Monday, May 12, 2014
The podcast is available at http://www.nichd.nih.gov/news/releases/Documents/NICHD_Research_Dvlpmts_050214.mp3 (MP3 - 8 MB).
Barrett Whitener: Can the preschool experience improve people’s health long after they’ve finished school and embarked on their adult lives? Researchers publishing in Science have found that disadvantaged children who attended a high-quality early childhood development program had, on average, become much healthier adults than those without the benefit of such a program. The researchers examined data from the Abecedarian program—funded by the National Institutes of Health, and created to determine whether an early intervention program for children born into poverty could promote healthy growth and development.
The program combined early childhood education with health screenings and nutrition. When they reached adulthood, graduates had much lower levels of high blood pressure, pre-diabetes, and obesity than those who didn’t participate in the program.
With me today is Dr. James Heckman, one of the study’s authors. Dr. Heckman is the Henry Schultz Distinguished Service Professor of Economics at the University of Chicago, and a Nobel Memorial Prize Winner in Economics. The study was funded by the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, the NICHD.
From the National Institutes of Health, I’m Barrett Whitener, and this is “Research Developments,” a podcast from the NICHD.
Welcome, doctor, and thank you for joining us.
Dr. James Heckman: Well, it’s my pleasure.
Mr. Whitener: Dr. Heckman, why did you and your colleagues look at the possible effects of early childhood development programs on later adult health?
Dr. Heckman: Well, it’s a very good question, especially if you look at the history of these early childhood programs and what they were designed initially to attack. The ABC program and many of the early programs, in fact many of the practitioners still in early childhood, focus on primarily cognitive outcomes, intellectual development, trying to prevent mental defectiveness and trying to promote mental functioning.
But we’ve learned over the last 40, 50 years of research that early childhood programs had much broader benefits, and we also understand that those broader benefits translate into a variety of capabilities, capacities that people have to act that enable them to function very successfully in many aspects of life, not just in terms of their health—in terms of their reduced crime, in terms of their promotion of school—sorry, in terms of their schooling attainment, in terms of their just general participation in society.
But an unexpected bonus, and I think this is unexpected by all of us initially, was that in fact precisely because social and emotional skills were enhanced, that because individuals were given greater capacities—we should say, both cognitive and social, emotional, or personality skills—that these translate into very effective lives, including lives that are healthier lives, that lead to less risky behaviors, that actually promote survival, and, I would say, flourishing into adulthood.
Mr. Whitener: Now, I noticed in the paper that you note that non-communicable diseases are responsible for roughly two-thirds of worldwide deaths.
Dr. Heckman: Yes.
Mr. Whitener: That was astonishing to me and also that—
Dr. Heckman: That’s not a figure that we arrived at. That’s just a citation to the literature, but yes.
Mr. Whitener: Right. And that another approach to combating disease is to prevent it, obviously, as opposed to our more typical efforts to focus on treatment after it occurs.
Dr. Heckman: Yes, I think this is a very important distinction. Now, I think the focus in much public policy discussion, whether it’s in health policy, or whether it’s in crime policy, or whether it’s anywhere across the board, has typically been to treat a problem after it shows up. It’s easier. “The squeaky wheel gets the grease” is the old adage. But when we look at what could be effective interventions and we say, well, suppose we target individuals who may be at high risk; then we can prevent the problem rather than treating it much later down the road. And it would seem, although the full evidence is not yet in, that treatment is less effective—treatment after the problem occurs is much less effective compared to targeted early interventions that actually prevent the program—sorry, the problem—the problem from happening.
And so I think this is a very important policy lesson for even health policy. We normally think of health policy as providing health insurance to adults. But we can also provide capabilities to individuals so that they don’t even encounter the health problems that the health care system has to deal with.
Mr. Whitener: Let’s take a step back into the process of the study itself.
Mr. Whitener: Could you please tell us, in your analysis, how did you determine the possible long-term effects of early childhood development programs on adult health?
Dr. Heckman: Well, that’s an interesting question, because if you look at the early studies of the ABC program and many early childhood programs, the main focus was on cognition. And so literally, there were only just a few indicators of health and healthy behaviors that were actually studied in the early analyses of these health programs—sorry, of the early childhood programs.
But then it occurred to many of us that indeed, and only recently in the last decade or so, that as we understood the dynamics of personality, we understood the dynamics of cognition, we understand the cognitive and social emotional basis of health, crime, and many other activities that it would be useful to come up with broader indicators and find out exactly how these programs altered these indicators. And that led us to very detailed medical examinations of individuals in the original ABC experiment. These people had been enrolled in the program in the 1970s, randomly assigned, some to treatment, some to control, and followed in this case through their mid-30s. And we then had these individuals, both treatment and control, have detailed physician visits in which their health was inventoried.
