Dr. David Nichols Talks Child Health Gains and Challenges

Lisa Hamilton:
From the Annie E. Casey Foundation, I'm Lisa Hamilton… and this is CaseyCast.

At the Casey Foundation, one of the ways that we work to support strong children and families is by producing an annual report called the KIDS COUNT Data Book. This report equips policymakers and child and family advocates with the latest data on how kids and families around the nation and in their state are faring. Earlier this month, we released our 30th Data Book, and this year's report continues to examine the vital role that health plays in shaping a child's overall well-being.

Exploring this intersection between health and well-being is a familiar topic for today's guest.

David Nichols is a pediatrician and the President and CEO of the American Board of Pediatrics. A longstanding and leading champion of higher standards for children's health care, David served as a professor at the Johns Hopkins University School of Medicine for 28 years. His involvement with the American Board of Pediatrics spans more than three decades, including six years and counting at the organization's helm. In addition to his medical career, we're delighted that Dr. Nichols is a trustee of the Casey Foundation and a proud partner in our pursuit of working to build a brighter future for America's children.

Welcome, Dr. Nichols. It's great to have you on CaseyCast.

Dr. David Nichols:
Well, thanks so much for having me.

Lisa Hamilton:
Why don't we start talking about a topic that has been in the news a lot over the last several years, and that's health insurance coverage.

I'd like to talk first about some of the health trends that we're seeing in this year's KIDS COUNT Data Book. First, there seems to be good news that we're seeing record rates of children with health insurance, which is wonderful, but I'd like to hear you as a pediatrician talk about why it's so important for children to have health insurance, and what it means for their overall well-being.

Dr. David Nichols:
Sure. This is a critical aspect of health care for children. In a nutshell, it is the gateway to accessing the health care system. If you think about what children need, the vast majority are healthy for sure, but that doesn't mean that they don't need health care.

I'll just give a few examples. One example is the access to professional screening. Vision screening is closely associated with better school performance. Lead screening is another example. We had a courageous pediatrician in Flint, Michigan, able to detect lead poisoning in the water system and a really save a community, not just children in the community.

We're going through a public health crisis now with vaccine avoidance and vaccine hesitancy, and we're seeing measles break out for the first time in my professional career in many places in the United States. Pediatricians play a great and important role in seeing that kids are getting vaccinated.

Maybe one more example of the importance of health insurance is just the ability to afford medicines. Most kids, again, grow up healthy, but most people don't make it through 20 years without needing a prescription for something, and the ability to have health coverage does make it possible for parents to afford important medications.

Lisa Hamilton:
Thank you for highlighting all of those.

You know, the work that the Casey Foundation does around policy has, we hope, contributed to the increase in the Children’s Health Insurance Program, and I know that's a program that's near and dear to your heart. There might even be changes in the usage of the Children's Health Insurance Program, but we know how vital it is to help lots of low-income children get the health care that they need. Is there anything you'd like to say about the CHIP program and its usage these days?

Dr. David Nichols:
Yeah. Yeah. No. I'm very happy to congratulate Casey and proud of Casey for the work that it has done in partnership with other organizations to try and ensure both the availability of CHIP and the availability of Medicaid, which are foundational insurance programs for children. Unfortunately, we're approaching a world in which 50% of children in the United States are poor, and without these government-supported insurance programs, they would not have access to care. And while we're highlighting the good news, I feel compelled to just raise a note of caution. It was just last week that several organizations have raised concern about decreasing enrollment in CHIP and Medicaid. And we'll have to watch that very closely.

Lisa Hamilton:
Why don't we turn to another of the positive trends we think we're seeing in the Data Book in recent years, and that's the drop in the percentage of teens who abuse alcohol and drugs. What do you think is behind this positive trend?

Dr. David Nichols:
Right. We did see a small decline nationally in the use of alcohol and drugs, and this is certainly a positive direction. I always want to be cautious about assigning cause and effect, but I'll comment on a few things that I think are working.

