Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring.

Policy Points Social indicators of young peoples' conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being. There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators. Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

Income is not an equalizer: health development inequities by ethnoracial backgrounds in California kindergartners.

BACKGROUND: Early childhood health development is positively associated with income, but the strength of this relationship with ethnoracial background remains unclear. This study examined the extent of health development inequities among California kindergarteners based on ethnoracial backgrounds and neighborhood-level income. METHODS: This cross-sectional study assessed health development inequities by analyzing neighborhood-level income, ethnoracial background, and health development data for California kindergarteners. Student-level data (n = 106,574) were collected through teacher report between 2010-2020 across 52 school districts and 964 schools. Student addresses were geocoded and linked to American Community Survey neighborhood income levels. Health development was measured using the Early Development Instrument, a population-level measure which includes physical health and well-being, social competence, emotional maturity, language and cognitive development, and communication skills and general knowledge domains. Outcomes included being "on-track" in each domain as well as overall health development. RESULTS: Using a Generalized Estimation Equation with a log-link function, while accounting for interactions between ethnoracial background, income, and income-squared, we found significant health development inequities by ethnoracial background and neighborhood-level income. Regarding overall health development, as well as the physical, social and emotional domains, Black students had a lower likelihood of being on-track compared to the weighted average across income levels, whereas Asian students surpassed the weighted average. White students exhibited the steepest slope, and at the lowest income levels, their health development scores were akin to their Black and Hispanic/Latino/a low-income counterparts but resembled their Asian counterparts at higher income levels. For the general knowledge and communication domain, white students consistently had the highest likelihood of being on-track, while Hispanic/Latino/a students had the lowest likelihood across all income levels. CONCLUSION: This study examines health development inequities among California kindergarteners in diverse communities. Our analysis shows that the relationship between neighborhood-level income and kindergartners' health development varies by domain and is weaker for students of color. Given the scarcity of population-level data on health development outcomes, these analyses offer valuable insights for identifying ecosystems necessitating support in promoting equitable early childhood health development.

Dashboards as Mechanisms for Community Empowerment: Developing a Prototype for Child and Adolescent Well-being in California.

CONTEXT: In recent years, stakeholders in public health have emphasized measuring young peoples' well-being as a more holistic and upstream approach to understanding their health and development. However, summarizing the available indicators of well-being in ways that strengthen ongoing policy and community efforts remains a challenge. PROGRAM: Our objective was to develop a measurement framework of young peoples' well-being that would be engaging and actionable to a broad and diverse set of stakeholders in California. IMPLEMENTATION: We began with a scan of the relevant literature documenting previous efforts to measure young peoples' well-being, both within the United States and internationally. Subsequently, we individually interviewed a set of key informants and then convened a multidisciplinary panel of experts to solicit feedback on our approach. Throughout this iterative and collaborative process, we developed and refined a measurement framework based on the information provided across these various sources. EVALUATION: Findings suggest data dashboards are a promising approach for presenting a parsimonious yet holistic picture of young peoples' well-being. Dashboards can highlight well-being's multidimensionality by categorizing indicators over different domains. Our framework organizes indicators over 5 types: child-centric, subjective well-being, contextual determinants, developmental, and equity-focused. The design and flexibility of dashboards can also highlight important gaps in data collection that are of interest to end users such as indicators not yet collected among the broader population. Furthermore, dashboards can include interactive features, such as selecting key data elements, that can help communities articulate priority areas for policy action, thereby generating momentum and enthusiasm for future iterations and improvements. DISCUSSION: Data dashboards are well suited for engaging a variety of stakeholders on complex multidimensional concepts such as young peoples' well-being. However, to fulfill their promise, they should be codesigned and codeveloped through an iterative process with the stakeholders and community members they intend to serve.

Inequality and child health: dynamic population health interventions.

