school readiness - pediatrics · technical report school readiness p. gail williams, md, faap,a...

TECHNICAL REPORT

School ReadinessP. Gail Williams, MD, FAAP,a Marc Alan Lerner, MD, FAAP,b COUNCIL ON EARLY CHILDHOOD, COUNCIL ON SCHOOL HEALTH

abstractSchool readiness includes the readiness of the individual child, the school’sreadiness for children, and the ability of the family and community to supportoptimal early child development. It is the responsibility of schools to meet theneeds of all children at all levels of readiness. Children’s readiness forkindergarten should become an outcome measure for a coordinated system ofcommunity-based programs and supports for the healthy development ofyoung children. Our rapidly expanding insights into early brain and childdevelopment have revealed that modifiable factors in a child’s early experiencecan greatly affect that child’s health and learning trajectories. Many childrenin the United States enter kindergarten with limitations in their social,emotional, cognitive, and physical development that might have beensignificantly diminished or eliminated through early identification andattention to child and family needs. A strong correlation between social-emotional development and school and life success, combined with alarmingrates of preschool expulsion, point toward the urgency of leveragingopportunities to support social-emotional development and addressbehavioral concerns early. Pediatric primary care providers have access to theyoungest children and their families. Pediatricians can promote and usecommunity supports, such as home visiting programs, quality early care andeducation programs, family support programs and resources, earlyintervention services, children’s museums, and libraries, which are importantfor addressing school readiness and are too often underused by populationswho can benefit most from them. When these are not available, pediatricianscan support the development of such resources. The American Academy ofPediatrics affords pediatricians many opportunities to improve the physical,social-emotional, and educational health of young children, in conjunction withother advocacy groups. This technical report provides an updated version ofthe previous iteration from the American Academy of Pediatrics publishedin 2008.

EARLY EXPERIENCE MATTERS

All of a child’s early experiences, whether at home, in child care, or inother preschool settings, are educational. When early experiences are

aDepartment of Pediatrics, Weisskopf Child Evaluation Center,University of Louisville, Louisville, Kentucky; and bCenter for Autism andNeurodevelopmental Disorders, University of California, Irvine, Irvine,California

Drs Williams and Lerner were responsible for conceptualizing, writing,and revising the manuscript and for considering input from reviewersand the Board of Directors; and all authors approved the finalmanuscript as submitted and take responsibility for the manuscript inits final form.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Technical reports from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, technical reports from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DOI: https://doi.org/10.1542/peds.2019-1766

Address correspondence to P. Gail Williams, MD, FAAP. E-mail:[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING: No external funding.

To cite: Williams PG, Lerner MA, AAP COUNCIL ON EARLYCHILDHOOD, AAP COUNCIL ON SCHOOL HEALTH. SchoolReadiness. Pediatrics. 2019;144(2):e20191766

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mailto:[email protected]

consistent, developmentally sound,and emotionally supportive, childrenlearn optimally and developresilience for life. To focus only on theeducation of children beginning withkindergarten is to ignore the scienceof early development and to deny theimportance of early experiences. Ourcurrent understanding of theimportance of experiences in earlybrain development and in cognitiveand social-emotional outcomes forchildren converge in ourcontemporary conceptualization ofschool readiness. Children who enterschool ready to learn are expected toachieve more academically. Academicsuccess has been linked to improvedsocial, economic, and healthoutcomes.1–3

The Adverse Childhood ExperiencesStudy revealed that multiple factorscan cause toxic stress that results inchanges in brain circuitry withsubsequent negative effects onphysical and mental health.4,5 Toxicstress occurs when a childexperiences strong, frequent, and/orprolonged adversity, such as physicalor emotional abuse, chronic neglect,caregiver substance abuse or mentalillness, exposure to violence, and/orthe accumulated burdens of familyeconomic hardship, without adequateadult support.6

According to data from the NationalChild Abuse and Neglect Data System,12.5% of all US children have hada documented episode of child abuseor neglect reported by 18 years ofage.7,8 According to data from theNational Survey of Children’s Health,48% of US children have had at least1 of the 9 key adverse childhoodexperiences, and 22.6% of childrenbetween 0 and 17 years of age hadexperienced 2 or more of theexperiences, although the data exhibitconsiderable variability acrossstates.9

Authors of a recent study used2011–2012 data from the NationalSurvey of Children’s Health to

examine the impact of adversechildhood experiences on schoolsuccess.10 Data analysis revealed thatchildren with 2 or more adversechildhood experiences were2.67 times more likely to repeata grade in school compared withchildren without any adverseexperiences. Children withoutadverse childhood experiences were2.59 times more likely to be usuallyor always engaged in schoolcompared with their peers with 2 ormore adverse experiences.10

Resilience, defined in that study as“staying calm and in control whenfaced with a challenge,” amelioratedthese effects. Clearly, there is a rolefor minimizing toxic stress andbuilding resilience in children asa way of promoting school readiness.

One of the most widely recognizedrisk factors for school readiness ispoverty. Fewer than half (48%) ofpoor children are ready for school at5 years of age as compared with 75%of children from moderate- or high-income households.11 Poverty affectsschool readiness across racial andethnic divisions, likely because ofboth lack of financial resources andparents having less education, higherrates of single and teenageparenthood, poorer health, etc. Whenfamily demographics are controlledfor factors such as single parenthoodand maternal education the poverty-related gap decreases; differences inparent characteristics and parent-child interactions account for much ofthe gap and have the potential forremediation to break the cycle ofnegative relationships that oftenimpact 1 generation to the next.12

Children in foster or kinship care orotherwise involved with child welfaremay be less ready for school forseveral reasons: the impact ofchildhood trauma and loss on thedeveloping brain (cognitive andemotional) and less access to earlychildhood education and programsthat may help to remediate losses.Children in foster care are at

particular risk, especially if theirplacement is unstable. These childrendemonstrate higher rates ofinternalizing problems, such asdepression, poorer social skills, loweradaptive functioning, and moreexternalizing behavioral problemssuch as aggression and impulsivity.13

Furthermore, there is evidence thatthe foster care experience itself (eg,instability of placements) may befurther damaging to thedevelopmental outcomes of childrenwho are maltreated.14 Other riskfactors that have been shown to havean effect on school readiness areprenatal exposure to tobacco andalcohol, low birth weight,developmental disability, andmaternal depression.15 Interventionssuch as home visitation programs,smoking cessation programs, andpreschool programs have thepotential of ameliorating thesenegative factors and creating morepositive early childhood experiencesthat may translate into improvedschool readiness.16,17 Pediatricprimary care has recently beenshown to have potential to facilitateschool readiness through bothprimary prevention programs thatseek to prevent disparities byworking directly with parents toenhance interactions (eg, within thecontext of reading, talking, and play)and through referral to secondaryand/or tertiary prevention programsthat identify and treat families atincreased risk (eg, maternaldepression) or children with alreadyexisting difficulties in 1 or moreschool readiness domains (behavioralhealth or education).18

HOW HAS SCHOOL READINESS BEENDEFINED?

