Beautiful Plants For Your Interior
Authors: Christopher B. Forrest, M.D., Ph.D., and Neal Halfon, M.D., M.P.H.
Child health has been deteriorating in important and alarming ways in the United States. In a recent study, which included 170 indicators, we documented pervasive declines in children’s health over the past two decades.1 Infants, children, and adolescents in the United States are 80% more likely to die than their peers in other high-income countries. Rates of chronic physical, neurodevelopmental, and mental health conditions, including obesity, have increased, and children in the current generation tend to enter puberty earlier, have more trouble sleeping, and report more physical and emotional symptoms than those in the previous generation.1 Another analysis found that 77% of Americans 17 to 24 years of age would be ineligible to enlist in the U.S. military without a waiver, for reasons including obesity, mental health problems, and other medical conditions.2 It can no longer be assumed that American children will grow up to be as healthy as their parents.
Researchers, policymakers, and the media have tended to attribute these trends to independent challenges — an obesity crisis, a mental health crisis, loneliness, gun violence — with distinct programmatic responses and potential remedies supported by separate advocacy groups and funding streams. But many of them have common origins and drivers. We believe these trends can be understood as manifestations of a syndemic — mutually reinforcing epidemics that cluster in particular places and groups of people, thereby amplifying harm. This pattern of harm hasn’t emerged from failures of parents, teachers, or physicians but is a signal that the developmental ecosystems in which children are growing up are themselves failing.
Children rarely encounter risk factors one at a time. Housing instability, social isolation, exposure to toxic chemicals, extensive screen time, and lack of access to robust civic institutions often co-occur and interact in ways that shape development. Rather than exploring the effects of individual risk factors or collections of social determinants of health, we therefore believe it’s necessary to examine children’s developmental ecosystems — the environments in which children grow up, inclusive of networks of health-related risks, protections, supports, and barriers — as a whole. Interventions that target a single risk factor may relieve immediate suffering but will generally be insufficient to change developmental ecosystems in ways that can reverse generational declines in health.
It may be helpful to think of the easily observed aspects of physical, neurodevelopmental, and mental health as the tip of an iceberg (see figure).3 Just beneath the surface are the developmental processes (including biologic, psychological, and relational processes) that drive health by means of epigenetic and neural mechanisms.4 Children raised in degraded ecosystems repeatedly face harmful exposures, which alter developing physiologic systems. These biologic changes can affect health and disease risk for decades.
Below these developmental processes sit natural and social systems, including the arrangements that communities use to manage resources such as income, housing, food, and energy; the built and natural environments that children inhabit; the economic, government, and legal institutions that order social life; educational systems; and health care, civil society, and social support systems. In the United States, decades of design choices have led to systems in which markets are the primary drivers of health, caregiving infrastructure is fragmented, and prevention is devalued and chronically underfunded.
At the base of the iceberg are a developmental ecosystem’s foundational values, which are often expressed in shared narratives about childhood: that raising children is chiefly a private responsibility, that markets are the fairest arbiters of who can be healthy, that childhood is a competition for achievement, that a child’s attention is a resource to be captured and monetized, and that public support should be provided for children’s health programs only in exceptional circumstances. The influence of these beliefs can be observed in the choices that society has made, including spending less than peer countries on early-childhood programs, opting not to regulate digital platforms that profit from the commodification of children’s attention, and organizing health care systems around the treatment of illness, rather than the promotion of healthy development. Because these narratives are so deeply embedded in Americans’ collective psyche, they determine the configurations of the developmental ecosystem that are understood to be legitimate and therefore the types of solutions to declining population health that researchers, policymakers, and community members can imagine. Transforming developmental ecosystems will ultimately require replacing the beliefs that underlie current structures.
Taking a whole-iceberg view highlights the importance of focusing on communities as the primary sites of investment and transformation to improve children’s health. Effective approaches can involve building cross-sector coalitions of schools, physicians, parents, housing authorities, and local policymakers that can examine neighborhood-level data to identify areas where children are persistently struggling. Siloed initiatives can then be replaced with a portfolio of complementary ecosystem-level strategies, which can be adapted as the community learns what works and for whom.
Some communities have adopted this type of ecosystem-level approach. In Pomona, California, a city-wide, cross-sector coalition took steps to improve early-childhood services.3 Catalyzed by neighborhood mapping of child health, the Pomona coalition launched the Early Childhood Ecosystem Transformation Accelerator, establishing a new governance model and creating several task forces with a goal of reforming the ways in which families were supported, health services were provided, and city resources were allocated. In Cincinnati, the All Children Thrive initiative aligned health systems, schools, and civic organizations in support of a shared childhood health agenda; its learning network has since documented reductions in hospital use and early preterm births and has strengthened early literacy in the neighborhoods it serves.5
Both initiatives began with local coalitions that convened diverse partners to examine neighborhood-level health and ecosystem data. Those data were then used to identify neighborhood conditions that promoted or hindered children’s development, establish collaborative learning processes, and produce strategies for effecting ecosystem-level change. Communities seeking to take a similar approach could assemble partners influencing children’s development and work with them to evaluate local data in order to develop a shared understanding of the community as a developmental ecosystem. That vision of the community could then drive the creation of an outcomes-focused learning system, which would be charged with planning and launching innovative prototypes, reorganizing and improving service-delivery pathways, engaging community members in codesign and shared governance, and measuring the effectiveness of various approaches. Community-level adaptation of plan–do–study–act cycles, which are a feature of many health care quality-improvement initiatives, could be used to inspire and inform a collaborative community agenda.
Reversing declines in children’s health will require new beliefs and narratives, shared by physicians, politicians, artists, journalists, and civic leaders, about raising children as a shared endeavor rather than a private responsibility; about childhood as a time for play, exploration, and development, rather than a competition for future economic success; and about a generation of healthy children as a public achievement rather than a personal accomplishment.
Child health has deteriorated because developmental ecosystems have made it too difficult to be healthy. To address the drivers of poor health, society should move from responding to health crises one symptom and one child at a time to reimagining ecosystems in ways that facilitate healthy development. We as a society designed and built these ecosystems, and we can redesign and rebuild them.
Notes
This article was published on September 19, 2026, at NEJM.org.
Disclosure forms provided by the authors are available at NEJM.org.
Supplementary Material
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References
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Forrest CB, Koenigsberg LJ, Eddy Harvey F, Maltenfort MG, Halfon N. Trends in US children’s mortality, chronic conditions, obesity, functional status, and symptoms. JAMA 2025;334:509-516.
2.
Office of the Under Secretary of Defense for Personnel and Readiness. FY20 Qualified Military Available key findings. Alexandria, VA: Department of Defense, April 2022 (https://amarkfoundation.org/wp-content/uploads/2023/07/DOD-QMA-2020-Brief-PUBLIC.pdf).
3.
Forrest CB, Halfon N. Thriving: understanding and improving health, wellbeing, and resilience for all. Cambridge, MA: MIT Press (in press).
4.
Hertzman C, Boyce T. How experience gets under the skin to create gradients in developmental health. Annu Rev Public Health 2010;31:329-347.
5.
All Children Thrive. Our network (https://actcincy.org/our-network).