Introduction and summary
As children transition from toddlerhood into early childhood, their health, development, and well-being continue to be strongly tied to an interconnected array of social and contextual factors that affect their access to safe housing, nutritious foods, health care coverage, educational opportunities, and economic security. The years between ages 3 and 6, sometimes referred to as the “preschool period,” also mark a shift in physical, cognitive, and behavioral development that sets early childhood apart from prior life stages and introduces a set of unique needs that should be addressed through holistic policies.
Although young children are still largely reliant on their primary caregivers, early childhood also marks the beginning of a greater sense of independence. Children become more self-sufficient as a result of their developing self-regulation and motor coordination skills, which allow for behaviors such as dressing, feeding, and toileting.1 The preschool years are also a period of important cognitive and behavioral change, during which many quintessentially human psychological abilities emerge. This development builds on the critical neurobiological foundations formed during the perinatal, infancy, and toddlerhood periods and sets the stage for later learning and development that continues into adulthood.2 The role of caregivers during this period therefore begins to take new shape, and having the support and resources needed to promote healthy early child development and learning is linked with improvements in child physical, social, and cognitive development; greater language skills; improved literacy and numeracy; better health outcomes; and greater economic stability throughout life.3
Inequities in socioeconomic and daily living conditions generate adverse outcomes that persist throughout the lifespan, but the birth-through-age-6 period can serve as a unique opportunity for intervention.
Inequities in socioeconomic and daily living conditions generate adverse outcomes that persist throughout the lifespan, but the birth-through-age-6 period can serve as a unique opportunity for intervention; in these years, children’s susceptibility to influential early experiences can be harnessed to support long-term well-being.4 This report takes a comprehensive view of health and well-being during the latter portion of this critical developmental window—early childhood—putting this developmental period into context beside the perinatal period and infancy and toddlerhood and establishing its importance for a strong family- and child-centered policy agenda.
Five domains of social determinants of health and well-being serve as the framework for this report. For each domain, this report discusses several examples that are relevant to the preschool period:
- Health care: expanding access to health insurance coverage, continuous eligibility for Medicaid and the Children’s Health Insurance Program (CHIP), preventive well-child visits, and childhood immunizations
- Neighborhood and physical environment: addressing the impacts of climate change, reducing exposure to environmental pollution and toxins, and promoting health and development through built environments
- Education: expanding access to high-quality child care, Head Start, and federal child care subsidies; reducing preschool expulsions; promoting culturally responsive early education; and mitigating the impact of COVID-19 on children with disabilities
- Economic stability: expanding the child tax credit (CTC), addressing food insecurity, and reducing child poverty
- Social and community context: combating racial and gender discrimination, addressing the impact of parental incarceration, and improving neighborhood safety
Read the series
The authors provide a rich foundation of research through a series of reports detailing how the social determinants of health affect three early stages of life: 1) the perinatal period; 2) infancy and toddlerhood; and 3) the preschool years.
During early childhood, access to preventive health care, developmental screening services, routine immunizations, socioemotional support, and intervention services enables children to meet and build on foundational early developmental milestones known to shape adult well-being. However, access to quality care continues to be plagued by systemic inequities that crosscut other social determinants of health. Even in the years leading up to the COVID-19 pandemic, children overall faced increases in anxiety and depression; reductions in physical activity and wellness visits; and increases in unmet health needs.5 COVID-related disruptions in health care services at the height of the pandemic presented a challenge for many families, resulting in missed well-child visits, missed vaccines, and loss or gaps in key intervention services for children with disabilities.6 Policymakers can ensure healthier children, families, and communities by reducing inequities in early childhood through better access to quality services and health coverage, reducing financial burdens on families, and fostering preventive models of care.
Policymakers can ensure healthier children, families, and communities by reducing inequities in early childhood through better access to quality services and health coverage, reducing financial burdens on families, and fostering preventive models of care.
