The Make America Healthy Again (MAHA) movement is full of theories about how to change the well-being of Americans. His strategic report Released this fall, 128 of them focus specifically on how to improve children's health through changes in diet, chemical exposure, physical inactivity and chronic stress. But this road map to child health largely ignores the psychological influences and social contexts that may be the most important drivers of poor health and which, if addressed wisely, can be a source of sustainable child well-being. There is also a lack of input from outside experts, including the children these strategies are intended to serve.
Depression, anxiety, post-traumatic stress disorder (PTSD), autism, eating disorders, asthma and prediabetes have increased significantly in children. All of them are directly caused or indirectly influenced or aggravated by the mental and emotional state of children, as well as the conditions in which children live and how they treat them.
The closest MAHA comes to acknowledging this is by emphasizing chronic stress, but some of the most important sources of this stress, as identified by authoritative, peer-reviewed surveys of young people, are ignored. Perhaps the most glaring omission is poverty. Children living in poverty are much more likely to experience health problems. They have far less access to high-quality education and healthy food. They suffer from asthma, diabetes and obesity, as well as cardiovascular and immune disorders, much more often than children from wealthy families, and are two to three times more likely to suffer from mental disorders.
There is also no violence from MAHA drivers. And violence, especially when it occurs within the family, is one of the most dramatic and influential of the well-studied adverse childhood experiences (ACEs). These factors, especially when repeated, predispose children to adult psychological disorders, alcoholism, and acts of violence. And gun violence, also not mentioned in the MAHA guidance document, is the No. 1 cause of death among children.
Read more: We've been thinking about gun violence wrong.
This exclusion of context narrows recommendations for correcting the situation. And this myopia is unfortunately compounded by MAHA's failure to take into account children's own understanding of what 'environmental factors' and 'stressors' are bothering them, or indeed to seek advice from the experiences and preferred choices of young people.
MAHA has a major opportunity to engage real experts in future research and analysis: mental health professionals, teachers and parents who work with children every day, and young people who can share their experiences and help find solutions that will be welcomed by them and other children.
To inform decision-making and increase national awareness of the issues that Secretary of Health and Human Services and MAHA leader Robert F. Kennedy, Jr. is passionate about, MAHA could consider holding public hearings across the country to hear from people of all ages with conflicting but potentially complementary viewpoints. That's what my colleagues and I did when, after being appointed by President Bill Clinton and retained by President George W. Bush, I chaired the White House Commission on Complementary and Alternative Medicine Policy. The several thousand scientists and members of the general public who testified helped us formulate recommendations for innovative programs that were then initiated by the Department of Defense, the Department of Veterans Affairs, and the National Institutes of Health, as well as at major medical centers.
Such MAHA testimony could provide instructive and even inspiring examples of comprehensive health and wellness programs that are already successfully serving American children, examples that reflect MAHA's stated goals. There are already dozens of them across the country: some focused on school well-being, others on promoting family health.
Outside experts will bring significant public attention to MAHA's special concern for nutrition and expand the scope and effectiveness of its recommendations. The comprehensive programs they are likely to recommend could combine examination of the scientifically proven benefits of various healthy diets with an understanding of the potential harms of ultra-processed and chemically adulterated foods, as well as a critical look at the economic forces that shape the production and marketing of these foods; shopping for food products while critically reading food labels that indicate they contain additives or contaminants; and hands-on experience preparing, cooking and sharing healthy foods.
MAHA's strategy addresses the perceived “over-medicalization” of children's behavior. Clinicians and advocates who have studied and used the alternatives I summarize below are calling for significant government funding to be directed toward understanding and studying non-pharmacological approaches to depression, anxiety, ADHD, and other psychological conditions that may affect up to 30-40% of our children. They, like many of us, will focus on educating the public about the evidence base and practical experience of various stress management and resilience-building techniques, including various forms of meditation, mindfulness and exercise, as well as counselling. All have been shown to promote improved mental health and positive changes in brain physiology and biochemistry, function and structure that are similar to those produced by some pharmacological agents, without negative side effects and with significant increases in self-efficacy and self-esteem. New funding for this type of work has not yet been allocated. That's how it should be.
Read more: Why is it so difficult to make school lunches healthier?
School counselors and physicians with years of clinical experience should be selected to provide input into MAHA decision making. They would almost certainly recommend that MAHA's strategy include ensuring that children have the opportunity to share with each other, without consequences, including their problems and fears about parental and peer relationships in an increasingly unpredictable and threatening world. I have seen how these small groups—some might call them “health,” “support,” or “mind and body”—play a central role in helping children, their families, schools, and communities combat mass shootings and climate-related disasters, as well as endemic violence and poverty. And I appreciated their value for young people who are not struggling with a crisis but are living with almost universally high levels of stress.
Public testimony is one way for experts to justify these alternatives. Hearing this could help Kennedy, who has sometimes been bold in his confrontations with lawmakers and business leaders, to challenge reimbursement models from the federal government and insurance companies that reinforce the medicalization he deplores. Psychiatrists and pediatricians find it difficult to resist a system that charges the same for a 12-minute medication review as for a 50-minute consultation. Removing these toxic incentives will go a long way in reducing the over-medicalization and resulting over-prescribing that MAHA is concerned about.
To ensure the success of these and other potential MAHA recommendations, it will be necessary to involve and train adults to implement and participate, and to teach and coach every aspect of the approach. For example, teachers trained in basic school wellness can bring a few minutes of mindfulness into a hectic classroom, help an unsure student choose an attractive form of physical activity, or engage with them in comprehensive nutrition education. Parents can be offered similar instructions.
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The training of health and mental health professionals could also be enhanced to include training and experience in self-help and peer support so that this approach can be fully integrated into the care of their young patients and clients – in schools, clinics, private practice and hospitals.
Broadening MAHA's horizons in this way will result in recommendations that are truly evidence-based and more firmly rooted in experience than some of the recommendations contained in the strategy document. For example, MAHA's blanket and uncritical promotion of the Presidential Fitness Test has little basis. The test, which includes calisthenics and running, was created by the Eisenhower administration in 1956 due to Cold War concerns about the potential military fitness of young men and women. It was discontinued by the Obama administration because the best research showed that it did not promote a healthy lifestyle and that most young people who took the test found it confusing, boring and, in many cases, a real barrier to enjoying physical activity.
Kennedy wants children to be much more active and almost certainly believes that physical activity can improve both mental and physical health. Why not then abandon the one-size-fits-all notions of physical fitness? Instead, he could advocate for children to be able to move in ways that give them pleasure and satisfaction, as well as confidence in their bodies and greater mobility, strength and endurance: for example, dancing, but also running, martial arts. And football, track running And outdoor hikes. If MAHA promoted this holistic and personalized approach to fitness, it could offer all of our children many of the opportunities and benefits that are available to wealthy children and children in the best-funded schools.
If MAHA receives broad public input and increases public support for children's health, it could strengthen Kennedy's (and Congress's) hand in privately and publicly advocating for MAHA's previously advocated priorities: providing healthy food, a clean environment, significant time in school for exercise and movement, and appropriate and adequate health care. Perhaps Kennedy will then even be asked to address the issue of gun violence.
Finally, if MAHA's viewpoint broadens and its recommendations gain authority and substance, Kennedy may consider reimagining the movement itself to reflect a more collaborative approach to the issues facing children. Instead of a guidance document called “Making America's Children Healthy Again,” which signals our children's passive acceptance of adult authority, a more forward-thinking title that signals partnership with children—such as “Partnering with Our Children to Create Healthy Futures”—could help them better understand and care for themselves.
