The Design and Implementation of the 2016 National Survey of Children's Health

Importance of medical home domains on emergency visits using a cross-sectional national survey of US children

BACKGROUND AND OBJECTIVES

Receiving care at patient-centred medical homes (PCMH) is associated with reduced emergency department (ED) visits among children. Adverse social determinants of health (SDoH), such as lower socioeconomic status and household poverty, are associated with increased ED visits in children. The objective of this study is to use machine learning techniques to understand the relative importance of each PCMH component among different populations with adverse SDoH on the outcome of ED visits.

METHODS DESIGN, SETTING AND PARTICIPANTS

This study used the 2018-2019 pooled data from the National Survey of Children's Health (NSCH), an annual survey of parents and caregivers of US children from birth to 17 years. PCMH components were operationalised by classifying parent/caregiver responses into five domains: care coordination (CC), having a personal doctor or nurse, having a usual source of care, family-centred care and ease of getting referrals. SDoH included five categories: (1) social and community context, (2) economic stability, (3) education access and quality, (4) healthcare access and quality and (5) neighbourhood and built environment.

PRIMARY OUTCOME MEASURE

We used a split-improvement variable importance measure based on random forests to determine the importance of PCMH domains on ED visits overall and stratified by SDoH.

RESULTS

Overall, between 3% and 28% experienced one or more gaps in PCMH domains. Models show that problems with referrals (rank, 2; Gini, 83.5) and gaps in CC (rank, 3; Gini, 81.0) were the two most important domains of PCMH associated with ED visits in children. This result was consistent among black and Hispanic children and among children with lower socioeconomic status.

CONCLUSIONS

Our study findings underscore the importance of poor CC and referrals on ED visits for all children and those from disadvantaged populations. Initiatives for expanding the reach of PCMH should consider prioritising these two domains, especially in areas with significant minority populations.

Risk and protective factors for mental health problems in children and adolescents during the COVID-19 pandemic: results of the longitudinal COPSY study

The COVID-19 pandemic has had profound effects on the mental health of children and adolescents worldwide, exacerbating existing challenges and introducing new stressors. This paper explores the impact of risk and protective factors on the mental well-being of young individuals during the pandemic. Using data from the German nationwide, population-based, longitudinal COPSY study (n = 2,471, girls: 50.0%, age 7-17 years) spanning nearly three years, this study investigates how factors such as gender, age, parental education, parental depressive symptoms, family cohesion, and social support influence mental health. Mental health problems were assessed using the Strengths and Difficulties Questionnaire (SDQ). Latent growth analysis and structural equation modeling were employed to analyze cross-sectional and longitudinal data collected at five measurement points (initial response rate: 46.8%). Findings revealed that boys and younger children are at a higher risk for mental health problems. Additionally, low parental education, single parenthood, parental burden due to the pandemic and parental depressive symptoms were significantly linked with mental health problems in children. Conversely, personal resources, family cohesion, and social support were associated with less symptoms. Family cohesion additionally buffered against the negative impact of parental depressive symptoms. The study underscores the importance of multi-level interventions that consider individual, familial, and societal factors in promoting positive mental health outcomes among children and adolescents during challenging times. Continued research and collaborative efforts are needed to develop evidence-based strategies for supporting the resilience of young individuals in the face of future adversities.

Breastfeeding Behaviors by Race/Ethnicity and Foreign-Born Status in the United States: An Analysis of the U.S. National Survey of Children's Health