PURPOSE OF REVIEW: Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity. RECENT FINDINGS: Children's health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity. SUMMARY: Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

The Gross Developmental Potential (GDP2): a new approach for measuring human potential and wellbeing.

Many factors influence the health and well-being of children and the adults they will become. Yet there are significant gaps in how trajectories of healthy development are measured, how the potential for leading a healthy life is evaluated, and how that information can guide upstream policies and investments. The Gross Developmental Potential (GDP2) is proposed as a new capabilities-based framework for assessing threats to thriving and understanding progress in achieving lifelong health and wellbeing. Moving beyond the Gross Domestic Product's (GDP) focus on economic productivity as a measure of progress, the GDP2 focuses on seven essential developmental capabilities for lifelong health and wellbeing. The GDP2 capability domains include Health -living a healthy life; Needs-satisfying basic human requirements; Communication-expressing and understanding thoughts and feelings; Learning-lifelong learning; Adaption -adapting to change; Connections -connecting with others; and Community -engaging in the community. The project team utilized literature reviews and meetings with the subject and technical experts to develop the framework. The framework was then vetted in focus groups of community leaders from three diverse settings. The community leaders' input refined the domains and their applications. This prototype GDP2 framework will next be used to develop specific measures and indices and guide the development of community-level GDP2 dashboards for local sense-making, learning, and application.

COVID-19 and Children's Well-Being: A Rapid Research Agenda.

PURPOSE: Understanding the full impact of COVID-19 on U.S. children, families, and communities is critical to (a) document the scope of the problem, (b) identify solutions to mitigate harm, and (c) build more resilient response systems. We sought to develop a research agenda to understand the short- and long-term mechanisms and impacts of the COVID-19 pandemic on children's healthy development, with the goal of devising and ultimately testing interventions to respond to urgent needs and prepare for future pandemics. DESCRIPTION: The Life Course Intervention Research Network facilitated a series of virtual meetings that included members of 10 Maternal and Child Health (MCH) research programs, their research and implementation partners, as well as family and community representatives, to develop an MCH COVID-19 Research Agenda. Stakeholders from academia, clinical practice, nonprofit organizations, and family advocates participated in four meetings, with 30-35 participants at each meeting. ASSESSMENT: Investigating the impacts of COVID-19 on children's mental health and ways to address them emerged as the highest research priority, followed by studying resilience at individual and community levels; identifying and mitigating the disparate negative effects of the pandemic on children and families of color, prioritizing community-based research partnerships, and strengthening local, state and national measurement systems to monitor children's well-being during a national crisis. CONCLUSION: Enacting this research agenda will require engaging the community, especially youth, as equal partners in research co-design processes; centering anti-racist perspectives; adopting a "strengths-based" approach; and integrating young researchers who identify as Black, Indigenous, and People of Color (BIPOC). New collaborative funding models and investments in data infrastructure are also needed.

The Kindergarten Early Development Instrument Predicts Third Grade Academic Proficiency.

School readiness skills predict later educational achievement, health, and social-emotional outcomes. Measures of school readiness can provide valuable information to assess both the impact of strategies and policies that prepare children for school as well as informing strategies for improving children's educational trajectories across their school years. The Early Development Instrument (EDI) is a measure of school readiness skills based on teacher-reported observational recall. It has been used extensively in Canada and Australia and is in the early stages of adoption in a number of U.S. cities. The current study uses data from roughly 3,000 children followed longitudinally from kindergarten through third grade from 7 school districts in Orange County, California. The study assesses whether EDI ratings in kindergarten predict third grade proficiency in mathematics and English Language Arts on state assessments. Ratings on the EDI were strongly associated with proficiency in both academic areas, even in the presence of controls for child-level factors and neighborhood fixed effects. Among its components, ratings on the language and cognitive development, communication skills and general knowledge, and social competence domains strongly differentiated children's likelihood of later proficiency in both academic areas. Implications for improving comprehensive early childhood education and schooling policies based on indicators of school readiness are discussed.