This is the most comprehensive study of its type so far, and it basically revealed some very fundamental differences between those who had treatment and those who had control. A surprising finding for people whose initial focus had been mainly boosting IQ and preventing mental retardation.
Mr. Whitener: In terms of the actual programs provided, or the services provided, the experiences for these children in the ABC program: can you describe those briefly for us, and what exactly was done for them and what experiences they had?
Dr. Heckman: Yes. One thing that’s really remarkable about the ABC program that’s in—compared to many other early childhood programs, is that the participation started very early, in the first eight, nine weeks of life. And for a subgroup of the children, they were followed through the third grade, essentially. And so what happened was, there were two treatment streams, really. What happened is that people were randomized into the treatment, were given a treatment zero to five, and then a second group was chosen. There was a second randomization at age five, and some were continued into the school years and others were dropped. And some people who had been dropped were recruited into the schooling years.
So there really are two different interventions here, with the most effective intervention being the one in the years zero to five years of age. But the intervention itself primarily was one that focused on cognitive, and social, and emotional stimulation, very much in keeping with the original goals of the program. In fact, the original goal was cognition. But then anybody implementing a cognitively rich program realizes that emotional stimulation, what the child-development psychologists would call scaffolding, is an integral part of any activity. And so that was conducted, and the treatment group children received that kind of scaffolding: individual attention and a kind of support system through their first lives, years zero to five.
So the curriculum was an eight-hour-a-day curriculum, but the core of the curriculum was a curriculum in the morning, which basically gave children cognitive and social and emotional stimulation with a very small pupil-teacher ratio, to use that term, although maybe it’s better to call it childcare worker/pupil ratio or a /child ratio. But what happened was that these interventions really were very much like what we could think of as supplementing the parenting of children, disadvantaged children whose ordinary environments may not be very rich. And it had interesting effects, not only on the child itself in the sense of, or the children themselves, I should say. But it also had effects on the parents and the way that they interacted with the children. And that had lasting effects, as well, on the child outcomes, because the parents are with the children—even if it’s an eight-hour-a-day program—they’re with the children many more hours a day and many more years than what any particular childcare program would.
There were health screenings as well, I should point out, that people were given some kind of screening but there wasn’t a lot of payment for medical services, per se. So there weren’t free medical services. There were nutritional supplements given to both the treatment and control group, just because of the level of poverty of the initial disadvantaged group and trying to level that playing field. Nutrition wasn’t the main focus of the study, and that was pretty much balanced between treatment and control, at least as what was provided at the childcare centers and by the intervention.
Mr. Whitener: You mentioned a moment ago that I.Q. was one of the differences between the two groups…
Mr. Whitener: …the control group and the treatment group. Could you tell us a little bit more about what specifically you found regarding the participants’ health status as adults?
Dr. Heckman: So what we found, and this is the case, which is really interesting: Some of the early childhood interventions have not shown very sustained effects on I.Q. And this is like a pure measure of I.Q., what some would call fluid intelligence. And what we found was that if you followed the children into age 21—that’s the last year I.Q. tests were given—you did find that there were sustained benefits in terms of I.Q. So there was a cognitive benefit that came from this very early intervention that started at eight weeks; very early, very intensive intervention.
But what also turned out to be there were some substantial enhancements in social and emotional skills. These are skills that have to do with regulating your lives, controlling your lives, and making decisions. And one important decision, of course, is about health. And so having more education, having [a] greater level of intelligence, and also having [a] greater level of social and emotional skills, what some psychologists would call executive functioning, those traits, those skills had played an enormous role in promoting the actual healthy behaviors and realized health of the young children who were in the treatment group.
So it’s a very interesting pattern in which we find that we increased the capabilities of the children, and those increased capabilities translate directly into a set of outcomes which are very, very promising and help the participants lead flourishing lives.
Mr. Whitener: Regarding physical health, what were some of the specific manifestations you saw of the benefits of participating in the early childhood development program?
Dr. Heckman: Well, there were differences by gender, and the most striking differences were for males, but for those in particular, you found—there were benefits for women as well, for the young girls, but the benefits were very striking for males. And for example, at age 35, which is still a pretty young age, we find substantial differences in diastolic and systolic blood pressure between the controls and the treatment group.
