Kindergarten Readiness, Later Health, and Social Costs Caroline Fitzpatrick, PhD,a,b Elroy Boers, PhD,c Linda S. Pagani, PhDc,d

OBJECTIVES: To estimate associations between kindergarten readiness and academic, abstract psychological, and health risks by end of high school. METHODS: This study is based on 966 Canadian children. At age 5, trained examiners assessed child number knowledge and receptive vocabulary. Teachers reported kindergarten classroom engagement. At age 17, participants reported academic grades, school connectedness, anxiety sensitivity, substance abuse, physical activity involvement, and height and weight. High school dropout risk was also estimated for each participant on the basis of grades, school engagement, and grade retention. RESULTS: Kindergarten math skills contributed to better end-of high school grades (b = .17, P , .01) and lower dropout risk (b = 2.20, P , .001), whereas receptive vocabulary predicted lower anxiety sensitivity (b = 2.11, P , .01). Kindergarten classroom engagement predicted higher end of high school grades (b = .17, P , .001), lower dropout risk (b = 2.20, P , .01), better school connectedness (b = .15, P , .01), lower risk of substance abuse (b = 2.21, P , .001), and more physical activity involvement (b = .09, P , .05). Kindergarten classroom engagement was also associated with a 65% reduction (odds ratio = 0.35) in the odds of being overweight at age of 17. Analyses were adjusted for key child (sex, weight per gestational age, nonverbal IQ, and internalizing and externalizing behaviors) and family (parental involvement, maternal depression and immigrant status, family configuration, and socioeconomic status) characteristics. CONCLUSIONS: Early childhood readiness forecasts a protective edge by emerging adulthood. With these findings, we build links between education and health indicators, suggesting that children who start school prepared gain a lifestyle advantage. Promoting kindergarten readiness could reduce the health burden generated by high school dropout.

’ aDepartement of Social Sciences, Université Sainte-Anne, Church Point, Canada; bCentre for Education Practice WHAT S KNOWN ON THIS SUBJECT: Researchers have Research, University of Johannesburg, Johannesburg, South Africa; cSainte-Justine Research Centre, Montréal, shown that being ready to learn in kindergarten can Canada; and dÉcole de sychoéducation, Université de Montréal, Montréal, Canada forecast achievement in later elementary school. Furthermore, separate researchers have established Dr Fitzpatrick had full access to the data, conceptualized the study, conducted the analyses, and a link between high school achievement, lifestyle choices, drafted the manuscript; Drs Boers and Pagani provided critical feedback and edited the and productivity. manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. WHAT THIS STUDY ADDS: With our results, we suggest DOI: https://doi.org/10.1542/peds.2020-0978 long-term protective associations between readiness to learn in kindergarten and personal success at age 17. Accepted for publication Sep 22, 2020 With this study, we therefore reaffirm the importance of Address correspondence to Caroline Fitzpatrick, PhD,1695 Highway 1, B0W1M0, Church Point, early childhood readiness and suggest that early Canada. E-mail: caroline.fi[email protected] interventions could benefit population productivity and PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). health. Copyright © 2020 by the American Academy of Pediatrics To cite: Fitzpatrick C, Boers E, Pagani LS. Kindergarten fi FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to Readiness, Later Health, and Social Costs. Pediatrics. 2020; this article to disclose. 146(6):e20200978

