Nora Gedgaudas

Growing up Paleo

Growing up Paleo

What every parent needs to know about kids and eating Paleo.

What every parent needs to know about kids and eating Paleo.

I probably need to admit right off the bat, by way of disclosure, that I don’t personally have any kids of my own at home. I have a delightful Somali cat, named Opus who is only too happy to eat “Paleo” (sans all the veggies).  I am also happy to report that he is beyond thriving now at 12 years of age and looks like an award-winning show cat; plus he has never, ever needed to visit a vet for anything his entire life with me.  But I digress…

In light of this disclosure I will say that I have, however, decidedly worked with innumerable kids and teens of all ages over the years, along with many families in my clinical practice that have elected to adopt this lifestyle and have seen some remarkably positive effects from that.   In fact I can think of one story in particular that inspires me to this day.  It seems to me that story is worth telling here, as this boy’s history is anything but unique or unfamiliar to many parents reading this.

Back in the year 2000 I was working at an extremely busy and successful neurofeedback clinic down in Eugene, Oregon where we specialized in working with learning disabilities and conditions like ADHD– but where we also saw a great many other kinds of issues coming through our office in persons of all ages that we were also able to successfully help.  Shortly after I arrived at my new job position there as supervisor of the neurofeedback clinic and also an already experienced neurofeedback practitioner, I began to work with this boy… We’ll call him Eric.

Eric had been diagnosed with pretty severe ADHD and was failing school, as well as having an extremely pronounced tic-related issue and seemingly intractable impulsivity and other behavior problems. He was on a cocktail of medications that both he and his parents hated, and which helped very little.  His ongoing symptoms were a source of considerable frustration to his parents, other family members, and notably, also to himself. In fact, his self-esteem was fairly challenged, too as a result of all this.  Everyone involved (including Eric) was motivated to see necessary changes. But let’s just say that’s not the way things were rolling the day I first arrived on that scene.

He had already been coming to the clinic for quite some time before I arrived and had undergone numerous brain training sessions which had yielded, let’s just say, highly variable results.  It was quite frustrating for everyone involved.  Everyone, including Eric, was doing their best.

One day, when Eric came in for one of his bi-weekly sessions I noticed his head was hanging down and that he looked positively downtrodden.  Palpably attuned to his distressed state I pulled him aside, feeling a heartfelt concern, to ask him what was the matter.  He told me that, “Oh–on the way over here, I was tic-ing again and it was totally driving my mom crazy.  She finally blew up at me and now she feels bad and I feel bad….”  I stopped him right there and asked, “Why do you feel bad? Are you saying that you feel sad, upset or maybe guilty in some way?”  What he said next is something I have never, ever forgotten and could scarcely believe was coming from the mouth of an 11-year-old boy. He said, “I feel guilty.  He then said, “I can’t possibly know what it is like for her to have a son like me… And she can’t really know what it’s like for me, either.”  He then said, “I hate the way I am! I hate this ADD and all these tics!”  He then slumped despondently into his chair with a thud and kicked the wall a little in his guilt and frustration.  My heart just broke witnessing that.  I also recognized in that very moment that there was something very wrong with this picture… This boy genuinely wanted to be helped. His parents desperately wanted him to be helped. We at the clinic wanted to help him and were seemingly doing all we could… Everyone was motivated. And yet for some reason nothing much was helping.

I told him to “sit tight” and that I would be right back.  I went to the waiting room to talk with his mom and asked her how things were going.  Immediately, she burst into tears and began to sob, saying “It just feels as though everything with him is two steps forward and one step back all the time.  We are running out of paid sessions and I don’t think we can continue anymore and I just don’t know what to do…”  Suddenly, a light bulb went on in my head and in that moment I put on “another hat”.  I asked her the following question,

“Can you tell me what he eats?”

In the description that followed everything suddenly became clear.  This boy was a died-in-the-wool “carbovore”.  Most of what he ate every single day was bread, and snacks and things like tater tots, pizza and candy bars.  He usually had a bagel or bowl of cereal for breakfast, then drank sodas throughout the day and went out with his friends for fast food fairly regularly.  He liked eating popcorn and chips.  He didn’t seem to like eating protein, and the fats that he consumed were anything but brain-building and mostly highly processed.  NOT good… No wonder this boy was suffering so much!  And no one around him, least of all himself, had actually made any connection between what he habitually ate and how he felt and behaved.  I, on the other hand, was instantly onto it.