One issue, of course, is with the opioid epidemic, every physician in America is highly sensitized to the benefits, but also now the risks of prescribing pain medications. And in fact, many states require physicians to take and pass an extra course on pain management, as a condition of retaining the license to practice. Part of the message that's gone out to physicians is the importance of considering alternatives to narcotics, only prescribing drugs that are likely to be used, and instructing patients to discard unused controlled substances that have been used for pain control. And, we're hopeful that these messages are taking effect, and I think they are, in fact, taking effect.

On the alcohol side, one of the very exciting things from the perspective of pediatricians, is that parents are finally getting the tools to actually affect the drinking habits of teenagers.

There's a body of literature that's emerged that's based on the concept of motivational interviewing. So, it essentially says that you talk to your teen and focus on their strengths, focus on their abilities, concentrate on coping mechanisms and setting up a plan to deal with drinking situations, and using all those tools to really help the teenager self-evaluate and self-regulate their behaviors, and those tools have turned out to be remarkably effective. So, I'm celebrating the efficacy and the impact of parenting.

Lisa Hamilton:
Well, that's fantastic, and I think gives lots of folks hope that there aren't just wide scale public health interventions that can make a difference, but also the role individual parents have in the lives of their kids are going to be able to help us turn the curve on these issues. So that's great to hear that there are lots of different strategies that could be helpful.

But you mentioned the opioid crisis, and I'd like to give you an opportunity to talk about that. We certainly know that while there might be decreases in alcohol and drug use among teens, we're certainly seeing a huge spike in opioid use across the country. Could you talk more about what this means for families, the children that are growing up in families where even parents are struggling with addiction?

Dr. David Nichols:
Oh, sure. Of course, the scourge of opioid addiction affects families deeply, not just the person who's addicted, and when children are in a household that includes an addicted adult, their lives become destabilized in a whole variety of ways. There is uncertain income, there is a lack of supervision, there is inadequate attention to the schooling and learning needs of the child, so the environment becomes highly unstable, and of course some of these children are ultimately going to end up in kinship care or foster care because the parents are not able to manage parenting.

I'll comment on perhaps one other aspect of this that I think is often lost in the conversation, and that is the potential creation of an abstinence syndrome or withdrawal syndrome in a newborn.

So, when a pregnant woman is addicted and delivers, most of those babies will have symptoms of withdrawal for a period of time. And this requires hospitalization for a period, and then, we've now developed ways of managing this on an outpatient basis, but it's still a significant health concern and health issue for the newborn. So, there are a variety of ways in which, even though children seem to be not on the leading edge of this crisis, that is young children, nevertheless they are affected when adults in their world are addicted.

Lisa Hamilton:
Well, you brought up newborns, and I'd love to talk about another of the findings in the Data Book that relates to our youngest children. We're seeing more babies born at a low birth weight, and you might be able to even connect that to what you were just discussing in the opioid crisis. But unfortunately, we know that the U.S. is an outlier among other affluent countries where babies are less likely to be born at a low birth weight. Could you, one, talk about what might be happening to drive this disturbing trend and what the ramifications are for kids and families and what we might need to do to focus on changing that?

Dr. David Nichols:
Right. Well, there are a number of things that are associated with preterm birth and low birth weight, and some are modifiable problems and others are deep seated and lasting problems. So, I'll just list a few that are potential associations with low birth weight.

We'll start off with teenage pregnancy, and I know the Casey Foundation has had a focus on trying to reduce teenage pregnancies, and with success, I would add.

Lisa Hamilton:
Right.

Dr. David Nichols:
There is, of course, the smoking and the drug use we were just talking about, which is part of the constellation of factors that may lead to a preterm birth, but then we get to more deep-seated issues that we as a society have to confront.

I go back to poverty, which afflicts many children and families, and when a newborn is brought into an impoverished family, the risk of that newborn being born ahead of the due date is higher, and we have to face that, and again, Casey is to be congratulated on focusing on poverty as one of the ways that its alleviation could strengthen families and give kids a better shot in life.