Health insurance continuous coverage and continuous eligibility
Children’s enrollment in public health insurance plans, such as Medicaid and CHIP, rose by nearly 15 percent between February 2020 and December 2021—roughly 5 million children—due to both increasing rates of financial hardship, which grew the number of eligible families, and public health emergency provisions during the COVID-19 pandemic that established temporary continuous eligibility.7 Between February 2020 and March 2023, when the continuous enrollment provision ended, Medicaid and CHIP enrollment for children under 19 increased by an estimated 7.5 million.8
However, the delinking of Medicaid and CHIP expanded coverage from the public health emergency means that states must now begin a 14-month period of redeterminations to reassess the eligibility of every enrollee in the state. As a result, nearly 7 million enrollees could face a loss of coverage due to administrative or clerical issues despite continued eligibility. Five states—Arkansas, Arizona, New Hampshire, Idaho, and South Dakota—began their redetermination protocols on April 1, the day following the expiration of the continuous coverage provision. Although the Centers for Medicare and Medicaid Services granted a 14-month redetermination window, some states have instituted a more abbreviated timeline. The Arkansas Department of Human Services, for example, instituted a six-month timeline, which raised concerns among advocates that even more still-eligible families could face disruptions to coverage.9
The omnibus spending bill for fiscal year 2023 reflects these concerns around disruptions to coverage by including funding and a permanent new requirement for states to provide 12 months of continuous Medicaid and CHIP eligibility for children under age 19.10 While states that do not already have continuous eligibility have until January 2024 to adopt the policy, this advancement will help to reduce insurance churn and protect child health and family economic security for years to come. Approximately two-thirds of states have adopted 12-month continuous coverage for children in Medicaid and/or CHIP, and Oregon has become the first state to continuously cover children from birth to age 6, regardless of fluctuations in family income or changes in family circumstances.11
Preventive well-child visits
Wellness checkups are critical for ensuring that children receive necessary immunizations; promoting healthy nutrition; and, generally, increasing family physical, behavioral, and mental health.12 The developmental screenings that children receive during wellness visits help identify early signs of developmental delays, autism spectrum disorder, and genetic syndromes and can pair families with appropriate intervention and supportive services.13 Lack of access to high-quality supportive services, particularly among marginalized communities, can have cascading adverse effects on cognitive and socioemotional development, physical and mental health, and even academic achievement in the long term.14
During the height of the pandemic, the rate of preventive well-child visits decreased for children of all ages.15 Children between the ages of 3 and 5 were even more likely to miss visits compared with infants and toddlers.16 In the first two months of the pandemic, 75 percent of parents and caregivers reported missing a scheduled well-child visit—a threefold reduction in well-child care over an extremely brief period—and the Centers for Disease Control and Prevention (CDC) reported significant drops in vaccinations for a number of preventable but dangerous childhood diseases.17 These reductions in routine care were also more prevalent among lower-income households compared with higher-income households, with a difference of 30 percent versus 23 percent, and among Black and Hispanic households compared with white households, at 35 percent versus 27 percent.18 Families largely reported missing visits due to an inability to get time off work or the need to care for others living in the home.19
Disruptions in well-child visits may be linked to the disproportionate impact that COVID-19 had on women’s time and economic security. Long-standing surveys have identified that mothers—more than 75 percent of the time—are the parents disproportionately responsible for choosing their child’s health care provider, getting them to appointments, and following through with care plans.20 Doing so can be difficult, if not near-impossible,21 for many given that women are also more likely than men to work in jobs that do not offer comprehensive benefits such as paid leave from work.22 After the COVID-19 pandemic hit, women became overwhelmingly responsible for the care and schooling of children now at home while continuing to engage in paid work to support their families.
As the country, and economy, has continued to recover from the height of the pandemic as a whole, there has been a promising decline in the rate of missed preventive health care visits since October 2022 across all demographic groups, indicating that more children are accessing preventive health care than during the early stages of the pandemic.23 For example, between October and December 2022, children under age 5 missed well-child and well-baby visits by an estimated 5 to 7 percent, compared with 31 to 34 percent between October and December 2021.24 Despite this positive trend, many children and families are still catching up on missed health care, developmental screenings, and intervention services.25
Furthermore, the barriers to paid time off that many families—particularly low-income families—faced well before the pandemic remain. Policies aimed at increasing continuous health insurance coverage; home visiting services that may span from the perinatal period to age 5;26 and efforts to increase access to care through a focus on availability, accessibility, infrastructure, and transportation systems can help close equity gaps in health care and improve long-term health outcomes for vulnerable children.
Immunizations among young children
Health officials have reported that childhood immunization rates are at their lowest in 30 years, raising concerns about the resurgence of life-threatening but preventable childhood illnesses such as smallpox, measles, polio, and tetanus.27 Measles cases, for example, have spiked in recent years despite the availability of a safe and cost-effective vaccine,28 even though children can receive their first dose between 12 and 15 months of age.29 In 2019, the CDC reported the highest number of measles cases in the United States since 1992, with 86 percent of cases linked to densely populated areas with low vaccination rates.30 In addition, a combination of pandemic-related barriers and a strong anti-vaccination movement has continued to drive down routine childhood immunization rates. The rate of routine immunizations declined in most states for all vaccines among kindergarteners for the 2021–2022 school year when compared with the 2020–2021 school year, during which vaccines were already below pre-pandemic levels.31
In June 2022, the U.S. Food and Drug Administration (FDA) authorized the Pfizer and Moderna COVID-19 vaccines for children ages 6 months to 5 years.32 Vaccine uptake among the youngest children has historically been low, and the COVID-19 vaccine has been no exception. As of April 5, 2023, only 12 percent of U.S. children, or 2.1 million children, ages 6 months to 4 years had received at least one dose of the COVID-19 vaccine,33 compared with 39 percent of 5- to 11-year-olds and 68 percent of 12- to 17-year-olds.34 The risk of severe COVID-19 infection among children under 5 has been low compared with that of older age groups.35 However, in rare cases, young children have developed the dangerous multisystem inflammatory syndrome, which can cause inflammatory damage to different organs and organ systems, including the heart, lungs, kidneys, skin, eyes, gastrointestinal organs, and the brain.36 Children with disabilities and those with preexisting health conditions have an even higher risk.37
Vaccine rates are not only low for young children; they are also inequitable and reveal disparities by race, ethnicity, income, and insurance coverage. An analysis of CDC data collected between 2018 and 2020 found that Black, Hispanic, and uninsured children, as well as children living below the poverty line, were significantly less likely to receive childhood vaccines than children who were white, insured, or living above the poverty line.38 Routine childhood vaccines and the COVID-19 vaccine are safe across all ages, reduce community spread and transmission to more vulnerable family members, and serve as an important factor in family and community health. In addition, childhood vaccinations minimize strain on the health care system by reducing the number of children who are hospitalized due to serious or multiple illnesses at one time.39
Neighborhood and physical environment
Decades of research have found associations between the characteristics of children’s neighborhood environments and children’s health and development.40 Structural considerations, such as where children live, grow, and go to school, affect their access to critical resources, parents’ childrearing strategies, and other behavioral and economic conditions. Having access to safe and secure housing, for instance, is important for early childhood health and development: A depth of research shows that experiencing homelessness or housing instability during early childhood increases household stress and can adversely affect children’s health, development, and even school performance later on.41 Meanwhile, built environments suited to family and community interactions and the presence of greenspaces are associated with greater child physical health and social competence.42 Everything—from the physical infrastructure in a neighborhood to the accessibility of family services such as quality child care, playgrounds and parks, clean water, and pollutant-free environments—is influenced by systemic inequities and can have a cascading influence on child and family health and well-being.