Objective: The foreign-born population is growing in the United States, but no nationally representative statistics of breastfeeding behavior disaggregated by race/ethnicity and foreign-born status have been published in recent years. This study examines breastfeeding initiation, any breastfeeding, and exclusive breastfeeding at 3 and 6 months among foreign-born and U.S.-born Non-Hispanic (NH) Black, NH White, and Hispanic women in the United States. Methods: This is a cross-sectional study utilizing years 2021 and 2022 of the National Survey of Children's Health. Sample children identified as NH White, NH Black, and Hispanic who were 6 months to 5 years old and residing with their biological or adoptive mother were included (n = 27,818). Results: Foreign-born women in all racial/ethnic groups (NH Black, NH White, and Hispanic) had significantly higher odds of any breastfeeding at 6 months relative to U.S.-born NH White women. However, they did not have significantly different odds of exclusive breastfeeding for 6 months relative to U.S.-born NH White women. U.S.-born Hispanic women had rates of exclusive breastfeeding for 6 months (23.2%) that were much closer to U.S.-born NH Black women (23.4%) than to foreign-born Hispanic women (29.4%) or U.S.-born White women (32.1%). Conclusions: The large percentage of foreign-born women who reported some breastfeeding at 6 months indicates a strong commitment to breastfeeding and may be a leverage point for future exclusive breastfeeding interventions among this group. U.S.-born Hispanic women appear to be struggling with exclusive breastfeeding and may need additional interventions.

Prevalence of Tourette syndrome among children and adolescents in the United States, 2016-2022

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental disorder. The prevalence of TS in 2016-2017 has been reported; however, little is known about the current prevalence and trend in children and adolescents with TS. This study aimed to estimate the prevalence and trend of Tourette syndrome (TS) among US children and adolescents aged 0-17 years from 2016 to 2022.

METHODS

We analyzed data from a nationally representative sample of 278,472 children and adolescents aged 0-17 years who participated in the 2016-2022 National Survey of Children's Health (NSCH), a nationwide, population-based, cross-sectional survey of US children and adolescents. TS was defined as the affirmative response in the questionnaire completed by a parent or guardian.

RESULTS

Among the 278,472 children and adolescents enrolled, 754 had been diagnosed with TS, with an overall prevalence of 0.23% in all children and adolescents aged 0-17 years. The weighted prevalence by age group was lower than 0.01% in children aged 0-2 years, 0.05% in children aged 3-5 years, 0.28% in children aged 6-11 years, and 0.38% in adolescents aged 12-17 years. There were significant sex and racial/ethnic differences in the overall prevalence of diagnosed TS (i.e., 0.35% in boys and 0.11% in girls, 0.22% in Hispanics, 0.28% in non-Hispanic whites and 0.16% in non-Hispanic blacks). There was no significant change in the estimated prevalence of TS from 2016 to 2022.

CONCLUSION

Based on nationally representative data, this study found that the national prevalence of TS among the US children and adolescents differed by sex and race/ethnicity but remained stable from 2016 to 2022.

State Differences in Children's Mental Health Care

OBJECTIVE

This study estimates and compares variation in the probability of child unmet need for mental health care and difficulties accessing care for each state in the United States. Estimates are also generated and compared for three socioeconomic and demographic subgroups nationwide: racial and ethnic group, household income, and insurance type.

METHODS

Using a retrospective, cross-sectional design, this study pooled 2016-2019 National Survey of Children's Health data. National, state, and subgroup adjusted probabilities of caregiver-reported child unmet need for mental health care and ease of access to mental health care were generated from logistic regression models with marginal post-estimation.

RESULTS

Adjusted national probabilities of caregiver-reported child unmet mental health need and difficulty in accessing care were 0.21 and 0.46, respectively. State probabilities of unmet need ranged from 0.08 to 0.32. One state was significantly above the national estimate; nine states were below it. State probabilities of difficulty accessing mental health care ranged from 0.28 to 0.57; nine states' probabilities were significantly below the national estimate and two states were significantly above it. Estimates of unmet mental health need and difficulty accessing care varied more widely across states than across racial or ethnic groups, income groups, insurance groups.

CONCLUSIONS

Geographic inequities in children's mental health care access persist; in some cases, they are larger than sociodemographic inequities.

Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs

OBJECTIVE

Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN).

STUDY DESIGN

We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52).

CONCLUSIONS FOR PRACTICE

Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.

Emergency Allotments in SNAP and Food Hardship Among Households With Children

Importance

Households with children and minoritized racial and ethnic groups experience a disproportionate burden of food hardship. During the COVID-19 pandemic, the US federal government implemented emergency allotments in the Supplemental Nutrition Assistance Program (SNAP), increasing the amount of food purchasing assistance received by many participating households.

Objective

To examine the association of implementing emergency allotments in SNAP with food hardship among households with children overall and for households with Black, Hispanic, and White children by comparing income-eligible households that did and did not participate in SNAP.

