Category Archives: Healthy Living

10 Steps for Benching Bullying

Tom Dahlborg
Tom Dahlborg

In the January 2013 NICHQ Leadership message Beyond Bullying, I shared that 42 percent of children in a Yale Rudd Center study reported being bullied by physical education teachers and sports coaches. Yes, 42 percent! Quite frankly I was shocked at this statistic.

That said, another study found that 45 percent of children “said their coaches called them names, insulted them or verbally abused them” and another study, this one from the United Kingdom, found that 25 percent of 6,000 young adults reported that they suffered emotional harm at the hands of their coaches.

Just think about that for a moment. Depending on the study, between 25 to 45 percent of our children who play sports are falling victim to a coach who is habitually cruel and abusing them. Let that really sink in. Up to almost half our children who play sports are being abused by coaches.

As Nancy Swigonski, MD, MPH, associate professor at Indiana University’s School of Medicine, has noted in her piece in the journal of Pediatrics, the damage these coaches are doing to our children is devastating and can be everlasting. “It can impair social and emotional development and cause substantial harm to mental health.”

As noted in Charlie Homer’s recent blog about NICHQ’s name change, there are many broader influences that affect children’s health outside of the clinical setting. This certainly includes the bullying that happens on our ball fields that can lead to physical injury, social problems, emotional problems, mental health problems (e.g., depression, anxiety), and even death. Not to mention bullying can turn children off from physical activities and this can potentially lead to obesity. As an organization that aims for all children to achieve their optimal health, there is much work to be done…together.

So what can parents do?

  1. Interview the coach and his/her staff. Ask about philosophy, priorities, playing time, values and also ask how he/she measures the outcomes of each.
  2. If your child is already on the team and you have concerns, ask your child about his/her experiences, the messages that are being sent, and follow each path your child raises a concern about.
  3. Inquire of other parents who currently or perhaps who previously had children on the team.
  4. Look for red flags: According to Kody Moffatt, MD, a pediatrician in Omaha and executive committee member of the Council on Sports Medicine and Fitness for the American Academy of Pediatrics, the number one red flag is a coach who wants “closed practices” where parents and other adults are barred from the practice. “That may be innocent, but as a pediatrician, a parent and a coach, I don’t think any coach should tell an adolescent not to tell another adult something.”
  5. Be sure to attend (or perhaps rotate with other trusted adults) your child’s practices.
  6. If you notice bullying behavior, document it and include specifics.
  7. Identify and map behaviors to team, school and/or league codes of conduct. Use this as a tool to share very specific examples of your concerns.
  8. Address your concerns directly with the coach. Focus on the impact on the children and be specific.
  9. If discussion with the coach is unsuccessful, reach out to the athletic director, school officials (if school based program), and/or league officials, and share your findings. NOTE: It is absolutely crucial to make note of how the coach is treating your child AND it is also critical to keep an eye out for how the other children are being treated as well. These are our communities and regardless of whom the child is these behaviors are unacceptable and it is incumbent upon us all to speak up for those who cannot do so for themselves and make a difference.
  10. Ensure that you also focus on developing warm family relationships and positive home environments so that if your child is bullied the negative outcomes from the bullying will be minimized. According to the study “Families promote emotional and behavioural resilience to bullying: evidence of an environmental effort” published in the Journal of Child Psychology and Psychiatry, “Warm family relationships and positive home environments help to buffer children from the negative outcomes associated with bullying victimization.”

Bullying is harmful and can lead to tragic ends. Together with these 10 steps we can identify it, stop it, mitigate its impacts, and help our children achieve their optimal health—mental and physical.

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Breaking the Food Reward Chain

Cindy Hutter
Cindy Hutter

As I’m about to introduce my young daughter to solid foods, I find myself thinking more and more about how I want to avoid using food as a reward—a practice that seems so ingrained in our culture.

There will be no rewards of sweets when my daughter finishes her vegetables or puts her toys away. There will be no lollipops for behaving well during a haircut or any other activity. Yes, I know. More seasoned parents everywhere are reading this and rolling their eyes thinking, “Just you wait.” But is it so crazy to think this isn’t possible? Why can’t rewards be extra outdoor play time or reading another book at bedtime or letting a child pick the family activity for the day, or even an old fashioned gold star sticker?