The built environment
The built environment—how buildings, recreational spaces, communities, and transportation are constructed—has the power to affect overall family and child mental and physical health. Numerous studies on housing conditions link housing quality and type to psychological and physical health outcomes, especially among parents with young children.43 For example, housing conditions that may include residential crowding, high-rise apartment complexes with little to no green space access, and areas with high noise pollution have been shown to heighten experiences of psychological distress; the added context of the COVID-19 pandemic has created additional distress among families living in crowded or high-density settings.44 Children and adults who live in settings with low levels of natural sunlight display higher rates of depressive symptoms.45 Long commutes to work are also associated with poorer mental health, particularly for women with young children.46 Caregiver mental health is linked to early childhood health, both through stress contagion and disruptions in caregivers’ ability to provide responsive, nurturing care, which is critical for young children’s development and well-being.47
Opportunities for outdoor play promote child health; children who live in neighborhoods without parks are more likely to have no physical activity each week, be obese, and be diagnosed with ADHD.48 In addition, proximity to parks and green spaces has been associated with improved emotional and behavioral health and resilience in childhood and reduced anxiety and depression diagnoses in adulthood.49 Play is a powerful driver of early learning and supports young children’s mental health, reduces stress levels, improves confidence, and helps young children process emotions.50 However, children who live in rural or impoverished areas are less likely to be near a public park.51
Playful Learning Landscapes
The Playful Learning Landscapes initiative looks to address this lack of public play-friendly spaces by transforming everyday spaces. The initiative embeds playful learning opportunities into aspects of children’s neighborhoods such as bus stops or supermarkets, capitalizing on existing spaces where children and their caregivers go or congregate.52 Pilot programs in low-income neighborhoods have successfully engaged both caregivers and children in meaningful learning activities and conversations that affect the development of key communication, collaboration, and critical thinking skills that support children’s later academic success.53 Impact studies of these installations find improvements in children’s language development, literacy, and STEM skills,54 as well as other foundational skills such as executive function; reasoning about shapes, which informs later spatial and math skills; and the ability to stay on task. Moreover, using a community-based research partnership model in the development of Playful Learning Landscapes is associated with more robust civic engagement, increased ownership of communal spaces, and enriching interactions between children and their caregivers.
Play is a powerful driver of early learning and supports young children’s mental health, reduces stress levels, improves confidence, and helps young children process emotions.
Climate change and environmental racism
Climate change poses an imminent risk for the health and well-being of young children around the globe, but racial and ethnic minority communities and families with disabled family members disproportionately face the earliest and most severe consequences related to climate change.55 Increased prevalence and severity of heat waves, exposure to air pollution, and environmental toxins from power plants, truck exhaust, and industrial sources have all been shown to harm early childhood health, in the short and long term. For example, childhood exposure to air pollution and environmental toxins impairs cognitive and motor development while increasing risk for disease, including respiratory conditions and childhood cancer.56 Less directly, the climate crisis also acts as a stressor that can worsen mental health over time.57
A long history of redlining in the United States continues to affect racial segregation of neighborhoods today and is linked to disparities in environmental pollution. Previously redlined neighborhoods have higher levels of air pollution and greater numbers of drilled and operated oil and gas wells compared with non-redlined neighborhoods.58 Women of color—many of whom are also overwhelmingly likely to be breadwinners and the primary caregivers for their families—experience some of the worst harms from climate change.59 Race is the single most significant indicator of whether a person in the United States will live within two miles of a hazardous waste facility, with people of color making up most communities closest to these facilities.60 One nationally representative study by the U.S. Environmental Protection Agency (EPA) in 2018 found that, compared with the overall population, Black communities experienced a 54 percent higher environmental burden of pollution, and communities of color experienced a 28 percent higher burden compared with white communities.61 The disparities in exposure that lead to long-term health consequences are also exacerbated by the fact that these communities are often simultaneously the ones with the most limited access to the resources needed to combat climate change. This inequity spans a range of consequences, including less tree cover to protect from high and rising temperatures, disparities in access to clean water, clean air, and limited access to and poorer experiences with necessary health services.
