Children’s emotional, physical, and cognitive development is on track, and delays are identified and addressed early.

A child’s developing brain is most flexible during the earliest months and years of life. This flexibility provides a window of opportunity for establishing a lifelong trajectory for health and wellbeing. Adverse childhood experiences during this period increase the likelihood of physical and mental health difficulties in adulthood, placing children on a trajectory toward physical health problems, such as cardiovascular disease, diabetes, and respiratory and immunological disorders, as well as challenges with learning and mental health.1,2 Despite the importance of this age period, children are more likely to experience abuse and neglect during their first three years of life than at any other age.3

Safe environments and good nutrition can support lifelong health, as can stable, responsive relationships with adults. Also, interventions that identify and treat early indications of disability or developmental delay during a child’s early years can improve a child’s trajectory, increasing the likelihood of positive health outcomes long term. Such interventions are important because 1 in 6 children in the US has a disability.4 Social predictors of health, such as poverty, increase a child’s risk of disability, as do factors such as low birthweight.5

Breastfeeding can boost children’s immune systems and improve long-term health outcomes, but challenges such as unsupportive workplace policies and hospital practices can limit mothers’ opportunities for breastfeeding, and data show that 60% of mothers do not breastfeed for as long as they intend to.6 These difficulties contribute to racial disparities—Black infants are less likely than Hispanic and White infants to ever have been breastfed.7

The policies and strategies reviewed in this section have proven effective at directly improving children’s health and wellbeing, and they can help states ensure that children’s emotional, physical, and cognitive development is on track and that delays are identified and addressed early.

Three outcomes illustrate factors that predict and reflect children’s healthy development: (1) breastfeeding, (2) immunizations, and (3) child maltreatment rates. These outcomes vary considerably across states, and most vary by race and ethnicity as well.

All three outcome measures were calculated intentionally in the negative direction to demonstrate where states have room for improvement and to help states prioritize the PN-3 policy goals that are lagging. Out of 51 states, the worst state ranks 51st, and the best state ranks first. The median state indicates that half of states have outcomes that measure better than that state, whereas half of states have outcomes that are worse.

 

OUTCOME MEASURE: NEVER BREASTFED
% of children ages 19 to 35 months whose mother reported NEVER breastfeeding
Median state value: 14.3%

Breastfeeding is associated with better health outcomes for mothers and children. Overall, 1 out of 6 babies is never breastfed, but the number is nearly double that in the five worst states and half that in the five best states. Black infants are twice as likely as White infants not to be breastfed, and 10 percentage points more likely not to be breastfed than Hispanic infants.

See the Prenatal-to-3 State Policy Roadmap Appendix for a table of state variation in Optimal Child Health and Development outcomes and corresponding ranks for each state.
Source: 2018 National Immunization Survey-Child (NIS-Child). For additional information, please refer to Methods and Sources.

 

OUTCOME MEASURE: NOT FULLY IMMUNIZED
% of children ages 19 to 35 months who are NOT up to date on the combined 7-vaccine series
Median state value: 27.5%

Immunizations protect against a variety of diseases that can lead to serious health consequences. In the US, more than one-quarter of infants and toddlers are not up to date on all of their immunizations. Babies in the five worst states are nearly twice as likely not to be fully immunized as babies in the five best states. Rates of immunization do not vary substantially by race and ethnicity.

Source: 2018 National Immunization Survey-Child (NIS-Child). For additional information, please refer to Methods and Sources.

 

OUTCOME MEASURE: CHILD MALTREATMENT
Number of unique maltreatment victims under age 3 per 1,000 children
Median state value: 16.9

The trauma from maltreatment has immediate and lifelong neurobiological consequences on children’s development. In the US, approximately 17 per 1,000 infants and toddlers will experience maltreatment, but rates vary widely across states. Infants and toddlers in the five worst states are maltreated at rates approximately 6 to 20 times higher than infants and toddlers in the five best states. Black infants and toddlers are more than twice as likely as White or Hispanic infants and toddlers to be victims of maltreatment.

Source: 2018 National Child Abuse and Neglect Data System (NCANDS) Child File, FFY 2018v2 and Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States, Vintage 2018. For additional information, please refer to Methods and Sources.

Effective policies have a demonstrated positive impact on at least one prenatal-to-3 goal, and the research provides clear guidance on legislative or regulatory action that states can take to adopt and implement the policy. By contrast, effective strategies have demonstrated positive impacts on prenatal-to-3 outcomes in rigorous studies, but the research does not provide clear guidance to states on how to effectively implement the program or strategy statewide.

 

EXAMPLES OF IMPACT

Effective state policies and strategies to impact Optimal Child Health and Development

Effective PoliciesExamples of Impact on Optimal Child Health and Development
Expanded Income Eligibility for Health Insurance
  • Medicaid expansion led to 422 fewer reported cases of neglect per 100,000 children under age 6 (U)
Paid Family Leave
  • Access to paid family leave led to a 1.3 percentage point increase in exclusive breastfeeding at age 6 months (G)

  • Among Black mothers, access to paid family leave led to a 7.5 percentage point increase in initiating breastfeeding (K)

  • Among low-income families, access to paid family leave led to a 5 to 7 percentage point decline in the likelihood of infants receiving late vaccinations (E)