Early Child Development, Residential Crowding, and Commute Time in 8 US States, 2010-2017.

OBJECTIVES: To examine relationships of residential crowding and commute time with early child development. METHODS: We used the Early Development Instrument (EDI), a teacher-reported, population-health measure of child development. The sample included child-level observations spanning 8 US states from 2010 to 2017 (n = 185 012), aggregated to the census tract (n= 2793), stratified by percentage of households in poverty. To test the association of commute times, crowding, and child development, we tested overall readiness and 5 EDI domains by using adjusted census tract-level multivariate regression with fixed effects. RESULTS: In the full sample, a 1-standard-deviation increase in crowding was associated with 0.064- and 0.084-point decreases in mean score for cognitive development and communication skills, respectively. For the high-poverty subsample, a 1-standard deviation increase in commute time was associated with 0.081- and 0.066-point decreases in social competence and emotional maturity. CONCLUSIONS: In neighborhoods with increased crowding or commute time, early child development suffers. POLICY IMPLICATIONS: This study suggests a potential relationship between the changing urban landscape and child health. Children would benefit from more multisector collaboration between urban planning and public health.

A lifecourse approach to health development: implications for the maternal and child health research agenda.

Lifecourse-informed models of health fundamentally challenge simple biomedical models, introducing new ways of thinking about how diseases develop. This paper considers the broad implications of lifecourse theory for the maternal and child health (MCH) research agenda. The Lifecourse Health Development model provides an organizing framework for a synthesis of the existing literature on lifecourse health and identification of gaps in knowledge. Priority areas identified for MCH research in order to close these knowledge gaps include: epigenetic mechanisms and their potential mutability; peri-conception as a critical and sensitive period for environmental exposures; maternal health prior to pregnancy; the role of the placenta as an important regulator of the intra-uterine environment; and ways to strengthen early mother-child interactions. Addressing knowledge gaps will require an emphasis on longitudinal rather than cross-sectional studies, long-term (lifetime) rather than short-term perspectives, datasets that include socio-demographic, biologic and genetic data on the same subjects rather than discipline-specific studies, measurement and study of positive health as well as disease states, and study of multi-rather than single generational cohorts. Adoption of a lifecourse-informed MCH research agenda requires a shift in focus from single cause-single disease epidemiologic inquiry to one that addresses multiple causes and outcomes. Investigators need additional training in effective interdisciplinary collaboration, advanced research methodology and higher-level statistical modeling. Advancing a life course health development research agenda in MCH will be foundational to the nation's long-term health.

Lifecourse health development: past, present and future.

During the latter half of the twentieth century, an explosion of research elucidated a growing number of causes of disease and contributors to health. Biopsychosocial models that accounted for the wide range of factors influencing health began to replace outmoded and overly simplified biomedical models of disease causation. More recently, models of lifecourse health development (LCHD) have synthesized research from biological, behavioral and social science disciplines, defined health development as a dynamic process that begins before conception and continues throughout the lifespan, and paved the way for the creation of novel strategies aimed at optimization of individual and population health trajectories. As rapid advances in epigenetics and biological systems research continue to inform and refine LCHD models, our healthcare delivery system has struggled to keep pace, and the gulf between knowledge and practice has widened. This paper attempts to chart the evolution of the LCHD framework, and illustrate its potential to transform how the MCH system addresses social, psychological, biological, and genetic influences on health, eliminates health disparities, reduces chronic illness, and contains healthcare costs. The LCHD approach can serve to highlight the foundational importance of MCH, moving it from the margins of national debate to the forefront of healthcare reform efforts. The paper concludes with suggestions for innovations that could accelerate the translation of health development principles into MCH practice.

Ensuring Optimal Outcomes for Preterm Infants after NICU Discharge: A Life Course Health Development Approach to High-Risk Infant Follow-Up.