A few other things. Poor nutrition, stress, depression, all of those things are associated with preterm birth, and to the extent that we can create a safe, secure, reasonably supportive environment around a pregnant future mom and a family that surrounds her, we will be able to turn the tide here. And as you point out, this is not an impossibility. Other countries have been able to do this.

Now, the impact, of course, being born at low birth weight is quite profound, and it starts with a higher risk of death in the newborn period. So, it can be a potentially fatal event if the infant is born severely underweight and preterm. The advances in neonatal and perinatal care in the period that I've been a pediatrician are simply astounding, and we're able to keep more and more of these babies alive, but it often requires heroic health care interventions to do so.

For those who survive, I suppose I would divide the impact into two categories. First there's the impact on the growing child, and that impact is usually manifested by the risk of neurological disabilities of various kinds and intellectual disabilities. This of course has longstanding impact on their lives.

For those who escape that fate and are able to make it into adulthood without that disability during childhood, there is still a risk that can be traced back to being born at low birth weight and preterm. And that is that there's a higher incidence of high blood pressure in adults who were born preterm, and there's also a higher risk of Type 2 diabetes, insulin-resistant diabetes. It has very wide-ranging effects, and we all together as a society need to be able to do everything that we can to allow babies to grow to term before they're delivered.

Lisa Hamilton:
It certainly sounds like there's significant reasons why we ought to pay attention to these issues, and we disaggregate the data in the Data Book by race, and this is one of many indicators that show profound racial disparities among children. Is there more you'd like to say about why we might be seeing racial disparities for this low birth weight? Certainly, the incidence of people of color being affected by the variety of issues you've talked about.

Dr. David Nichols:
Right. That's right. I think many of the issues that I mentioned, those deeper issues, do have a higher prevalence amongst people of color, and this is part of the array of health care disparities that we have to face in the United States.

I will go back to poverty. More prevalent in people of color, and African-American and Native American populations, and Hispanic populations in particular. The issue of poor nutrition, the issue of stress and racism. Those are all factors that I believe have a role to play in the disparity of people of color having higher incidence of preterm births.

Lisa Hamilton:
I know one of the programs and policies that Casey's invested in for quite a while are home-visiting programs that I think can make a difference here. Could you talk about what home-visiting programs are and how they might help us change these kinds of statistics?

Dr. David Nichols:
Right. The home visiting programs involve often a prenatal contact between the visiting nurse and the mom, the future mom. The contact establishes what the visiting nurse will be able to do, and begins to build the relationship, and much of health care for new parents involves just explaining what's going to happen with this miraculous little baby in front of them, as they're developing day by day, and what the baby's needs are going to be, and what to anticipate, to be prepared for changes in sleep pattern, or changes in eating habits, and new diets, and what happens if the baby doesn't seem to want to latch onto the breast for breastfeeding.

There are all kinds of things that parents have to be ready for, and a lot of it also is just encouragement. "You're doing the right thing. You're a good mom. You're really taking care of your baby well." And that alone goes a long, long way, especially in a world where family networks are often not as tight as they were generations ago, and young parents don't have a deep family network to provide the support and the experience. We've found — and the literature supports — that these programs are highly effective, and one of the ways we know this is that they have been shown to decrease the incidence of child abuse, as an example, by having this very straightforward type of support that parents can take advantage of.

Lisa Hamilton:
Sounds like it's an intervention we all ought to keep supporting, because it sounds like it has multiple benefits even before babies are born and as they are becoming toddlers. Thank you for that insight on the benefits of that.

We've talked a bit about individual data trends this year, but I'd like to talk a little about the differences between generations. This year marks the 30th anniversary of the KIDS COUNT Data Book, and as somebody who's a leading voice in caring for kids and their well-being, I'm curious what you see as the issues that might be different since the time that we started this Data Book. How are the current generation of kids, Generation Z, faring differently than millennials?

Dr. David Nichols:
Well, it's a fascinating story actually. I think all of us have Generation Z kids in our world, as well as millennials in our world, so you can actually observe those differences firsthand. I'll just comment on the health care challenges, perhaps, and note that there are many other things that one could talk about.

