Head Start: Evolution of a Successful Comprehensive Child Development Program

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COMMENTARIES

441

not, and they experienced only half as many school

failures. In addition, the program was found to have

sharpened children’s language skills and boosted

their achievement test scores from the bottom 25%

to near the national average (Education

Week,

Oct

23, 1985, p 8).

Such promising results have led to calls for

ex-panded preschool programs. Recently, the

Commit-tee for Economic Development, a group of business

executives, called for “a serious and systematic

investment in enriched early childhood education

for children from poor families.” The research

re-sults, however, indicate that not all preschool

pro-grams are created equal. Head Start appears to

achieve some of its goals, but it does not provide

the long-term educational gains that are the

pri-mary reason for its popularity. What is the

solu-tion?

Clearly, the answer is not to cut the program or

reduce funding. Its short-term and social benefits

alone justify its continuation. And, as the poverty

rate for children continues to increase, preschool

programs are more important than ever. At present,

only one in six eligible low-income children

partic-ipates in Head Start, a proportion that is decreasing

as the poverty rate for children is increasing.

But the answer is not to ignore Head Start’s

problems. Knowledgeable observers have a clear

agenda for reform: closer ties between Head Start

providers and elementary schools, more and better

parental participation, more emphasis on

educa-tional activities, and more attention to building the

children’s school readiness skills in parents as well

as children.

It is one thing to talk about reforms and another

thing to enact them. Political realities intrude.

No-body wants to see the program changed.

Conserv-atives are hesitant to propose any changes in Head

Start lest they be accused of being antipoor or

seeking to shred the social safety net. Indeed, the

Reagan administration could not even figure out

how to issue a press release about the Head Start

report without getting clobbered. Liberals are

Un-willing to press for changes for fear of alienating an

important part of their constituency. Child

devel-opment and Head Start groups are afraid that

ac-knowledging the program’s weaknesses will open

the door to budget cuts, especially in the wake of

Gramm-Rudman. The result is an uneasy-and

unstated-truce.

In the meantime, the program is popular, does

some good, and, except for misplaced expectations,

does no harm. The sad part is that Head Start could

easily be made much more effective. The biggest

losers, of course, are not the politicians (who will

get reelected) or the interest groups (their funding

continues); it is disadvantaged children. They

de-serve

better.

REFERENCES

DOUGLAS J. BESHAROV JD, LLM

TERRY W. HARTLE, PHD

American Enterprise Institute for Public

Policy Research

Washington, DC

1. McKey RH, Condelli L, Ganson H, et al: The Impact of

Head Start on Children, Family and Communities: Final

Report of the Head Start Evaluation Synthesis and

Utiliza-tion Project. US Department of Health and Human Services publication No. (OHDS) 85-31193. Government Printing

Office, 1985

2. Cicirelli VG: The Impact ofHead Start: An Evaluation of the

Effects of Head Start on Children’s Cognitive and Affective

Development, report presented to the Office of Economic Opportunity pursuant to contract B89-4536 (report No. PB

184 328), Westinghouse Learning Corporation. Washington,

DC, National Bureau of Standards, Institute for Applied

Technology, 1969

3. Lazar I, Darlington B: Lasting effects of early education: A report from the Consortium for Longitudinal Studies. Mon-ogr Soc Res Child Dev 1982;47(serial No. 195):2-3

4. Berrueta-Clement J, Schweinhart L, Barnett W, et al:

Changed Lives: The Effects of the Perry Preschool Program on Youths ThroughAge 19. Ypsilant, MI, High/Scope Press, 1985

Head

Start:

Evolution

of a

Successful

Comprehensive

Child

Development

Program

The commentary by Besharov and Hartle’

con-cludes that disadvantaged children deserve better

than what they are getting. Indeed, it is our

view-along with virtually all Americans-that all of our

children deserve better. The improvement of the

health, education, and welfare of all children is a

never ending quest.

Perhaps the frustration with the Head Start

pro-gram that permeates the Besharov and Hartle

com-mentary is due to a fundamental misconception of

the goals of the Head Start program. From its

inception, Head Start has been a comprehensive

child development program and not a program

fo-cused solely on long-term cognitive gains. Besharov

and Hartle claim that Head Start’s popularity is

at Viet Nam:AAP Sponsored on September 7, 2020

www.aappublications.org/news

(2)

based on the widespread impression that “it lifts

poor children out of poverty by improving their

learning ability and school performance” or that

“long-term educational gains . . . are the primary

reason for its popularity.” Ifpoverty was only solved

so easily!

