Who Is Caring for Health Care Workers' Families Amid COVID-19?

Amid the COVID-19 pandemic, women in medicine, including faculty, residents, medical students, and other health care workers (HCWs), are facing unparalleled challenges. The burdens of pandemic-associated increases in domestic and caregiving responsibilities, professional demands, health risks associated with contracting COVID-19, and the resulting psychosocial distress have exacerbated existing gender disparities at home, at work, and in academia. School and day care closures have created additional childcare needs, primarily for women, yet little support exists for parents and families. These increased childcare and domestic responsibilities have forced women HCWs, who make up the overwhelming majority of the workforce, to adapt their schedules and, in some cases, leave their jobs entirely. In this article, the authors detail how COVID-19 has exacerbated existing childcare accessibility and affordability issues as well as gender disparities. They argue that unless government and health care organization support for childcare increases, families, specifically women and children, will continue to suffer. Lack of access to affordable childcare can prevent HCWs from doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society. COVID-19 should serve as a call to action to all sectors, including the government and health care organizations, to prioritize childcare provision and increase support for women HCWs, both now during the pandemic and going forward.

Evaluating the Implementation of a Before-School Physical Activity Program: A Mixed-Methods Approach in Massachusetts, 2018.

PURPOSE AND OBJECTIVES: Our aim was to evaluate the implementation of a widely available, before-school, physical activity program in a low-resource, racially/ethnically and socioeconomically diverse, urban school setting to identify adaptations needed for successful implementation. INTERVENTION APPROACH: We used a collaborative effort with stakeholders to implement the Build Our Kids' Success (BOKS) program in 3 schools in Revere, Massachusetts. Program structure followed a preexisting curriculum, including 60-minute sessions, 3 mornings per week, over 2 sessions (spring and fall 2018). Programs had a capacity of 40 students per school per session and the ability to adapt as needed. EVALUATION METHODS: We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RE-AIM domains were assessed by use of baseline and follow-up student measures, parent interviews, and program administrative records. RESULTS: From a district of 11 schools, 3 schools (2 elementary, 1 middle) implemented the BOKS program. Program enrollment reached 82% capacity (188 of 230 potential participants). Of the 188 enrolled students, 128 (68%) had parental consent for study participation. Among the 128 study participants, 61 (48%) were male, 52 (41%) identified as Hispanic/Latino, and mean age was 9.3 years (SD, 2.2). Program duration varied by school (25-60 minutes), with a mean of 33% (SD, 16%) of the session spent in actigraphy-measured moderate-to-vigorous physical activity (MVPA), or mean 16.3 (SD, 9.3) minutes of MVPA. Participants attended a median 90% (interquartile range [IQR], 56%-97%) of sessions. We observed no change in body mass index (BMI) z score or self-reported quality of life from baseline to follow-up assessment. Parents reported positive program effects. Enrollment was sustained in elementary schools and decreased in the middle school during the study period, expanding to 3 additional schools for spring 2019. IMPLICATIONS FOR PUBLIC HEALTH: Implementation and evaluation of an evidence-based physical activity program, in a low-resource setting, are feasible and yield relevant information about program adaptations and future dissemination of similar programs.

Early Childhood Obesity Prevention: Challenges and Barriers of Implementing Child and Adult Care Food.

INTRODUCTION: The Child and Adult Care Food Program requirements promote healthy eating behaviors and increased physical activity in the daycare setting to help prevent childhood obesity. Some of these standards can be difficult to meet for early childhood education centers. This study examines the challenges and barriers daycare centers face when implementing these guidelines. METHODS: Focus groups consisting of participants from early childhood education centers within our community were conducted in April and May of 2018. RESULTS: Three focus groups were conducted, with a total of 7 childcare center directors. Eight themes that affect nutrition and physical activity curriculums at early childhood education centers arose: teacher philosophy and involvement, training/expertise of staff, parental involvement, financial constraints, children's interests, food availability, physical environment, and regulations/guidelines. Overall, participants expressed their sense that child care facilities are undervalued. They agreed that healthy, fresh food choices are expensive, difficult to obtain due to the volume needed, and require additional training to prepare. Emphasis on gross motor development has a varied level of support from families and teachers. Challenges and barriers to providing adequate gross motor activities include limited financial support, lack of physical space, lack of teacher willingness to engage in outdoor activity, and parental resistance. CONCLUSIONS: Financial constraints and the "undervaluing" of childcare contribute greatly to many of the challenges and barriers early childhood education centers face in meeting nutrition and physical activity standards. Findings from this study shed light on the significant role early childcare centers play in nurturing child development and the efforts these centers undertake in the interest of children.