I'll just give you an example. Often, people use the benchmark of 140 as a measure of—physical measure of systolic blood pressure. And we found that using that benchmark of 140, we find that basically it’s 143 for the control group and about 125 for the treatment group. Which means, then, the treatment group had much lower systolic blood pressure. And the same is true of the diastolic blood pressure. So indicators in terms of pre-hypertension and in terms of hypertension, there are substantially more beneficial outcomes for the treatment group. We find that the treatment group children are much less likely to be Vitamin D-deficient and much [more] likely to be holding higher levels of what’s called good cholesterol. We find that they’re much less likely to be obese, and so forth and so on.
So we find a number of risk factors are substantially attenuated. One of the most striking findings is probably the finding on what’s called a Framingham Heart Index or the Framingham Risk Score that was just recently computed. And there’s substantial differences. This is the risk that people have for [a] cardiac condition in the next ten years of their lives. These are people still, now, remember, at age 35, and there’s substantial differences favoring the treatment group as a result of this.
So across a variety of outcomes: metabolic syndrome, the Framingham test score, obesity, waist-hip ratios, all of these are showing very beneficial effects, and I think that’s very promising when we think about health policy. Because this is one way to essentially prevent putting these children as adults into the medical care system, placing demands on the whole system. It’s really a very effective way to essentially promote well-being and functioning.
Mr. Whitener: Why do you think that the participation in the ABC program made such a difference in the health of these people years later?
Dr. Heckman: Well, you see, this gets to a deeper issue, which is, I don’t think, properly appreciated still in the medical community. And it certainly shows up in medical education even today, where most doctors are taught to treat diseases that manifest themselves and not to provide a kind of lifestyle and background, and early pre-conditions that essentially determine health. I think it’s still—cognitive epidemiology and non-cognitive personality epidemiology—are still very early on in their development and their acceptance in the medical and biomedical community. And I think one of the important lessons from this study is that these factors, both cognitive and social-and-emotional, play very important roles in shaping the ways we act and control our lives.
And this, to me, means that we need to think very differently. Part of it, I would argue, even the medical school education, should consist much more of thinking about how important early life conditions are, how that effective medicine and effective health policy will actually target those early years in ways that currently are just not even on the agenda, both in public policy discussions and in medical training, of a physician’s training.
Mr. Whitener: You’ve mentioned the policy implications of your findings. In the article, you and your colleagues write that early childhood programs could also help reduce the nation’s healthcare costs. Could you elaborate on that?
Dr. Heckman: Well, precisely. These conditions we’re talking about—diabetes, blood pressure, high blood pressure, obesity—all of these conditions are major determinants of health care costs. I mean, when we think about expanding health care to large populations, especially to disadvantaged populations, we recognize that there are a lot of risk factors that have already been incurred by those groups. And one way to avoid the cost of sort of treatment and the larger social costs, both the private costs for the individual, the pain and the suffering of the individual, as well as the collective social cost of taking care of those who are ill, that we can avoid those costs. And in fact, stating it more positively, think about health as essentially health policies creating more flourishing lives, lives that essentially provide opportunities to live sort of pain-free, trouble-free lives, or at least longer pain-free, trouble-free lives and therefore reduce the kind of burdens on society and the burdens on individual welfare.
This was not an option that many people who talked about “bending the cost curve” talked about. But that’s exactly what we are talking about. These kinds of policies will bend the cost curve, but they bend it not by essentially changing physician’s fees, as much as by changing the nature of what we think of as medicine, and what are the determinants of a healthy life.
Mr. Whitener: Are there any final thoughts on the study you’d like to share?
Dr. Heckman: Well, I think it’s exciting. I think it’s the beginning. I mean we clearly need other evidence; we need to confirm this. There are plans underway right now. We have funding actually from NIH to collect similar data on an even earlier childhood study, the Perry Preschool Study and that was done, started, in the 1960s. And so I think that like in any part of science, replication, reanalysis, and challenge is really an integral part of all research process. But I think that this really does direct our thinking in a different way, and I think it really causes people to think more broadly about what we mean by health, and how we get it, and it kind of moves us out of the treatment mode and really gets into the notion of a prevention mode and early life intervention as an important part of that prevention mode.
Mr. Whitener: I’ve been speaking with Dr. James Heckman. He’s the Henry Schultz Distinguished Service Professor of Economics at the University of Chicago, and a Nobel Memorial Prize Winner in Economics. Thank you for joining us today, doctor.
Dr. Heckman: Well, thank you for the opportunity.
About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute’s website at http://www.nichd.nih.gov/.