The Head Start program was established to

pre-vent the specific developmental attrition seen in so

many 3- to 5-year-old poor children,2 to give them

an equal opportunity when they entered public

schools-the strongest and largest equal

opportu-nity program in the United States. Head Start

attacked one of the many roots of poverty. The

focus on cognitive development, and IQ testing in

particular, was not the exclusive mission of Head

Start; but its ability to be easily quantified

(profes-sionals measure what they know), and perhaps the

overblown initial hyperbole of many of its media

enthusiasts, led to an overemphasis on this aspect

of development. From the beginning, Head Start

had a much broader set of goals3: (1) improving the

child’s physical health and physical abilities; (2)

helping the emotional and social development of

the child by encouraging self-confidence,

spontane-ity, curiosity, and self-discipline; (3) improving the

child’s mental processes and skills, with particular

attention to conceptual and verbal skills; (4)

estab-lishing patterns and expectations of success for the

child that will create a climate of confidence for

future learning efforts; (5) increasing the child’s

capacity to relate positively to family members and

others, while at the same time strengthening the

family’s ability to relate positively to the child and

his or her problems; (6) developing in the child and

his or her family a responsible attitude toward

society and encouraging society to work with the

poor in solving their problems; and (7) increasing

the sense of dignity and self-worth within the child

and his or her family.

To evaluate the success of a comprehensive child

development program requires an examination of

its effects in many areas-health, nutrition,

cogni-tive development, social services, parent

involve-ment, citizen’s participation, to mention but a few

of its objectives. The evidence for the success of

Head Start, as a comprehensive child development

program, is considerable.4’5 Children’s health is

im-proved through the program; immunization rates

are better; participants have a better diet, better

dental health, better access to health and social

services; their self-esteem and cognitive abilities

are improved; parents are educated and become

involved both as volunteers and employees. Thus,

it is not surprising that virtually all summary

anal-yses of Head Start reveal successes across a wide

range of domains.4’5 The singular focus on cognitive

development in Besharov and Hartle’s commentary

obscures an appreciation of the multifaceted

bene-fits of the Head Start program for disadvantaged

children.

Indeed, the early childhood education efforts,

which seem to be the main concern of Besharov

and Hartle, are much more complex than the

au-thors indicate. Their argument that there are no

long-term cognitive gains associated with Head

Start participation appears to be based entirely on

one summative study-the recently completed

Head Start Synthesis Project.5 Besharov and

Har-tle try to dismiss Head Start advocates by stating

they “have resorted to criticizing the methodology

of their new Department of Health and Human

Services study to explain it away.” The reality is

that the authors’ commentary hinges critically on

the topic of long-term cognitive development and

the distinctive meta-analysis methodology used by

the Synthesis Project to assess it.

Meta-analysis is a new form of evaluation

re-search, which allows for a summative synthesis of

multiple smaller studies on the same topic. It

re-duces each study to a single common

Z

score metric,

which can then be manipulated statistically.

Al-though this is not the forum for a full discussion of

the methodologic and public policy critiques of the

current meta-analysis, certain features must be

noted

(High

Scope

Resource,

1986, vol 5, pp

1,20-23).

First, meta-analysis essentially reduces the full

richness of Head Start research into a single,

all-encompassing study. It lumps everything-summer

and multiyear programs, programs with and

with-out handicapped children, programs with a

cogni-tive curriculum and programs with a traditional

preschool curriculum-all together. For example, if

a project is composed of a 60% black population

and 40% white population, it receives a single

im-pact score, even if the program has quite different

impacts on the different subgroups. The lack of any

overall impact could obscure areas of demonstrable

strength. Second, meta-analysis does not

compen-sate for the quality of the research. Both poor and

good research studies are lumped together. Prior

poor studies continue getting factored in the newer

analyses. Not surprisingly, no overall effect can be

detected. Quantity of research cannot replace

qual-ity of research. Third, meta-analysis does not

com-pensate for the selection bias inherent in virtually

every

Head Start study. T. J. Gample and E. F.

Zigler (personal communication, 1986) remind us

that, because Head Start programs did not

ran-domly select its participants and nonparticipants,

there is likely to be strong selection bias in all Head

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COMMENTARIES 443

off than the Head Start population, much mischief

can be deduced from their comparisons. The public

policy implications of these kinds of methodologic

problems are well documented in the powerful

sta-tistical critiques of earlier Head Start summative

evaluations by Campbell et al8’9 but do not appear

to have been addressed by the present Synthesis

Project.