The Role of Work-Family Balance Policy for Enhancing Social Sustainability: A Choice Experiment Analysis of Koreans in their Twenties and Thirties.

Korea is facing problems, such as inequality within society and an aging population, that places a burden on public health expenditure. The active adoption of policies that promote work-family balance (WFB), such as parental leave and workplace childcare centers, is known to help solve these problems. However, there has, as yet, been little quantitative evidence accumulated to support this notion. This study used the choice experiment methodology on 373 Koreans in their twenties and thirties, to estimate the level of utility derived from work-family balance policies. The results show that willingness to pay for parental leave was found to be valued at 7.81 million Korean won, while it was 4.83 million won for workplace childcare centers. In particular, WFB policies were found to benefit workers of lower socioeconomic status or belonging to disadvantaged groups, such as women, those with low education levels, and those with low incomes. Furthermore, the utility derived from WFB policies was found to be greater among those who desire children compared to those who do not. The results suggest that the proactive introduction of WFB policies will help solve problems such as inequality within society and population aging.

Barriers and Facilitators to Compliance with a State Healthy Eating Policy in Early Care and Education Centers.

BACKGROUND: Early care and education (ECE) policies can improve childhood obesity risk factors. We evaluated barriers and facilitators to implementing mandatory nutrition standards for foods provided in South Carolina ECE centers serving low-income children, comparing centers participating in the Child and Adult Care Food Program (CACFP) with non-CACFP centers. METHODS: We mailed 261 surveys (demographics, policies and practices, barriers and facilitators) to center directors after new state nutrition standards were implemented in South Carolina. We conducted univariate and bivariate analyses to explore relationships between barriers, facilitators, and center-level characteristics, by CACFP status. RESULTS: We received 163 surveys (62% response rate). Centers had a median [interquartile range (IQR)] of 5 (4-7) classrooms and 59 (37.5-89) total children enrolled. More than half (60.1%) of directors reported they were moderately or fully informed about the standards. The most common barriers were food costs (17.8%) and children's food preferences (17.8%). More non-CACFP directors reported food costs as a barrier (28.6% vs. 6.5%, p < 0.001), having to spend additional money on healthier foods (48.8% vs. 28.6%, p = 0.01), and having to provide additional nutrition education to parents (28.6% vs. 11.7%, p = 0.01), compared with CACFP directors. CONCLUSIONS: Center directors were generally well informed about the nutrition standards. The most common barriers to implementing the standards were food costs and children's food preferences. Centers participating in CACFP may be in a better position to adhere to new state nutrition standards, as they receive some federal reimbursement for serving healthy foods and may be more accustomed to regulation.

Food Purchasing and Preparation at Child Day Care Centers Participating in the Child and Adult Care Food Program in the United States, 2017.

BACKGROUND: More than 3.6 million children are served daily by the Child and Adult Care Food Program (CACFP)-participating child day care centers. This study provides a nationwide assessment of center-level responsibilities for menu, meal/snack preparation, meal preparer training, and food and beverage (F&B) purchasing. METHODS: A nationally representative survey of 5483 CACFP child day care centers was conducted between August 22, 2017, and September 30, 2017. One thousand three hundred forty-three centers (25% response) in 47 states and the District of Columbia responded. Descriptive statistics describe center-level menu, meal, and purchasing practices and center characteristics. Multivariate logistic regressions examined characteristics associated with F&B purchasing sources. RESULTS: Menus were primarily prepared by directors/assistant directors and on-site food manager/cooks, while site staff primarily prepared meals/snacks. Fifty-two percent of meal preparers held a food sanitation license, but only 5% had formal nutrition training (e.g., Registered Dietician). Most centers purchased F&B from food service providers (63%), local grocery stores (59%), warehouse stores (40%), or from 2+ sources (50%). Independent centers were more likely to purchase F&B from local grocery stores or 2+, while free or state-subsidized sites were more likely to purchase from a food service provider and less likely to purchase from other sources than were centers charging between $101 and $201.99 per week. Centers where an on-site cook/food manager prepared the menus were significantly more likely to purchase their F&B from local grocery and/or warehouse stores and/or from 2+ sources. CONCLUSIONS: Opportunities exist to target CACFP training to specific roles within and specific types of CACFP-participating child day care centers to facilitate compliance with the updated CACFP standards.