“Ready to Learn” became a nationalmantra in 1991 when the NationalEducation Goals Panel adopted as itsfirst goal that “by the year 2000, allchildren will enter school ready tolearn.”19 This panel identifiedreadiness in the child as determined

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by a set of interdependentdevelopmental trajectories. Threecomponents of school readiness werebroadly described as follows:

1. readiness in the child, defined bythe following:

○ physical well-being and sensorymotor development, includinghealth status and growth;

○ social and emotionaldevelopment, including self-regulation, attention, impulsecontrol, capacity to limitaggressive and disruptivebehaviors, turn-taking,cooperation, empathy, and theability to communicate one’sown emotions; identification offeelings facilitates accuratecommunication of these feelings;

○ approaches to learning,including enthusiasm, curiosity,temperament, culture, andvalues;

○ language development,including listening, speaking,and vocabulary, as well asliteracy skills, including printawareness, story sense, andwriting and drawing processes;and

○ general knowledge andcognition, including earlyliteracy and math skills;

2. schools’ readiness for children,illustrated by the following:

○ smooth transition betweenhome and school, includingcultural sensitivity;

○ opportunities for parentengagement with schools;

○ understanding of early childdevelopment and that childrenlearn through play and naturalexperiences;

○ continuity between early care,intervention, and educationprograms and elementaryschool;

○ use of high-quality instruction,provided within the context of

relationships and at a ratedesigned to challenge but notoverwhelm a child;

○ demonstration of commitmentto the success of every childthrough awareness of the needsof individual children, includingthe effects of adverse childhoodexperiences, including povertyand racial discrimination, andtrying to meet special needswithin the regular classroom;implementation ofindividualized educationprograms that includeadaptations to support childrenwith disabilities;

○ demonstration of commitmentto the success of every teacherin providing effective instructionto children;

○ introduction of approaches thatraise achievement, such asparent involvement and earlyintervention for children fallingbehind;

○ alteration of practices andprograms if they do not benefitchildren;

○ provision of services to childrenin their communities within thecontext of a safe, secure, andinclusive environment thatsupports student health andwellness and promotes learning;

○ willingness to takeresponsibility for results; and

○ strong leadership; and

3. family and community supportsthat contribute to child readiness:

○ excellent prenatal care andongoing primary care withina medical home setting that iscomprehensive, compassionate,and family centered;

○ optimal nutrition and dailyphysical activity so that childrenarrive at school with healthyminds and bodies;

○ access to high-qualitypreschool and child care for allchildren; and

○ time set aside daily for parentsto help their child learn alongwith the supports that allowparents to be effective teachers.

WHAT DETERMINES SCHOOLREADINESS?

An individual child’s school readinessis determined in large measure by theenvironment in which he or she livesand grows. The Child Welfare Leagueof America described a vision for theUnited States in which every child ishealthy and safe and develops to hisor her full capacity.20 Five universalneeds of all children were described.First, children need the basics ofproper nutrition, economic security,adequate clothing and shelter,appropriate education, and primaryand preventive physical and mentalhealth services. Second, children needstrong nurturing relationships withintheir families, their communities, andtheir peer groups. Third, childrenneed opportunities to develop theirtalents and skills and to contribute totheir communities. Children withindications of disability need earlyassessment and intervention toprevent later, more serious problems.Fourth, children need protection frominjury, abuse, and neglect as well asfrom exposure to violence anddiscrimination. Fifth, children havea basic need for healing. Whencaregivers and providers have notbeen able to protect them, childrenneed us to ease the effects of anyharm they have suffered by providingemotional support, by addressingphysical and mental health careneeds, and by sometimes makingamends through restorative judicialpractices. Meeting these needs buildsresilience and requires collaborativecomprehensive approaches so thatchildren become a priority at thelevels of the family, the community,and the nation.20

Although various constructs of schoolreadiness have been proposed in thepast, the conceptualization of schoolreadiness that is widely accepted at

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present is an “interactional relational”model. This model is focused on theongoing interaction between the childand the environment. The modelsuggests that school readiness is “theproduct of a set of educationaldecisions that are differentiallyshaped by the skills, experiences andlearning opportunities the child hashad and the perspectives and goals ofthe community, classroom andteacher.” This construct suggests thatreadiness assessments “can only bedone over time and in context” ratherthan by means of a 1-time screeningtest.21 This conceptualization is mostconsistent with the currentunderstanding of the importance ofearly experiences and earlyrelationships at home and incommunity and early educationsettings in promoting childdevelopment.22

SCHOOL READINESS TESTING

Six fundamental misconceptionsprevalent regarding school readinessare as follows: (1) learning happensonly at school; (2) readiness isa specific condition within each child;(3) readiness can be measured easily;(4) readiness is mostly a function oftime (maturation), and some childrenneed a little more; (5) children areready to learn when they can sitquietly at a desk and listen; and (6)children who are not ready do notbelong in school.23

An emphasis on kindergartenreadiness that only considers theskills of a child places an undueburden of proof of readiness on thatchild and is particularly unfairbecause of economic, experiential,and cultural inequities in our society.Typical or normal development in4- and 5-year-old children is highlyvariable, so labeling children as notbeing school ready at such an earlyage may cause them to be isolatedfrom a more appropriate learningenvironment. In a 1988 nationalsurvey, 10% to 50% of children in

various states who were eligible toenter kindergarten on the basis of agedid not enter because of readinesstest scores.24 A follow-up survey in199625 revealed a response togrowing concerns about misuse ofthese kinds of data. Since that time,there has been increased recognitionthat school readiness assessmentshould not be used to exclude age-eligible children from kindergarten.In 2010, only 6% of children inkindergarten were delayed entry.26