Our critique of the Synthesis Project’s

meta-analysis is similar to our critique of the infamous

Westinghouse study,’#{176}which Besharov and Hartle

also quote approvingly. To quote from a paper by

one of us published several years ago”:

The much discussed Westinghouse study, for example,

in an expensive way, predicted what we already knew:

that if in a simplistic way one makes the gross error of

collapsing samples across all kinds of critically important variables, such evaluations are destined to demonstrate

nothing. Successes are bound to cancel failures in

suffi-cient measure to prohibit our learning anything construc-tive to guide further planning. As a matter of fact, in going back over the Westinghouse data, and looking at

sub-groups, it is possible to identify many significant

gains-especially by urban, black Head Start children. Thus, we need to know what kind of intervention pro-duces specific effects in different children.

The present commentary does note several other

major successful preschool programs that have been

more rigorously evaluated (Cornell’s Consortium

for Longitudinal Studies,’2 Perry Pre-school

Proj-ect,’3 Frank Porter Graham Child Development

Center’4). Besharov and Hartle undervalue the

im-portance of these research efforts and assert that

these studies cannot be generalized to demonstrate

that Head Start programs have positive long-term

cognitive and social benefits. We disagree.

These preschool programs are closely tied to the

Head Start program. Of the 1 1 Consortium

stud-ies,’3 five predated the Head Start program and

were some of its direct antecedents, two were actual

Head Start programs, and five became the models

used in the Head Start Planned Variation

Pro-gram.’5 These preschool studies represent part of

the intellectual resources for early Head Start

plan-ning efforts.

These research studies can be viewed as the

an-alogs of medical research in teaching and research

hospitals, which provide the data to help medical

practitioners improve their practices in the

com-munity. We do not reject the lessons from academic

biomedical research just because it does not take

place in the physician’s offices in the community.

The results of these associated preschool research

and demonstration projects tell us what is possible

from Head Start programs. These studies clearly

show that long-term cognitive gains can and do

occur.’2’4 Specifically, the Consortium for

Longi-tudinal Studies’2 reports that preschool program

graduates are substantially less likely to

subse-quently fail a grade or to be in special education

classes; yet, Besharov and Hartle disparage these

same positive findings, even when noted by the

Synthesis Project,5 claiming they are based on only

a few Head Start studies.

The absence of a consistent impact on

medium-term cognitive development by Head Start

gradu-ates may be more a critique of public schools than

of the Head Start program. Virtually all studies

demonstrate that Head Start has immediate

posi-tive cognitive, socioemotional, and health status

effects.4’5 When the young children are actual

par-ticipants, Head Start accomplishes what it is

sup-posed to do. The developmental attrition of poverty

can be reversed. Head Start is not, however, an

inoculation. Countering the developmental effects

of poverty is not a one-time affair but must be a

continuous process. It may be that cognitive and

socioemotional gains of Head Start diminish over

time because the educational environment in

ele-mentary schools does not support and stimulate the

children as effectively as Head Start did. The

Fol-low-Through Program of Head

Start’6

was designed

to carry over the program benefits into the early

elementary grades. Other elements of our society,

including but beyond schools, must also take on the

challenge of continually combating the negative

effects of poverty.

Besharov and Hartle’s commentary makes a

fac-tual error, which conveys a negative image of the

Head Start staff at the national and local levels,

when they state that “the demonstration programs

were professionally staffed” in contrast to Head

Start programs. From its inception, Head Start has

emphasized professional standards and has

facili-tated much in-service professional training. It has

contributed-more than any other organized

ef-fort-to the pool of early childhood educators in

the United States. It has also developed a new

category of professional training-the Child

Devel-opment Associate-under the vigorous advocacy of

the former director of the Office for Child

Devel-opment, Dr Edward Zigler.

Head Start has not been and is not now a static

program. Provisions for evaluation were built-in

from the beginning. In the late 1960s, a massive,

innovative, formal Planned Variation Program was

put into place to learn what type of programs and

curricula worked best.’5 Standards and curriculum

have been continuously developed by staff and

con-sultants nationally and locally. There has been no

paralysis in program development, and recent years

have been no exception. Indeed, the Synthesis

Proj-ect’s findings confirm that both immediate- and

(4)

long-term cognitive gains are greater in more recent

years compared with the earlier years of the

pro-gram implementation.5 It would appear that the

evolving program is becoming more effective.

The Head Start program can still be improved.

Besharov and Hartle claim that “knowledgeable

observers” have a clear agenda for reform, yet the

agenda they describe appears to be almost exactly

the suggestions written by Clennie Murphy, Jr,

Acting Associate Commissioner, Head Start

Bu-reau, in the forward to the report of the Synthesis

Project.5 These proposals have been many of the

long-term goals of Head Start for years. For

ex-ample, “more parental participation” or “more

em-phasis on educational activities” are not new-nor

wrong. Without disparaging these general

sugges-tions, it is difficult to see from where in the

Syn-thesis Report they were specifically derived. Both

Besharov and Hartle’s commentary and the

Syn-thesis Report seem lacking in suggestions of new

strategies to better accomplish these traditional

goals.