Rogue Nuns Grow Services to Combat Growing Problems.

This paper tells the story of how an experiment in caring for the children of poor, working mothers became a multimillion-dollar early learning center. It follows the evolution of two nuns who began providing day care in a church and came to realize that children living in poverty need a much greater range of services. It covers how the sisters broke with the Catholic Church and engaged alternative and unorthodox sources to help the operation survive and to extend its reach. It documents how far the sisters went to keep the doors open and how they sustained success.

Factors Influencing the Food Purchases of Early Care and Education Providers.

BACKGROUND: With the majority of US children enrolled in some form of early care and education, the settings for early care and education represent a valuable opportunity to positively impact young children's diets and their interactions with food. Little evidence exists on how early care and education providers make food purchasing and service decisions for this population of young children. OBJECTIVE: Our aim was to explore the factors that influence early care and education providers' food purchasing and service decisions. DESIGN: A qualitative design consisting of individual, in-person, and semi-structured interviews with providers and on-site observations was used. PARTICIPANTS/SETTING: Sixteen early care and education providers-selected across a variety of characteristics that might affect food selection (eg, size of site, participation in reimbursement programs, presence of staff assigned to foodservice) using maximum variation purposive sampling-based in the Puget Sound region, Washington, were interviewed from June to September 2014. MAIN OUTCOME MEASURE: Provider perspectives on food purchasing and service decisions. STATISTICAL ANALYSES PERFORMED: Inductive analysis of transcribed interviews using TAMS Analyzer software (GPL version 2, 2012) to identify themes. RESULTS: Ten main influencers emerged from the data. These were grouped into four categories based on an ecological framework: macro-level environments (ie, regulations; suppliers and vendors, including stores); physical environment and settings (ie, organizational mission, budget, and structure; the facility itself); social environments (ie, professional networks; peers; the site-specific parent and child community); and individual factors at both a provider and child-level (ie, providers' skills, behaviors, motivations, attitudes, knowledge, and values; child food preferences; and, child allergies). A model was then developed to identify potential pathways of intervention and underscore the need for a comprehensive approach to improve early care and education nutrition. CONCLUSIONS: This study suggests that a more system-based understanding and approach-one that accounts for an array of influencers and their interactions-is necessary to take advantage of opportunities and address barriers to improving early care and education-based nutrition.

The Saskatchewan/New Brunswick Healthy Start-Départ Santé intervention: implementation cost estimates of a physical activity and healthy eating intervention in early learning centers.

BACKGROUND: Participation in daily physical activity and consuming a balanced diet high in fruits and vegetables and low in processed foods are behaviours associated with positive health outcomes during all stages of life. Previous literature suggests that the earlier these behaviours are established the greater the health benefits. As such, early learning settings have been shown to provide an effective avenue for exploring and influencing the physical activity and healthy eating behaviours of children before school entry. However, in addition to improving individual level health of children, such interventions may also result in a number of social benefits for the society. In fact, research among adult populations has shown that sufficient participation in physical activity can significantly lower hospital stays and physician visits, in turn leading to positive economic outcomes. To our knowledge there is very limited literature about economic evaluations of interventions implemented in early learning centers to increase physical activity and healthy eating behaviours among children. The primary purpose of this paper is to identify inputs and costs needed to implement a physical activity and healthy eating intervention (Healthy Start-Départ Santé (HS-DS)) in early learning centres throughout Saskatchewan and New Brunswick over the course of three years. In doing so, implementation cost is estimated to complete the first phase of a social return on investment analysis of this intervention. METHODS: In order to carry out this evaluation the first step was to identify the inputs and costs needed to implement the intervention, along with the corresponding outputs. With stakeholder interviews and using existing database, we estimated the implementation cost by measuring, valuing and monetizing each individual input. RESULTS: Our results show that the total annual cost of implementing HS-DS was $378,753 in the first year, this total cost decreased slightly in the second year ($356,861) and again in the third year ($312,179). On average, the total annual cost is about $350,000 which implies an annual cost of $285 per child. Among all inputs, time-cost accounted for the larger share of total resources need to implement the intervention. Overall, administration and support services accounted for the largest portion of the total implementation cost each year: 74% (year 1), 79% (year 2), and 75% (year 3). CONCLUSIONS: The results from this study shed lights for future implementation of similar interventions in this context. It also helps to assess the cost effectiveness of future interventions.