Design, Setting, and Participants

This ecologic cross-sectional study used 2016-2022 National Survey of Children's Health data and a difference-in-differences approach to compare changes in the risk of food hardship from before implementation of emergency allotments in SNAP (2016-2019) to during implementation (2020-2022). Households with children younger than 18 years and incomes 130% or less of the federal poverty level (FPL) in all 50 states and Washington, DC, were included.

Exposure

Implementation of emergency allotments in SNAP.

Main Outcome and Measures

The primary outcome was caregiver report of household food hardship during the past 12 months.

Results

Of 44 753 households with incomes 130% or less of the FPL, a weighted 23.4% had Black children, 56.7% had White children, and 19.9% had children of other races. More than one-third of households (37.8%) had Hispanic children, and 31.8% had young children aged 0 to 5 years. The percentage of households that experienced food hardship decreased from 2016 to 2021 (from 62.9% to 48.2% among SNAP-participating households and from 44.3% to 38.9% among income-eligible nonparticipating households) but increased in 2022 (to 58.0% among SNAP-participating households and to 47.5% among nonparticipating households). Adjusting for confounders, implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among SNAP-participating compared with nonparticipating households (risk ratio [RR], 0.88; 95% CI, 0.81-0.96). Implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among SNAP-participating households with Hispanic (RR, 0.86; 95% CI, 0.72-1.02) and White (RR, 0.85; 95% CI, 0.76-0.94) children compared with nonparticipating households but not among households with Black children (RR, 1.04; 95% CI, 0.87-1.23).

Conclusions and Relevance

In this ecologic cross-sectional study, implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among households with children. Efforts are needed to ensure that all populations benefit from economic policies.

Clinical Signs and Symptoms of Anxiety Due to Adverse Childhood Experiences: A Cross-Sectional Trial in Adolescents

BACKGROUND

Adverse Childhood Experiences (ACEs) are linked to the development of anxiety in adolescence. According to recent studies, the COVID-19 pandemic represents a novel ACE that is associated with anxiety among adolescents. This study investigates the relationship between ACEs, COVID-19, and anxiety in adolescents.

METHODS

A cross-sectional study was conducted using a community sample of 248 boys and girls ages 12 to 15 years (mean = 13.50 years) from five high schools in Eastern Attica. A total of four questionnaires were used: (1) Demographic Questionnaire, (2) State-Trait Anxiety Inventory for Children-STAIC, (3) Adverse Childhood Experiences Scale, and (4) COVID-19 Impact Scale.

RESULTS

The results demonstrated a moderate association between the total number of ACEs and anxiety (trait and state) in adolescence (trait anxiety: ρ = 0.37, p < 0.001; state anxiety: ρ = 0.29, p < 0.001). Girls scored significantly higher than boys on both trait anxiety (U = 4353, p < 0.001; mean difference = 5.5) and state anxiety (U = 5822.5, p = 0.014; mean difference = 2). The number of ACEs was found to be significantly related to the impact of COVID-19 (β = 0.025, p < 0.001).

CONCLUSIONS

This study highlights the significant link between ACEs and increased anxiety in adolescents, which is further exacerbated by the COVID-19 pandemic. The findings indicate that girls are more affected than boys. These results emphasize the need for targeted mental health interventions to enhance coping mechanisms, reduce stress, and address anxiety in adolescents, particularly during global crises like the pandemic. Developing such programs is essential for supporting the mental well-being of youth facing multiple stressors.

Prevalence and Correlates of Unstable Housing Among US Children

Importance

Housing instability is an important public health issue, particularly for children. This study provides nationally representative estimates of unstable housing among US children.

Objective

To examine unstable housing prevalence; differences by sociodemographic characteristics, health, and state of residence; and associations with other hardships.

Design, Setting, and Participants

This survey study examined data from the 2022 National Survey of Children's Health, a population-based, nationally representative survey of randomly selected children whose parent or caregiver responded to an address-based mail or web-based survey. Participants were children aged 0 to 17 years living in households in the 50 US states and District of Columbia (N = 54 103). Bivariate analyses tested for observed differences in unstable housing between groups; logistic regression models tested for significant disparities. Associations between unstable housing and health care and food-related hardships, neighborhood conditions, and adverse childhood experiences were examined.

