Most states in the US allow the use of exclusionary discipline for pre-k and primary school students, despite concerns about the effectiveness and fairness of these strategies. Long-standing disparities in its application exist, in the form of exclusion of African-American children, particularly boys, who are suspended at many times the rates of other children. Because of these disparities, suspensions, expulsions, and other forms of exclusionary discipline may weaken otherwise effective programs to reduce racial achievement gaps.     

In collaboration with the HighScope Educational Research Foundation the project will a) examine  national and state data to document the extent of racial disparities; b) summarize published studies of  effective programs c) conduct case studies of exemplary school districts that have banned exclusionary discipline and reduced disparities; and d) provide technical assistance to school districts seeking to replace suspension and expulsion with an effective disciplinary alternative. 

This project will also evaluate the extent and impact of exclusionary discipline in primary schools, asking:   

1. How prevalent are "Ban and Replace" policies in the US and how are they implemented?  

2. Do "Ban and Replace" policies result in lowering reliance on exclusionary discipline practices and a reduction of racial inequalities in school discipline? 

3. How prevalent are the use of Positive Behavioral Interventions and Supports, Restorative Practices, Socio-emotional Learning, or diversion programs, and is their use associated with reductions in disparities? 

4. Can information dissemination and technical assistance improve school adoption and teacher acceptance of bans on suspensions and expulsions? 

This research will generate key evidence needed to understand the effects of exclusionary discipline on equitable access to education and potential alternative strategies that address or prevent the behavioral and emotional difficulties that have given rise to exclusion.  

High-quality, early childhood education (ECE) boosts early-life skills in disadvantaged individuals. These skills translate into better outcomes later in life, in areas like employment, education, income, and criminal activity. But ECE is also costly, and as such, it is important to have a complete picture of the social returns throughout life. In particular, it is not known whether ECE can improve health over the course of a lifetime. This study will examine two important ECE programs—the Carolina Abecedarian Project (ABC) and the Carolina Approach to Responsive Education (CARE) programs in North Carolina—to assess lifetime health returns to ECE.

In ABC and CARE, 'at-risk' children born in the 1970s received intensive (and costly) child care and education starting at very early ages. A control group received more traditional social support. ABC and CARE have been shown to reduce crime, improve earnings, and promote education. Evidence shows important health benefits, including lower risk factors for cardiovascular and metabolic disease in early adulthood, and this study will forecast the health returns over the lifetime. Overall, this study should provide an economic rationale for combining separate interventions into a comprehensive approach that fosters better human development, economic, health, and social outcomes for disadvantaged children.

Prior research suggests that universal pre-kindergarten (UPK) programs can generate lifetime benefits, but the mechanisms generating these effects are not well understood. In 2014, New York City made all 4-year-old children eligible for UPK programs that emphasized developmental screening. We examine the effect of this program on the health of children enrolled in Medicaid using a difference-in-regression discontinuity design that exploits both the introduction of UPK and the fixed age cut-off for enrollment. We posit that one mechanism through which UPK might generate benefits is by accelerating the rate at which children are identified with conditions that could delay learning and cause behavioral problems.

In a secondary study, we examine the epidemiological pattern of influenza following the UPK rollout. Increasing the number of children in congregate settings could increase the speed or pattern of infectious outbreaks. Exploiting the age-cutoff for enrollment using a regression discontinuity framework, we apply both a survival analysis and harmonic regression to assess timing and infection rate. 

There is an urgent need to understand long-term health, developmental, and educational outcomes for children who experience early life stressors. In Tennessee alone, over 22% of all children live in poverty. The number of children born between 2001 and 2014 with neonatal abstinence syndrome (NAS) increased 25-fold, and children of immigrants, 36% of whom live in poverty in Tennessee, often struggle to access the social services they need to thrive.

To fill this gap, the multidisciplinary research team will work alongside key state partners to develop an actionable research portfolio that clarifies the long-term effects of these early life experiences and illuminates the ways state policies can be adapted or modified to better serve the needs of Tennessee families.

Leveraging more than a decade’s worth of data, the researchers will examine relationships between at-risk children’s health and education outcomes, as well as access to public services. This is vital information as states across the country, and Tennessee in particular, adopt new laws and resolutions that encompass a wide range of policy actions related to child health and education.