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 146, number 6, December 2020:e20200978 ARTICLE Many children begin kindergarten economic implications. A compelling that took place in the province inadequately prepared to benefitfrom way to evaluate that adage would be between 1997 and 1998. Sex was classroom instruction.1,2 Children to examine the extent to which equally represented, with 49% girls who are unprepared risk struggling cognitive and learning skills predict and 72% of parents described their throughout their academic journey.3 long-term outcomes and indictors of child as being Canadian. Most parents Among physical wellbeing, general life success. (81%) reported that their spoken knowledge, and social emotional language was French. Finally, 21.7% The objective with this study is to wellbeing characteristics, compelling of parents reported being under the examine the extent to which evidence suggests that fundamental poverty line cutoff for Canadian kindergarten readiness skills, skills in math and vocabulary are families. For complete sample reflecting previous experiences and invariably the most crucial predictors description, see Supplemental learning, forecast later mental and of academic success in later Information. – physical health risks by the end of elementary.3 5 Kindergarten high school, an important life course classroom engagement skills, which turning point for youth. As a result, Main Predictors (Age 5, reflect the ability to successfully we examine academic performance, Kindergarten Entry) adjust to classroom demands, also dropout risk, school connectedness, Math skills were assessed by using an appear to foster an academic edge anxiety sensitivity, substance abuse, abridged version of the Number throughout elementary school.6 physical activity, and healthy weight Knowledge Test (NKT).17 The NKT Indeed, productive learning behaviors outcomes by age 17, which marks the measures the child’s degree of in kindergarten predict educational end of high school in the province of familiarity with basic notions of attainment by emerging adulthood.7 Quebec. Given that development is arithmetic such as counting, adding, In addition to academic success, presumably influenced by multiple and subtracting, as a function of age. school readiness has been linked to individual and environmental factors For additional details on this measure health and social outcomes. across childhood,15,16 we adjust for see Supplemental Information. According to researchers of one study, child sex, birth weight per gestational students who began kindergarten age, kindergarten nonverbal IQ, and Verbal skills were assessed by using with better vocabulary and math behavior problems as well as parental the Peabody Picture Vocabulary 18 skills showed greater chances of and family demographic Test, which was administered healthy lifestyle behavior by the end characteristics as potential individually in French or English by of fourth grade.8 Kindergarten confounding variables. Furthermore, a trained research assistant. This test classroom engagement has also been in regressions addressing links comprises practice images, followed found to forecast more optimal between school readiness and end of by 170 other images in order of emotional adjustment, relationships high school physical activity and BMI, increasing difficulty. The starting with classmates, participation in we control for kindergarten BMI and point depends on the child’s age. physical activity, and BMI by the end physical fitness. Scores are standardized as a function of elementary school.6,9–11 of tables of age-related normative criteria.19 The results of the Peabody Educational attainment is closely METHODS Picture Vocabulary Test are strongly intertwined with important health, Sample correlated with typical language wellbeing, and productivity outcomes subscales of most standardized 12–14 for both individuals and society. We conducted secondary analyses intelligence tests.18 However, to date, much of the work using data from the Quebec on school readiness has examined Longitudinal Study of Child Classroom engagement was reported how school readiness contributes to Development (QLSCD; 1998–2019). by kindergarten teachers using – success in later elementary school.3 5 The QLSCD originates from a 7-item scale: works and plays A longer-term follow-up of school a randomly selected, stratified cooperatively with other children, readiness on later indicators of potential sample of 2837 infants from follows rules and instructions, follows vocational success can therefore the birth registry between 1997 and directions, listens attentively, afford crucial evidence of the 1998 in Quebec, Canada. From these, completes work on time, works importance of ensuring that all 2120 children were retained for autonomously, and works neatly and children are ready to learn at the time longitudinal follow-up from 5 months carefully (a = .94). Responses were of school entry. The 20th century onward. The retained participants, made on a Likert scale and ranged expression that all one really needs to representing 82% of the eligible from 1 (never) to 3 (always) for each know they learned in kindergarten target population, are considered item. Higher scores reflect better appeals to us for its health, social, and representative of all singleton births engagement. This classroom