Although the use of readinessassessments to restrict kindergartenentry has markedly decreased,a growing number of states are usingreadiness assessments for otherpurposes. At least 25 states in 2010reported mandatory kindergartenassessments. These assessmentsvaried significantly in scope: 11evaluated between 5 and 9 domainsof school readiness, 4 evaluated onlyreading readiness, 2 evaluated mathand reading, and 2 evaluatedunspecified domains. Of the statesthat assessed multiple domains, 7used a state-created assessmentinstrument and 4 used a commercialinstrument. Authors of a technicalreport from the National Conferenceof State Legislatures (NCSL) notedthat although state-createdinstruments are less costly and betterreflect state-specific learningrequirements, they need to meetstandards for reliability andvalidity.27 Most state readinessassessments used single teacherchecklists completed on the basis ofchild observation; these can beinaccurate because of rater bias andcan have problems with reliabilitybetween raters and consistent over-or underrating on the basis ofa general impression of the child.

Reported use of assessments includedguidance for planning, curriculum,and instruction (18 states), informingpolicy decisions or trackingkindergarten readiness at the statelevel (12 states), feedback to parents(4 states), and evaluation of the

readiness of schools to receiveincoming students (2 states). Of the25 states that required kindergartenassessment, 12 did not publish anyresults. Of the 13 that publishedresults, 4 published only state-leveldata, and 7 reported results bygeographic region. In general, thesedata were much less detailed thanstudent performance results requiredfor later grades by the No Child LeftBehind Act, which was in place from2002 to 2015. Of concern is the factthat only 22 states in 2010 hada formal definition of schoolreadiness.28

Recent federal initiatives havebolstered funding for state earlychildhood assessments. The federalRace to the Top Early LearningChallenge allowed 9 states to putsizeable funding from their grant intodevelopment and implementation ofkindergarten entry assessment. Otherstates received funding through thefederal Enhanced Assessment Grantsprogram to develop comprehensivekindergarten through third-gradeassessment systems. An update bythe NCSL in 2014 documented anadditional 14 states that establishedor amended school readinessassessments of young children,yielding a total of 34 states and theDistrict of Columbia, which now usea state-approved assessment forchildren entering kindergarten.29

Approaches to school readinesstesting are subject to frequent change.The most recent information on statelaws is available through theAmerican Academy of Pediatrics(AAP) Division of State GovernmentAffairs (https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Pages/State-Advocacy.aspx).

A position paper by the EarlyChildhood Education StateCollaborative on Assessment andStudent Standards in 2011 stated thatkindergarten readiness assessmentscan be helpful if used to directlysupport children’s developmental andacademic achievement to improve


https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Pages/State-Advocacy.aspx



educational outcomes.30 Suchassessment efforts should (1) usemultiple tools for multiple purposes,(2) address multiple developmentaldomains and diverse culturalcontexts, (3) align with early learningguidelines, (4) collect informationfrom multiple sources, (5) implementa systems-based approach, and (6)avoid inappropriate use ofassessment, such as labeling children,restricting kindergarten entry, andpredicting children’s future academicsuccess.

As the NCSL data from 2010reveal, there is considerablevariability in the approachtaken to kindergarten readiness onthe state and national level, both withregard to assessment tools and use oftest results. One effort atstandardizing results for statereporting is the Early DevelopmentInstrument created by TransformingEarly Childhood Community Systems,a collaboration between theUniversity of California, Los AngelesCenter for Healthier Children,Families, and Communities and theUnited Way Worldwide.31 Thisinitiative currently operates in morethan 40 communities across thecountry and reports the percentage ofchildren who are developmentallyvulnerable in 5 areas (physical healthand well-being, social competence,emotional maturity, language andcognitive development, andcommunication and childknowledge). Transforming EarlyChildhood Community Systems statesthat the reports help guidecommunity efforts to help childrenreach school healthy and ready tosucceed. To the extent that suchefforts decrease the disparitybetween school and child readinessby using the assessments as a tool tohelp schools prepare for the childrenthey will be serving and promoteopportunities for early childhoodexperiences leading to educationalsuccess, readiness assessments canbe highly useful.

SCHOOLS’ READINESS FOR CHILDREN

The current disparity between schooland child readiness may beattributable to schools not beingprepared to offer the necessary andappropriate educational setting forage-eligible children, not becausechildren cannot learn in anappropriate educational setting. Ifthere is a predetermined set of skillsnecessary for school enrollment, thencommitment to promoting universalreadiness must address early-lifeinequities in experience. Promotinguniversal readiness may beaccomplished by providing access toopportunities that promoteeducational success, recognizing andsupporting individual differencesamong children, and establishingreasonable and appropriateexpectations of children’s capabilitiesat school entry for all children.32 Thedata gained from testing children atkindergarten entry need to beinterpreted carefully. Ideally, data canbe used as a tool to help prepareschools for the diverse group ofchildren they will be serving. It is theresponsibility of the schools to beready for all children and to workwith families to make the schoolexperience positive for all children,even those who may be at varyingstages of readiness. School programsshould be flexible and adaptable toeach child’s level of readiness.

One example of schools seeking toaddress the school readiness needs oflow-income and ethnically diversepopulations is the Boston PublicSchool System. In 2006, this schoolsystem implemented full-daypreschool programming for 25% of4-year-old children in the city andidentified key elements ofa successful prekindergartenprogram: a strong curriculum withfocus on language, social skills, andconcept development (manuals);significant educational supports forteachers in implementing thecurriculum; adequate staffing;coaching and training of preschool

teachers; and ongoing, independentassessment of instruction andchildren’s skills.33 The results of thiseffort were significant: participants inthe prekindergarten program scoredhigher on third-grade language artstests than did nonparticipants, andthe African American–whiteachievement gap was one-thirdsmaller among prekindergartenparticipants than amongnonparticipants. In addition, theprekindergarten program was able toclose the gap between children fromlow-income and affluent families bymore than half. The authors ofRestoring Opportunity: The Crisis ofInequality and the Challenge forAmerican Education conclude that“well-designed and well-implementedpre-K programs have the potential tobe a vital component of a strategy toimprove the life chances of childrenfrom low income families.”33

HOW READY ARE CHILDREN IN THEUNITED STATES AS THEY ENTERKINDERGARTEN?