Children born prematurely (<37 weeks' gestation) have an increased risk for chronic health problems and developmental challenges compared to their term-born peers. The threats to health and development posed by prematurity, the unintended effects of life-sustaining neonatal intensive care, the associated neonatal morbidities, and the profound stressors to families affect well-being during infancy, childhood, adolescence, and beyond. Specialized clinical programs provide medical and developmental follow-up care for preterm infants after hospital discharge. High-risk infant follow-up, like most post-discharge health services, has many shortcomings, including unclear goals, inadequate support for infants, parents, and families, fragmented service provisions, poor coordination among providers, and an artificially foreshortened time horizon. There are well-documented inequities in care access and delivery. We propose applying a life course health development framework to clinical follow-up for children born prematurely that is contextually appropriate, developmentally responsive, and equitably deployed. The concepts of health development, unfolding, complexity, timing, plasticity, thriving, and harmony can be mapped to key components of follow-up care delivery to address pressing health challenges. This new approach envisions a more effective version of clinical follow-up to support the best possible functional outcomes and the opportunity for every premature infant to thrive within their family and community environments over their life course.

Unveiling early childhood health inequities by age five through the national neighborhood equity index and the early development instrument.

There is growing public urgency to close equity gaps in health and development by addressing inequities at multiple levels of children's developmental ecosystems. Current measurement strategies obscure the dynamic structural and relational patterns of oppression, adversity, and disadvantage that children can experience in their local intimate developmental ecosystem, as well as the leverage points that are necessary to change them. The purpose of this study is to examine the relationship between a universally available measure of neighborhood socio-economic context, the National Neighborhood Equity Index (NNEI), and a population measure of early child development and well-being, the Early Development Instrument (EDI). Data from a convenience sample of 144,957 kindergarteners in neighborhoods across the US demonstrate that children living in neighborhoods with more equity barriers are more likely to be on vulnerable developmental trajectories than those who reside in neighborhoods without any equity barriers. A multi-dimensional measurement approach that incorporates both the EDI and the NNEI can be used to quantify ethnoracialized patterns of structural disadvantage during critical periods of health development. These measures can inform community action to intervene early in the lifecourse to optimize children's health development trajectories at a population level.

The role of social capital in resilience among adolescents with adverse family environments.

The Life Course Health Development (LCHD) framework underscores the profound impact of stressors during critical developmental phases on an individual's lifelong health, including their mental well-being. Among these developmental transitions, adolescence emerges as a pivotal life stage where an adolescent's mental health trajectory is significantly influenced by the various risk and promotive factors embedded within their social ecosystem. Adolescents from adverse family environments (AFEs) face heightened susceptibility to mental health challenges. Nevertheless, there are opportunities within the adolescent's environment to foster resilience. In this paper, we employ an interdisciplinary approach grounded in the LCHD framework to assess existing research pertaining to resilience, social capital, and health development. Furthermore, we aim to provide actionable recommendations tailored to healthcare providers, with a specific emphasis on strategies to augment mental health outcomes among adolescent populations, particularly those experiencing AFEs.

Positive Childhood Experiences and Adult Health Outcomes.

OBJECTIVES: Adverse childhood experiences (ACEs) can drive poor adult mental and physical health, but the impact of early life protective factors should not be overlooked. Positive childhood experiences (PCEs) measures quantify protective factors, but evidence is lacking on their link to health conditions independent of ACEs in nationally representative studies. This study examines associations between composite PCE score and adult health, adjusting for ACEs. METHODS: The most recent 2017 wave of the Panel Study of Income Dynamics, a nationally representative study and its 2014 Childhood Retrospective Circumstances supplement (n = 7496) collected adult health outcomes, PCEs, and ACEs. Multivariable logistic regression assessed associations between PCE score and adult self-rated health or condition diagnosis, with and without ACEs adjustment. Cox proportional hazards models examined relationships between PCEs, ACEs, and annual risk of diagnosis. RESULTS: Adults with 5 to 6 PCEs had 75% (95% confidence interval [CI], 0.58-0.93) of the risk of fair/poor overall health and 74% of the risk of any psychiatric diagnosis (CI, 0.59-0.89) compared with those with 0 to 2 PCEs, independent of ACEs. In survival analysis models accounting for PCEs and ACEs, reporting 5 to 6 PCEs was associated with a 16% lower annual hazard of developing any adult psychiatric or physical condition (hazard ratio, 0.84; CI, 0.75-0.94); reporting 3+ ACEs was associated with a 42% higher annual hazard (CI, 1.27-1.59). CONCLUSIONS: PCEs were independently associated with lower risks of fair or poor adult health, adult mental health problems, and developing any physical or mental health condition at any given age after adjusting for ACEs.

