School Readiness Among Children Insured by Medicaid, South Carolina

William B. Pittard III, MD, PhD, MPH; Thomas C. Hulsey, ScD, MSPH; James N. Laditka, DA, PhD; Sarah B. Laditka, PhD


Prev Chronic Dis. 2012;9 

In This Article

Abstract and Introduction


Introduction The American Academy of Pediatrics recommends a schedule of age-specific well-child visits through age 21 years. For children insured by Medicaid, these visits are called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). These visits are designed to promote physical, emotional, and cognitive health. Six visits are recommended for the first year of life, 3 for the second year. We hypothesized that children with the recommended visits in the first 2 years of life would be more likely than others to be ready for school when they finish kindergarten.
Methods We studied children insured by Medicaid in South Carolina, born during 2000 through 2002 (n = 21,998). Measures included the number of EPSDT visits in the first 2 years of life and an assessment of school readiness conducted at the end of kindergarten. We used logistic regression to examine the adjusted association between having the recommended visits and school readiness, controlling for characteristics of mothers, infants, prenatal care and delivery, and residence area.
Results Children with the recommended visits had 23% higher adjusted odds of being ready for school than those with fewer visits.
Conclusion EPSDT may contribute to school readiness for children insured by Medicaid. Children having fewer than the recommended EPSDT visits may benefit from school readiness programs.


Lack of school readiness is a public health concern with adverse physical, psychological, social, and economic consequences for many children, particularly those insured by Medicaid.[1,2] Children unprepared for school often perform poorly academically, have low self-esteem, and in the long term are at greater risk than others for unemployment, poverty, and crime.[3,4] School readiness begins to develop early in life, well before formal schooling.[5–9] Inadequate school readiness has been associated with poverty and poor health,[10–12] a lack of reading materials and cognitive stimulation in the home, and cultural variation in beliefs and attitudes about education.[2,3]

Well-child care may contribute to school readiness.[13] In Medicaid, well-child care is called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). The American Academy of Pediatrics (AAP) recommends a widely accepted national standard of well-child care, including at least 6 EPSDT visits in the first year of life and at least 3 in the second.[14] The recommended content for EPSDT visits in the South Carolina Medicaid system is all age-based preventive care services recommended by the AAP, screening procedures designed to promote normal child development and school readiness, and anticipatory guidance for parents or caregivers.[5,11,15–17] Anticipatory guidance during a well-child visit gives parents education and counseling intended to promote child health. For example, these visits include advice about physical activity, nutrition, appropriate use of health care, parent–child reading, and avoiding exposure to household toxins such as lead.

The AAP has called for research on the effectiveness of EPSDT. However, this effectiveness has been confirmed only for vaccinations.[18] A large proportion of children do not have the recommended number of EPSDT visits.[19,20] Underuse of these visits and lack of readiness for first-grade learning disproportionately affect children insured by Medicaid.[1,3,13]

EPSDT visits provide an opportunity for clinicians to identify and address physical, developmental, emotional, social, or other problems that may impede optimal development. Beginning with anticipatory guidance during prenatal care, the visits include vaccinations, developmental and sensory evaluations, evaluation of nutrition and oral health, guidance about parenting, and other preventive services. Parents of children with the recommended number of EPSDT visits in infancy also receive more information than others about cognitive stimulation for their children and about avoiding risks to cognitive health such as lead exposure, accidents, and undernutrition.[8,11,15] AAP guidelines promote guidance during these visits about excessive television watching, which has been associated with attention deficit hyperactivity disorder, poor school performance, and possible delays in the development of language skills among infants younger than 2 years.[21] Thus, our hypothesis is that children insured by Medicaid who have at least the AAP-recommended number of EPSDT visits in the first 2 years of life will be more likely to be ready for school when they finish kindergarten than those with fewer visits.


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