A landmark study by the NationalCenter for Education and Statistics(NCES) (1998–1999) surveyeda nationally representative sample of22 000 first-time kindergartenstudents and their schools, classroomteachers, and families.34,35 The EarlyChildhood Longitudinal Study (ECLS)was designed to gather informationabout the entry status of the nation’skindergarteners. Progress of thiscohort is still being monitored toinform educational policy andpractice. Information was obtainedregarding children’s cognitive,emotional, social, and physicaldevelopment as well as their familyinteractions and home literacyenvironment. In the study, children“at risk for school difficulty” weredefined as children whose mothershad less than a high school education,children who were being raised bysingle mothers, children whosefamilies had received publicassistance, and children in families


whose primary language was notEnglish.34,35

Fifty-one percent of parents ofchildren who entered kindergartenfor the first time in 1998 rated theirchild’s general health as excellent,and 32% rated it as very good.34,35

Kindergarteners whose mothers hadhigher levels of education, who werefrom 2-parent families, whosefamilies had not used publicassistance, and who were of whitenon-Hispanic descent were rated ashaving generally better health bytheir parents. Six percent of first-timekindergartners were experiencingvision problems, and 3% wereidentified as having hearingproblems. In that study, 12% of boysand 11% of girls were at risk foroverweight, defined as BMI at orabove age- and sex-specificguidelines. The risk was greater forchildren whose mothers had notattained a bachelor’s degree and forchildren from homes in which theprimary language spoken was notEnglish.34,35

The study attempted to examine thesocial and emotional status of first-time kindergartners. Teachersreported that 10% to 11% of childrenoften argued or fought with others orwere angered easily. Single parentswere more likely to report behaviorproblems, such as fighting, arguing,and getting angry. Parents withpartners, those with higher education,and those who had not receivedpublic assistance were more likely tohave kindergartners with prosocialbehaviors, such as often formingfriendships. Teachers were less likelythan parents to report that childrenwere eager to learn (75% vs 92%).Children with lower maternaleducation, those from single-motherhomes, and those whose families hadreceived public assistance were lesslikely to be viewed as eager to learnby their teachers.34,35

Variability also was seen in homeliteracy environments and in family

interactions for first-timekindergartners. Forty-five percent ofall parents reported reading withtheir child every day, and this valuedecreased to 36% if mothers had lessthan a high school education, 38% ifEnglish was not the primary languagespoken at home, 35% for AfricanAmerican non-Hispanic children, and39% for Hispanic children. Almostthree-fourths of parents reportedhaving more than 25 children’s booksat home, but this was true for only38% of kindergartners whosemothers had not graduated from highschool and only 35% of those fromhomes where English was not theprimary language spoken.Approximately half of kindergartnersfrom African American non-Hispanic,Hispanic, or American Indian orAlaskan native families had morethan 25 children’s books at home.34,35

Early academic competencies werealso surveyed in the study. In 1998 inthe United States, as children enteredkindergarten for the first time, two-thirds recognized their letters, and29% also recognized beginningsounds; 94% recognized singlenumerals and shapes and could countto 10, and 58% could count beyond10, recognize sequence patterns, anduse nonstandard units of length tocompare objects. Of those children,37% demonstrated strong printfamiliarity skills, including knowingthat print reads from left to right andknowing where to go when a line ofprint ends. Kindergartners’performance on math, reading, andgeneral knowledge items increasedwith the level of their mothers’education and was higher for childrenfrom 2-parent families.34,35

Overall, children with few risk factorswere more likely to have attainedthese various proficiencies and werein better general health than werechildren at risk. Follow-up evaluationof the same children in the spring offirst grade revealed that children whodemonstrated early literacy skills andwho came from a positive literacy

environment, who possesseda positive approach to learning, andwho enjoyed very good or excellentgeneral health at kindergarten entryperformed better in both reading andmathematics after 2 years of formalschooling than did children who didnot have these resources. Therelationships between the resourceschildren possessed at kindergartenentry and their reading andmathematics performance in thespring of first grade remainedsignificant after controlling for theinfluence of children’s poverty statusand their race and/or ethnicity.36

When these children were evaluatedafter 4 years of education, in thespring of third grade, children withmore family risk factors (eg, livingbelow the poverty level, primarylanguage spoken in the home was notEnglish, mother had not completedhigh school, and single-parent home)demonstrated lower meanachievement scores in reading,mathematics, and science. Over thattime, children with more family riskfactors made smaller gains in mathand reading, so the achievement gapsbetween disadvantaged and moreadvantaged children grew wider overthe first 4 years of school. The third-graders also completed self-descriptive questionnaires evaluatinginternalizing (eg, shy, withdrawn, orsad) and externalizing (eg, fighting,arguing, or distractibility) behaviorproblems. Overall, problem behaviorscores were low; however, childrenwith lower achievement and morefamily risk factors tended to ratethemselves higher on both of theproblem behavior scales.37

These findings, although they aredisturbing, are not surprising topediatricians, who have long beenadvocates for underserved pediatricpopulations. This inequity in schoolreadiness, which is apparent at schoolentry and is associated withpersistent academicunderachievement and social-emotional risk, points to a need to


address these differences beforechildren enter kindergarten,especially for families and childrenat risk.

More recent studies have alsoaddressed school readiness. Datafrom the 2007 National HouseholdEducation Surveys Program of theNCES were used to look at howparents perceived the schoolreadiness of their young children.38

Among the findings were that 58% ofchildren 3 to 6 years of age and notyet in kindergarten were reported tobe attending preschool or a child carecenter. Eighty-nine percent ofchildren’s parents planned to enrollthem into kindergarten on time; 7%planned delayed enrollment. A higherpercentage of boys (9% vs 4%) hadparents who planned to delaykindergarten entry. When surveyedabout literacy issues, 55% of childrenwere read to every day, 28% wereread to 3 or more times in the pastweek, 13% were read to once ortwice a week, and 3% were not readto at all in the past week; mean dailyreading time was 21 minutes. A lowerpercentage of children residing inpoor households (40%) were read toevery day compared with childrenresiding in households living abovethe poverty level (60%).