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 FITZPATRICK et al engagement measure is empirically 3 (agree), or 4 (completely agree), in kg]/height in m2) specific for age related with academic ability.5,6 a = .82. and sex. Outcomes (Age 17, End of High Substance Abuse Control Variables School) Substance abuse was based on youth Child nonverbal IQ was directly Academic Achievement responses of yes (scored as 1) or no assessed by trained professionals Academic performance was based on (scored as 0) to the following when children were in kindergarten student self-reported average marks situations over the past 12 months: by using the Wechsler Intelligence 22 in math and English and French my alcohol or drug use has had Scale for Children, Third Edition. language from the previous year. A negative psychological effects on me This subtest, which assesses visual global academic achievement variable (anxiety, depression, problems perception and organization and reflecting mean marks in percentage concentrating, etc), my alcohol or abstract reasoning, provides an across both disciplines was drug use has had negative effects on estimate of nonverbal IQ. computed, sample mean (SD) = my relationships with my family, Kindergarten teachers reported on 75.62% (10.29). my alcohol or drug use has had child emotional distress and physical negative effects with my friends or in aggression using items derived Dropout Risk my love life, my alcohol or drug use from the Child Behavior Dropout risk was assessed by has had negative effects on my Checklist and Preschool Behavior – creating an index comprising studies, I committed a delinquent act Questionnaire.23 25 Finally, weight for academic performance, school (even if I was not arrested by the gestational age, child age, and sex engagement, and previous grade police) while under the influence of were derived from medical records. retention. alcohol or drugs, I have had the Parental involvement was measured feeling as though the same quantities by using the Home Observation for School Engagement of alcohol or drugs were having less Measurement of the Environment, This index has been shown to be effect on me than they once had, I Infant version.26 Trained examiners a valid predictor of high school have spoken with a health care made assessments after observing dropout by age 25.20 For additional worker or counselor about my alcohol parent–child interactions for a period details on this measure, see or drug use. Sums were then of 3 hours. The following 5 items Supplemental Information. converted to scores ranging from were assessed: provides toys that 0 to 10. challenge child to develop new skills, School Connectedness structures child’s play periods, Physical Activity School connectedness was based on interacts with her child while students answers to the following Participants answered questions engaged in other tasks, encourages questions: I am proud I go to this regarding their level of physical her child’s progress, and values school, I am happy to go to this activity during their free time. Items educational toys (a = .85). These school, I feel safe at my school, most included frequency of physical items were rated as 1 (never), 2 mornings I look forward to going to activity during a typical week, the (rarely), 3 (sometimes), 4 (often), or 5 school, I like my school (a = .86). amount of time they spent being (always). When children were 5 Items were rated using the following physically active on a typical day, months, mothers also self-reported scale: strongly disagree, disagree, their level of effort during physical depressive symptoms using the unsure, agree, strongly agree. activities, and the amount of time modified lifetime depression spent surfing the Internet for school section of the Diagnostic Interview Anxiety Sensitivity work and leisure, playing video Scale, and family configuration Participants indicated the extent to games, watching television shows and (2 parent = 1 and not = 0) and which they agreed with the following movies, and reading for school work. maternal immigration status statements from the substance use For additional details, see (nonimmigrant or European risk profile scale21: it is frightening to Supplemental Information. immigrant = 0, non-European feel dizzy or faint, it frightens me immigrant = 1). An index of when I feel my heart beat change, I BMI socioeconomic status was derived get scared when I am too nervous, I To derive BMI, participants self- from mother and father reports of get scared when I experience unusual reported weight and height. Weight income, level of education, and body sensations (feelings), it scares status was classified as healthy occupational prestige. Scores were me when I am unable to focus on or overweight and/or obese standardized to a mean of 0. Details a task. All items were rated as either according to International Obesity on this method have been published 1 (completely disagree), 2 (disagree), Task Force cutoffs for BMI ([weight elsewhere.26,27