Socioeconomic and health factors associated with kindergarten retention in Australian children.

AIM: We aimed to identify key socioeconomic and health factors that are associated with a child's likelihood of being retained in kindergarten prior to commencing first year of school in Australian children. METHODS: We used data linked from the School Entrant Health Questionnaire administered to children commencing school in 2012 (N = 42 002). Kindergarten retention here is defined by children accessing a second year of funded kindergarten prior to commencing school. We used logistic regression analysis to estimate the strength of associations between a range of socioeconomic and health factors to the likelihood of kindergarten retention. RESULTS: Of the 25 289 children included in our analysis, 903 (3.6%) had a second year of funded kindergarten prior to commencing school. In comparison, 1680 children out of 42 002 in the Kinder-School Entrant Health Questionnaire dataset had a second year of funded kindergarten (4.0%). From our final regression model, the highest association was found in children whose parents reported a history of speech and language difficulties (odds ratio 2.25, 95% confidence interval (1.91-2.66)) (adjusting for a range of demographic, health and developmental factors). Similarly, children from an indigenous background were twice as likely to be retained in kindergarten compared with those with a non-indigenous background (odds ratio 2.06 (1.17-3.64)). CONCLUSION: This analysis adds to the evidence base that children who are more socially disadvantaged as well as children with health difficulties, particularly speech and language difficulties, are more likely to be retained in kindergarten.

Physical activity-related and weather-related practices of child care centers from 2 states.

BACKGROUND: Young children's physical activity (PA) is influenced by their child care environment. This study assessed PA practices in centers from Massachusetts (MA) and Rhode Island (RI), compared them to best practice recommendations, and assessed differences between states and center profit status. We also assessed weather-related practices. METHODS: Sixty percent of MA and 54% of RI directors returned a survey, for a total of 254. Recommendations were 1) daily outdoor play, 2) providing outdoor play area, 3) limiting fixed play structures, 4) variety of portable play equipment, and 5) providing indoor play area. We fit multivariable linear regression models to examine adjusted associations between state, profit status, PA, and weather-related practices. RESULTS: MA did not differ from RI in meeting PA recommendations (ß = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (ß = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (ß = -0.20; 95% CI: -0.38, -0.02; P = .03), but they did not differ for weather (ß = 0.12; -0.19, 0.44; P = .44). CONCLUSIONS: More MA centers allowed children outside in light rain or snow. For-profit centers had more equipment­both fixed and portable. Results from this study may help inform interventions to increase PA in children.

Características cognitivas, emocionales y conductuales de niños preescolares del programa buen comienzo en el noroccidente de Medellín / Cognitive, emotional, and behavioral characteristics of preschoolers of the good start program in the northwestern area in Medellin

En el presente artículo derivado de investigación, se describen las características cognitivas, emocionales y conductuales de una muestra de 20 niños preescolares, que oscilan entren los 3 y 5 años de edad, de estrato socioeconómico bajo y que han sido beneficiados del programa estratégico de la Alcaldía de Medellín (Colombia), perteneciente a la Secretaría de Educación, denominado Buen Comienzo. El programa Buen Comienzo tiene como propósito la promoción del desarrollo integral,diverso e incluyente de niñas y niñas, desde en una perspectiva interdisciplinaria del ciclo vital, protección de los derechos y articulación interinstitucional.

In this current article, derived from a piece of research, the cognitive, emotional, and behavioral characteristics, of a sample of 20 preschoolers, are described and whose ages range between 3 and 5 years. They belong to a low socio-economic level and they have benefited from the strategic program at the Mayor’s Office in Medellin (Colombia), belonging to the Secretariat of Education program called theGood Start. Such a program aims the promotion of comprehensive, diverse, and inclusive development of children, from an interdisciplinary perspective of the life cycle, the protection of rights and the inter-institutional coordination.

A widening gap? The political and social organization of childcare in Argentina.

