S24 Ep5: Cognitive Development in Adolescence with Expert Dr. Daniel K. Keating

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Hi friends.

Today we have a special data points episode featuring an interview with Dr.

Daniel Keating, professor of psychology, psychiatry, and pediatrics.

Dr.

Keating has contributed a great deal of work to research surrounding adolescent cognitive, behavioral, and brain development.

and neurodevelopmental outcomes of early adversity through large-scale longitudinal and neuroimaging projects.

He's also the author of Born Anxious, which explores the lifelong impact of early adversity and was the winner of the American Psychological Association 2019 Eleanor Maccabee Book Award.

Dr.

Keating, if you don't mind, we typically start by having every guest introduce themselves and share a bit about their background.

My background professionally is in the discipline of psychology, particularly particularly developmental psychology.

I became interested early on in terms of what makes people tick and how are people different from each other and what are the sources of that.

I have a PhD in psychology from Johns Hopkins.

Since then, I've been on faculties at a number of places, including the University of Minnesota, University of Maryland.

University of Toronto, and now at the University of Michigan, where I'm a professor of psychology with appointments as well in psychiatry and pediatrics.

I also am a research professor at the Michigan Survey Research Center, which is an internationally well-known place where you can look at large populations and do all kinds of research.

I've also written and participated in various research networks focusing on the impact of developmental adversity, particularly early life adversity.

And I had a book a few years ago that came out and covered a lot of that territory.

My real interest is in research and what are the social environmental factors in particular that have an impact on how individuals' development, particularly things that may impact their physical and mental health across the life course, which we know a lot more about than we used to.

We're involved in coining the term biologically embedded.

Things that people experience get under the skin.

They affect your stress system.

They affect your brain.

And those can have lifelong impacts.

Most specifically, recently, I've headed up a research program funded by a couple of different groups, specifically the National Institute of Child Health and Human Development and the National Institute of Mental Health, where we've looked at trying to understand adolescent risk behavior, particularly health risk behavior.

Where does it come from?

How does it work?

And what are the sorts of things that are going on there?

We have a longitudinal database where adolescents that we started seeing when they were around 15, 16.

We're going to be going out in the field next year to look at how they're doing at age 25, 26.

So that's basically the area that I work in, cognitive development, to some extent, brain development as well.

Thank you so much.

Such incredibly important work.

And I'm truly honored to speak with you.

For those of us who have very limited knowledge on typical cognitive brain development, when is someone's brain fully developed?

Generally speaking, at least on the biological maturity side, the brain development, the general consensus is that it reaches maturity at around age 25 or so.

It's not precise by age, but about that amount of time.

Typically, we look at a couple of different things in that area.

One of them is to colloquially say that we can think about this in terms of a bottom brain, a top brain, and how they get along.

The bottom brain.

Another term for it is the limbic system.

And it's those things that have to do with emotional arousal, reactivity to events, incentives and rewards.

What is it that you pay attention to that matter to you in terms of either repeating or avoiding going into the future?

That shows a very sharp peak beginning in early to mid-adolescence.

It reaches its highest peak sometime around late adolescence, 17 to 20, let's say.

and then gradually by about age 25, more or less stabilizing as to where it will be throughout adulthood.

So that's the bottom brain.

The top brain, more formally known as the prefrontal cortex,

has to do with judgment, the ability to inhibit impulsive behavior, understanding more complex cognitive problems, solving more complex cognitive problems, and so forth.

So the general terminology that gets used is that adolescence is a time of what we can think of as a developmental maturity maturity mismatch.

So you have a fast developing bottom brain and a slower, more gradually developing top brain.

The other thing to keep in mind is it's not as though adolescents aren't capable of understanding things in a more complex way.

If we take situations that we often refer to as cold cognition, where there's not a high-stakes situation where you have the opportunity to reflect and so forth, there's nothing pressuring you or arousing you or causing you to seek out certain rewards.

That cold cognition scenario, actually by around age 15 or 16, most adolescents are as good as adults in solving problems like that.

But where we get into hot cognition, where there's arousal, incentives, rewards, that's when we see this developmental maturity mismatch coming to the fore.

I feel like a lot of teens, they're really trying to figure out who am I?

What is my identity outside of my family?

Their peers are extremely important important to them.

Their special interests are extremely important to them.

But within the teenage experience, a lot of times there can be experimenting.

What level of that experimentation and seeking outside identity would you classify as typical teenage behavior versus when it is becoming concerning?