In terms of health care, things that we're focused on in pediatrics as challenges that have to be met and solved, number one, I would list the high incidence and growing incidence of obesity in children of this generation, and many reasons for that. Food deserts. The decline of physical education and recess, and opportunities for kids to exercise. And of course, the nature of the food intake that is often unhealthy in many neighborhoods. So, this is a big concern for us. We used to think of type two diabetes, which I mentioned I think earlier in the conversation, as an adult onset problem, and it is now a pediatric disease, and it's a pediatric disease that is skyrocketing, particularly in the African American and Native American communities, often related to diabetes. I'm sorry. To obesity.

Lisa Hamilton:
What's the incidence of obesity in kids these days?

Dr. David Nichols:
Well, it's fairly high. I would say it's in the 10% to 30% range depending on the community that you're in, and it's much, much higher than we've ever seen any previous generation experience. Of course, it's not just children. It's adults too.

Lisa Hamilton:
True.

Dr. David Nichols:
The adults in their world are also larger than previous generations were.

I think another area that is worth mentioning is the stresses around social media, and, what I'll call the digital media addiction, that even young babies now face. I don't know if you have seen babies holding their iPads in the shopping cart.

Lisa Hamilton:
Right. I have.

Dr. David Nichols:
And if you try to take that device away from them, you will get an earful typically. So parents have to confront this, and pediatricians typically recommend that parents not give their children devices in the first couple of years of life because of the powerful effect this has, these tools have in creating the need to have the colors and the lights and the flashing images in front of you all the time.

I think a third thing that is different about Gen Z or that that we're tracking, and following is the way that this current generation of youth think about gender identity. We have a growing a transgender youth population that is receiving health care, and the pediatric community has had to adapt to that with clinics and programs to care for these kids. This was not something that existed 30 years ago when KIDS COUNT first started.

And the last thing I'll comment on, it's probably the biggest public health concern right now, is the mental health crisis that children are facing.

The latest data from the Department of Health and Human Services indicate that we have somewhere in the neighborhood of 20% of girls certainly who had a major depressive episode, major depressive episode now in the last year, and a major depressive episode is one that interferes with functioning, and of course the lethal outcome of that is a suicide attempt that is completed. 50% of adult mental health problems begin in childhood or adolescence, so we have very substantial problems going on in mental health of the children today. Anxiety is another diagnosis highly prevalent in kids today.

Lisa Hamilton:
I think you told me at a board meeting once that 50% of the doctor's visits were related to mental health a couple of years ago?

Dr. David Nichols:
That's right. Yeah.

Lisa Hamilton:
That's stunning.

Dr. David Nichols:
Yeah. I would say the general pediatric practice now is dominated by children with behavioral or mental health concerns being presented by the parents, and there's a whole long list of the types of concerns that parents have about their children's behavior and their mental health, but this is what pediatricians are spending a great deal of time trying parents with.

Lisa Hamilton:
Do we have the infrastructure we need in order to deal with children's mental health in this way?

Dr. David Nichols:
No.

Lisa Hamilton:
It sounds like pediatricians are certainly prepared to be on the frontlines of this, but I would suspect there are other practitioners and providers that we need to have to help support kids through this, even in schools.

Dr. David Nichols:
No. I mean, the infrastructure is woefully inadequate. The providers, it really doesn't matter what kind they are, whether they're school nurses, whether they are physician’s assistants, pediatricians, family physicians, psychologists. The entire system is overwhelmed right now, and there, again, there are many reasons for it. Simply the numbers of children who are presenting with this has overwhelmed the system, and frankly the financial support to manage this crisis has not been forthcoming. There is simply not enough resources being devoted to this for us to really provide adequate care for these kids.

I think pediatricians are certainly doing the very best they can, and the child psychiatrists whose specialty this really would fall under, there are just far too few of them to begin to be able to manage this. And they've acknowledged this and are partnering with pediatricians in many ways to try and help all of us who didn't train in child psychiatry learn enough of what we need to know to at least do the first-line care.