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 146, number 6, December 2020 3 Data Analytic Strategy TABLE 1 Descriptive Statistics for Continuous Variables Our aim was to estimate prospective Mean (SD) Minimum to Maximum n associations between kindergarten Predictors readiness skills (age 5) and educational No. knowledge 13.26 (3.27) 3 to 18 949 andhealthoutcomesbytheendof Receptive vocabulary 80.38 (17.20) 12 to 130 931 Classroom engagement 2.68 (0.37) 1.14 to 3.00 966 high school (age 17). A series of Outcomes multiple regressions were used to Global achievement 76.28 (9.71) 44.5 to 98.5 671 simultaneously estimate the respective Dropout risk .24 (.25) .01 to .99 670 and unique contribution of kindergarten School engagement 13.87 (2.40) 5.00 to 18.00 673 number knowledge, receptive Anxiety sensitivity 3.32 (2.38) 0 to 10.0 746 Substance abuse 0.75 (1.17) 0 to 10 641 vocabulary, and classroom engagement Physical activity 3.12 (1.55) 1 to 5 730 to achievement, dropout risk, school Control variables (kindergarten) connectedness, anxiety sensitivity, Nonverbal IQ 19.86 (10.02) 0 to 52.0 958 substance abuse, and physical activity. Emotional distress 1.68 (1.64) 0 to 8.33 965 Logistic regressions were used to Physical aggression 0.95 (2.04) 0 to 10.0 964 Child BMI 15.80 (2.03) 11.10 to 31.00 937 estimate associations between school Child fitness (sit up test) 7.05 (4.79) 0 to 24 880 readiness characteristics and odds of Control variables (preschool) being overweight. Analyses were Parental involvement 4.90 (2.33) 0 to 10.0 854 adjusted for key child and family Maternal depression 1.34 (1.30) 0 to 9.23 964 2 contextual characteristics. Socioeconomic status 0.09 (0.96) 3.01 to 2.82 965 —, not applicable.

RESULTS Descriptive Statistics Tables 3 and 4, respectively. To engagement scores predicted a 4.66- In Tables 1 and 2, we provide facilitate effect size comparisons U increase in academic grades (P = descriptive statistics on continuous across measures, we report .007), a 0.872-U increase in school and categorical variables. Boys scored standardized regression coefficients connectedness (P = .005), a 0.406-U significantly lower on classroom in Table 3. After holding all other increase in physical activity (P = engagement than girls (mean = 2.76 variables constant, a 1-point increase .047), a 0.138-U decrease in dropout vs 2.60, P , .001); however, there on the number knowledge risk (P = .002), and a 1.01-U decrease were no sex-based differences in assessment corresponded to 0.518-U in substance abuse scores (P , .001). number knowledge or receptive increase in academic grades (P = In terms of the logistic regression, vocabulary scores. Boys also had .001) and a 0.016-U decrease in high each 1-point increase in classroom lower academic averages at the end of school dropout risk (P = .001). Each engagement scores was associated high school (mean = 68. 35 vs 74.38, 1-point increase in kindergarten with a 65% reduction in the odds of P , .001). vocabulary scores was associated being overweight (odds ratio = 0.35, fi Missing Data and Attrition Analysis with 0.016-U decreases on our 95% con dence interval, 0.16 to 0.74; measure of anxiety (P = .001). Finally, P = .009). To interpret these results Given that it was possible to estimate a 1-point increase in classroom more concretely, increasing classroom incomplete data on outcome variables based on covariates, we conducted multiple imputation on outcome and control variables, assuming that data TABLE 2 Frequency Distribution for Categorical Variables 28 were missing at random. All Percentage n regression analyses are based on of Sample pooled imputed data. A comparison BMI (age 17) 719 of children with and without Overweight 22.4 161 kindergarten reported data is Sex (5 mo) 966 available in Supplemental Boys 46.8 452 Information. Birth weight 965 Low birth weight 4.0 39 Immigrant (5 mo) Predictive Statistics Non-European immigrant 5.1 966 Adjusted linear and logistic Family configuration (5 mo) 965 regression results are documented in Nonintact 23.3 225