Over the next several minutes I talked with his mom about diet and its connection to symptoms like Eric’s and presented her with a challenge:  To change his diet in a way that eliminated all the sugars and starches and processed junk he was eating/drinking and instead replace it all with a diet that included only meats/fish, a variety of vegetables and greens, and quality fats. If he needed to snack he could snack on nuts if he wanted… But no bread, no pasta, no potatoes, no pizza, no sodas and no other junk food of any kind.  No gluten.  I told her to try this for just two weeks.   By then, I figured, we would know at least something we didn’t know before.  I reminded her that anyone could pull off almost anything for just a couple of weeks and that the results would likely yield some valuable revelations (or at the very least we could better rule out a thing or two).  Mom thought about it a minute and then said, “OK—we’ll do it. We’ll give it a try.  It’ll be hard for him…but the whole family will do it so we can be supportive of him.”

Wonderful!

The long and the short of it all is this… Just ONE WEEK LATER we had a totally different kid who was no longer tic-ing and no longer exhibiting erratic and distractible behavior.  Everyone— Eric included— was 100% sold.  –Including my boss, by the way, who pulled me aside to inform me that I was to do the very same approach with every single patient that came into the clinic going forward.  I certainly had my work cut out for me.

But Eric was clearly a changed boy, and was so extremely excited about how differently he felt and functioned that no one had to police his diet at all. He made all his own positive dietary choices, even when hanging out with his friends or attending parties. Eating carbs and junkfood was unthinkable to him now. I was never so impressed with a young man as I was with this boy. And although he mightily struggled with low blood sugar symptoms and cravings for while (which I was able to help through adjusting his brain training protocol), the changes stuck and Eric ultimately flourished.  I encouraged his mom to enroll him in a martial arts program to help him develop his body and mental discipline in a way that would further his gains.  Everyone loved that idea, including Eric, and he eventually went on to earn a black belt in tae kwon do.  I couldn’t have been more proud for him had he been my own son.

His family actually ended up selling their home and moving out into the country so that they could plant their own vegetable garden and start growing and raising a lot of their own food.  They had come to truly appreciate the difference that food quality made on the health of the entire family.  They were most impressed by the profound way Eric had changed and everyone was on board with their own dietary and lifestyle changes.  It was immensely inspiring for me to witness.

In the meantime, I was beginning to try and implement a similar dietary education with other clients of all ages coming to our clinic.  It got to be a bit overwhelming for everyone involved. Anyone who knows me or has heard me speak recognizes that it’s a little like drinking out of a fire hose sometimes and can be a bit difficult to absorb everything all in one sitting. For me, it was overwhelming simply trying to educate everyone at the same time I was also trying to train their brain.  It just wasn’t an optimal approach.

One Friday night I went home after work and sat down at my laptop computer. In what amounted to a fit of frustration as much as anything else, I began typing in earnest. I eventually created what was a 10-page article on the subject of nutritional basics, along with diet and health from an evolutionary perspective.  I began handing this article out to all the clients I saw as a way of saving time and giving them something they could review on their own away from our appointments, where they could better focus on the information.  All fine and good… Only I realized there was ever more information I needed or wanted to impart, and I began adding regularly to that article.  Bit by bit, the article began to grow into a fairly substantial size.  Some of my clients were actually adult medical practitioners and mental health professionals who were extremely interested by what they were reading but wanted to know what my sources were for this information.  So I began adding a bibliography to the text, which also grew in tandem with the rest of it.  In no time at all I ended up with about a hundred-page “manuscript” I began to make copies of, with a spiral binding at Kinko’s.  This is the manuscript that eventually was built upon and greatly expanded to create Primal Body, Primal Mind.  The rest, as they say, is history.

I am pleased to report that I still hear from Eric from time to time.  No longer an awkward and insecure young boy he went on to graduate high school and eventually college as a straight-A student following my work with him.  Today he has grown into a tall, handsome and successful young man, and is now happily married with a family of his own.  On occasion he contacts me over email with questions about nutrition, etc., and he has even stopped by once or twice to say a warm hello in more recent years.  He is someone I will never, ever forget.  And thanks to him and his earlier suffering, I was inspired to write a book that has since been able to inspire and help many, many thousands of others.