Average television or video time forthose who watched was 2.6 hoursdaily. Television time was somewhatlonger for children of mothers whoworked 35 hours or more (3 hoursdaily) as compared with mothers whoworked less than 35 hours weekly(2.5 hours daily) or were not in thelabor force (2.4 hours). With regardto school readiness skills, 93% ofparents reported that their child hadspeech that was understandable toa stranger, 87% of children could holda pencil, 63% could count to 20 orhigher, 60% could write their firstname, 32% could recognize all theletters of the alphabet, and 8% couldread written words in books.Alphabet recognition varied by age,with only 13% of 3-year-olds, 38% of

4-year-olds, and 59% of 5- and 6-year-olds not enrolled inkindergarten recognizing all letters.When parents were surveyedregarding essential skills needed toprepare for kindergarten, 62%reported that sharing was essential,56% reported that teaching thealphabet was essential, 54% reportedthat teaching numbers was essential,45% reported reading was essential,and 41% reported holding a pencilwas a needed skill.38

Child Trends analysis of the NationalHousehold Education Surveys data in2015 indicates an increase in earlyliteracy skills over time.38 Thepercentage of 3- to 6-year-oldchildren able to recognize all lettersincreased from 21% in 1993 to 38%in 2012, and those able to count to 20or higher increased from 52% to 68%during that period. Between 1999and 2007, the percentage of theseyoung children who read words ina book increased from 8% to 22%.Significant discrepancies existbetween early childhood readinessskills on the basis of factors such aspoverty status, parents’ educationalstatus, and race and/or ethnicity. In2007, only 21% of children livingbelow the poverty level were able torecognize all letters of the alphabetcompared with 35% of those livingabove the poverty level; similarly,counting to 20 was a skill that 49% ofpoor children at this age achievedcompared with 67% of those abovepoverty.39 In 2012, only 15% ofchildren between 3 and 6 years of age(not yet in kindergarten) whoseparents had not completed highschool could recognize all letters ofthe alphabet and only 38% couldcount to 20, which is between 46%and 142% lower than for childrenwhose parents had completed somecollege. Young Hispanic children wereless likely to demonstrate the abilityto recognize all letters (27%) thanwhite (41%) or African American(44%) children in 2012; AsianAmerican and Pacific Islander

children had the highest rate of letterrecognition (58%). The sex gap inreadiness skills has disappeared;although girls in 1999 weresignificantly more likely to haveachieved skills for letter recognitionand counting than boys, there wereno such differences by 2012. Thesedata reflect improvement in overallreadiness skills of young childrenfrom earlier studies, but gaps inachievement based on poverty andrace and/or ethnicity are still readilyapparent.39

THE RELATIONSHIP BETWEEN EARLYCHILDHOOD EDUCATION AND SCHOOLREADINESS

Measurements from 2016 of thebenefits of early childhood educationvary depending on the type ofprogram studied and educationaloutcomes tracked. In general, benefitson standardized academicachievement tests are higher formodel programs (0.57 SD; 95%confidence interval [CI], 0.24 to 0.81)than for those organized at thedistrict, state (0.32 SD; 95% CI, 0.25to 0.38), or federal (Head Start; 0.17SD; 95% CI, 0.12 to 0.23) levels.40

Model programs, such as theAbecedarian Project and PerryPreschool Program, have generallybeen implemented as part of well-funded research projects and areclosely monitored for fidelity ofimplementation and staffed by highlytrained individuals. Evaluation ofprograms at the school district andstate level found a statisticallysignificant positive effect on studentself-regulation (0.23 SD; 95% CI, 0.12to 0.33), whereas a nonsignificantbenefit was shown for Head Start(0.16 SD; 95% CI, 20.09 to 0.41).Long-term follow-up of participantsin Head Start revealed a positiveeffect on high school graduation rate(0.18 SD; 95% CI, 0.03 to 0.33).Nonsignificant beneficial effects arealso reported on measures of graderetention, assignment to special


education, teenage birth rates, andcriminality.16

A study from 2005 that evaluated theeconomic features of investing in a 1-year, high-quality, universal,preschool education in Californiaestimated a $7000 net present-valuebenefit per child. This benefit equaleda return of $2.62 for every $1invested, with an annual return rateof 10% over 60 years. This model didnot include other benefits to society,such as the improved health and well-being of participating children andthe potential intergenerationaltransmission of favorable benefits.41,42

Economists at the Federal ReserveBank of Minneapolis examined therate of return on investment for earlyeducation. When considering thePerry Preschool Program, conductedin Michigan in the 1960s, whichprovided high-quality preschool to 3-and 4-year-old children in poverty,along with home visitation to involveparents, the economists found a “real”return on investment, adjusted forinflation, of 16%, with at least 75% ofthose benefits going to the generalpublic.43,44 The benefit/cost ratio (theratio of the aggregate programbenefits over the life of the child tothe input of costs) was found to begreater than 8:1.41 These benefitspersisted to age 40, at which timemore of the program group wereemployed than the nonprogramgroup (76% vs 56%), moreearned over $20 000 dollarsper year (60% vs 40%), and fewerwere arrested more than 5 times(36% vs 55%).45 The CarolinaAbecedarian Project conductedin 1972 provides data thatsupport the developmental andbehavioral benefits of qualityeducation provided within thecontext of day care programs intoadulthood.46 Economic benefits werereported in maternal earnings,decreased schooling costs fromkindergarten through grade 12,increased lifetime earnings, anddecreased costs related to smoking.

A position paper by the NationalInstitute for Early Education Researchwas published in 2013, concludingthat expanding access to qualityprekindergarten programs is soundpublic policy.47 That authors pointedto a meta-analysis that summarizesthe effects of preschool programs, theresults of which pointed to 2 basicfindings: (1) state and localprekindergarten programs, almostwithout exception, improve academicreadiness for school; and (2) thereare persistent impacts onachievement well beyond schoolentry, even though these aresomewhat smaller than short-termimpacts.