Although the research portfolio will evolve with input from partners including state agencies and non-profits focused on child outcomes, the team will focus their initial efforts around several key issues:

The Opioid Epidemic

Tennessee is one of the states most affected by the opioid epidemic, particularly among its children. Opioid-related policies operate amid a backdrop of public programs like the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and The Early Intervention Program for Infants and Toddlers with Disabilities (IDEA Part C), which seek to mitigate health and educational disparities between opioid-exposed children and non-opioid-exposed children.

The research team will begin by examining longitudinal health outcomes for opioid-exposed children, assessing how likely they are to have developmental delays, special health care needs, and adequate utilization of preventive services. The team will also examine whether county-level trends in the proportion of children with attendance and discipline problems and low test scores correlate with periods of time when neonatal abstinence syndrome (NAS) reached epidemic proportions in their counties. They will then use linked TennCare Medicaid and educational data to undertake individual-level analyses of differences in educational outcomes (e.g., attendance, discipline, and test scores) between children born with NAS and children not born with NAS.

Access to Public Services

Past research has shown that children living in poverty are less likely to complete secondary and tertiary education and more likely to lack health insurance. Children of immigrants who are eligible for public programs and benefits may also need additional support in accessing those benefits, which in turn could aid families in creating a healthier and more nurturing home environment for their development.

Since 2009, Tennessee has introduced more than 20 legislative actions addressing eligibility verification for public program participation. To better understand the impact of these policies, the research team will examine associations between these policy changes and children’s access to Medicaid coverage and other social services in Tennessee, particularly for special needs children.

In addition, the team will investigate ways to improve children’s access to essential health, education, and other social services in Tennessee by conducting key informant interviews with state and local agencies that administer programs, along with school district personnel and nonprofit organizations that assist families in accessing program benefits for children.

Late elementary school and middle school has long been seen as a critical point in child development, and several studies have shown that students experience a decline in performance when they transition from elementary to middle or middle to high school, and that they do not recover from these dips. Local school boards may choose to operate schools as K-8 combined elementary and middle schools or as K-5 elementary schools with separate middle schools, but little is known about how this structuring of grades might influence health outcomes or behavior.

Some argue that standalone middle schools can be more sensitive to the needs of an adolescent population, while others argue that the transition to a standalone middle school environment is disruptive. Schools serving a wider range of ages may also vary in resources or structure due to the different ages they serve (e.g., in physical activity infrastructure, physical education curricula, in-school food environments, or the presence of school clinics). The structuring of grades may therefore have associations with health outcomes through pathways that had not previously been measured by studies focused on academic or psychosocial outcomes.

As children are substantially more likely to attend nearby schools, the probability that a child in NYC attends a standalone or K-8 middle school is dependent on the locations of these schools. Using school attendance data from the Department of Education, the research team will estimate effects of middle schools structure on health-specific outcomes including obesity, trauma, mental health, and sexual health.

In 2014, the Centers for Medicare & Medicaid Services (CMS) issued new guidance to allow providers in educational settings to seek Medicaid reimbursement for free preventive services covered by the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provided to Medicaid-enrolled children. However, following CMS’ announcement, states retained policies restricting reimbursement for these services. As of 2016, three states expressly prohibited billing, while 22 others had policies and provisions that would impede school efforts to seek reimbursement.

To help education policymakers and other stakeholders understand the state policy landscape impacting Medicaid billing for school-administered services, the research team at Child Trends and the National Health Law Program will investigate how state policy has shifted following CMS’ 2014 rule, focusing on three research questions:

1. To what extent do state policies support Medicaid billing for school-administered free care?
2. How has Medicaid billing for school-administered services shifted since CMS' reversal of the free care rule, and what is the relationship between such billing and state free care policies?
3. For states with supportive free care policies, what factors influence how districts and schools use Medicaid to support student health?

The team will conduct a content analysis of state policies, including state Medicaid plans, plan amendments, and requests for Medicaid Managed Care contract proposals (from all 50 states and DC), to identify obstacles to Medicaid billing for school-administered care. They will then analyze how Medicaid billing for school-administered services has shifted since CMS' 2014 decision, while comparing states with different policies for differences in billing. Lastly, they will interview state officials and education stakeholders in Massachusetts and Louisiana to examine how shifts in state Medicaid policy have influenced schools' capacity to support student health.