for victims, and school nutrition improvement initiatives, which have been proven to decrease obesity and – in some cases – to even generate school food profits. Such information also will allow for individual schools and districts to address unique needs within the framework of their state and local governance structures, to build collaborative partnerships with other organizations or districts that share similar missions or programming needs, and to share best practices.
American Academy of Pediatrics. Policy Statement: “School-Based Health Centers and Pediatric Practice.” Pediatrics, 2011. www.pediatrics.org/cgi/doi/10.1542/peds.2011-3443 13
American Academy of Pediatrics Page 9 The success of our nation’s education system rests largely on the physical and emotional health of our children, as young people who demonstrate intellectual, physical, emotional, and social health are more likely to be productive citizens and workers. Education policy must respond to the mounting evidence that early childhood experiences have life-long health and economic impacts. By focusing on the unique health and educational needs of America’s children, we can ensure that they can succeed as members of a modern, highly-educated global workforce The American Academy of Pediatrics appreciates your continued work on behalf of our nation’s children. If we may be of assistance in the development or implementation of any relevant initiatives, please do not hesitate to contact Pat Johnson in the AAP Department of Federal Affairs at 202-347-8600 or
[email protected]. Thank you for your consideration. Sincerely,
Sandra G. Hassink, MD, FAAP President
SGH/pmj