Percentage of Native communities located within one mile of a supermarket
Disruption of food and clean water pathways is another concern linked to the climate crisis and has already decreased global food and water security, particularly for marginalized communities.62 For instance, the forced relocation of Native people to government reservations, a lack of sufficient infrastructure, and systemic discrimination have created disproportionately high rates of food and water insecurity in Indigenous communities. Meanwhile, the increasing prevalence of events such as floods and droughts, along with changes in temperature and pollution of water, air, and soil, poses an ongoing threat to the yield and safety of existing crops and water supply.63 Before March 2020, more than 40 percent of Diné Nation Native families were water insecure, a situation that was exacerbated by the pandemic.64 Indigenous people are also disproportionately affected by food deserts, with only 26 percent of Native communities located within one mile of a supermarket, compared with 59 percent of the general United States.65
Climate action that prioritizes equity is necessary to ensure a healthier and safer future for all children. The Inflation Reduction Act, signed into law on August 16, 2022, marks the single-largest climate investment in U.S. history and shifts the nation toward clean energy, which will benefit young children and their families.66 The Inflation Reduction Act, for instance, dedicates $1 billion in funding for urban forestry grants that will help expand green spaces in urban centers, combat extreme heat, and boost equitable access to nature; it also dedicates nearly $3 billion for a Greenhouse Gas Reduction Fund designed to improve air quality in low-income and marginalized communities. However, decades of inaction on climate and ongoing subsidies for fossil fuels mean that more is needed to accelerate the transition to clean energy, forestall the worst of the climate crisis, and protect communities most affected by climate change.
Access to high-quality education is globally recognized among researchers and advocates as a great equalizer that sets the foundation for all subsequent development and learning.67 Education, and particularly early learning, affects health through several mechanisms, including by promoting neural development, health literacy and healthy behaviors, and higher adult earnings, which are associated with greater economic stability over time.68 In early childhood, high-quality learning opportunities often coincide with other forms of care that address overall child and family health through intergenerational approaches. Programs such as Head Start have a strong, documented influence on children’s learning and health outcomes through enduring caregiver-child relationships, an emphasis on healthy food and nutrition, and connections to wraparound services that support families across the spectrum of social determinants. Access to high-quality, affordable child care starts children on an early trajectory linked to positive cognitive and academic outcomes.69
Access to high-quality child care
Researchers have known for decades that enriching early social interactions are the bedrock for children’s learning and development. Learning does not start at age 6 when children sit in their school desks, or even at age 5 when they enter kindergarten; from the time they are born, children are gathering information from the world around them and integrating that information into a cohesive picture of the world and how it works. While much of children’s early learning happens in the context of the home, it is critical to ensure that when parents enter or return to the workforce, as is the case for most children in the United States,70 children have access to continued enrichment through high-quality care and early learning settings.71
High-quality early care and education promotes children’s learning and development and helps close opportunity gaps that create and perpetuate socioeconomic and racial inequalities still prevalent in the United States.72 In these critical early years, children develop socioemotional skills—including sharing, empathy, turn-taking, and emotion regulation—which are essential components of their later skill development in literacy, numeracy, and the cognitive skills they need for success throughout their schooling.73 While not as severe as those for infants and toddlers, child care deserts continue to present challenges for families seeking high-quality, affordable preschool and care options for their children, largely due to persistent worker shortages resulting from inadequate pay and working conditions.74 This shortage of child care options leaves families in a bind, often forcing parents—disproportionately mothers—to make difficult financial decisions that can affect their attachment to the workforce and their families’ long-term economic stability and growth.
The loss of productivity and economic return associated with issues of finding and affording child care costs the nation $122 billion annually.75 These costs are felt across a range of sectors: Families lost $78 billion per year in forgone earnings and job search expenses; challenges to productivity cost businesses and employers approximately $23 billion per year; and taxpayers lost $21 billion each year in lower federal and state tax revenue. Access to affordable, high-quality child care is therefore as much a question of economic health as it is early learning support. Local, state, and federal investments in care result in more take-home income for families that they can use for food, education, debt payments, and savings, contributing to more jobs, inclusive economic recovery, and growth.76
Since 1964, the Head Start program has provided free, high-quality educational, social-emotional, health, and nutritional services to low-income children and their families.77 Head Start currently serves more 800,000 children and pregnant people annually through 1,600 locally operated agencies.78 As the longest-running publicly funded early learning program in the United States, it provides evidence for the lifelong benefits of holistic early childhood interventions, particularly among low-income children.79 Longitudinal studies of the Head Start program have demonstrated increased school readiness, high school completion, educational attainment, and health outcomes,80 including reduced risk for childhood obesity.81 Head Start is also associated with more robust social, emotional, and behavioral development that manifests in improved self-control,82 self-esteem, positive parenting practices, and positive intergenerational effects, including reduced teenage pregnancy and increased educational attainment.83
Unfortunately, stagnant and insufficient workforce compensation remains an issue for retaining and recruiting Head Start educators: Although educator credentials and qualifications have increased in the past decade, Head Start educators’ work, as well as the work of early child educators across the sector, is still severely underpaid.84 The task of raising worker wages has fallen primarily on local providers, but greater federal investment is needed to ensure workforce retention of high-quality early childhood educators.