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 FITZPATRICK et al TABLE 3 Adjusted Standardized Regression Coefficients Depicting Associations Between Kindergarten School Readiness Skills and Outcomes at Age 17 Global Dropout Risk School Anxiety Substance Abuse Physical Achievement Connectedness Activity b P b P b P b P b P b P No. knowledge .17 ..001 2.20 ..001 2.01 .764 .024 .337 .06 .206 .01 .888 Receptive vocabulary .04 .834 2.03 .162 .06 .264 2.11 .007 2.04 .445 .01 .078 Classroom engagement .17 .004 2.20 .002 .15 .005 2.08 .098 2.21 ..001 .09 .047 R2 .30 — .35 — .05 — .10 — .06 — .10 — Models are adjusted for child sex, low birth wt, kindergarten nonverbal IQ, emotional distress and physical aggression, parental involvement, maternal depression and immigrant status, family configuration, and socioeconomic status. engagement scores by 1 point was kindergarten math competence is involvement with delinquent peers, associated with an additional 4.66 a key contributor to academic and a higher frequency of problem percentage points in academic grades achievement in elementary school behaviors including substance – – as well as a full-scale point decrease students.3 5 Although vocabulary use.34 36 Our results are consistent in substance abuse risk, which can skills were not related to academic with this literature and suggest that both be interpreted as clinically outcomes beyond math, they did the roots of less-effective engagement significant effects. To further predict subsequent decreases in self- may be traceable to kindergarten. contextualize these results, we found reported anxiety sensitivity in Classroom engagement skills are also small to moderate effect sizes for adolescence. Large-scale population- strongly reflective of impulse control, models predicting academic based findings have shown that goal-directedness, and cognitive and achievement and dropout, explaining kindergarten math skills become attentional control.37 Children need 30% and 35% of the variance, more important than vocabulary,3 self-control to follow classroom rules, whereas models predicting anxiety suggesting that the influence of work cooperatively with other (10%), physical activity (10%), language becomes indirect, as students, and remain focused in the substance abuse (6%), and school children transition from learning to face of distractions. As such, it is connectedness (5%) were smaller. read to reading to learn, over the possible that classroom engagement course of elementary and high represents an important mechanism school.33 With our findings, we also through which self-control ultimately suggest that solid vocabulary skills DISCUSSION contributes to academic promise an important edge for At a time when youth obesity and adjustment.38 In line with this psychological adjustment and, mental health risks have hypothesis, researchers have found ultimately, overall mental health. increased,29,30 with the current study that classroom behavior accounts for we provide timely evidence that early Children’s kindergarten classroom the association between executive readiness for school sets the stage for engagement was a consistent functioning and achievement.39 population increases in wellbeing, predictor of high school outcomes Furthermore, other researchers have health, and human capital formation. predicting academic achievement, linked preschool self-control to better With these results, it is also suggested dropout risk, school connectedness, economic, health, and interpersonal that early success begets continued substance use, physical activity, and functioning in adulthood.40 success, which has been previously weight status. Previous researchers Children’s ability to learn at the time noted in education research.31,32 have found that being less invested in of school entry reflects the quality of Early math skills predicted academic school is associated with their experiences and relationships achievement and was the strongest underachievement, reduced academic during the preschool years. Sensitive predictor of high school dropout risk. motivation, less supportive caregiving, linguistically and Previous work has revealed that relationships with teachers, more cognitively stimulating environments, and protection from chronic adversity TABLE 4 Adjusted Odds Ratios Depicting Associations Between Kindergarten Classroom Engagement and wt Status at Age 17 and stress support optimal brain development and capacity for lifelong Overweight OR (95% CI) P learning, wellbeing, and health.41 In – Number knowledge 1.01 (0.93 1.10) .804 contrast, there is evidence that Receptive vocabulary 1.01 (0.99–1.02) .284 Classroom engagement 0.35 (0.16–0.76) .010 growing up in poverty is associated with developmental risks for regional Models are adjusted for child sex, low birth wt, kindergarten BMI, fitness, emotional distress and physical aggression, fi parental involvement, maternal depression and immigrant status, family configuration, and socioeconomic status. CI, gray matter de cits in the frontal and confidence interval. temporal lobes and hippocampi,