Moreover, there is another, different agenda that

many professionals, politicians, and parents are

developing from the Head Start experience. Head

Start success has spurred calls for the development

of more formal early preschool education. New

York City, for example, has recently proposed plans

to make formal instruction available through the

schools for all 4-year-old children-in part by

ex-panding the existing Head Start program. Fifteen

states already fund prekindergarten programs for

some 4-year old children in public schools. And

Maine directly augments federal Head Start funds.

The bipartisan political assessments of this

pro-gram, locally and nationally, are highly favorable.

It is therefore, somewhat disconcerting to note

that the authors attempt to cast support for the

Head Start program in a conservative or liberal

political framework. We rather think that all

Amer-icans would agree with the commitment on the

membership certificate of the American Academy

of Pediatrics, “to foster and stimulate interest in

pediatrics and in all aspects of the work for the

welfare of children.” Certainly the Academy has

never used a political litmus test to measure the

commitment of its members to children.

It is time to acknowledge that there can never be

a singular “definitive” evaluation ofthe

comprehen-sive Head Start program, for the simple reason that

it is important to learn what Head Start program

characteristics are best for what children and with

regard to what objectives. Head Start programs

today are much better than they were 20 years ago.

But 20 years hence, we will still be struggling with

how to make them even better. In the meantime,

millions of poor children will have experienced

bet-ter environments than would have been the case

without the Head Start program. A humane society

need never apologize for that. It is certainly what

pediatricians have worked for throughout the years.

REFERENCES

MILTON KOTELCHUCK, PHD, MPH

JuLIus B. RICHMOND, MD

Division of Health Policy Research

and Education Harvard University Boston

1. Besharov DJ, Hartle TW. Head Start: Making a popular program work. Pediatrics 1987;79:440-441

2. Richmond JB, Caldwell BM: Mental retardation-Cultural

and social considerations: A day care program for disadvan-taged infants and young children-Observations after one year, in Dorfman A (ed): Child Care in Health and Disease.

Chicago, Yearbook Publishers, 1968, pp 126-139

3. Cooke R: Memorandum to Sargeant Shriver, “Improving the Opportunities and Achievements of the Children of the

Poor,” Ca February 1965. Cited by Richmond JB, Stipek DJ, Zigler EF: A decade of Head Start, in Zigler EF, Val-entine J (eds): Project Head Start. New York, Free Press, 1979, pp 135-152

4. Zigler EF, Valentine J: Project Head Start: A legacy of the War on Poverty. New York, The Free Press, 1979

5. McKey RH, Condelli L, Ganson H, et a!: The Impact of Head Start on Children, Family and Communities: Final Report of the Head Start Evaluation Synthesis and

Utiliza-tion Project, US Department of Health and Human Services publication No. (OHDS) 85-31193. Government Printing

Office, 1985

6. Mann AJ, Herrell A, Hurt M: A Review of Head Start Research Since 1969. Washington, DC, Social Research

Group, George Washington University, 1976

7. An Annotated Bibliography of Head Start Research Since

1965, US Department of Health and Human Services pub-lication No. (OHDS) 85-31194. Government Printing Of-fice, 1985

8. Campbell DT, Boruch RF: Making the case for randomized assignment to treatments by considering the alternatives: Six ways in which quasi-experimental evaluations in com-pensatory education tend to underestimate effects, in Ben-nett CA, Lumsdaire AA (eds): Evaluation and Experiment.

New York, Academic Press, 1975, pp 195-296

9. Campbell DT, Erlebacherr A: How regression artifacts in

quasi-experimental evaluations can mistakenly make

com-pensatory education look harmful, in Helmuth J (ed): Corn-pensatory Education: A National Debate. New York, Brun-ner/Mazel, vol 3: The Disadvantaged Child, 1970, pp 185-223

10. Cicirelli VG: The impact ofHead Start: An Evaluation of the Effects of Head Start on Children’s Cognitive and Affective Development, report presented to the Office of Economic Opportunity pursuant to contract B89-4536 (report No. PB 184 328), Westinghouse Learning Corporation. Washington, DC National Bureau of Standards, Institute for Applied Technology, 1969