The Child Care and Development Block Grant
A vital component of the child care landscape is the Child Care and Development Block Grant (CCDBG) Act, passed in 1990, which authorizes the use of federal funding through the Child Care Development Fund, and entitlements via the Child Care Entitlement to States section of the Social Security Act, to subsidize the high cost of child care for low-income families. Though initially designed as a workforce support, establishing eligibility based on parents’ need to attend work or school, the steeply rising cost of care has made this federal program a necessity for families, critical to parents’ ability to participate in the workforce while providing enriching early experiences to their children.85
Unfortunately, even with recent investments in the CCDBG with the passage of the December 2022 omnibus spending bill, the program has struggled to keep pace with inflation and still only serves a fraction of eligible families. Between 2006 and 2013, nearly 150,000 fewer children could access child care subsidies due to declines in total spending on child care assistance, including via federal and state CCDBG and TANF funds.86 Today, the CCDBG reaches less than 15 percent of eligible children across the country; in 50 percent of states, including South Carolina, Oregon, North Dakota, and Michigan, that number dips to 10 percent of eligible children under age 6.87 Moreover, in half the country, most residents live in child care deserts, where, despite subsidy support to help with the cost of care, there are not enough slots to meet the community’s need.88
Funding for the CCDBG was temporarily expanded through the American Rescue Plan Act (ARPA) of 2021 to help child care providers and families cope with the fall-out of the COVID-19 pandemic, but these funds will soon expire. However, the fiscal year 2023 spending package includes $8 billion for the CCDBG, a 30 percent increase over FY 2022;89 and President Joe Biden’s FY 2024 budget includes a proposed $9 billion for the CCDBG, $13.1 billion for Head Start, and $360 million in preschool development grants.90 While the increase in funding is necessary and enough to provide subsidies to an additional 130,000 children, it is less than what advocates had hoped for and far below what is needed to sustain a system that is rapidly approaching a funding cliff when pandemic-era relief funding will expire. The CCDBG, as an existing federal subsidy program with bipartisan support, is a prime component of the child care landscape that states can strategically leverage to increase child care worker wages, expand eligibility to more families, and stabilize reimbursements to providers.91
Preschool exclusionary discipline
No child, especially those who are only 3 or 4 years old, should be at risk of losing educational opportunities due to disciplinary practices. However, preschool expulsions happen at a rate that is more than three times that of K-12 students.92 Black boys are overwhelmingly affected by preschool expulsions and suspensions, often due to vaguely reported behavior problems;93 although Black children make up only 18 percent of enrolled preschool children, they make up 48 percent of students who receive one or more suspensions.94 Studies indicate that preschool teachers’ implicit biases are a crucial factor in suspensions and expulsions. In one study, preschool educators watched a video of children engaging in typical classroom behaviors after being prompted to expect challenging behaviors. Educators focused longer on the Black children in that video, and particularly on the Black boys.95 In addition, other studies of preschool classrooms find that white teachers report more challenging behaviors from Black boys and give Black students lower school-entry language and literacy ratings compared with when Black teachers evaluate Black students.96 These findings highlight the power of diversity and the need for culturally sensitive practices in early childhood settings.
Preschool expulsions do little to improve behavior or academic outcomes,97 and in return, they create a host of negative impacts for child learning and development. Expulsions increase young children’s future risk of dropping out of school and entering the justice system.98 Moreover, some children who are expelled have undiagnosed disabilities or behavioral health issues and could benefit from early intervention services instead of punitive measures.99 Preschool expulsions also stress parents who rely on child care to work; families rarely receive assistance finding a seat in another child care program, and disruptions occur even for the families who do find a new program.100
Reducing preschool expulsions and addressing racial disparities requires work at several levels of the preschool system. On the program level, workforce development should identify implicit bias and guide early educators on how to deal with challenging behaviors through nonexclusionary methods.101 State measures of program quality and exclusionary discipline policies can help reduce expulsion and suspensions and ensure children receive appropriate social-emotional support.102 Federal investment is also needed to adequately compensate early educators and ensure that programs have the resources and capacity needed to provide high-quality care.103
Culturally responsive pedagogy in early childhood education
Conversations about culturally responsive pedagogy often center K-12 education, but young children can also benefit from more inclusive curriculum and teaching strategies. Through culturally relevant pedagogy, educators intentionally design learning experiences and environments that reflect and affirm various parts of learners’ identities, including race, ethnicity, gender, religion, disability status, language, family structure, housing status, and cultural identity.104 When executed effectively, this approach helps increase the relevance of children’s learning and improves engagement, motivation, and connection to the learning process.105 In addition, educators are encouraged to hold high expectations for their students and their abilities, which has been seen to improve students’ learning and performance outcomes.106
Culturally relevant pedagogy in AIAN Head Start programs
Since 1965, Head Start has offered a range of American Indian and Alaska Native (AIAN) programs with the purpose of honoring the rich heritage of AIAN children and families and implementing culturally relevant and affirming learning experiences into Head Start programs.107 Today, 44,000 children of Native heritage are enrolled in both AIAN and non-Tribal Head Start programs—approximately half of which are served by AIAN programs.108 These programs engage communities in Tribal revitalization efforts by teaching and exposing children to Tribal languages and affirm Indigenous ways of life; lesson plans and teaching strategies are infused with important cultural skills, values, beliefs, and ways of life.109 AIAN program leaders and early childhood staff also involve elders, families, and community members as important resources for cultural knowledge.110