Enrollment of children in state-funded preschool programsnationwide doubled from 2001 to2016, with states serving nearly 33%of 4-year-old children in 2016.47

However, enrollment of 3-year-oldchildren has changed little (5% totalof 3-year-old children served inpublic preschools in 2016). Thosenumbers improve when looking at allpublic preschool programs (includingspecial education and Head Start) to43% of 4-year-old and 16% of 3-year-old children. Provision of preschoolservices is highly variable from stateto state, with some states offeringnearly universal services at 4 years ofage and others having no programs. Anegative trend of decreased stateexpenditure per child occurred from2008 to 2014, but that trend hasreversed from 2014 to 2016, withtotal state funding for preschoolprograms increasing to almost 7.4billion dollars. There has also beena positive move toward improvementin developing and implementing earlylearning standards and developingquality standards.48 Benchmarksneed to be applied to preschoolprograms, including teacher trainingrequirements, rules on class size andstaff/child ratios, adequate teachercompensation, adherence to earlylearning standards, provision ofcomprehensive services, provision of

at least 1 meal, and monitoringquality of sites. In 2016, many statesmet fewer than half of the currentquality standards benchmarks, andcharter schools are not required tomeet these benchmarks.47

The data are not as clear-cut for thebenefits of child care programs.Approximately 58% of children 4 and5 years of age received center-basedcare in 2012, 13% received home-based relative care, and 19% had noearly childhood educationarrangement on a regular basis.49 TheNational Institute of Child Health andHuman Development Study of EarlyChild Care and Youth Development(2006) found that children in higher-quality nonmaternal child care hadsomewhat better language andcognitive development during thefirst 4.5 years of life but that thosechildren with high number of hours inchild care demonstrated morebehavior problems; parent and familycharacteristics were more associatedwith developmental outcome thanwere facility features.50

In general, school readiness appearsto have improved over the past 2decades. The NCES tracked 2 large,nationally representative cohorts ofchildren entering kindergartenthrough its ECLS.51 The studycompared school readiness in the1998 kindergarten cohort versus the2010 cohort. Children in the 2010cohort were more proficient acrossa variety of math and reading skills,regardless of race or socioeconomicstatus, with particularly large gains inmath and literacy proficiency amongAfrican American children. Theauthors suggested that earlyachievement gaps are narrowing andthat the skills and knowledgechildren possess when enteringschool are increasing. However, theyalso noted that teachers rated the2010 cohort somewhat less favorablywith respect to their “approaches tolearning,” a measure thatencompasses eagerness to learn,ability to work independently,


persistence, and attention. Authors ofanother study using the same ECLSdata concluded that “despitewidening income inequality,increasing income segregation, andgrowing disparities in parentalspending on children, disparities inschool readiness narrowed from 1998to 2010.”52 The authors hypothesizedthat the narrowing of the disparitywas attributable to a relatively rapidincrease in overall school readinesslevels among poor and Hispanicchildren, along with less rapidincreases in readiness among high-income and white children. Althoughthese findings are encouraging, thereis still reason for concern. Authors ofa previously mentioned article onschool readiness in poor childrennoted that preschool programs offerthe best chance to increase schoolreadiness in this population.11

Although investment in earlychildhood education programsincreased for most states from 2001to 2009, that trend has changed sincethe recession in 2008. Earlychildhood programs receive muchless funding than public educationand are often at greater risk forfederal and state budget cuts.Continued recognition of theimportance of quality early childhoodprograms and the need for adequatefunding will be critical.

CHILDREN WITH SPECIAL EDUCATIONALNEEDS

Children with developmentaldisabilities are particularly at risk fordeficits in school readiness. TheIndividuals with DisabilitiesEducation Act (IDEA) of 2004 wasenacted to ensure that children withspecial needs have access to a freeand appropriate education in theleast restrictive environment withadequate supports and services. PartB of the IDEA covers children withdevelopmental disabilities from 3 to21 years of age, and Part C addressesthe need for early interventionservices for children from birth to

3 years of age with qualifyingconditions.

Approximately 6% of childrenbetween 3 and 5 years of age in theUnited States are served under Part Bof IDEA with significant variabilityamong states (4% in AL to 14% inWY).53 The majority of these childrenare served under a speech andlanguage delay category (3.1%). Thesecond largest category isdevelopmental delay (2.5%), and thethird largest category is autism(0.6%). White children account for52% of this population with specialneeds, Hispanic children represent25%, and African American childrenaccount for 13%. This disparity ofservices among ethnic minoritygroups likely representsunderidentification of minoritychildren with disabilities at an earlyage, especially given the fact thatAfrican American children representa higher percentage (15%) than dowhite children (13%) whenevaluating the number of children inspecial education services between 3and 21 years of age.53

With regard to early interventionservices covered under Part C ofIDEA, approximately 3% of children0 to 3 years of age are served, withboys accounting for 64% ofchildren.54 The categories underwhich children received serviceswere not available, but white childrenaccounted for 52.6%, Hispanicchildren accounted for 25.9%, andAfrican American children accountedfor 12.4%. The majority(approximately 86%) of thesedevelopmental intervention serviceswere provided in home settings.Approximately 8% of childrenreceiving Part C services were nolonger eligible for Part B services at3 years of age, perhaps reflecting theeffectiveness of early intervention.

These data seem to reflect anunderrepresentation of minorities inearly childhood interventionprograms. Pediatricians, through

developmental surveillance andscreening, play an important role inidentifying all children withdevelopmental disabilities at anearly age. It also appears from thedata that autism spectrum disordersmay be underrecognized at an earlyage. The prevalence of autismspectrum disorders has increaseddrastically, and there is evidence thatintensive early intervention makesa positive impact in schoolreadiness.43–57 Addressing the needsof children with developmentaldisabilities in a timely fashion withappropriate educational services andfamily resources improves potentialoutcomes.58