Lisa Hamilton:
Well, you've certainly identified some really important emerging issues that we don't just need to manage but also figure out how to track, and make sure that we've got the right sort of data in order to help inform our decisions, both individual decisions but also policy decisions as it relates to children. So, thank you for that perspective on how things are changing for kids.

Part of what we know good data relates to is often the census, and we have had lots of conversations about the upcoming census and why it's a focal point for Casey.

It might not seem related to child health and well-being, but you are a passionate advocate for understanding why the census is important, and have been a leader in helping the American Academy of Pediatrics and American Board of Pediatrics think about how they can help promote an accurate count of children, who are the largest part of our population that are undercounted. So. could you talk about why you think the census is so important for pediatricians to get engaged with?

Dr. David Nichols:
Sure. This is a critical moment in our history. Children have been undercounted in the census for quite some time, and the mental health challenges that children are facing is just one example where knowing precisely how many children are affected by this and making sure the programs that are needed to support them get the adequate funding, all of that is tied to the census.

And children rely on the types of programs we talked about earlier in the conversation, CHIP and Medicaid and SNAP (Supplemental Nutrition Program), and many others, and those various programs do depend ultimately on an accurate count of children. So, if we care about children's health, we've got to count them all first, and that's why we're passionate about the census.

Lisa Hamilton:
Well, fantastic. And pediatricians are such trusted advisers in the lives of families, and to have them on the frontline of this issue, really helping parents access the digital resources they'll need in order to fill out an online census, and understand what the questions are, it's really great to have your leadership and the leadership of your field in helping us get to an accurate count. That's fantastic.

Dr. David Nichols:
Well, it's Casey that's been at the lead here.

Lisa Hamilton:
Oh, thank you.

Dr. David Nichols:
So we're delighted to support all the work that Casey is doing too.

Lisa Hamilton:
Thank you so much. Well, the last question I want to ask is really connecting child well-being to parents. So often in this country, we think we can help children without paying attention to the families or the communities that they are growing up in.

Could you give us some final insight into the ways that the circumstances of parents are influencing the lives of their kids?

Dr. David Nichols:
Well, the best predictor of a healthy, successful and resilient child is to grow up in a loving, supportive, intact family with adults who care, and if we can provide that, we're 90% the way there to making sure that we have healthy children. The circumstances that parents face are challenging for many, and you just have to open up the newspaper a little bit to get a sense. Oh, they range from the economic insecurity that some parents have, their own health problems that some parents have. The fact that we have children who in fact do not grow up with their birth parents around them and are in foster care and kinship care and other places that have been called upon to fill a gap that the parents were not able to fill.

I think the underlying predictor that I'm trying to highlight perhaps throughout this entire conversation of what it means to be a healthy child does ultimately lead back to the environment that the parent can provide. Pediatricians are there to help and support parents, to be a guide, and to be an advisor. Sometimes to provide medications and active interventions, but mostly it's to just help guide along the way, and to the extent that we can empower parents to be effective agents in their children's best interests will go a long way to having a healthy group of Gen Z children grow up around us.

Lisa Hamilton:
Thank you so much for that perspective and thank you for all of the insight you have offered. Everything from how we can make sure our children are born at healthy birth weight, to helping them avoid alcohol and drugs as teens, and having the kind of health care that they need throughout their lives, and even giving us perspective on some of the emerging trends that you're saying we need to pay attention to, like mental health and obesity.

I for one am delighted that we get to partner with you as a trustee of the foundation, and even more excited to have your leadership in the field to help guide all of our pediatricians as they support our kids to be healthy. Thank you so much for joining us and for sharing your insights with us.

Dr. David Nichols:
Thank you, Lisa. I really enjoyed the conversation.

Lisa Hamilton:
Wonderful, and I want to thank our listeners for joining us as well.

If you've enjoyed today's conversation, please rate our show on Apple Podcasts to help others find us. You can ask questions and leave us feedback on Twitter by using the CaseyCast hashtag.

To learn more about Casey and the work of our guests, you can find our show notes aecf.org/podcast, and you can download the 2019 KIDS COUNT Data Book at www.aecf.org/databook.

Until next time, I wish all of America's kids — and all of you — a bright future.