America is failing its children and, in doing so, is jeopardizing its future. Infant and child mortality rates in the United States consistently exceed rates in 19 other developed nations. Moreover, significant inequities in child health outcomes by race and income persist. The COVID-19 pandemic has highlighted these inequities, with children of color significantly more likely than white children to be hospitalized due to COVID-related illness. The continual failure to adequately promote the health of children and to take active measures to eliminate inequities is surprising given research by Nobel Laureate economist James Heckman, who suggests that enhancing the social environments of 0-5 year-old children provides a return on investment of up to 13 percent — translating to potentially billions of dollars in net benefit to society. Because social and environmental factors substantially drive health outcomes, addressing persistently inequitable outcomes requires a broader approach than traditional health service delivery. Such an approach harkens back to the outlook of the founder of pediatrics in America, Abraham Jacobi, who emphasized the importance of addressing social conditions to improve child health.
A Fully Integrated Approach to Addressing Social Needs
Addressing social conditions in the context of health service delivery requires stronger action than simply identifying health-related social needs, such as food insecurity, and providing the telephone numbers of social service agencies. We need meaningful integration, coordination, and connection to services, which will require the health field to explore new financial and structural strategies that allow health systems and other child-serving sectors (e.g., health, education) to assume shared accountability for a population. Indeed, non-health child-serving sectors, along with generations of health care and public health experts, have recognized the common needs of children and families, and developed promising interventions to address them. However, each child-serving system — health and non-health-related — typically works in a silo, therefore failing to achieve the successes that might result were these systems to work together. To enhance shared initiatives, innovation, and progress across sectors, we must identify and align the primary drivers of child health and gain consensus on measurement.
The Child Health and Well-Being Framework
We propose a four-part framework that child-serving sectors could use to focus their efforts to improve child health and well-being. Built on the recognition that clinicians and the health system will succeed in improving child health outcomes only if they partner with other sectors, this framework is designed to enable adopters to identify cross-sector partners with whom child-health interventions should be developed. Shared metrics can then be used to create a comprehensive child health and well-being dashboard to help drive improvements. Whether used by an individual health system or by a community or state, this framework could help identify which challenges need greater focus and where targeted, highly integrated programs, policies, and system changes could be implemented to improve child outcomes, as well as track progress toward achieving common goals.
1. Optimal Physical and Emotional Health of the Child
Many comprehensive and complex definitions of child health exist. We embrace the definition of child health from the National Research Council and Institute of Medicine report, which is “the extent to which individual children or groups of children are able or enabled to develop and realize their potential, satisfy their needs, and develop the capacities that allow them to interact successfully with their biological, physical, and social environments.”
Pragmatically, this translates into whether both immediate physical and psychological needs are addressed and whether the foundation for lifelong physical and mental health is established. Outcome markers will vary by age, but must expand beyond traditional health care process metrics (e.g., immunizations) to include: functional abilities to participate in learning, play, and peer interactions; sense of well-being/optimism about the future; and resilience, such as ability to respond to stressors with adaptive coping mechanisms.
2. Safe, Stable, and Nurturing Relationships with Healthy Adults
The Centers for Disease Control and Prevention (CDC) identifies Safe, Stable, and Nurturing Relationships (SSNR) as foundational for promoting the healthy social and emotional development of children and is particularly important for the prevention of child maltreatment. Within the context of safe, stable, and nurturing relationships, adults can buffer children’s fight or flight responses in the face of stressors. These relationships further allow children to optimize positive personal development and promotes their social skills. The CDC defines these three qualities as follows:
- Safety refers to the extent to which an individual is free from fear and secure from physical or psychological harm within their social, physical, and work environments;
- Stability means predictability and consistency in one’s relationships as well as the social, emotional, and physical environments;
- Nurturing consists of the extent to which parents and children have access to individuals who are able to sensitively and consistently respond to and meet their needs.
The CDC also emphasizes that adults need SSNR with other adults, often referred to as social support or social capital, to maintain such relationships with their children. One critical outcome of SSNR is secure attachment, while indicators of the presence of SSNR include positive child-caregiver interactions and the presence of sufficient social support for parents.
3. Safe Community that Meets Core Environmental Needs
In 2017, nearly 10 percent of families in the United States lived in poverty, defined as a family household income below $25,094 for a family of four. Specific characteristics of poverty that directly harm children’s health include hunger and food insecurity, homelessness and other forms of housing instability, and exposure to violence. In contrast, healthy diets, stable housing, and safe neighborhoods provide children with an environment to thrive, while also stimulating development of the areas of the brain that promote social-emotional and linguistic skills. We must measure the aforementioned social needs of children, with the addition of specific neighborhood measures such as cohesion.
4. Education Beginning at Birth that Promotes Multidimensional Skill Building
Education plays a critical role in health, with multiple studies documenting that life expectancy is lower for adults with a high school diploma (or less) as compared to their more educated peers. Early education opportunities that support both cognitive and social-emotional child development have especially long-lasting and wide-ranging benefits, including improved health, education, and employment outcomes. Receiving a high-quality education enhances a cadre of skills such as self-efficacy, problem-solving ability and impulse control while reducing the risk of future poverty. Measures of educational achievement include school readiness, third-grade reading comprehension, and high school graduation.
While there has always been an imperative to act to improve child health, recent events — including the impact of COVID-19 and the growing recognition of the impact of racial inequities on children and families — have magnified the urgency. Our framework provides high-level directional guidance for a road map to improve child health. It can serve as a tool to facilitate partnerships across sectors, and these partnerships can begin to address health-related social needs by incorporating interventions into care delivery, implementing community-wide interventions, and advocating jointly for aligned policy change. Common metrics can then track progress toward making our nation the best place for children to grow up.