Using a life course health development framework to combat stigma-related health disparities for individuals with intellectual and/or developmental disability (I/DD).

In the U.S., 1 in 6 children has an intellectual and/or developmental disability (I/DD). This population experiences a multitude of negative health outcomes across the life course, relative to the general population. Stigma-the social devaluation of individuals with certain characteristics, identities, or statuses within interpersonal, educational, healthcare, and policy contexts-is a potentially preventable contributor to health disparities. To date, existing approaches for addressing and preventing stigma are limited to discrete and siloed interventions that often fail to address the lifelong, cumulative impacts of the specific types of stigma experienced by the I/DD population. In the current paper, we describe three elements of Life Course Health Development (LCHD)-a novel translational framework that draws on evidence from biology, sociology, epidemiology, and psychology-that healthcare providers can use to prevent stigma-related health disparities and improve outcomes for individuals with I//DDs. We discuss the utility of targeting prevention to sensitive periods; prioritizing interventions for the most damaging types of stigmas; and leveraging supports from multiple service systems and sectors. By incorporating evidence from life course science into efforts to address stigma-related health disparities, providers can more effectively and strategically prevent and combat stigma-related health disparities for the I/DD population in childhood and across the life course.

Supporting early childhood routines to promote cardiovascular health across the life course.

Optimal cardiovascular health is an essential component of human health and well-being across the life course. Heart healthy practices around diet, physical activity, and sleep early in childhood have the potential to greatly improve lifespan and quality (Mehta et al., 2020). Early childhood routines, defined as functional practices that are predictable and repeatable, predict positive growth and development across the lifecourse (Fiese et al., 2002; Ferretti and Bub, 2017; Spagnola and Fiese, 2007). The American Heart Association has identified key heart healthy routines, such as daily regular activities including diet, physical activity, and sleep that promote cardiovascular health (Lloyd-Jones et al., 2022). Integrating the strength-based relational aspects of routines with the acquisition of cardiovascular health development capabilities allows children to establish their own optimal cardiovascular health trajectory early on. A systematic life course approach to supporting heart healthy routines in early childhood would inform clinical, research, and policy strategies to promote long-term cardiovascular health, and contribute to reducing inequalities in cardiovascular outcomes.

Childhood antecedents to adult cardiovascular disease.

Through research in the prevention and treatment of adult diseases, it has become clear that many adult diseases have their origins in childhood. As illustrated in this review, these antecedents are largely a function of the nutrition, physical activity, and habits of developing children. There is also increasing evidence that chronic and toxic levels of stress can play a significant role not only in the development of mental and behavioral conditions but in the developmental pathways that lead to a number of chronic physical health conditions. Internists, family medicine physicians, and medicine-pediatrics physicians generally are comfortable managing patients with a number of cardiovascular risk factors or conditions. Although pediatric clinical guidelines have recommended universal screening for hypertension since 1977 and targeted screening for dyslipidemia since 1992 and type 2 DM since 2000, this screening is not yet common practice in general pediatrics. As the population of children and youth with risk factors for metabolic syndrome--hypertension, dyslipidemia, and type 2 DM--increases as a result of the obesity epidemic, pediatricians will have to screen routinely, and diagnose and treat these conditions in the primary care setting. Pediatric residency programs and continuing medical education programs will have to provide knowledge and clinical training in the management of these conditions before primary care pediatricians are comfortable treating children and youth with multiple cardiovascular conditions.