This article examines how social policies and programmes implemented in Argentina shape the political and social organization of childcare. The author seeks to analyse how welfare institutions are currently responding to emerging needs, and to what extent they facilitate the defamilialization of childcare for different social classes. Because Argentina lacks a truly unified 'care policy', four different kinds of facilities and programmes are examined: employment-based childcare services; pre-school schemes; social assistance care services; and poverty reduction strategies. It is argued that far from offering equal rights and services with a universalist cast, these 'caring' institutions reflect the ethos of the current welfare model in Argentina: a fragmented set of social policies based on different assumptions for different social groups, which in turn filter down to the social organization of childcare.

Stratified familialism: the care regime in India through the lens of childcare.

This article explores the political and social economy of care in India through a focus on childcare practices, from the viewpoint of the care giver ­ a perspective frequently ignored or touched on only generally in earlier discussions on development or social policy. It is argued that the care regime is an ad hoc summation of informal, stratified practices. It is shaped by the institutional context, in particular the economic and social inequalities of work and livelihoods, as well as trends and absences in state economic and social policy. Central to the dynamics of care practices in India is the ideology of gendered familialism in public discourse and policy, which reiterates care as a familial and female responsibility and works to devalue and diminish the dimensions of care. By delineating the range of institutions through which everyday childcare practices are organized, this contribution draws out the differentiations and actualities of stratified familialism and care. At one end of the spectrum are those who have the possibility to retain familial carers at home and supplement them with paid and other institutional carers; at the other are those who are neither able to retain family members at home nor fill the care gap through formal institutions.

Putting two and two together? Early childhood education, mothers' employment and care service expansion in Chile and Mexico.

In recent years, several middle-income countries, including Chile, Mexico and Uruguay, have increased the availability of early childhood education and care (ECEC) services. These developments have received little scholarly attention so far, resulting in the (surely unintended) impression that Latin American social policy is tied to a familialist track, when in reality national and regional trends are more varied and complex. This article looks at recent efforts to expand ECEC services in Chile and Mexico. In spite of similar concerns over low female labour force participation and child welfare, the approaches of the two countries to service expansion have differed significantly. While the Mexican programme aims to kick-start and subsidize home- and community-based care provision, with a training component for childminders, the Chilean programme emphasizes the expansion of professional ECEC services provided in public institutions. By comparing the two programmes, this article shows that differences in policy design have important implications in terms of the opportunities the programmes are able to create for women and children from low-income families, and in terms of the programmes' impacts on gender and class inequalities. It also ventures some hypotheses about why the two countries may have chosen such different routes.

Liminal cultural work in family childcare: Latino immigrant family childcare providers and bicultural childrearing in the United States, 2002-2004.

Immigrants find themselves in a liminal state of limbo between two societies. In this zone, competing cultural ideas coexist. This essay examines how Latino immigrant family childcare providers in the United States questioned US norms of childrearing and how they engaged in liminal cultural work to produce a bicultural childrearing. They are exposed to US norms through family childcare certification programmes that they were legally required to participate in, in order to receive the accreditation required to care for young children in their homes. They were simultaneously critical and embracing of US mainstream ideas of childrearing. Two contested areas for them are the emphasis on individual child development and the levelling of authority relations between adults and children. Their traditional values are absent from the training programmes, yet they develop a process of selective adaptation which both maintains and discards traditional ideas of childrearing and integrates them with some of the new ideas they learn in the US. The liminal cultural work that immigrant family childcare workers do is both for themselves and for the children and the families for whom they provide care. The providers experience a process of ongoing liminal cultural work.

[Disguises, invisibility and disqualification of the guards of children in French-speaking Switzerland]. / Déguisements, invisibilité et disqualification des gardes d'enfants en Suisse Romande aujourd'hui.

Various factors oblige today's parents to entrust their children to a child-care worker (CCW), providing services in the domestic sphere, either at the child's parental house or at the day-care worker's (DCW's) own home. Taking this into account, this paper examines job offers and applications for DCWs published in a regional Swiss newspaper as well as other job offers and applications published on a website called bestnounou.ch. The parents often tend to use a variety of terms, which do not point to the child-caring or rearing activity itself, but rather emphasise sociological characteristics of the CCW (age, gender, civil status), requesting, for example, a "lady", a "grandmother", a "student". Thereby, the parents present the child-care work as: (1) a secondary and temporary activity in relation to another major stable activity (motherhood, apprenticeship, retirement); and (2) an activity that does not require professional skills but inborn aptitudes. Moreover, employers use as synonyms distinctive terms, which refer to various categories of CCW and domestic workers, whose schedules of conditions and salaries are regulated and differ. The parents' inclination to use terms designating the most precarious and underpaid CCW underscores the importance of child-care in the domestic sphere. It leads also to a public image of child-care workers as being a fragmented, unstable, little qualified and economically inconsistent workforce, in contrast to the stable and structural need for their specific services, allowing parents to face their familial and professional responsibilities.