That's a hard question because kids are all different from each other.

One way to think about it is that evolution, if you will, has prepared us to have a period of time when we're exploring all kinds of things.

We're trying to figure things out.

How do you interact with peers?

That's a very challenging situation.

Part of the problem is trying to figure out what is actually risky for kids as opposed to what adults may think of as being bad for them.

That's a difficult sort of thing because you don't want to squelch all kind of experimentation.

And it depends on what barriers or what boundaries, I should say, individual parents and families will have.

Trying to shut it all down generally is not going to help because it will still come out and in ways that may be more risky than trying to understand what's going on.

I think that's a big part of the problem.

With reference to the troubled teen industry, A lot of it that strikes me is that it's too much of a focus on the kids' behavior and not enough of a focus on the relationship status and the family functioning that may be coming into play here.

For example, being labeled as bad or antisocial or a real problem individual can have the effect of confirming to the kid, that's who I am, that's my identity.

I'm a bad kid, so I'm going to live up to that identity.

So there's always a risk of figuring out what's the balance there.

And I think understanding the fact that there's always a tension between wanting to protect one's kids from things that can become seriously bad or may be seriously bad versus the opportunity for them to exercise some autonomy to figure out who they are in the world.

They're only going to be teens for a short period of time.

They're going to be adults for the rest of their lives.

It's a difficult thing often for parents to watch.

You're always trying to figure out, Am I being overprotective?

Am I not taking enough care to be protective of what's going on?

Am I squelching their autonomy or do they need to have more boundaries in place at this point in time?

That's an inescapable tension that just is there.

I think what some of this industry profits by is trying to suggest that it's non-developmental.

They've really gone off the rails.

And so they're bad kids.

And we can change that, as opposed to seeing this as an ongoing process of development that the individual adolescent has to be involved in too, not just as an object of adults' beliefs about what they should be.

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Disabilities such as neurodivergence, ADHD, autism.

Would these types of environments be more stress-inducing, would you say, to somebody who has disabilities?

Generally speaking, they're going to be much more at risk.

Whether it's neurodivergence or whether it is some symptomatology that points them to more externalizing behavior, acting out behavior, or more internalizing behavior, withdrawal, anxiety, depression, whatever it might be, those kids need significant special attention.

What seems to me to be lacking, at least in the descriptions that I've read about it, is that there's not anywhere near sufficient oversight or involvement of licensed clinical professionals, whether they're child and adolescent psychologists or licensed clinical social workers, to really do the hard work of diagnosing what's going on with the kid should always be individualized programs.

You can't just take a bunch of kids and say, oh, they're showing the same behavior that their families don't like.

Therefore, we're going to toss them into a program and that'll shape them up.

That is unlikely to be successful and highly likely to make things worse.

There should be a lot more involvement by clinicians for kids who have significant problems.

With respect to the things that are neurodivergent, that's a complex diagnostic process.

And without that, you're as likely or more likely to make a misstep with those kids than you are to provide something for them that'll help them in their development.

We've seen and heard in the data from survivors, from parents of survivors of these institutions that are abusive, that there are high rates of addiction, suicidal ideation, self-harm that often follow leaving these programs.

Is some of that because of the harm that's done during this really important time of development?

For any individual case, it's hard.

unless you're studying that individual case to know exactly what it is.

The parents may have been seeking help from from wherever they can think they can find useful help because these kids had preexisting problems that led in that direction.

So it's almost surely a sort of dynamic interaction.

What the mix is, I think, is hard to say without doing the important clinical workup to understand what's going on here.

And I speak to that as a researcher and scientist.

I'm not a clinician, but I do know that it's a necessary sort of thing.

Let's take the autism spectrum syndrome.

That disorder has so wide a range of things.

But one of the things is that they may well express various behaviors that are troublesome to those around them, including their families, over which they have very little control.

So in a sense, putting them in a situation that demands more conformity is A, not going to work, and B, it just increases the stress on them tremendously.

Unless you actually understand what's going on with an individual kid.

And particularly, I would include in that what their history is.

Do they have a history of of trauma of one kind or another?

And being neurodivergent doesn't mean that you have immunity from having had trauma.

They often can co-occur.

What are the relationships like within the family?

Relational health is a term that's come into play and is kind of a new field of research.

Understanding an individual in terms of the health of their relationships with others, especially the others that are closest to them.

