Supporting Healthy Development is a Big Bet For Children

How do we best identify the big ideas that should attract and deserve the generous funding now made available by contemporary philanthropic practices? By what criteria should we evaluate candidates for a pediatric big bet?  I offer a personal perspective on such criteria based on the evolution of child health services over my career spanning four decades. I often describe the focus of my career as the relentless pursuit of the answer to the question, “How do we best strengthen child health services to promote children’s optimal health, development, and well-being?”  I view the evolution of such services through three distinct periods over the past half-century.

During the 1970s-1980s, research, including our own, examined the efficacy of the traditional content of child health services. For example, we found that anticipatory guidance is most effective when parents set the counseling agenda and providers address issues at the level of parents’ cultural, cognitive, and psychological readiness. We similarly demonstrated the importance of engaging parents as partners in developmental monitoring and ensuring that parents’ opinions and concerns are solicited through the process of developmental surveillance and screening.  Such research contributed to incremental progress in strengthening child health services.

The 1990s, the so-called, “decade of the brain,” was noteworthy for the widespread dissemination of our greatly expanded knowledge of brain development and early child development. Implications included the need to attend to the critical interface among child health services, early care and education, and such family support services as home visiting. Child health services innovations sought to expand the capacity of the child health services sector through such evidence-based models as Healthy Steps, the Medical-Legal Partnership program, Reach Out and Read, and our own Help Me Grow.

During the new millennium, a focus on the “biology of adversity” encourages that we view the effectiveness of child health services through the lens of adverse childhood experiences, toxic stress, health disparities, and social determinants of health. We now recognize the extent to which the outcomes that we seek – children’s optimal health, development, and well-being – are overwhelmingly influenced by social, environmental, behavioral, and genetic/epigenetic factors. As a consequence, we must embed child health services within comprehensive system building, engaging all sectors critical to children and their families through cross sector collaboration.  A prime example of such an approach is the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau’s Early Childhood Comprehensive Systems (ECCS) initiative. Such a perspective offers the opportunity to elevate the promotion of all children’s optimal health, development, and well-being to an even higher priority than prevention of disease, disorders, and delays, and highlights the need for innovations to strengthen families to promote children’s optimal health, development, and well-being.

This evolution of child health services helps to inform the key questions in consideration of big bet candidates. Such queries must extend beyond the “usual suspects” of whether there is sufficient evidence for effectiveness of an innovation. We must certainly be mindful of the importance of proposed interventions being evidence-based or evidence-informed, as scientific validity is a strong determinant of the likelihood of successful impact. However, we must also be cognizant of and even encourage the validity of community-driven priorities, such as those informing the development of the impressive King County, Washington Best Starts for Kids initiative, and we must not be inordinately constrained by limitations of scientific evidence of efficacy.

We propose five key questions in assessing the candidacy of innovations possibly deserving support through the Pediatric Big Bet:

1. What is the feasibility of scaling? We are cognizant of the failure of many evidence-based innovations to achieve scale. A prime example is group well-child care, for which initial evidence of efficacy was first published in the 1970s. While many factors may contribute, a lack of the innovator’s interest beyond proof of concept and efficacy likely contributes to their lack of capacity. Our own experience with scaling Help Me Grow and our familiarity with innovation science reinforce the importance of delineating the core components and structural requirements of scalable innovations to ensure fidelity to the successful model, while also maintaining the flexibility to accommodate local priorities, culture, and resources since “all politics is local.” We also recognize the benefits of securing backbone organizations from diverse sectors and the imperative of scaling innovation in context of a comprehensive systems approach.

2. Is there a plan to ensure sustainability? A variety of strategies may be employed such as: 

   1. Blending of administrative and financial resources across agencies, including public-private partnerships
   2. Building capacity to demonstrate the return on investment (ROI)/cost savings/cost benefit to support an “invest/reinvest strategy”
   3. Applying meaningful, feasible pay for success approaches

   Such approaches require that we have the capacity to adjust the time frame to capture longer-term savings and perform the accounting to credit subsequent savings realized in other sectors on earlier investments made in child health, early care and education, and family support. Currently, savings in sectors such as special education, behavioral health, and the juvenile justice/corrections system are being realized as a result of investments in early childhood initiatives, but they are not attributed to such investments. We also need to be mindful to frame and tailor the narrative to local interests and needs. Early childhood system building is supported as a workforce development strategy in Vermont, as a national defense strategy in Florida given the need for a physically-fit military and the academic demands of cybersecurity, and as a vehicle to address disparities and achieve health equity in Mississippi.

3. Does the innovation lend itself to meaningful, important measures and metrics? “What we measure we do” speaks to the importance of metrics and the imperative that they be meaningful to families, front-line providers, payers, and policy makers. We must abandon the convenient, but non-productive, use of measures because they are available, analogous to a “looking under the lamppost for the lost keys” approach. We have found three useful categories of measures:
    

   1. Process measures that inform quality/performance improvement activities
   2. Efficacy measures that include both proximate measures, which are short-term gains predictive of long-term outcomes such as kindergarten readiness and 3rd grade reading, as well as the elusive, long-term outcomes such as academic success and occupational status
   3. Measures that capture ROI, cost benefit, and cost savings 

    

4. Does the innovation engage and support child health services transformation? Child health services offer a universal platform to engage almost all children and their families in the United States. We must support the role of child health providers in strengthening families to promote children’s optimal health, development, and well-being by enhancing such protective factors as family resiliency.

    

5. Is there a clear articulation of the availability/application of relevant tools, processes, and supports? We must consider resources at the interface among all relevant service sectors and apply evidence-based tools in the context of comprehensive, integrated approaches. In drawing upon promising and best practices, we must avoid “reinventing the wheel.”

In our work diffusing the Help Me Grow model across the nation, we are often asked our thoughts on the Pediatric Big Bet. Help Me Grow is focused on the early detection of vulnerable, young children at risk for developmental and behavioral problems and the linkage of such children and their families to community-based programs and services. In the context of a big bet discussion, our response to “what will we do?” is:

Bring to scale and impact an early childhood comprehensive system that engages all sectors in a collective effort to strengthen families to promote all children’s optimal healthy development through an integrated process of developmental promotion, early detection, referral and linkage to community-based programs and services.

Our answer to “how will we do it?” is:

Apply the process of collective impact to engage all sectors to build a robust early childhood system that brings to scale and impact evidence-based programs, services, and interventions that strengthen families’ capacity to promote their children’s healthy development. Provide technical assistance, training, data collection, advocacy, and support the dissemination of innovations that address critical contemporary issues.

Contemporary philanthropic trends create enormous opportunity. The Pediatric Big Bet must be a big idea. It should not be limited to a specific intervention, program, or service; there is no “magic bullet,” and no single approach will promote children’s optimal health, development, and well-being. Rather, the big bet must embrace the inherent complexity of system thinking, with “all sectors in” and “cross sector collaboration.” This complexity demands thoughtful communication and messaging. We must also remain mindful that a bet, by definition, involves risk and we should not be daunted by recent, highly publicized “failures” in K-12 philanthropy. Rather, we should reframe these efforts as ambitious, bold attempts and focus on lessons learned. This unprecedented opportunity demands our altruism, thoughtfulness, and, perhaps most of all, our courage.

Paul H. Dworkin, MD is executive vice president for community child health at Connecticut Children’s, director of Connecticut Children’s Office for Community Child Health and founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at UConn School of Medicine.

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