These same issues seem to follow us into adulthood. In almost every office I’ve worked, treats always seem to magically appear on Fridays as a defacto reward for making it through another week. Or, how about the promises to buy a friend a drink if they help you out with a favor. Instead of rewarding behaviors with food, what about a manicure or downloading of a new phone app. Surely food (or drink) isn’t the only motivator for people.

As NICHQ CEO Charlie Homer points out in his recent blog post about viewing health as a system, if we really want to improve children’s health, we need to focus not just on improving the quality of care children receive when they go to the doctor’s office; we need to change all influences that affect a child’s health. This includes modeling and practicing healthy behaviors at home, in school and in the community.

Are you willing to break the food reward chain with me? Start small. Pick one time this week when you would have traditionally used food as a reward and pick a non-food reward. See how your reward-receivers (your child, your spouse your coworkers) react and share your experience in a comment on this post. I’ll bet nearly 100 percent of people crave the satisfaction of being rewarded in any form, not necessarily by the food that serves as the reward. Once it works, pick another time and another time to swap in non-food rewards.

If enough of us practice this new behavior, as adults with other adults or as adults with children, it won’t seem so odd after a while and we can start to break the chain.

Time to Pause, Celebrate, and Keep Pushing Ahead

Shikha Anand
Shikha Anand

If you’ve read anything about obesity in the lay press over the past week, you already know that there has been a decline in the prevalence of obesity in American preschoolers. The CDC’s latest National Health and Nutrition Examination Survey (NHANES) data, published in the Feb. 26 issue of the Journal of the American Medical Association, show a significant decline in obesity among children aged 2 to 5 years. Obesity prevalence for this age group went from nearly 14 percent in 2003-2004 to just over 8 percent in 2011-2012. This information has been rippling throughout the press this week, with headlines like “U.S. Childhood Obesity Rates Fall 40% in Decade.”

For me, this news is both exhilarating and anxiety provoking. On one hand I have been working throughout that period alongside countless others to achieve a population decrease in body mass index (BMI) and the news that the day may have finally come for one segment of the pediatric population is incredibly encouraging. On the other hand, the rate is still 8.1 percent, as compared to 4.1 percent in the 1971-1974 NHANES cohort, and celebrating too early could distract from the fact that there is so much more work to be done, especially for our most vulnerable children.

The first question that crossed my mind when the news first landed in my inbox is whether the tide has really turned. Experts agree that the sampling methodologies in NHANES are robust and the data are valid. The pressing questions are (a) whether we are really seeing a trend and (b) whether that trend applies to the most vulnerable children.

There are two ways in which I think about data like this.  The first is with a gut check—does this jive with what I see in my Community Health Center patients?  Although I am not sure that my observation techniques are sensitive enough to see a change from 12 percent in the last cohort to 8 percent in this one, it does seem like recent changes in WIC, SNAP and childcare settings, among others, have made families in my clinic more aware of the impact of healthy eating and active living on the weight and health of their children. And when I saw an obese 2-year-old child this week, I actually thought to myself that I had not seen an obese preschooler in at least a few clinic sessions—certainly a change from five years ago. So is it possible that the tide has turned for preschoolers based on my clinical experience with an underserved urban population? I think so.

But I would be hard pressed to claim that my clinical experience is sufficient to validate public health trends. So I did what improvement junkies do. I went back to the numbers.  The most recent data stratified by race and ethnicity has not yet been made available so I was only able to look for a trend among all preschoolers. I plotted the NHANES data from 1999 to 2012 using CDC data to determine if there really is a trend, creating a graph of obesity prevalence over time, what is known in quality improvement as a run chart.

shikhaA run chart is designed for the early detection signals of improvement over time through recognition of non-random patterns in the data. The first possible pattern is a “shift,” defined as six or more successive points that are all above or below the median, which in this case is 10.6 percent. If our recent changes in policy and practice had caused a shift beginning in 2005-2006, we would see that the next six points fall below the median. But in fact, the four points from the 2005 cohort to the 2011 cohort alternate between being above and below the median, indicating we don’t have enough data to see a shift and that we don’t appear to be on our way to one just yet. We can also look for a “trend,” defined as five or more consecutive points that are either ascending or descending. Similar to the case of the shift, we neither have enough data points, nor do we have indication that we are on our way to a trend. So despite the change in prevalence, it is challenging to use the data to either establish a new, lower baseline prevalence or to attribute the decrease to the changes we have made to the environments of preschoolers.