I think that when one does a proper evaluation of what's the source of the behavior, what are the source of the problems, you cannot do that effectively without looking at the family.

The reality is a lot of these issues have to do with trauma that's incurred early in that individual's life or even intergenerational trauma, which we know now has a substantial impact.

So what's the trauma history like?

What's the family functioning like?

Are there healthy or not very healthy relationships within the family?

Parenting's a hard job.

I don't want to jump on parents, but the fact is that when we look back at this period where we used to jail kids for being incorrigible, a lot of times it was basically parents wanted to not have the inconvenience of dealing with a kid who was somewhat challenging in their behavior.

Or misunderstanding their motivations a lot of times with the neurodivergent kids.

Exactly.

Understanding where a kid's coming from and where the problems that they're expressing come from.

You can't do that in isolation with the child.

You have to understand what their general social environment is, but most closely right at hand, of course, is what's their family social environment like.

Understanding that is an essential part of figuring out, A, what's wrong, diagnosing what's wrong, and then B, figuring out what are the remedies that will or won't work in the situation.

And it's not a one-size-fits-all in any way.

It needs to be specific to what their particular circumstances are.

All those things really do need to be taken into account if you're going to actually make a serious effort to help kids.

Lumping kids together because their behavior looks similar on the surface and then treating them as if it's all the same.

I think we have lots of evidence it's not going to work.

I'm so glad you touched on that because that's what strikes me.

Children are just so different, and the care that they need is so individualized.

A lot of the survivors that we interviewed came in with trauma, to your point.

They may have been neurodivergent, their parents recently went through a divorce, or they were sexually abused, or something really hard happened.

How does stress or prolonged stress impact cognitive development for teens specifically?

Would you say?

That's actually a major topic of the book, Born Anxious, that I put out a while back.

A couple of things to understand quickly.

The stress system is fundamentally important to our survival.

All animals have it of one sort or another.

And basically what your stress system is to tell you that something is dangerous, something is not right.

It alerts you to that.

And it's not a very smart system.

It can be right or wrong about whether there actually is a threat.

But when it kicks in, obviously it directs the flight or fight response.

We've add to that now the freeze response.

You're not thinking about it really.

You're reacting to what it is that's going on.

One of the things that we know is that if you're exposed to excess levels of stress or toxic stress, particularly early in development, but it continues certainly through the adolescent period, it changes your stress response system.

What's known as stress dysregulation can come about.

The most typical response is that if you've suffered that kind of experience and it has changed your basic biology of your stress system into a dysregulated state, you're going to react to things that other people would see as neutral in a way that you regard as a threat or a challenge, and that you've got to act on it for your own self-protection.

So, it's more often that you're going to react with a not thinking stress reaction, reaction, which expresses itself in, as I say, fight.

You're challenging others and getting into problems that way.

Or it can be flight, that is typically through an internalizing response where you withdraw into yourself.

You don't interact with others.

You get depressed, lonely, anxious.

And that system is, you're reacting to more things.

You go to a higher level of a stress response.

The dominant neurohormone here is cortisol, which most people have heard about.

You shoot up to a much higher level of cortisol, but also very importantly, it takes a lot longer to come back to baseline.

You stay in this high alert state much more often.

In a sense, your stress system is on most of the time.

And that doesn't lead to good behaviors in the sense of getting along with others.

So that stress system can get dysregulated.

In fact, we now have very good evidence.

if your mother is stressed while you're being carried in the womb, if it is severe enough, that can reset your stress system even before you're born.

So you can wind up with that stress dysregulated response very early on.

And in the first couple of years of life, you're similarly highly vulnerable to that.

It can still be impacted at the biological level on into adolescence as well.

But if you can imagine a kid who's had that throughout their development, what's happening is not that they're deciding to be bad.

It's that they're on high alert and afraid most of the time and don't know how to react to that kind of a stressful situation, where a neutral situation to most people becomes stressful to them.

Based on your research, what are some factors that can help promote healthy adolescent development?

It comes back to this general notion of a balance.

On the one hand, you want them to have the freedom to develop themselves, to have autonomy, to be able to make choices that turn out to be good choices for them versus protection.

You clearly want to protect individuals during this developmental period.

And I think the solution there is to recognize you're trying to build a scaffold.

If you think of an infant, they have no ability to regulate themselves.

If you have a crying infant expecting them to take care of themselves, it's just not going to happen.

So it's external regulation from the parent.