HOW SCHOOLS AND COMMUNITIESPROMOTE SCHOOL READINESS

Limited research is availableregarding readiness of schools andcommunities to meet the needs of thediverse population of children. Oneapproach to identifying and trackingindicators of school and communitypreparedness is the School ReadinessIndicators: Making Progress forYoung Children program,a partnership of 16 states funded bythe David and Lucile PackardFoundation, the Ford Foundation, andthe Ewing Marion KauffmanFoundation.59 This initiative has 3goals: (1) to create a set ofmeasurable indicators related to anddefining school readiness that can betracked at the state and local levels;(2) to have states adopt thisindicator-based definition of schoolreadiness, to fill in gaps in data, totrack data, and to report findings totheir citizens; and (3) to stimulatepolicies, programs, and other actionsto improve the ability of children toread at grade level by third grade.Sample system indicators tracked bythis group include (1) the proportionof children with health coverage; (2)the proportion of 3- and 4-year-oldchildren enrolled in high-quality earlyeducation and child care programs;(3) the proportion of schools offering


universal access to full-daykindergarten; (4) the proportion ofchildren with hearing, vision, ordental problems not detected atschool entry; (5) the number of adultsenrolled in adult education programsor programs teaching English asa second language per 100 adultsseeking those services; (6) theproportion of births to mothers withless than a 12th-grade education; and(7) the proportion of childrenyounger than 6 years in foster carewho have had more than 2placements in 24 months. Thecomplete set of indicators selected byeach state is available online (http://www.rikidscount.org/IssueAreas/EarlyLearningampDevelopment/GettingReady.aspx). It is the belief ofthose investigators that this work willplay an important role in shaping theeducational agenda for youngchildren and their families across thecountry.60,61

Evidence-based interventions withsubstantial effects on schoolreadiness include early interventionprograms for formerly preterminfants, which have been shown toprevent developmental delay, toimprove grade retention, and toaccelerate placement into specialeducation.62–64 Food supplementprograms, such as the SupplementalNutrition Program for Women,Infants, and Children, have beenshown to reduce rates of low birthweight65 and iron deficiency.66,67

Children attending schools withschool nutrition programs haveimproved scores on standardizedacademic tests.68 Home visitingby nurses has been shownconsistently to reduce rates ofchildhood injury, to increase fathers’involvement, to reduce family welfaredependency, and to improve schoolreadiness.69,70 Housing subsidieshave resulted in improvedneighborhood safety and reducedexposure to violence.71,72

In addition, there are numerouspediatric primary care programs that

have been shown to have impactsacross varying domains of schoolreadiness.73 These programs includeboth primary prevention programs(which seek to prevent gaps inreadiness before they emerge) as wellas secondary and/or tertiaryprevention programs (which seek toprovide additional services forfamilies at increased risk and/or forchildren with observed gaps in childschool readiness); these target earlyliteracy and/or social-emotionaldevelopment. All of these programscapitalize on the unique reach ofpediatric well-child visits for familieswith young children, especially frombirth to 3 years of age, and facilitatepopulation-level intervention at a lowcost. The most studied and scaledprimary prevention program is ReachOut and Read (http://www.reachoutandread.org/), whichimpacts more than 25% of allchildren in low-income families byimproving child language skills andincreasing reading aloud activities,according to more than 15 publishedstudies.74 An enhancement to ReachOut and Read, the Video InteractionProject, promotes parental self-reflection and positive actionsthrough review of videotaped parent-child interactions and was recentlyfound to have positive impact on childsocial-emotional development.75

HealthySteps uses a specialist whofacilitates the delivery of well-childcare on the basis of the standards inBright Futures: Guidelines for HealthSupervision of Infants, Children, andAdolescents, Fourth Edition, andprovides primary prevention throughenhanced parenting and secondaryprevention through appropriatescreening and referral for services.76,77

A primary care adaptation of TheIncredible Years has been shown topromote effective parenting andimprove child behavior for familieswith children with behaviorproblems.78 Two additionalprograms, Assuring BetterChild Health and Development andHelp Me Grow, provide effective

secondary prevention by linkingfamilies with appropriate communityservices.79,80

WHAT PEDIATRICIANS DO TO SUPPORTSCHOOL READINESS

The role of the pediatrician inpromoting school readiness waspreviously delineated in a recent AAPpolicy statement, “The Pediatrician’sRole in Optimizing SchoolReadiness.”81 It is clear that pediatrichealth care providers promote schoolreadiness in the children they serve inmany ways. In their office practices,they provide medical homes thatpromote optimal nutrition, growth,development, and physical health aspart of health maintenance. Fullimplementation of therecommendations in Bright Futures:Guidelines for Health Supervision ofInfants, Children, and Adolescents,Fourth Edition, includes not onlyprovision of immunizations ina timely manner but also anticipatoryguidance regarding nutrition, safetyissues, vision and hearing screening,lead and anemia screening, adviceregarding dental needs, anddevelopmental surveillance and/orscreening.77 By providing ongoingsurveillance and informationregarding injury prevention, pediatricproviders help protect children frominjury and abuse.

Pediatric health care providerspromote positive parent-childrelationships by screening forpsychosocial risks, such as parentalmental illness, substance abuse,family violence, poverty, and lack ofconnection to community and familysupports, and then identifyingappropriate community resources forfamilies.82 The AAP Web site on socialdeterminants of health offersnumerous screening and toolkitresources for pediatric primary careproviders (https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Social-Determinants-of-Health.aspx).Modeling appropriate interactions in


http://www.rikidscount.org/IssueAreas/EarlyLearningampDevelopment/GettingReady.aspx




http://www.reachoutandread.org/

http://www.reachoutandread.org/

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Social-Determinants-of-Health.aspx




the office and providing materials andeducational opportunities thatpromote parental knowledge of childdevelopment enhance parent-childinteractions. Ongoing assessment ofthe interactions between the parentand child and guidance regardingbehavior, temperament, anddevelopment facilitate parentunderstanding of child differences.Primary care parenting models suchas HealthySteps, Very ImportantParenting, and colocated behavioralhealth models have been found to beeffective in supporting positiveparent-child relationships and modelappropriate disciplinary strategies.For families whose children presentwith significant behavior concerns,use of evidence-based models, suchas the Positive Parenting Programand Circle of Security, and referral toappropriate behavioral healthresources provide assistance tofamilies. The Positive ParentingProgram is designed to prevent andtreat behavioral and emotionalproblems in children and teenagersby equipping parents with skills andconfidence to address theseproblems. The Circle of Security seeksto support secure parent-childrelationships by helping parents readtheir child’s emotional needs,enhance the child’s self-esteem, andsupport the child’s ability to manageemotions.83 Resources available topediatricians in promoting earlyliteracy include such evidenced-basedprograms as Reach Out and Read andthe AAP Books Build ConnectionsToolkit, as well as communitylibraries and early childhoodeducation programs. Pediatriciansoften provide guidance to parentsregarding quality early child care andchild education programs, includinginformation from the NationalAssociation for the Education ofYoung Children, Children’s HomeSociety, Child Care and Resource andReferral Centers, and Help Me Grow.Pediatricians also encouragecommunication between parents andearly learning centers.84 Pediatric

health care providers identifychildren with delays in theirdevelopment by integrating regular,systematic, developmental screeningand surveillance into their practices.Children identified as having delaysand children at risk for delays canthen be referred to community-basedservices, such as early interventionprograms, home visitation programs,Head Start, and special educationprograms available through schooldepartments.85