11. Richmond JB: Disadvantaged children: what have they corn-pelled us to learn? Yale Biol Med 1970;43:135

12. Lazar I, Darlington B: Lasting effects of early education: A

report from the Consortium for Longitudinal Studies. Mon-ogr Soc Res Child Dev 1982;47(serial No. 195):2-3

13. Berrueta-Clement J, Schweinhart L, Barnett W, et al:

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COMMENTARIES 445

on Youths through Age 19. Ypsilant, MI High/Scope Press, 1985

14. Ramey CT, Campbell FA: Preventive education for

high-risk children: Cognitive consequences of the Carolina

Abe-cedarian Project. Am J Ment Defic 1984;88:515-523

15. Bissell JS: Implementation of Planned Variation in Head

Start, Office of Child Development, US Department of Health, Education, and Welfare. Washington, DC, Govern-ment Printing Office, vol 1: Review and Summary of the

Stanford Research Institute Interim Report: First Year of Evaluation, 1971

16. Abelson WD, Zigler E, DeBlasi CL: Effects of a four-year

follow through program on economically disadvantaged chil-dren. J Educ Psychol 1974;66:756-771

Day

Care

for Sick

Children

Children in day care, like their home-reared

peers, frequently become ill. Whether they are sick

more frequently than those not in day care has been

a question difficult to resolve because of the

prob-lem of appropriate control studies. Many

pediatri-cians are convinced that this is so. There are data

that infections due to certain specific agents

includ-ing hepatitis A, Haemophilus influenzae

type

B, and

Giardia

lamblia

occur more often in day-care center

attendees. Clinical entities such as diarrhea,

men-ingitis, and otitis media have also been shown to be

more common in day-care center attendees. A

re-cent review in

Pediatrics’

provides a good overview

of the problem.

Whether infections actually occur more

fre-quently among day-care center attendees or not is

irrelevant to those parents whose children are in

day care and become ill. These parents are faced

with the question of what to do with their children

who usually attend day care when they become ill.

Available options in sick child care have been

re-viewed in the Sick Child Care Project at Work/

Family Direction.2

Sometimes a parent is able to stay home with the

child, and this would appear to be optimum from

the child’s viewpoint. However, it may not be so for

the parent. Unlike other developed countries, the

United States has no national parental leave policy,

and parents may lose pay, jeopardize their

oppor-tunity for career advancement, or even be in danger

of losing their jobs if they stay home with their sick

children.

An excellent alternative from the child’s

perspec-tive is to have another member of the (extended)

family stay with the child in the child’s home or at

the home of a relative. A baby-sitter, previously

known to the child, may fulfill the same needs of

the child for a known comforting caretaker in a

familiar environment at a time when the child’s

needs for comforting are greatest.

Some day-care centers allow children with mild

illnesses to attend their regular programs, and this

also satisfies the child’s needs for being in familiar surroundings with known care givers provided that

the child is not too ill to be there and does not have

an illness such as chicken pox or uncontrollable

diarrhea which would be too great an infectious risk

to other children.

Many centers, however, because of lack of

suffi-cient staff or space to give the extra care needed by

a sick child, or because of excessive concerns about

risk of infection, or because of state or local

regu-lations, exclude all sick children. There are a few

care centers that provide home care by regular

day-care center staff for children in the center who are

too ill to attend, but this is rare, and expensive,

unless alternate funding in the form of a grant is

available.

During the past few years, day-care centers for

sick children have become established, and there is

currently a great interest in expanding this concept.

Unfortunately, many of those wishing to establish

such units are using what Fredericks2 calls the

infirmary model. This really is a largely outmoded

infectious disease-type model in which children are

frequently put into isolation cubicles with

person-nel, whose major focus is in infection control,

ob-serving them, frequently through glass windows.

Early childhood educators and others skilled in

the provision of day-care services may not be

in-volved in the planning or administration of the

centers. Many of the centers are being developed

by medical groups and hospitals primarily as a

means of keeping personnel available on the job

rather than at home with their sick child. For

hospitals with underutilized pediatric units, this is

also being seen as a way to occupy some of the

vacant space and available personnel.

The in-hospital or pediatric sick day-care units

are posing an additional risk to sicker children who

are inpatients in the hospital. As the use of pediatric

hospital beds has decreased, the intensity of the

illness of the children in the units has increased,

with many of these children being

immunosup-pressed from either illness or therapy related to

their illness. Relatively common childhood

infec-tions may pose an unacceptable risk to these chil-dren.

Concerns about infections conflict with, and at

times override, appropriate attention to the

emo-tional, developmental, and cognitive needs of the

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1987;79;441

Pediatrics

MILTON KOTELCHUCK and JULIUS B. RICHMOND