As you grow up, you have to move towards self-regulation.

And that's a challenging process for everybody.

Parents who will scaffold that to provide enough of the external boundaries and constraints, but to do it in a warm and responsive way has lots of evidence to suggest that is one of the critical features.

Another way of saying the same thing really is to talk about becoming an individual, the process of individuation, finding out who you are, finding out your identity and allowing kids to do that.

but retaining the emotional closeness.

You're not tossing them out of the family situation.

They have to know that there's this warm, secure base, but there are boundaries.

There are a lot of the various psychological theories that really are similar in a variety of ways, focusing on different aspects of development.

One of the ways of thinking about this that brings a lot of it together is that the two things that are most central to adolescents is that they have a sense of belonging.

And you want to feel like you matter.

You matter in the world and you matter to people.

And so if we think about what are the aspects of resilience for kids that experience various kinds of hardships, you want to foster social connections.

That's a central feature of what we understand about resilience in the individual development case, is strong positive social connections.

In addition to that, some sense of purpose and meaning that you're doing something that's worthwhile.

Those two things together carry most of the weight of what we think about in the literature and research as contributing to resilience.

Thank you so much.

Where does shame live in the brain?

When I think of stress, you can feel it in your gut.

Where does the brain process that?

We don't know in any precise way.

It's likely to be a network of things that are triggered by it.

Shame plays an important role for a variety of reasons.

It's a way of figuring out, I feel ashamed when I feel like I haven't lived up to something that I want to do.

So in that sense, it's a positive one.

We might wish that some of our contemporary political leaders had a little bit of shame left.

It's not just for little kids.

Obviously, it carries throughout life.

It's a recognition that I'm not acting like the person I want to be or the person I think I should be.

And so there's a positive aspect to it.

External shaming is quite different.

External shaming is to say you ought to be thinking poorly of yourself because you didn't do what I wanted you to do.

You didn't do what I told you to do.

That isn't the productive value of shame.

That's what obviously creates various kinds of problems.

And kids can react to it in different ways.

They can withdraw into themselves and just see themselves as a bad person, or they can act out and say, I'll just do what I want to do.

I don't care what you think of me.

That external shaming coercively is, I think, where the core of the problem lies, not in the sense internally that I really have not lived up to the person that I'd like to be.

I love the way you explain that.

In looking at the history of these sort of private programs, a lot of it was rooted in the cult synonym and what we call now, quote, attack therapy or the game.

Is that sort of therapy actually healthy and effective for proper development?

Again, not speaking as a clinical psychologist, but generally speaking, to my understanding of how a lot of this works, it's highly unlikely to be healing.

And it's essentially trying to expose an external set of behaviors and values independently of what your identity identity development might say.

What this is most similar to is when juvenile incarceration for incorrigible children was typical.

Half a century ago, or maybe even more recently, you had situations where kids could just simply be declared by their parents to be incorrigible to the authorities who would then incarcerate them in public institutions.

Status offenses like truancy or promiscuity, as the parents would define it, would be sufficient for kids to be incarcerated.

And even though a lot of the juvenile incarceration facilities claimed to have a protective and rehabilitative impact, really it was just incarceration.

And the evidence became clear over time that it was doing no good at all.

To me, generally speaking, looking at some of the basics, it looks most similar to that.

historically.

And we realized as a society that wasn't working and it went against what we came to understand to be the patterns and social arrangements that support healthy development.

The other part that I would look at would be to say, okay, where you've got accredited residential treatment programs, accredited mental health programs like psychiatric units in children's hospitals and so forth, they treat individuals as individuals.

They seek ways to try to address the impact of trauma histories that have had on these kids.

At least the most advanced places are working very hard on how do we try to reestablish healthy relationships, whether it's within the family or outside the family.

Sometimes one's nuclear family just isn't going to be able to live up to it because of their own trauma past, their own mental illness.

But are there alternatives?

Where can we find a way to create healthy and positive relationships?

What are the characteristics of individuals who have beat the odds, who had very traumatic, disadvantaged adolescent development and still turned out out okay.

Almost always, it's because they managed to find some other way to have positive, healthy relationships with others.

Sometimes it's referred to as surrogate attachment figures.

Looking at things like mentors and coaches have a very positive impact potentially on resilience.

Even though they're saying, look, you've got to do it this way.

If you want to be part of our group, you matter to other team.

You matter to us.