The Emergence of Life Course Intervention Research: Optimizing Health Development and Child Well-Being.

Advances in life course health science, systems biology, and epigenetics suggest that health development can be represented as a trajectory affected by multiple risk and protective factors arrayed in a relational developmental ecosystem across child, family, community, and systems levels. Despite tremendous potential for early life interventions at multiple levels of this ecosystem to improve children's life course health trajectories, this potential has not been fully explored. In fact, Life Course Health Development is a low priority for both health care and research funding. Representing the work of the Life Course Intervention Research Network, this supplement to Pediatrics reports on the first steps taken to define the emerging discipline of life course intervention research. Articles cover the characteristics of life course interventions together with a research framework and core competencies for this work. Topics include family, community, and youth engagement as vital components of grounding this work in health equity, family health development and its measurement, supporting children after prematurity, and new approaches to early childhood mental health. Schools and telehealth are considered innovative platforms for life course interventions, whereas cross-sector partnerships are recognized as key components of interventions to address childhood adversity. Researchers apply a Life Course Health Development lens to juvenile justice issues, including the minimum age law, and consider potential trade-offs whereby "striving" (education and income mobility) can limit "thriving" (health mobility) for people of color and those raised in low-income families. Finally, we present the Australian experience of embedding life course interventions in longitudinal studies.

Using a Life Course Health Development Framework to Redesign Medicaid.

Since the Affordable Care Act, Medicaid programs serve millions more enrollees across the life course, yet beneficiaries continue to experience high rates of preventable morbidity and mortality rooted in earlier life experiences. By incorporating evidence from life course science into Medicaid, using the Life Course Health Development (LCHD) framework, states can more effectively achieve lifelong health improvement. We describe 5 elements of an LCHD-informed strategy states can use to align Medicaid redesign initiatives toward a common goal of improving life course health outcomes: targeting prevention to sensitive periods; prioritizing intervention on social exposures; maximizing longitudinal continuity in coverage and service delivery; building technological systems with capability to measure performance and outcomes over time; and selecting financial models that support LCHD-informed care. With this framework, states can strategically direct investment to improve health for vulnerable Americans, and assure their investment will pay off over time.

Reimagining Children's Rights in the US.

Importance: The US faces a pivotal moment of opportunity and risk regarding issues affecting children (aged 0-17 years). Although the US remains the only United Nations member state to not have ratified the Convention on the Rights of the Child (CRC), a child rights framework is essential for child health professionals seeking to advance many issues affecting children in the US. The Reimagining Children's Rights project (2020-2021) conducted an in-depth environmental scan of relevant literature and policy analysis using the Three Horizons design process to assess strategies that could advance the rights and well-being of children in the US. The project was overseen by a steering committee and informed by an advisory committee composed of youth leaders and experts in children's rights, advocacy, health, law, and a range of child-specific issues (eg, youth justice, early childhood development), who provided expert input on strategic considerations for advancing children's rights. Observations: Seven findings about advancing children's rights in the US are notable, all reflecting current gaps and opportunities for using a whole-child rights framework in the US, even without formal adoption of the CRC. Actionable strategies, tactics, and tools to leverage sustainable change in the multitude of issue areas can advance the current state of children's rights. High-potential strategies for catalyzing advancement of children's rights include youth activism, innovations in governance and accountability, legislative action, impact litigation, place-based initiatives, education and public awareness, alignment with other children's movements, and research. The child rights framework is unifying and adaptive to future unforeseen challenges. Conclusions and Relevance: Children's rights provide a powerful, synergistic framework for child health professionals-in partnership with youth and other leaders-to increase equity and protect the rights and well-being of all children in the US.