But many, many kids today are really struggling with issues like Eric’s and their families struggle right along with them.  In fact, the numbers seem to only be growing.

According to the CDC and the New York Times:

  • 11% (between the years 2011-2013) of children 5-17 years of age—numbering some 6.4 million– are diagnosed with ADHD.
  • 14.0% (2011-2013) of boys 5-17 years of age are diagnosed with ADHD
  • 5.9% (2011-2013) of girls 5-17 years of age ever diagnosed with ADHD
  • Number of ambulatory care visits (to physician offices, hospital outpatient and emergency departments) with attention deficit disorder as primary diagnosis is estimated at 9.0 million (average annual, as of 2009-2010)

Nearly one in five high school age boys in the United States and 11 percent of school-age children overall have received a medical diagnosis of attention deficit hyperactivity disorder. These rates reflect a marked rise in the US over the last number of years– a 16 percent increase since 2007 and a 41 percent rise in the past decade.  The rates of ADHD diagnosis in Australia have been quite similar.  Medication with amphetamines is implemented as “the treatment of choice” by medical professionals 2/3rds of the time.   Yet there is little quality evidence in the scientific literture of the safety or even efficacy of these medications.  More than half of the studies used to approve these medications for use in children involved less than 100 participants, yet this is the data that is currently used to justify treating 4.6 million children![1]  In a study in PloS One that revealed these troubling findings the researchers concluded that, “Clinical trials conducted for the approval of many ADHD drugs have not been designed to assess rare adverse events or long-term safety and efficacy.” In fact,  pharmaceutical companies have been publicizing the syndrome for over two decades and promoting these unproven and potentially harmful drugs to doctors, educators and parents.  These drugs are BIG business…and they ultimately cure nothing.  ADHD is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma, according to a New York Times analysis of C.D.C. data.[2]  And the medications used to “treat” the condition can have highly significant side effects.  In fact, they are regulated in the same class as morphine and oxycodone because of their potential for abuse and addiction.  In 30 years there has been a twentyfold increase in the consumption of drugs for attention-deficit disorder.[3]  L. Alan Sroufe,  professor emeritus of psychology at the University of Minnesota’s Institute of Child Development and author of a New York Times article titled, Ritalin Gone Wrong pointed out that many parents who take their children off the drugs find that behavior worsens, which most likely confirms their belief that the drugs work. But the behavior actually worsens only because the children’s bodies have become adapted to the drug (not unlike what happens with adults when they try to get off caffeine or quit smoking). In other words, these stimulant drugs merely foster their own physiological dependence.  And to date, no study has found any long-term benefit of attention-deficit medication on academic performance, peer relationships or behavior problems, the very things most parents would most want to improve.

 

So is ADHD really an amphetamine deficiency?  Or for that matter, is any emotional, cognitive, behavioral or physical disorder ANY kind of medication deficiency?

There is yet another way of thinking about this your doctor might not be inclined to consider.

The ADHD-Gluten Connection

The authors of one study published in The Journal of Attention Disorders in 2006 said “The data indicate that ADHD-like symptomology is markedly overrepresented among untreated celiac disease (CD) patients and that a gluten-free diet may improve symptoms significantly within a short period of time. The results of the study also suggests that celiac disease should be included in the list of diseases associated with ADHD-like symptomology.”  In their conclusions the author stated that, “All ADHD patients or their parents report a significant improvement in their behavior and functioning after six months on a gluten-free diet.”[4] Note the word “all” in this last sentence!  No ADHD medication— or any other medication, for that matter, has ever come even close to demonstrating results like this!  And celiac disease comprises no more than about 12% of the totality of what may be termed “gluten immune reactivity”— all of which has similar brain dysregulating effects, generating damaging neuroinflammation and impairment of cerebral perfusion (i.e., blood flow and oxygen) to the frontal cortex, which regulates attention, focus, affect (i.e., mood), impulsivity and judgment.

Gluten is likely not the only culprit when it comes to ADHD.  There are also gluten cross-reactivities, as well as other food sensitivities to consider.  Also, dietary refined sugar, dysglycemia, and essential fatty acid (and other nutrient) deficiencies are other issues  that can demonstrably result in brain-based, mood, behavioral and/or attentional issues.