That belonging and mattering is a core part of what goes on in that context, from both the research, from comparison to effective treatment programs at the current time, and the history of jailing so-called incorrigible children.

What I see is that the lessons happening in that industry go against all of them.

Life is busy.

Running out of coffee must be avoided at all costs.

If, like me, you're trying to support more ethical stores, but you still desire a wide selection and quick shipping, you'll love Thrive.

Even if you're not going back to school, this is the perfect time to reset.

Thrive makes it easy to shop for high-quality pantry staples, snacks, vitamins, and even skincare without the errands or the ingredient labeled deep dives.

I just place an order with Thrive for my office snack cart, and I highly recommend the Made Good Organic Granola Bites.

I also love Thrive for stocking up on clean beauty products like Mighty Patch, Dr.

Brauner's, and a Cure.

Now's the best time to try Thrive Market.

You'll get up to 25% off select items, and new members get 30% off their first order plus a free gift.

Go to thrivemarket.com/slash sww to start saving.

The sale ends August 31st.

Don't miss it.

That's thrivemarket.com/slash sww.

Thank you so much.

This Labor Day, gear up, save big, and ride harder with cycle gear.

From August 22nd to September 1st, score up to 60% off motorcycle gear from your favorite brands.

RPM members get 50% off tire mount and balance with any new tire purchase.

Need to hit the road now?

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And here's the big one: August 29th through September 1st only.

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This is Larry Flick, owner of the Floor Store.

Labor Day is the last sale of the summer, but this one is our biggest sale of the year.

Now through September 2nd, get up to 50% off store-wide on carpet, hardwood, laminate, waterproof flooring, and much more.

Plus two years interest-free financing, and we pay your sales tax.

The Floor Stores Labor Day sale.

Don't let the sun set on this one.

Go to floorstores.com to find the nearest of our 10 showrooms from Santa Rosa to San Jose.

The Floor Store, your area flooring authority.

Now, if we're talking about current day parents who are looking for solutions for their child and they're looking at different institutions, facilities, what key features can people be on the lookout for when they're considering something like this?

One of the things that I would always recommend is look to credible and reliable organizations that will provide unbiased evidence-based approaches.

For parents who are just starting to look, I would say the first place to go is the government organization, the Substance Abuse and Mental Health Services Administration.

They've got a website, S-A-M-H-S-A.gov.

It has find help and support.

They have a national helpline.

They have the suicide crisis lifeline.

They have treatment locators.

To be eligible to be on that website, you have to have some level of accreditation, some level of believability.

When you're looking at a specific place, I would ask, do you have licensed mental health professionals as part of your staff that's contributing to what it is that's going on?

If you don't insist on having some kind of substantive evaluation before bringing kids into that environment, then you're not paying attention to the kid.

You're wanting to make your program profitable, I guess.

I would also then ask, what's your range of professionals that you have available to you?

How much involvement do they have?

And what kind of an evaluation system do you have?

If it's just, we've got a program and if parents say, we think we need to get them off to you because they can't control their behavior anymore, that's a bad sign.

In terms of cognitive development, if one suspects and worries that there may be neurodiversity issues, developmental delay issues going on, other kinds of substantive cognitive problems, get an evaluation.

These happen everywhere.

School psychologists used to do a lot more of that.

They've been cut back, so they don't do quite as much, but one can get it through healthcare providers.

If it's just a cognitive area, then a psychoeducational evaluation can point up a lot of those things.

If you think that it may be in the neurodivergent dimension, then yes, getting something like an autism assessment, which if done right, are very good because they not only can provide a diagnosis, they say what are the kinds of things that are going to work for individuals because it is a spectrum.

So there are various kinds of things that'll work with parts of the spectrum and and useless with other parts of the spectrum and vice versa.

The key to that is having a really solid evaluation.

And that can be accessed in some places still through schools.

But if not, they can refer out to various kinds of clinics and whatnot that can do those sorts of things.

But you want it done by somebody who knows what they're doing in evaluation.

Otherwise, you can wind up with a completely wrong picture of what's going on with the kid.

And you're either losing time by not addressing what needs to be addressed or even wind up doing stuff that's not going to help them.

Some of these kids are placed in these programs due to, quote, internet addiction.

How do you think social media and technology is impacting cognitive development?

Way less than people think.

I've been researching this in great detail, partly because I teach a course in adolescent development.

There is a real adolescent mental health crisis, but a lot of it is focusing on this as a silver bullet.

