NEJM Interview: Christopher Forrest on declines in the health of U.S. children and the role of communities in reversing those trends.

The health of U.S. children has declined in recent years. Researchers, policymakers, and the media have tended to attribute increases in various physical, neurodevelopmental, and mental health conditions to independent challenges. But many of these trends may have common drivers. I'm Stephen Morrissey, Managing Editor of the New England Journal of Medicine, and I'm talking with Christopher Forrest, a professor of pediatrics and director of the Applied Clinical Research Center at Children's Hospital of Philadelphia. Dr. Forrest has co-authored a perspective article about developmental ecosystems and children's health. Dr. Forrest, broadly, what types of patterns have been observed in U.S. children's health in recent generations?

There used to be a time when we could expect that children would be healthier than their parents, but that kind of generational improvement is no longer the case. Over the last 20, actually, in some cases, 50 years, we've seen a broad-based decline in children's health. I think the best way to think about the decline is to kind of organize it into four dimensions. So today, children are 80% more likely to die than counterparts in high-income nations. That was not always the case. In fact, children up until about 1975 were more likely to survive into adulthood in this country than high-income nations. Second would be diseases. We're seeing a broad-based increase in rates of chronic conditions, not just neurodevelopmental conditions or mental health conditions like anxiety and depression, but also physical conditions. Furthermore, we're seeing increasing rates of disability. In 1960, just 2% of kids reported a limitation in their ability to engage in everyday activities. Today, that's almost 10%. Children are sleeping less, a decline that's been actually ongoing for the last hundred years, and girls are going through puberty earlier. And then one of the surprising findings that's emerged recently is that not only are we seeing increasing rates of emotional distress, with nearly one in two high school students saying that they're sad, or stressed out almost all the time, we're also seeing increased rates of physical distress, pain, respiratory symptoms, and so on. So across death, disease, disability, and distress, we're seeing marked declines across multiple data sets.

So is this what you call in your article, manifestations of a syndemic?

Yeah, exactly. People tend to isolate each of these, what you might call epidemics, as a single epidemic. So we talk about the epidemic of obesity, the epidemic of children's anxiety, and the epidemic of loneliness. And what that leads to is a very focused intervention, trying to focus on obesity, trying to focus on mental health, etc., Although that's useful to address that single problem, these issues co-occur. They're interrelated. They're interrelated within children themselves. Children often experience clusters of these conditions, and they're interrelated within specific places. So that interrelationship, that correlation, is best thought of as a syndemic. And when you see a syndemic, you start to back up and you say, well, what are the common drivers of the multitude of