But children today are increasingly vulnerable to far more than just attentional problems. Overall, based on the National Research Council and Institute of Medicine report (Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities, 2009) that gathered findings from previous studies, it is estimated that 1 out of 5 children experience a mental disorder in a given year and an estimated $247 billion (as of 2009 estimates) is spent each year on childhood mental disorders.[5]  The term childhood mental disorder refers to all mental disorders that can be diagnosed that begin in childhood (for example, attention-deficit/hyperactivity disorder (ADHD), Tourette syndrome, behavior disorders, mood and anxiety disorders, autism spectrum disorders, pediatric bipolar disorder, substance use disorders, etc.).

Data collected from a variety of data sources between the years 2005-2011[6] show:

Children aged 3-17 years currently had:

  • ADHD (6.8%)
  • Behavioral or conduct problems (3.5%)
  • Anxiety (3.0%)
  • Depression (2.1%)
  • Autism spectrum disorders (1.1%)
  • Tourette syndrome (0.2%) (among children aged 6–17 years)

Adolescents aged 12–17 years had:

  • Illicit drug use disorder in the past year (4.7%)
  • Alcohol use disorder in the past year (4.2%)
  • Cigarette dependence in the past month (2.8%)

Other Health Considerations

Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.[7] [8]  It is estimated by The American Cancer Society that about 10,380 children in the United States under the age of 15 will be diagnosed with cancer in 2016 and that cancer rates, which have been climbing steadily over the last several decades are expected to continue to climb.[9]  Jeanne Van Cleave and others, using data from three National Longitudinal Survey of Youth groups aged 2-8, reported that the prevalence of any chronic health condition was 12.8 percent for a group in 1988 that was followed to 1994, 25.1 percent for a group in 1994 followed to 2000, and 26.6 percent for a group in 2000 followed to 2006.[10] Using data from the Centers for Disease Control and Prevention, Lara Akinbami and others showed an increase in the prevalence of childhood asthma (an autoimmune condition) from approximately 3.6 percent in 1980 to about 9.7 percent in 2007.[11] Some 14 percent were reported as either currently having or having once been diagnosed with asthma during their lifetimes, based on the 2009 National Health Interview Survey.

Beyond Health Implications, Alone

As an interesting shift in perspective seldom considered, researchers James Smith and Gillian Smith used retrospective PSID health data to uncover substantial effects of recalled childhood depression on future economic well-being.[12] Their estimations showed substantial reductions in income largely caused by a reduction in weeks worked per year. Respondents who reported childhood mental problems were less likely to pursue higher education; although this effect was small relative to the overall impact on lifetime income. The authors estimated that the family of each affected individual lost about $300,000 over a lifetime, on a discounted net value basis. The corresponding cost to the current American population would be $2.1 trillion. Two other researchers, Currie and Stabile used Canadian data to examine the long-term effects of ADHD. Controlling for confounding factors, they found that the effects of ADHD on economic status are much greater than those of physical health problems.[13]  Clearly, the costs of poor nutrition (and the consumption of gluten) go well beyond the mere price paid for the junk food that is responsible for generating that.  The implications are simply too critical to ignore.

By shifting the emphasis from treatment of illness or dysfunction to more proactive, preventative measures with a greater focus on building health through quality nutrition, it can be possible to shift the balance of these rather grim statistics.

So how do you get your kids and especially teens on board with going Paleo? 

As is reasonable to expect, any major transition is bound to be a creative and somewhat incremental process.  A lot depends on the kids themselves and how suggestible/cooperative they are by nature and/or how open they might be in general to change.  But among more resistant kids, starting slow and taking baby steps in the direction of improved nutrition is generally a good strategy.  Making sure that there is at least one meal out of the day to start with that meets a healthy Paleo criteria (usually dinner) is a helpful first step.  If this is too much for them then just go for removing one simple thing– something like bread or starch from the plate. If they have a favorite starch-based food like, say, rice or mashed potatoes then you can try substituting cauliflower rice for cauliflower mashers as a start.    Chances are they won’t even notice. From there you can gradually replace common food items around the house with healthier alternatives.  If they scream for dessert, then supply them with a small dish of berries with, say, some whipped coconut cream (sweetened with perhaps a drop or two of Stevia) as an alternative to the usual sugar-laden fare.  Think of the foods your child normally favors and ways in which they can be modified to better meet Paleo-friendly criteria.  Sometimes, appealing to a child’s sense of adventure can get you some decent mileage. You can talk about “eating like a caveman” and turn it into something fun, adventurous and exciting for them.  Bring the child with to the grocery store and allow them to help you pick out the quality new foods you would like them to try and then get them to help you in the kitchen while preparing it.  Engage them in the process and help them feel a part of it.  This accomplishes two things: it engages the child in a way that can create greater interest and sense of pride in the food they eat (that they helped prepare) and 2) this teaches better self-reliance and helps prepare them for life and living on their own someday, where they may be more likely to be comfortable preparing quality food for themselves healthfully later on rather than simply resorting to fast food and other less healthy kinds of choices once they’re out of the house.