So where does that leave me? Trend or no trend, this news means thousands and thousands fewer preschoolers are obese in 2011-2012 vs. 2003-2004 and this fact will have an enormous impact on our health resources and outcomes as they mature. And these data give us hope that sustainable improvement could be just around the corner. In any case, we must continue to invest heavily in activities and policies that promote healthy weight to create a change in prevalence that will persist over time. If nothing else, this is a moment to pause, applaud all of the wonderful changes we have made to date, and energize ourselves for the long road ahead—to the day when we have reversed the trend for ALL Americans, regardless of age, race, or class.

Taking a Bite Out of Mixed Food Messaging

Cindy Hutter
Cindy Hutter

When I first saw McDonald’s Olympic themed advertising that shows Olympians biting their metals contrasted with good looking, fit, young adults biting into chicken nuggets with the tagline, “The greatest victories are celebrated with a bite,” the marketing professional in me thought that was very clever. The parent and healthcare professional in me were horrified.

There are millions of kids watching the Olympics and dreaming of being the next Ted Ligety or Meryl Davis. They are fantasizing about walking into the Olympic stadium for the opening ceremony in a (probably ridiculous looking) red, white and blue outfit. They are picturing themselves standing on the winner’s podium with a shiny metal around their neck and the US national anthem playing in the background. (Even way past my youth in Olympic years, I’m mesmerized by the Olympic spirit and still hold onto the dream of one day being an Olympian regardless of how unrealistic it is.)

But in between watching Gracie Gold on the ice or Bode Miller on the slopes, nearly every commercial break has that McDonald’s bite commercial. How many kids are seeing this commercial and equating McDonald’s chicken nuggets with being an Olympian? McDonalds is an official sponsor after all and there are easily two dozen Olympians featured in the short ad.

Chobani yogurt is also an Olympic sponsor. They’ve been running ads with the tagline, “It’s one thing to sponsor US Olympians. It’s another to be in their fridge.” I wonder how many kids are watching this commercial and see eating Chobani yogurt as a way to be just like hockey player Zach Parise or snowboarder Lindsey Jacobellis, both featured in the commercials.

It’s impossible to control the spin that is put on food advertising. However, as adults who make food purchasing decisions for the children in our lives, we have near complete control in deciding what our children eat and establishing and modeling healthy eating behaviors. It’s not like children can get in the car and drive to McDonalds or the grocery store to get yogurt themselves—even though some days that would be nice.

So, I have a challenge for you. Take 5 to 10 minutes this week, and ask the kids in your life (your own, nieces, nephews, neighbors) about what they think US Olympians eat. Ask them about the McDonald and Chobani ads. Do they think eating these foods will help them become an Olympian? Make note of how you respond and post your findings in the comments below. Let’s get a conversation going about how to talk to children about healthy eating behaviors.

Should We Ban Valentine’s Day Candy in Schools?

Karen Sautter Errichetti
Karen Sautter Errichetti

As a school committee member, one of the questions I get asked most often about any holiday we celebrate in schools is “Will you be banning sweets this year?” I’m always surprised by this question because the practice of bringing in sweet treats is itself a longstanding cultural tradition in my school system.  In fact, I think there would be people with pitchforks and torches in my yard if we banned this practice.

A friend sent me this article this morning with the provocative title “School Bans Valentine’s Day Candy,” making me revisit this topic.  In this case, the principal explained the rationale for the ban to parents like this:

We are working to encourage healthy practices as well as manage food choices in classrooms where food allergies are present in order to maintain a safe environment.
Similarly, other schools across the US have made the choice to limit or ban candy and other indulgent food. The rationale is the same in almost every case: wellness and safety.
At a recent staff gathering at NICHQ I asked the question: Why do we ban things in the name of health? In public health, we use law and regulation to ensure public safety and prevent illness and death. It seems like the right thing to do: ban the things that are bad for people and promote or incentivize the things that are good for health.  In particular, schools become targets for these kinds of strategies. But what is the evidence that this actually works?
In our work to prevent childhood obesity, for example, many states have implemented policies to limit or ban sweetened beverages in public schools. The link between sugary drinks and obesity is well-researched. According to the Harvard School of Public Health, children and adults are drinking more sugary drinks than ever before, and there is evidence that both children and adults are better able to control their weight when they reduce their consumption of sugared beverages.
Based on this evidence, it seems like the right thing to do to ban sugary drinks in schools. Unfortunately, the literature presents a mixed bag regarding whether these policies actually reduce student consumption of those drinks overall, and in turn reduces obesity.  A 2012 national survey in 40 states by Taber et al. illustrates this point.  Taber and his colleagues found that while fifth and eighth grade public school students reduced their access to sugar-sweetened beverages, these children had not reduced their consumption of these drinks. It’s still early in our battle with childhood obesity, and many child advocates are still experimenting with these policies.
If I’ve learned one thing from NICHQ’s work in the obesity space, it is that there is no one magic bullet to prevention and reduction of obesity.  It takes multi-sector partnerships including all stakeholders to try to move the big dot toward healthier children. Policies to restrict access to foods linked with increased obesity are only part of an arsenal of tools we have tried to curb obesity.  As we continue to experiment using policies limiting or banning access as a means to improve public health, we can benefit from applying quality improvement approaches to test our ideas.
In our community of North Reading, my school committee has never voted to ban candy or any other food item in my history of being on the committee. We prefer to think of policy as something we create in the greater context of student well-being and change, setting the foundation for application of evidence-based practice. Simply banning a food item is a band-aid on a larger problem that deserves a comprehensive approach. We still have a long way to go on the topic of childhood obesity, and we owe it to our children to think outside the cupcake.
What are your thoughts about banning Valentine’s Day candy to improve child health? Please share your thoughts by commenting!
Karen Sautter Errichetti is a two-term elected member of the North Reading School Committee in Massachusetts.  The views expressed in this post are those of the author and do not necessarily reflect those of NICHQ.

9,000 Too Many

Karen Sautter ErrichettiEarlier this week, members of the public health community rejoiced at a major victory for healthier Americans. After years of lobbying and the activism of public health professionals everywhere, we realized the fruits of our labor and paved the way for our children to live longer lives. I would have done cartwheels if I were coordinated, athletic, and wore proper cartwheeling shoes.

No, I am not talking about CVS’ decision to stop selling tobacco (although that’s pretty ground-breaking too).

I’m talking about this story. “Fewer U.S. children dying in car crashes.” According to a CDC report released on Tuesday, deaths occurring to children under 12 due to car crashes decreased by 43% from 2002 to 2011. Since crash deaths are the leading cause of child death in the country, this is a big deal.

As a public health advocate, there is nothing more I like better than seeing this kind of headline. But it was accompanied by this statistic: one in three children who died in car crashes 2011 were not wearing a seat belt. That means 3,000 car accident deaths of the 9,000 that occurred over the last decade might have been prevented if seat belts had been worn.

Even more startling was this study finding: Almost half of all black (45%) and Hispanic (46%) children who died in crashes were not buckled up. That’s 1 in 2 children between 2009-2010.

So how can we make sure we continue this downward trend in child deaths due to car crashes in the next decade? The evidence is very clear on public health strategies to prevent child deaths in car accidents. Parents should use appropriate car seats, booster seats and seat belts on every car trip. Strategies to reduce disparities in car accident deaths should also be developed and tested.

At NICHQ, we have applied quality improvement to some of the most daunting public health problems facing children, including childhood obesity, asthma, and sickle cell disease. When we start a project, it begins with a bold aim statement: What are we trying to accomplish?

Healthy People 2020’s objective is a good place to start: Increase age-appropriate vehicle restraint system use in children aged 0 to 7 years by 10% by 2020. But how can we get this done faster? How about 20% or even 30%? Let’s expand this goal to children aged 12 and under. Because 9,000 children is too many.

Weigh in on your ideas to realize this goal in the comments section. Or join our Facebook page and share your opinion!

Bravo CVS! Now It’s Time for More Health Advocates (You) to Step Up

Cindy Hutter
Cindy Hutter

When I saw the first headline come across my Twitter feed that CVS plans to kick the habit and stop selling cigarettes and tobacco products at its stores, I almost didn’t believe it. Wow! Wow Wow!

This is a huge step, and likely a decision that was not made lightly. Could you imagine the pressure all of the tobacco companies must have put on CVS when CVS called to cancel their standing purchase orders? I’m sure there were talks about discount pricing, profit sharing and more to keep the cigs on the shelves.

But also in CVS’s ear was the voice of healthcare provider partners. These are the people who CVS is wooing as it moves beyond the pharmacy and into the treatment arena with its MinuteClinics. I have no doubts the healthcare provider partners said this phrase, “Cigarettes and tobacco products have no place in a setting where health care is delivered,” so often to CVS CEO Larry Merlo that he used it in his press release about the decision.