In early childhood, culturally responsive pedagogy may involve storybooks, toys, and classroom materials that reflect children’s diverse backgrounds and identities; songs and language can also affirm and represent children’s identities.111 In addition, efforts to engage family members in early childhood settings, coupled with consistent family-educator interactions, can help build trust and understanding that educators can use to better respond to difficult behaviors in the classroom.112 In many cases, home-based child care can provide more culturally responsive care than center-based options; home-based options are typically embedded within a community and, as typically smaller operations than their counterparts, allow for uniquely close provider-family relationships.113 Home-based providers may also be more representative of a family’s linguistic and/or cultural background.114
The effects of the pandemic on young children with disabilities
The COVID-19 pandemic and its accompanying economic, educational, and health fallouts have been difficult for all families, but especially those of disabled children.115 During the pandemic, families of children with disabilities have disproportionately faced higher rates of material hardship, hunger, and emotional distress, on top of existing racial and ethnic disparities.116 At the same time, the pandemic also led to severe disruptions in fundamental screening mechanisms and the delivery of intervention services.117 Child care programs and well-child health care visits frequently serve as early identifiers for disabilities, including developmental delays in communication and autism spectrum disorder.118 However, pandemic-related child care closures and declining attendance at well-child visits reduced access to these services.119
Percentage of families of children with an IEP who reported that their child was not receiving individualized services during the pandemic
Many young children who were diagnosed with a disability prior to the onset of the pandemic experienced a sudden shift from in-person to virtual therapy services—that is, if those services were even available in their communities.120 Closures of early learning programs also reduced children’s access to educational accommodations and adapted learning materials while disrupting routines and placing additional therapy and child care responsibilities on family members who were also struggling with the economic and social fallouts of the pandemic.121 For example, during early stages of the pandemic, nearly 40 percent of families of children with an individualized education program (IEP) reported that their child was not receiving individualized services.122 In addition, rising unemployment rates created gaps in many children’s health insurance coverage, which were particularly challenging for young children who require frequent medical or therapy appointments.123
Poverty, food insecurity, and other material hardships that create household stress can negatively affect the brain and biological systems that develop during early childhood. Communities facing systemic barriers to accessing and maintaining stable employment, fair housing, food, child care, and transportation endure persistently high rates of poverty, as well as face discrimination based on a range of social identities.124 For women of color who serve as breadwinners in their families, the intersectional impact of the racial and gender wage gap can be severe.125 In particular, Black mothers are significantly more likely than white or Hispanic mothers to be the primary source of economic support for their families, with nearly 85 percent of Black women serving as primary or co-breadwinners.126 In addition, during the height of the pandemic, Black and Latina women experienced job losses at a significantly higher rate than white women.127
Continuing and expanding anti-poverty policies, including expanding benefits and supports for families and children, is critical to ensuring that child poverty continues to decline and that families have the resources they need to improve their economic futures.
Since 1993, with the implementation and expansion of several social safety net programs aimed at mitigating financial and material hardships, child poverty has declined by nearly 44 percent—amounting to more than 6.5 million individual children no longer living in poverty.128 Still, with a federal poverty line at only slightly more than $27,000 for a family of four,129 even those families not officially considered as living in poverty face challenges affording basic needs.130 Continuing and expanding anti-poverty policies, including expanding benefits and supports for families and children,131 is critical to ensuring that child poverty continues to drop and that families have the resources they need to improve their economic futures.
Percentage of households with children under age 6 living with food insecurity in 2021
Although food insecurity (a measure of limited or uncertain access to food) and insufficient nutrition (a measure of food quality related to eating the foods a body needs for healthy functioning) are harmful at any age, young children are particularly vulnerable to the adverse effects of poor nutrition on physical, cognitive, and social-emotional development.132 Poor nutrition and food insecurity during early childhood has been associated with health conditions, including anemia and asthma as well as higher risk for behavioral problems.133 The harms of food insecurity are often compounded by other adversities, such as poverty and material hardship, which increases the risk for long-term health consequences.134 Overall, households with young children are more likely to be food insecure than households without children or with older children only.135 As of 2021, nearly 13 percent of households with children under age 6 were living with food insecurity.136 Disparities also exist by race and disability status, increasing disparities in long-term health outcomes; a significantly higher percentage of Black and Hispanic households are food insecure compared with white households, and the same is true of children with disabilities compared with children without disabilities.137
Support for family financial stability makes a significant difference in children’s food security. For example, evidence suggests that ARPA expansions to the child tax credit (CTC) effectively reduced food insecurity during the pandemic, which reached a two-decade low for households with children during 2021. The Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) both provide critical food and nutrition support to low-income families with young children.138 SNAP emergency allotments during the pandemic kept more than 4 million people out of poverty,139 and with those emergency allotments expiring, nearly 32 million Americans are being pushed off a “hunger cliff,” making essential food goods more challenging to afford, contributing to increases in rates of poverty nationwide.140 Expanded work requirements for SNAP and TANF in the debt ceiling agreement present bureaucratic barriers that may reduce the number of families and children who receive benefits from these critical security programs.141