Simply avoiding the purchase of sugary/starchy and processed fare automatically ensures these things will not be in the house and within reach.  You can always then tell a child that you simply “ran out of” something, which is hard to argue with.  It’s important to stand your ground, but it’s also important first to pick your battles and not create a polarized situation that often can be difficult to transcend.  Always leave the child feeling as though they have positive choices: “You can either have a (grass-fed) burger with (free range) bacon or you can have fish tacos (made with yummy coconut wraps).  Which would you like to have for dinner?”   Or, “You can have eggs this morning or we can just heat up some yummy bone broth.  Which sounds better to you?”    Once your child or teen has begun to adopt more consistent, healthier dietary habits you are likely to see FAR fewer tantrums or willful behavior.  It simply becomes easier. The elimination of blood sugar instabilities through a more fat-based approach to eating (that eliminates sugary, starchy and processed foods) generates a rather miraculous form of mental and emotional stability that builds on itself.  In the end, they will progressively grow accustomed to better quality foods and simply seek them out as a matter of course.  You stop craving the sugary stuff once your brain has stopped depending on that.  This is the goal: to set up healthy habits for life.  But in the process of doing so, oftentimes the best inspiration comes through setting the right example, yourself.

In the days when I worked a lot with teenage boys, I often appealed to their interest in sports by talking to them about making some of these dietary changes and then paying attention how that might affect their performance at, say, football practice or soccer.  I tried to get them to keep a journal on this, keeping track of what they have eaten on any given day, what their mood was like and how they performed in their chosen sports (or even things like skateboarding and video games!).  Teenage boys like the trendy description: “biohacking your own performance”.  Sometimes they are truly excited to start connecting their own dots!  I talk to them about the ways in which a Paleo way of eating is now being adopted by Olympic athletes and professional sports teams around the world as a means to a performance edge.  With girls I generally appeal to their need to be recognized as smart, capable and mature in their choices or perhaps their interest in competitively “outdoing” their brothers or other kids when it comes to building their brains and other things with “smart foods.”   Or find a creative way to turn it all into a positive game with personal goals they set themselves.  These approaches have all helped turn a few young heads along the way.

I am never patronizing, punitive or judgmental when it comes to communicating with children or teens and they can always see in my eyes that I am being 100% candid and telling them the plain truth.  I speak in my normal tone of voice and don’t “talk down” to them.  I don’t believe in lying to manipulate the situation in any way.  Kids have the best-honed BS meters of anyone, and trust here is key… as is respect, which of necessity is something to be earned and not forced upon anyone.

If carbohydrate cravings are truly problematic in your household, I recommend you read the article on my personal website, titled, Taming the Carb Craving Monster (http://www.primalbody-primalmind.com/taming-the-carb-craving-monster/).  It is filled with ideas and suggestions for addressing this not uncommon stumbling block along the way to better health.

Obviously, my young client, Eric didn’t need a whole lot of convincing to know what a change in diet could do for him once he actually experienced it.  Once convinced, he never again required an adult looking over his shoulder to make the right choices.  I do concede that Eric is a notable and rather unusually evolved exception to the rule. But offering positive reinforcement along the way— either by exhibiting signs of approval when your child makes a healthy choice or through making verbal observations of improved physical appearance, behavior or grades starting with “ever since you started eating Paleo more…” (as long as you aren’t sounding manipulative) is another way to get them hooked on the idea of further self-improvement efforts and also make them more conscious of how what they eat affects the way they feel, behave or perform.