Since the announcement, there has been a ton of speculation by press pundits if other pharmacy chains will follow suit. As child and public health community members, as concerned citizens, as parents, we all have a voice in helping to get other cigarette sellers to see that banning the smokes is “the right thing to do”—another Merlo phrase.

Yes, a company can ignore concerns from one or two customers. It can’t ignore concerns of one or two million customers. Our collective voices can make a difference. And, it is easier than ever to be heard.

Go right now to Facebook and make a post praising CVS’s decision and like the CVS page. Get on Twitter and tweet or retweet your support for CVS’s decision. Send a tweet or email to Walgreens or any other pharmacy selling cigarettes in your hometown asking them to consider changing their policy. Reach out to others in your sphere of influences—those in your place of worship, children’s schools and sports leagues—and ask for their signature on a letter asking your local store to extinguish their cigarette sales.

Just as peer pressure is what gets many young people to start smoking, peer pressure is what it is going to take to get other cigarette retailers to stop. Let’s start loading on the pressure.

An Improvement Wake-Up Call

Contributed by Jonathan Small
NICHQ Senior Director of Communications.
Originally posted February 2012.

Jonathan Small
Jonathan Small

It never ceases to amaze me what I learn from my children, especially the youngest ones – my eight-year-old twin daughters. I’ve been working in the quality improvement field for longer than they’ve been alive. But now they’re the ones teaching me about it!

Until two weeks ago, every weekday morning brought the recurring challenge of trying to get these two seemingly responsible third-graders to school on time. How complicated could it be? We set their alarm clock so they would have a whole hour to get dressed, eat breakfast, prepare lunches, wash up, and get out the door and down the block to school. It should have been enough time. But far too often, they arrived late. And the last few rushed minutes of getting them out the door were among the most irritating and stressful times in our relationships.

Their latest progress reports listed 18 “tardies” for each of them – and always just an agonizing two or three minutes late. My wife and I pride ourselves on being prompt. Surely we could get our children to shave a couple of minutes off their morning routine. But we just couldn’t push any harder.

Every system is perfectly designed to get exactly the results it gets, say the improvement experts.

So, we decided to change the system. We did the only logical thing we could think of – we set the alarm clock for fifteen minutes earlier. We reasoned that the extra time would be more than enough to make up for the difference. I had no doubt that this was the right solution. But no! The girls simply lingered in bed longer and were more irritable and less cooperative. Still arriving late. Still stressful. Still “tardy” noted on the progress reports. Our first Plan-Do-Study-Act cycle was a failure – and we had all lost an extra fifteen minutes of sleep to boot.

Now, I’ve been working in quality improvement for more than a decade, and I’ve been a parent even longer. I was determined to find a way to improve our performance here.

Then my wife had a brilliant idea – ask the girls to solve the problem themselves. I began thinking about the quality management principle that the frontline workers (not management) are in the best position to identify possible causes of a problem and find a solution. My wife had empowered our “frontline workers.”

Their recommended solution, however, was preposterous, so counterintuitive that it was almost laughable. The girls suggested that instead of setting their alarm clock earlier by fifteen minutes, they would set it fifteen minutes later. Ridiculous. That would leave them only 45 minutes to get to school. If they couldn’t get there in an hour, how could they possibly think they could get there in 45 minutes?

They reasoned that if the alarm clock went off later instead of earlier, they would pop out of bed and kick it into gear more rapidly and efficiently. Ha. Just an excuse for sleeping 15 minutes longer and getting to school 15 minutes later.

But we decided to try it – just for one day. It was a small test of change with no risk – after all, what was one more “tardy” at this point?

And what do you know: they made it to school on time. So we tried it again the next day. Same result. Since we made that change two weeks ago, the girls have not been late to school even once! No more “tardies.” They are less irritable (probably due, in part, to the extra sleep) and more in control. So far, we are holding the gains.

So, what did my eight-year-old children teach me about quality improvement?

My wife and I never would have thought of this solution ourselves. It was completely counterintuitive to us. Yet, it was as clear as a new day to the people who mattered most in this process. And when they were empowered to solve the problem, they came up with a solution that worked – for them. And now, they own and care about the results more than ever, because it was their idea and they have a stake in seeing that it’s successful – if for no other reason than it allows them to stay in bed an extra fifteen minutes each morning.