The United States has one of the highest rates of poverty among industrialized countries142—higher than 25 member nations of the Organization for Economic Cooperation and Development.143 In 2019, even before the COVID-19 pandemic, more than 10.5 million children were living in poverty.144
Living in poverty during early childhood has a strong negative impact on health and developmental outcomes and is considered an adverse childhood experience that can lead to toxic stress and the harmful disruption of early developing brain circuitry, including the stress response system.145 Poverty has also been linked to an increased risk for a host of negative health outcomes in adulthood, including shorter life expectancy along with chronic health issues and disabilities such as cardiovascular disease and Type 2 diabetes.146 Children who grow up in poverty are also much more likely to remain in poverty during adulthood, creating an intergenerational cycle of poverty.147 Generational poverty directly results from unjust policies and systems that are deeply rooted in systemic racism—meaning that child poverty disproportionately harms children of color and historically marginalized communities.148
Single mothers, who are more likely to live in poverty than men overall, face more significant financial challenges than single fathers, 149 underscoring the need to address the gender wage gap and a variety of intersectional factors that affect these families’ financial well-being. Across the country, nearly 24 million children live in single-parent families and are more likely to live in poverty.150 The United States has the resources and ability to end childhood poverty, but prior efforts have failed to implement the holistic, intersectional approaches necessary to end intergenerational poverty and create a more equitable future for all children from all family types.151
ARPA expansions to the CTC in 2021 dramatically reduced child poverty rates and improved family financial stability, demonstrating the power of direct cash payments to families. One study released by the Center on Poverty and Social Policy estimated that the October 2021 iteration of the CTC kept 3.6 million U.S. children out of poverty that month, a nearly 5 percentage point drop in the estimated child poverty rate without the CTC expansions.152 Child poverty rates fell by 46 percent in 2021 compared with 2020, when calculated using the supplemental poverty measure.153 In addition to reductions in child poverty, the CTC also decreased experiences of other material hardships, such as housing, food, and diaper insecurity.
Unfortunately, Congress’ failure to make these expansions permanent has forced millions of children back into poverty: An estimated 3.7 million children slipped into poverty in January 2022 after the CTC expansions ended in December 2021.154 During the pandemic, states could exercise flexibility around administration of SNAP in order to provide supplemental benefits, reach families whose children missed school meals due to closures, and reduce administrative demands to ensure that families could access food.155 The Families First Coronavirus Response Act of 2020 also made it easier for families to apply for SNAP benefits, waived the typical interview process for determining eligibility, and suspended work requirements so that all families could access the program.156 Proposed expanded work requirements for SNAP in the 2023 debt ceiling deal would add barriers for proving eligibility and likely result in many recipients, especially older adults, losing coverage.157 These two pandemic-era policy decisions, and the near-immediate impact they had on supporting families, demonstrate the power of programmatic changes on young children’s health and well-being.
Social and community context
The social and community contexts shaping early childhood experiences have deep and enduring effects on health and development. Race—as a common thread throughout this report and others within this series—plays a significant role in children’s early experiences. Young children of color are exposed to race-based discrimination very early in life, and these experiences have strong negative effects over time on their health and well-being. Experiencing discrimination for long periods can induce high levels of stress that accumulate to create significant adverse consequences for an individual’s health and well-being—a process known as “weathering.”158 Young children of color, both directly through their experiences and indirectly through the experiences of their parents, face systemic racism and other forms of structural discrimination.159 Those experiences include higher parental incarceration rates and even higher rates of preschool expulsion. Exposure to vicarious racial trauma during early childhood has been associated with doubling the risk of poor mental health years later.160 There is even some evidence that race-based discrimination can affect children’s immune pathways,161 making them more susceptible to illness and other negative health consequences.162
Children’s social environments and the communities where they grow and learn affect their short- and long-term well-being. A lack of neighborhood safety, for example, is associated with a reduced sense of belonging, decreases in social cohesion, and limited community-building potential, as well as poorer language, socio-emotional, and behavioral outcomes for children.163 Interventions aimed at addressing population- and community-level factors such as these are shown to improve healthy behaviors, including positive changes to nutrition and increased physical activity.164 Advancing anti-discriminatory policies in multiple sectors is also critical to children’s health, educational, and economic futures.
Discrimination based on race and ethnicity
The wide-reaching effects of discrimination based on race or ethnicity extend across the five social determinants of health, affecting child and family well-being at every stage of development. For example, research links long-term experiences of racism to chronic stress, which has well-documented negative consequences for developing brains and biological systems.165 Racial weathering likely underlies the higher rate of Black, Indigenous, and other people of color who experience chronic illnesses across a lifespan,166 and structural racism across sectors, laws, and policies in the United States has also established societal conditions that undermine the health and well-being of children and families of color.