It's been written about, and I tend to agree with this perspective, that it's more of a moral panic.

We had that same reaction when radio came, when television came.

It's ruining what you think about reality.

So I think there is a great deal of that involved in this.

This is not to say that there are not some risks, but by and large, when you do large population studies, when you do longitudinal studies, and ideally you'd want to do experimental studies.

It turns out there's just not much there.

There are lots of kids who would not get much social interaction if it weren't for social media.

You think of kids from the LGBTQ community.

You think of kids who are rurally isolated.

You think of kids who have mobility issues and can't get face-to-face very easily.

Internet gaming disorder is actually a recognized condition in the diagnostic and statistical manual of the American Psychiatric Association.

And it's partly defining what you mean by social media.

You're scrolling through Instagram or are you messaging with your friends?

It's a whole big wide open definition problem here as well.

So generally speaking, within reason, you don't want to have kids who are doing nothing else.

And for kids who already have significant mental health problems in particular, trying to exert some control over that and encouraging other kinds of behaviors, I'm not saying we ignore it, but I think that the notion of trying to place blame on this is problematic.

And that's partly because a fair bit of what I write about is the stress epidemic.

And a stress epidemic that we've got for adolescents is not primarily around social media or the internet.

It's because we have created huge, stressful burdens for them that we're not working on as adults.

There's good evidence for a bunch of these.

Climate change, inequality, lack of social mobility, lack of opportunity, the whole othering process that individuals who are different don't deserve respect reflected in all kinds of things.

If you look at the percentage of kids, high school kids in particular, one of their biggest stressors, 70-some percent of them say they have recurring fears of going to school because of the potential for mass shootings occurring while they're at school.

They're extra stressful because they look at adults and say, why aren't you trying to fix this?

Why are we going in the wrong direction on all of these things?

We're the ones that are going to pay the cost for this.

We're the ones that are going to have an unlivable planet.

Why aren't you doing something about that?

Those stressors we're ignoring.

if we focus entirely on the social media moral panic.

So I have a vested interest in trying to get people to wake wake up and say, look, not only are these things problematic and stressful for everybody, they're extra stressful for youth because they're the ones that are going to suffer the long-term consequences the most.

When I'm seeing this, quote, big, beautiful bill being passed and people's Medicare being removed, I can't help but think of disabled children and the people who rely on those services to exist.

In your opinion, is that an added stress also to our communities and cognitive development and people's ability to find resources.

Yes, it's an absolute travesty and it's going to do exactly the things that you're saying.

Although we have a lower level of safety net here than many other countries who, by the way, have much better outcomes on all of these sorts of things, it's going to further unravel that safety net.

I don't like to think of it as a safety net so much because it implies that we're going to be charitable and take care of people.

It's an investment in human development.

To the extent that we unravel those investments even further in human development, we're going to see consequences for individuals going forward.

It becomes more and more apparent with time, making it much harder to get health care, making it much less likely that we're going to provide high quality schools.

We're going to cut out a Department of Education.

We're not even going to spend the money on education that Congress already approved.

All of those things that we're doing to disinvest in human development are going to have very negative consequences for those individuals.

And so one has to ask why, if you look at this so-called one big beautiful bill, it's entirely to make billionaires trillionaires.

This notion that somehow we're going to claim to care about how kids are getting along and then eliminate investment in their well-being in order to make the wealthiest even wealthier, that becomes apparent over time.

I know that's not necessarily the widespread understanding of what's going on, but it certainly is what's going on.

And that centralization of money and power, we used to say, oh, well, it's really hurting the poor, but now it's not just hurting the poor, it's hurting the working class.

It's not just hurting the working class, it's hurting the middle class.

If you want to have a country where the average performance across the whole population is good, whether it's on health, education, working in a meaningful way in the society, these are the wrong ways to go about it.

But beyond that, to the extent that you also increase the inequality so fewer and fewer people have option to have a dignified life.

That's the opposite of population developmental health.

My view is that we pay way too much attention to business and economic trends and way too little attention to population developmental health.

Where can people go to find out more about your books, your work?

The easiest way is to just look me up at the University of Michigan.

I have a website at the University of Michigan.

And it has a lot of the stuff that we're working on.

Dr.

Keating, thank you so, so much for being willing to share all of your amazing knowledge.

Thank you for the work you're doing.

It's incredibly important.

Thank you.

I've enjoyed it.

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