Finally, I get a lot of questions about “how much protein should my child eat?” 

In general, I encourage a less restricted approach to protein intake for anyone that is pregnant or lactating, an infant, growing child or teen.  Their growth and development requirements demand an increased level of nutrient intake from the best quality foods.  No child or person of any age ever has a dietary requirement for sugar, starch or gluten containing foods, much less dairy.  That said, growing kids do need the extra protein.  I normally tell average adults to limit their protein intake to just 0.8 g protein/kilogram of their estimated ideal body weight per day, dividing this total amount (roughly in alignment with government guidelines for protein intake) into three meals for optimal effect.   BUT for pregnant/lactating women, growing infants, children and teens I recommend boosting that amount of protein by a good 25%. In general, I am inclined to let this population eat as much protein as they feel the need to (which also encouraging ample quality fat). The need or craving for more protein may be increased slightly during rapid growth spurts, for instance, so I tend to be less formulaic about that when it comes to kids and just let them eat the amount of protein feel they need to.  Athletic teens will naturally require more protein and fat.  Dietary fat should essentially be unrestricted other than with respect to quality.  That said, no child (or adult, for that matter) should be consuming highly processed or rancid fats.  Quality fully pastured meats contain critical brain building omega-3 fatty acids along with other brain enhancing nutrients.  Nutrient density for developing a healthy body and mind is beyond critical.   Quality fats (including animal fats from healthy, fully grass-fed and finished animals) and fat-soluble nutrients are the ultimate cornerstone for any healthy brain, nervous system, endocrine (hormone) system and immune system, plus overall health and disposition at ANY age.  A child never gets a second chance to develop healthy brain, however, and healthy animal fats are KEY.

In Conclusion:

Above all, demonstrate all the positive benefits of a healthy Paleo approach by setting a positive example for your children.  Every child learns far more by example than by lecture or ultimatums.  Kids aren’t dumb.  They automatically know something real when they see it.  And what they take in subconsciously in this regard from subtle observation is frequently what has the most powerful influence of all.

By applying the health principles handed down to us by our Stone Age ancestors at the youngest possible age, we all have a greater reason in today’s world for optimism when it comes to the direction and quality of any child’s life, not to mention humanity’s very future.

[1] Bourgeois FT, Kim JM, Mandl KD (2014) “Premarket Safety and Efficacy Studies for ADHD Medications in Children.”  PLoS ONE 9(7): e102249. doi:10.1371/journal.pone.0102249.

[2] Schwarz, Alan. “The Selling of Attention Feficit Disorder.” The New York Times. December 15, 2013

[3] Sroufe, L.Alan. “Ritalin Gone Wrong.” New York Times Sunday Review.  Jan. 28, 2012

[4] Niederhofer H and Pittschieler K. “A preliminary investigation of ADHD symptoms in persons with celiac disease.” Journal of Attention Disorders 10, no. 2: 200-204.

[5] National Research Council and Institute of Medicine. “Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities.” Washington, DC: The National Academic Press; 2009.

[6] Centers for Disease Control and Prevention. “Mental health surveillance among children — United States 2005–2011.” MMWR 2013;62(Suppl; May 16, 2013):1-35.

[7] Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association 2014;311(8):806-814.

[8] National Center for Health Statistics. Health, United States, 2011: With Special Features on Socioeconomic Status and Health . Hyattsville, MD; U.S. Department of Health and Human Services; 2012.

[9] http://www.cancer.org/cancer/cancerinchildren/detailedguide/cancer-in-children-key-statistics

[10] Jeanne Van Cleave, Steven Gortmaker, and James Perrin, “Dynamics of Obesity and Chronic Health Conditions among Children and Youth,” JAMA 303, no. 7 (2010): 623–30.

[11] Jeanne Van Cleave, Steven Gortmaker, and James Perrin, “Dynamics of Obesity and Chronic Health Conditions among Children and Youth,” JAMA 303, no. 7 (2010): 623–30.

[12] James P. Smith and Gillian C. Smith, “Long-Term Economic Costs of Psychological Problems during Childhood,” Social Science and Medicine 71, no. 1 (2010): 110–15.

[13] Janet Currie and others, “Child Health and Young Adult Outcomes,” Journal of Human Resources 45, no. 3 (2010): 517–48.

By Nora Gedgaudas

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