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 146, number 6, December 2020 5 which are critical factors in The present research is not without group of children over the course of supporting the development school limitations. First, in our study, we did 17 years, represents compelling readiness skills.42 Children who not account for preschool attendance. strengths. grow up in socioeconomically As a result, it is possible that this High school dropout incurs high disadvantaged families are therefore unmeasured variable accounts for medical and social costs. In particular, especially likely to begin school less some of the variance in school dropout is associated with increased well prepared than their more- readiness. Given the tremendous 43 risk of poverty, nicotine dependence, advantaged peers. popularity of affordable day care low self-esteem, depression, policy implementation in the province underemployment, and involvement Several interventions can help offset – of Quebec, we estimate that preschool in criminal behavior.50 52 Given that the significant burden experienced by participation is unlikely to represent high school dropout exacts a heavy vulnerable children. These include an important confounding variable. cost on individuals and society, in the access to high quality universal Furthermore, the contextual variable current study, we underscore that preschool44 and community support most closely related to preschool early interventions which aim to systems such as home visitation45 participation in Quebec is boost school readiness could and parental training programs.46,47 socioeconomic status, which we translate into important economic In addition to providing young statistically adjust for in our savings across the life span. With our children with experiences that are 49 analyses. Second, our correlational findings, we further highlight the cognitively challenging, protection design precludes us from making any usefulness of conceptualizing from toxic stress and adversity also causal attributions. It may be the case kindergarten readiness as a public represent essential components of 53,54 that important unmeasured child and health issue and indicate that the impactful interventions.41 family characteristics are responsible decreased quality of life experienced Encouragingly, home visit programs for the observed associations. by youth who fail to complete high have been found to have positive Nevertheless, to reduce the school may be rooted in early effects on child health and school possibility of confounding, we childhood risk. readiness and offer mechanisms for accounted for influential child intervening to reduce parent stress. (nonverbal IQ) and family (socioeconomic status, parental ACKNOWLEDGMENTS Pediatricians can play a key role in involvement) characteristics in our The QLSCD was supported by funding promoting school readiness by analyses. Third, the current study was from the Quebec Government’s helping ensure that children receive based on secondary data, and as Ministry of Health, Ministry of the nutrition, sleep, and a result, direct assessments for Education, Ministry of Family Affairs, developmental experiences they need outcome measures were nonexistent. the Lucie and Andre Chagnon to develop strong school readiness Consequently, it is possible that social 48 Foundation, the Robert-Sauve and learning skills. In addition, desirability motives or recall bias led Research Institute of Health and fi pediatricians can screen children for to some of misclassi cation on the Security at Work, and the Quebec exposure to environmental threats behalf of respondents. Nevertheless, Statistics Institute. Additional funding including lead, toxins, and excessive the use of multiple measures, was received by Social Sciences and screen time, as well as exposure to including direct assessments as well Humanities Research Council and chronic adversity, which can take the as teacher and self-reports, allows us Nova Scotia Research. form of housing or food insecurity, to reduce the chances of shared family violence, parental mental measurement bias. The use of health problems, and the experience prospective longitudinal data, which ABBREVIATIONS of discrimination and systemic allowed us to assess child school racism. Finally, when needed, readiness long before they begin to NKT: Number Knowledge Test pediatricians can share information develop dispositions toward health QLSCD: Quebec Longitudinal Study on community resources with and productivity and to study the of Child Development parents. evolution of a large population-based

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

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2020/10/29/peds.2 020-0978 References This article cites 47 articles, 7 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2020/10/29/peds.2 020-0978#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Developmental/Behavioral Pediatrics http://www.aappublications.org/cgi/collection/development:behavior al_issues_sub Cognition/Language/Learning Disorders http://www.aappublications.org/cgi/collection/cognition:language:lea rning_disorders_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 28, 2021 Kindergarten Readiness, Later Health, and Social Costs Caroline Fitzpatrick, Elroy Boers and Linda S. Pagani Pediatrics originally published online November 2, 2020;

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