America’s maternal mortality and morbidity crisis underscores how racial discrimination affects health. Compounding the economic harms discussed above that fall heaviest on women of color, medical racial discrimination contributes to preexisting disparities in maternal health, mortality, and birth outcomes that exist regardless of income. Despite America’s already unacceptable maternal death rates, maternal morbidity rates continue to rise and can have a significant and long-term impact on families.167 Black women, in particular, face higher maternal mortality rates than any other racial group and also experience higher rates of premature births and infant deaths.168
Children of color often experience the direct effects of racism early in life, and by the time they enter preschool, children already show an understanding of the social construct of race.169 By as young as age 3, children’s assessments of social status reflect broader societal associations of racial categories with different characteristics.170 For many parents of color, having “the talk” with their young Black or brown child about their race and how they are perceived in the world reflects an effort to protect their children growing up in society amid racism. When they enter formal school, children of color are more likely to be treated differently by their teachers, punished for minor infractions, referred for special education services, and experience teachers who underestimate their capabilities.171
Disproportionate impact on women
From the mothers who still largely take on the roles of primary caregivers even within two-parent households to the overwhelmingly female makeup of the child care and early education workforces, women inarguably play an outsize role in raising and shaping the futures of the next generation. The high cost of child care forces many women out of the workforce at a higher rate than men, often resulting in decreased lifetime earnings for women who become mothers.172 At the same time, women and women of color disproportionately make up the child care industry and are compensated with few benefits and poverty wages.173 While the gender wage gap is significant, this is not the only area where women face disparities. Especially within the many families where women serve as the primary or sole breadwinner, the discrimination women, and women of color in particular, face in key areas such as housing and their own health care access can have a dramatic impact on the well-being of their children.174
Parental incarceration and child health
In the United States, 1 out of every 50 children has a parent who is currently in prison, and nearly 1 out of every 14 children has a parent who served some amount of time in prison; an estimated 22 percent of all children with a parent in prison are under the age of 5.175 Parental incarceration is a traumatic and stressful experience for both the child and the family, producing a range of negative impacts on child health and well-being that disproportionately affects children of color. For example, Black children are nearly eight times as likely as white children and three times as likely as Hispanic children to have a parent in prison.176 It is often difficult to isolate and examine the co-occurring adversities that children with incarcerated parents experience, as one adverse consequence can be related to or affected by another; however, what can be said is that these children are more likely to witness or be the victim of violence, loss of income, or relocation to a different living situation.177 Moreover, exposure to multiple adverse childhood experiences—one of which is parental incarceration—increases the risk for several health issues and maladaptive behaviors in later adulthood, including depression, substance abuse, and unintended pregnancy.178
The relationship between a child and parent or primary caregiver is foundational to early learning, and disruptions in this relationship during early childhood may lead to maladjustment and insecure attachment—particularly if the incarcerated parent was the child’s primary caregiver.179 A strong, nurturing relationship with a grandparent or co-parent can aid a child’s adjustment and buffer adverse health effects following parental incarceration.180 In some cases, children with incarcerated parents may be placed into foster care settings, which can be emotionally confusing and stressful for young children.181 Children’s health outcomes are an often-overlooked consequence of mass incarceration that disproportionately affects children and families of color and perpetuates racial and socioeconomic disparities.182
Unsafe neighborhoods present a barrier to health and well-being in early childhood, both directly and indirectly. Environmental pollutants, neighborhood violence, community gun violence, and physically unsafe conditions create a risk for injury and poor health, even death, in childhood. Neighborhoods indirectly influence patterns in how communities and young children spend their time; unsafe neighborhoods are associated with lower rates of outdoor play and physical activity and higher rates of sedentary activities such as TV-watching and screen time, compared with children who grow up in safer neighborhoods, even when controlling for other socioeconomic and family factors.183 Parents who perceive their neighborhoods as unsafe are more likely to restrict their child’s outdoor play and may rely on screen media or sedentary activities to keep their children entertained, especially in households with limited space or toys. Simple neighborhood safety features such as sidewalks and traffic safety infrastructure—stop signs, crosswalks, speed bumps, and others—boost young children’s outdoor play,184 and neighborhood proximity to green spaces and public parks has been linked to improved child health, well-being, and self-esteem.185
Children of color, particularly Black children, may also experience the trauma of witnessing police brutality, discrimination, and violence directed toward family and community members, which heightens their risk for mental health disorders and later maladaptive behaviors.186 The disproportionate police presence in Black communities also exposes Black children to law enforcement at a young age: Studies have found a positive association between police exposure and heightened anxiety and adverse mental health effects for Black youth.187 Increased police presence in these neighborhoods also does not ultimately improve neighborhood safety and leads to criminalization of members of these communities.188 Racism is a public health issue that has real consequences both throughout a lifetime and across generations.189
Early childhood social determinants of health and wellness in context: Policy and legislative priorities
The preschool years represent an opportune moment in child development to intervene and mitigate the impact of harmful conditions on early life. Policymaking at the local, state, and federal levels that is holistic—in that it considers the intersecting nature of the social determinants of health for children and families—can help expand access to critical resources. In addition, bringing together a range of policy priorities can inform the development of a robust and comprehensive family support system. The policies and programs below offer a snapshot of the range of initiatives that leadership can adopt that are related to the social determinants detailed above.
The preschool years are foundational to overall learning, development, health, and well-being, building on the neural and biological frameworks established during infancy and toddlerhood and setting the stage for the K-12 schooling years and beyond. Early childhood rounds out a period of profound social and emotional development during which young children quickly develop a more complex understanding of the world and gain a greater sense of independence. Holistic, multigenerational interventions during these years have proven effective at improving long-term health, economic, and educational outcomes that can last across the lifespan and even across generations. Paying particular attention to the early years of development in creating a robust family-centered policy agenda is vital to improving public health and well-being and promoting equity for this generation and the next.
The authors would like to thank Rasheed Malik, Madeline Shepherd, Emily Gee, Mia Ives-Rublee, Jill Rosenthal, Marquisha Johns, Lily Roberts, and Maggie Jo Buchanan for their thoughtful review and support in the development of this report.