  • Access to paid family leave led to 2.8 fewer cases of pediatric abusive head trauma per 100,000 children under age 2, and 5.1 fewer cases per 100,000 children under age 1 (I)
State Minimum Wage
  • A $1 increase in the minimum wage reduced child neglect reports by 10.8% for children ages 0 to 5 (L)

  • A $1 increase in the minimum wage from birth through age 5 increased by 8.7% the likelihood that a child was reported to be in excellent or very good health from ages 6 through 12 (R)

Effective StrategiesExamples of Impact on Optimal Child Health and Development
Comprehensive Screening and Referral Programs
  • Family Connects had both positive and null impacts on total infant emergency care use (A, B, C, D)

  • Healthy Steps families had 1.3 times higher odds of timely vaccinations and 2.3 times higher odds of timely pediatric appointments (F)

Group Prenatal Care
  • Group prenatal care had both positive (twice the odds) and null impacts on breastfeeding initiation (G, N, I, J)
Early Head Start
  • Children in EHS were more engaged during play (effect size 0.18) (J, S)

  • Children in EHS had higher developmental functioning assessment scores (effect sizes 0.14) (I, S), particularly Black children in EHS (effect size 0.23) (N)

Early Intervention Services
  • A meta-analysis of 31 studies found an average effect size of 0.62 for improving children’s cognitive skills (F)

  • Low birthweight, premature infants who were assigned to EI services saw better cognitive and behavioral outcomes at age 3 than infants in control groups (C, D)

  • EI services improved toddlers’ receptive language skills relative to a control group (0.35 effect size) (E)

Note: The letters in parentheses in the tables above correspond to the findings from strong causal studies included in the comprehensive evidence reviews of the policies and strategies. Each strong causal study reviewed has been assigned a letter. A complete list of causal studies can be found in the Prenatal-to-3 State Policy Roadmap Appendix. Comprehensive evidence reviews of each policy and strategy, as well as more details about our standards of evidence and review method, can be found at in the Prenatal-to-3 Policy Clearinghouse.

 

POLICY VARIATION ACROSS STATES

Have state adopted and fully implemented the effective policies to impact Optimal Child Health and Development?

Expanded Income Eligibility for Health Insurance

37 states have adopted and fully implemented the Medicaid expansion under the Affordable Care Act (ACA) that includes coverage for most adults with incomes up to 138% of the federal poverty level (FPL).

Sources: As of October 1, 2020. Medicaid state plan amendments (SPAs) and Section 1115 waivers.

Paid Family Leave

5 states have adopted and fully implemented a paid family leave program of a minimum of 6 weeks following the birth, adoption, or the placement of a child into foster care.

Sources: As of October 1, 2020. State statutes and legislation on paid family leave.

State Minimum Wage

19 states have adopted and fully implemented a minimum wage of $10 or greater.

Sources: As of October 1, 2020. State labor statutes and State Departments of Labor.

STRATEGY VARIATION ACROSS STATES

Have states made substantial progress toward implementing the effective strategies to impact Optimal Child Health and Development?

Comprehensive Screening and Referral Programs

8 states have both evidence-based comprehensive screening and referral programs: Family Connects and Healthy Steps.

Sources: As of June 12, 2020. Family Connects and Healthy Steps national websites.

Group Prenatal Care

10 states have supported the implementation of group prenatal care financially through enhanced reimbursements for group prenatal care providers.

Sources: As of June 8, 2020. State health department websites and proposed and passed state legislation.

Early Head Start

7 states supplement federal funding, and the estimated percentage of income-eligible children with access to EHS is at or above the median state value (8.9%).

Sources: As of 2020. National Head Start Association report, confirmation emails and phone calls from state EHS experts, 2019 Early Head Start (EHS) Program Information Report (PIR), and 2018 American Community Survey (ACS) 1-Year Public-Use Microdata Sample (PUMS).

Early Intervention Services

5 states have moderate or broad criteria to determine eligibility and serve children who are at risk for later delays or disabilities.

Source: As of 2018. IDEA Infant and Toddler Coordinators Association.

Note: Some states in the “no” category for Policy Variation Across States have adopted a policy, but they have not fully implemented it, or they do not provide the level of benefit indicated by the evidence reviews necessary to impact the PN-3 goal. Many states in the “no” category for Strategy Variation Across states have implemented aspects of the effective strategies, but states are assessed relative to one another on making substantial progress. For additional information, go to the State Data Interactives.

  1. Shonkoff, J., & Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., Pascoe, J., Wood, D. L. , & Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-246. https://doi.org/10.1542/peds.2011-2663
  2. National Scientific Council on the Developing Child (2020). Connecting the brain to the rest of the body: Early childhood development and lifelong health are deeply intertwined, Working Paper No. 15. www.developingchild.harvard.edu
  3. Child Trends. (n.d.). Child maltreatment. https://www.childtrends.org/indicators/child-maltreatment
  4. Jenco, M. (2019). Study: 1 in 6 children has developmental disability. AAP News. https://www.aappublications.org/news/2019/09/26/disabilities092619
  5. Jenco, M. (2019). Study: 1 in 6 children has developmental disability. AAP News. https://www.aappublications.org/news/2019/09/26/disabilities092619
  6. Centers for Disease Control and Prevention. (n.d.). Facts: Nationwide breastfeeding goals. https://www.cdc.gov/breastfeeding/data/facts.html
  7. Centers for Disease Control and Prevention. (n.d.). Facts: Nationwide breastfeeding goals. https://www.cdc.gov/breastfeeding/data/facts.html