Organizational and operational capabilities of specialist centres for children with psychomotor disability in Abidjan.

OBJECTIVE: To describe the organizational and operational capabilities of specialized centres for children with psychomotor disability in Abidjan, Republic of Côte d'Ivoire. MATERIALS AND METHODS: This descriptive study was carried out from February to May, 2006 at the various specialized centres for children with psychomotor disability that exist in the district of Abidjan. The procedure comprised a clinical description of the disabled children admitted to these centres and an assessment of the centres' organization and operational capabilities. RESULTS AND COMMENTS: Six specialist centres for children with psychomotor disability were identified, namely the Infant Guidance Centre, the Awakening and Stimulation Centre for disabled Children, the "Sainte-Magdeleine" Centre, the Medical and Training Institute, the "Page Blanche" institute and the "Colombes Notre Dame de la Paix" Centre. Among the children, 97.15% were day patients, 66.37% were mentally challenged, 30.96% had psychomotor impairment and 2.66% had motor impairments. The level of organization varied but the centres nevertheless had operational administrative, medical and paramedical staff, despite the absence of certain specialties. However, the lack of personnel, equipment and infrastructure is hindering the delivery of adequate services to the children. CONCLUSION: In Abidjan District, reception centres for children with psychomotor impairments are essentially privately run. Organizational and operational performances were suboptimal, with a low carer-to-patient ratio. Reinforcement of the centres' operational capabilities appears to be necessary.

Quality improvements in the early care and education workforce: outcomes and impact of the T.E.A.C.H. Early Childhood Project.

To date there has not been a systematic, longitudinal research to assess the efficacy of public investments in the professional development of early childhood educators that are funded through the T.E.A.C.H. Early Childhood Project. This study of the T.E.A.C.H. Early Childhood Project Pennsylvania provides a longitudinal analysis of the data for the first three cohorts of applicants and scholars that participated in Pennsylvania's T.E.A.C.H. program. Over a 5-year period, we followed the scholars that participated in this program to examine the direct outcomes, as well as the indirect impact, of participating in the T.E.A.C.H. scholarship program. We found a number of positive outcomes for the scholars with respect to: educational achievement, increased compensation, reduced turnover, and improved knowledge, skill, and practice. The downside of T.E.A.C.H., as implemented in Pennsylvania, is keeping caregivers in the program. Only 15% of the scholars were still in the program at the end of the 5th year. The dropout/withdrawal rate after the first contract was 43.5% representing a sizable investment in scholars that never completed the initial contract. Based on these findings, the implications policy and practice are discussed.

Cost-effective early childhood development programs from preschool to third grade.

Although findings on the positive effects of early childhood development programs have been widely disseminated, less attention has been given to program impacts across the entire period of early childhood. This review summarizes evidence on the effects and cost-effectiveness of programs and services from ages 3 to 9. The major focus is preschool programs for 3- and 4-year-olds, full-day kindergarten, school-age programs including reduced class sizes, and preschool-to-third-grade interventions. Participation in preschool programs was found to have relatively large and enduring effects on school achievement and child well-being. High-quality programs for children at risk produce strong economic returns ranging from about $4 per dollar invested to over $10 per dollar invested. Relative to half-day kindergarten, the positive effects of full-day kindergarten have been found to be relatively small and generally do not last for more than a year. Although no formal economic analyses have been conducted, the economic return per dollar invested would be expected to be close to zero. Among early-school-age programs, preschool plus school-age interventions (PK-3) for children at risk are linked to higher levels of school performance into adolescence. The Child-Parent Center PK-3 Program shows a return of $6 to $9 per dollar invested. Class-size reductions show evidence of positive effects, with economic returns of roughly $3 per dollar invested. The causal mechanisms of long-term effects are discussed. Key principles to promote intervention effectiveness are offered.