Many pediatricians take an active rolein advocating for those evidence-based practices that promote optimalearly brain and child development.Some examples include (1) access tohealth care, including mental healthservices, for all children; (2)standards for state Medicaid andEarly and Periodic Screening,Diagnosis, and Treatment programsthat conform, at a minimum, to AAPpolicy recommendations86; (3)universal funding for clinic-basedearly literacy programs such as ReachOut and Read; (4) Head Start andEarly Head Start programs; and (5)federal child care subsidies. AAPchapters can be centers for advocacybecause they have experience,resources, and establishedrelationships with policy makerswho will be making decisions atthe state level. The AAP offersopportunities to effect thesepolicies through their stateAAP chapters and in collaborationwith state early childhoodcomprehensive systems. Ona national level, the Federal AdvocacyAction Network provides anadditional avenue of advocacy forinterested pediatricians.

Pediatricians, in their work withyoung children and families, providethe skills and expertise that promotenot only physical health but alsosocial-emotional health and guidancewith regard to development. Theirpartnership with families allows forongoing assessment of strengths andstressors and the development of

collaborative strategies andinterventions, which support optimalchild well-being.82,87 Pediatricians, incollaboration with school, community,and national agencies, contribute tothe school readiness of youngchildren.81

CONCLUSIONS

Knowledge of early brain and childdevelopment has revealed thatmodifiable factors in a child’s earlyexperience can greatly affect thatchild’s learning trajectory. Severalqualities that are necessary forchildren to be ready for school arephysical and nutritional well-being,intellectual skills, motivation to learn,and strong social-emotional capacityand supports. These qualities areinfluenced by the health and well-being of the families andneighborhoods in which children areraised. Many US children enterkindergarten with limitations in theirsocial-emotional, physical, andcognitive development that mighthave been significantly diminished oreliminated through early recognitionof and attention to child and familyneeds. School readiness testing, whenused appropriately, can yield helpfulinformation regarding the progress ofcommunities and states in meetingthe needs of young children. Earlychildhood education programs canlessen the disparity in schoolreadiness created by poverty andother toxic stressors. Community andnational programs that support youngchildren and their families also playa significant role in optimizing schoolreadiness. Pediatricians, by the natureof their work with young children andfamilies, are at the forefront of theeffort to promote school readiness.Pediatric primary care providers canboth model and promote effectiveearly childhood practices andinterventions to promote schoolreadiness and collaborate withcommunities and schools to ensuretheir implementation.


LEAD AUTHORS

P. Gail Williams, MD, FAAPMarc Alan Lerner, MD, FAAP

COUNCIL ON EARLY CHILDHOOD EXECUTIVECOMMITTEE, 2017–2018

Jill Sells, MD, ChairpersonSherri L. Alderman, MD, MPH, IMH-E, FAAPAndrew Hashikawa, MD, MPH, FAAPAlan Mendelsohn, MD, FAAPTerri McFadden, MD, FAAPDipesh Navsaria, MD, MPH, MSILS, FAAPGeorgina Peacock, MD, MPH, FAAPSeth Scholer, MD, MPH, FAAPJennifer Takagishi, MD, FAAPDouglas Vanderbilt, MD, FAAPP. Gail Williams, MD, FAAP

LIAISONS

Lynette Fraga, PhD – Child Care AwareRebecca Parlakian, MS – Zero To ThreeKatiana Garagozlo, MD – American Academyof Pediatrics Section on Pediatric TraineesDina Lieser, MD, FAAP – Maternal and ChildHealth Bureau

Alecia Stephenson – National Association forthe Education of Young Children

STAFF

Charlotte O. Zia, MPH, CHES

COUNCIL ON SCHOOL HEALTH EXECUTIVECOMMITTEE, 2017–2018

Marc Alan Lerner, MD, FAAP, ChairpersonCheryl L. De Pinto, MD, MPH, FAAP,Chairperson ElectElliott Attisha, DO, FAAPNathaniel Beers, MD, MPA, FAAPErica Gibson, MD, FAAPPeter Gorski, MD, MPA, FAAPChris Kjolhede, MD, MPH, FAAPSonja C. O’Leary, MD, FAAPHeidi K. Schumacher, MD, FAAPAdrienne Weiss-Harrison, MD, FAAP

LIAISONS

Susan Hocevar Adkins, MD, FAAP – Centersfor Disease Control and Prevention

Laurie G. Combe, MN, RN, NCSN – NationalAssociation of School NursesVeda Johnson, MD, FAAP – School-BasedHealth Alliance

STAFF

Madra Guinn-Jones, MPHStephanie Domain, MS

ABBREVIATIONS

AAP: American Academy ofPediatrics

CI: confidence intervalECLS: Early Childhood

Longitudinal StudyIDEA: Individuals with Disabilities

Education ActNCES: National Center for

Education and StatisticsNCSL: National Conference of State

Legislatures

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2019-1766 originally published online July 22, 2019; 2019;144;Pediatrics

COUNCIL ON SCHOOL HEALTHP. Gail Williams, Marc Alan Lerner, COUNCIL ON EARLY CHILDHOOD and

School Readiness

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DOI: 10.1542/peds.2019-1766 originally published online July 22, 2019; 2019;144;Pediatrics

COUNCIL ON SCHOOL HEALTHP. Gail Williams, Marc Alan Lerner, COUNCIL ON EARLY CHILDHOOD and

School Readiness

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