We learned that sometimes the best thing a parent (manager) can do is get out of the way and let the child (worker) solve the problem.

Next on the agenda: let them figure out how to keep their room clean. Believe it or not, that’s working too!

Beyond Bullying

Contributed by Tom Dahlborg
Vice President for Strategy and Project Director.
Originally posted January 2013.

Tom Dahlborg
Tom Dahlborg

In the online December issue of Pediatrics, researchers from the Rudd Center for Food Policy and Obesity at Yale University recently shared outcomes from their study, “Youth Seeking Weight Loss Treatment Report Bullying by Those They Trust.”

The study design included a survey of adolescents to better understand bullying behaviors, including the location, frequency, duration and types of bullies involved.

The study found that:

  • 64 percent of those surveyed reported getting bullied at school (with the risk of bullying increasing relative to the child’s body weight).
  • Most of the kids suffered bullying for at least one year (78 percent) while over a third (36 percent) had been dealing with bullying for five years.
  • The most common bullies involved were the child’s peers (92 percent) and even those kids that they considered friends (70 percent).

But one of the most disturbing findings to me is the fact that these children also report being bullied by physical education teachers and sports coaches (42%), parents (37%) and classroom teachers (27%).

I should not be so surprised. I have personally encounted an incident of an adult bullying a child I know well, but until I read this study, I assumed that event was an aberration and that bullying of this kind was nowhere near as prevalent as highlighted in this study.

About 12 years ago we lived in a picturesque community on the coast in what seemed the ideal neighborhood.

In this neighborhood lived a five-year-old boy who was overweight. He loved to run, play and have fun, and one day he was outside playing with some of the other neighborhood children when they all decided to go inside a neighbor’s home. As they walked up to the door the mother of one of the boys greeted them and let them in one by one until she saw this child and yelled, “You are too big to come in and play. Go home!”

This would be devastating to anyone, never mind a five-year-old child. The tears and the pain he felt were heartbreaking. As was the pain felt by his parents. And the impact of this bullying along with many other examples this child endured in this neighborhood lasts to this day.

Now contrast this experience with one I witnessed repeatedly at a dance class for young children in the same community at around the same time. The dance instructor truly connected with each of the children in her class. She set expectations, she encouraged, she shared compassion and empathy for those challenged to perform and honored these children for their individual gifts, regardless of their body types.

My daughter was one of the lucky children in that class. She began dancing at a very young age and developed a special relationship with this teacher, a bond and a trust which she cherishes to this day. Years later, now as a college freshman, she has decided to continue to dance as part of a healthy lifestyle. She has taken it upon herself to research schools of dance and to fund the program of her choice.

My daughter loves exercising (with dance being at the top of the list) and maintains a healthy body image, self-esteem level and perspective on life, thanks in large part to the influence of this teacher from years ago.

Quite a dichotomy between the neighbor’s approach with the five-year-old boy and the dance instructor’s approach to her students…and both will have lasting influence on these children.

Now that I have the opportunity to work for a quality improvement organization with a vision of ensuring each child achieves his or her optimal health, and to process this information through the lens of my own experiences (personal and professional), my heart still breaks for those children harmed by bullying…AND I see great opportunities for improvement:

  • To meet children where they are while also educating adults as to the impact we can all have on children (both positive and negative).
  • To bring this perspective to healthcare and expand current thinking around patient-centeredness (child-centeredness) and the patient-centered medical home.
  • To evolve the medical home concept to a neighborhood perspective where patients and families, neighbors and friends, and coaches and teachers are all engaged to learn and grow and help the children of a community achieve their optimal health (by addressing bullying at all levels as well as many other barriers to children’s safety and optimal health).
  • To ensure that each child is recognized as unique, and receives appropriate interventions and support that will best position the child to achieve his or her optimal health.

NICHQ has helped lead the patient-centered medical home evolution since the 1990s and continues to do so. Currently, the US healthcare system is struggling with optimizing behavioral health integration into the medical home. We must continue our improvement efforts and to evolve and expand our thinking in this arena even more.

These are invigorating times to be working in healthcare quality improvement with a focus on children. We have a great opportunity to change communities for the better through evolved medical home concepts and I am excited to be part of this ongoing work as NICHQ continues to lead the way.

As a healthcare leader, a coach, a friend, a husband and a father, I have seen the positive impact we can have on children from both a systemic perspective and on a one-to-one basis. At NICHQ I am blessed with an opportunity to do both.