Exposure

Unstable housing experiences.

Main Outcomes and Measures

Unstable housing, comprising 3 indicators: inability to pay mortgage or rent on time in the past 12 months, 2 or more moves in the past 12 months, and homelessness in the child's lifetime. Analyses were adjusted for child age and family poverty ratio. Secondary analyses examine caregiver-reported stress or worry about eviction, foreclosure, or condemned housing in the past 12 months. Weighted prevalence estimates accounted for probability of selection and nonresponse.

Results

In 2022, 17.1% (95% CI, 16.4%-17.8%) of children living in US households, representing more than 12.1 million children, experienced 1 or more forms of unstable housing: 14.1% (95% CI, 13.4%-14.7%) lived in households that were unable to pay mortgage/rent, 2.9% (95% CI, 2.6%-3.3%) moved frequently, and 2.5% (95% CI, 2.2%-2.8%) experienced lifetime homelessness. Additionally, 9.0% (95% CI, 8.5%-9.5%) of children had caregivers who reported stress/worry over housing. Prevalence of unstable housing varied across states (range, 12.0%-26.6%). Unstable housing was highest among American Indian or Alaska Native children (27.9%; 95% CI, 21.3%-35.6%), Black or African American children (30.4%; 95% CI, 27.8%-33.1%), and Native Hawaiian or Pacific Islander children (27.6%; 95% CI, 16.6%-42.1%) and also differed by special health care needs, family poverty ratio, caregiver education and unemployment status, and whether the family rented or owned their home. Unstable housing was associated with all other types of hardships examined.

Conclusions and Relevance

This study found that 1 in 6 US children experienced unstable housing, varying by state and sociodemographic factors. The prevalence is likely underestimated because the sample excluded children who are currently institutionalized or experiencing homelessness. Results may help move the field toward a unified national definition of unstable housing for families with children and lead to clinically appropriate and evidence-based screening and interventions to support housing stability and improve children's health.

Assessing the Role of Asthma on the Relationship between Neurodevelopmental Disabilities and Adverse Birth Outcomes

BACKGROUND

Investigating asthma as an effect modifier between adverse birth outcomes and neurodevelopmental disabilities (NDDs) across different races is crucial for tailored interventions and understanding variable susceptibility among diverse populations.

METHODS

Data were collected through the National Survey of Children's Health. This cross-sectional study included 131,774 children aged 0 to 17 years. Study exposures comprised adverse birth outcomes including preterm birth and low birth weight. Weighted prevalence estimates and odds ratios with 95% confidence intervals (CIs) among children with and without adverse birth outcomes were calculated for NDDs including attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, seizure, and several others including behavior problems. Adjusted odds ratios were stratified by asthma status and separate interactions were assessed for each outcome.

RESULTS

Of 131,774 participants, 10,227 were born low birth weight (9.12%; 95% CI: 8.77% to 9.49%), 14,058 were born preterm (11.35%; 95% CI: 10.94% to 11.76%), and 16,166 participants had asthma (11.97%; 95% CI: 11.58% to 12.37%). There were 68,100 males (51.11%), 63,674 females (48.89%), 102,061 non-Hispanic Whites (NHW) (66.92%), 8,672 non-Hispanic Blacks (NHB) (13.97%), and 21,041 participants (19.11%) categorized as other. NHB children with adverse birth outcomes had higher prevalence of several NDDs compared to NHW children.

CONCLUSIONS

Asthma was not shown to be an effect modifier of the association between adverse birth outcomes and NDDs. Nevertheless, these results suggest that NDDs are more prevalent within US children with adverse birth outcomes, with higher rates among NHB compared to NHW children. These findings support screening for NDDs in pediatric health care settings among patients with adverse birth outcomes, particularly among those from ethnic minority backgrounds.

Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care

To examine the association between scope-of-practice (SoP) regulations and racial disparities in pediatric mental health services. We used the National Survey of Children's Health (2016-2020; n = 33,790) to examine racial disparities in unmet mental health care needs and receipt of mental health medication between states with and without SoP expansions for psychologists and nurse practitioners (NP). Our primary outcomes were (1) unmet mental health care needs and (2) receipt of mental health medication. We examined heterogeneous treatment effects of SoP expansion on the outcomes using logistic regression with interaction terms between SoP expansion and race/ethnicity. We estimated population-level racial disparities for both outcomes stratified by SoP expansion to identify differences in racial disparities. The psychologist SoP expansion-associated reduction in unmet need was 15.8 percentage-points (CI= -25.3, -6.2) larger for Other-race children than for White children. The psychologist SoP expansion-associated increase in medication was 5.1%-points (CI=. 0.8, 9.4) larger for Black children and 5.6%-points (CI = 0.5, 10.8) for Other-race children. No differences were found for NP SoP expansion. Racial disparities in both outcomes were lower in psychologist SoP expansion states but varied in NP SoP states. Expanded SoP was generally associated with lower racial disparities in pediatric mental health care access.

Family resilience mediates exposure to adverse childhood experiences on insufficient sleep among children: findings from a population-based study

Background

Sleep plays a vital role in the well-being of children and adolescents. Researchers have identified adverse childhood experiences (ACEs) as an important factor associated with poor sleep among adolescents. The objective of this study was to examine the mediating role of family resilience on the association between ACEs and insufficient sleep among adolescents in the United States.

Methods

Data for this study came from the 2018-2019 National Survey of Children's Health (N = 28,097). The outcome variable in this study was insufficient sleep, and the main explanatory variable was exposure to ACEs. The mediating variable was family resilience. Data were analyzed using binary logistic regression.

Results

Based on parent reports, one in five (22.4%) adolescents did not meet the recommended sleep hours on an average night. About half of the adolescents had no ACEs, 24.2% had one ACE, and 14.6% had three or more ACEs. Controlling for the effect of other factors and family resilience, the odds of having insufficient sleep were 1.63 times higher for children exposed to three or more ACEs (AOR = 1.63, 95% CI = 1.30-2.05). Family resilience partially mediates the association between exposure to ACEs and insufficient sleep. Each additional increase in family resilience decreased the odds of having insufficient sleep by a factor of 12% (AOR = 0.88, 95% CI = 0.86-0.91).

Conclusions

Family resilience partially mediated exposure to ACEs on insufficient sleep. There are modifiable factors that may improve sleep outcomes among adolescents who have been exposed to adversity. Future research can help elucidate findings and establish the directionality of this association.

Understanding health behaviors that modify the risk for obesity in ADHD

OBJECTIVE

Research provides support for the associated risk of inadequate sleep duration, limited physical activity, and excessive media use in attention-deficit/hyperactivity disorder (ADHD) and obesity. The present study aims to (1) examine the association between ADHD and overweight or obese status (OW/OB); (2) comprehensively examine sleep duration, physical activity, and media use as potential moderators of OW/OB; and (3) examine the moderating effects of these health behaviors cross-sectionally by comparing medicated youth with ADHD, unmedicated youth with ADHD, and youth without ADHD.

METHODS

Data were acquired from the 2018 and 2019 National Survey of Children's Health, a nationally representative survey of caregivers conducted across the United States. The current study used data for youth 11-17 years old with a final sample size of 26,644. Hours of sleep, physical activity, and media use per day were dichotomized based on national recommendation guidelines for each health behavior (i.e., either meeting or not meeting guidelines).

RESULTS

The OW/OB prevalence rate was 7% greater among unmedicated youth with ADHD than among medicated youth with ADHD. Medicated youth with ADHD and peers without ADHD had similar OW/OB rates. Among medicated youth with ADHD, physical activity, sleep duration, and media use did not contribute to OW/OB risk after controlling for family poverty level. However, among unmedicated youth with ADHD, meeting sleep duration guidelines was linked to a lower OW/OB risk.

CONCLUSION

Overall, findings suggest that clinical providers and parents may wish to prioritize improved sleep duration in the management of OW/OB risk in youth with ADHD.

An Expanded Approach to the Ascertainment of Children and Youth With Special Health Care Needs

OBJECTIVE

To describe the prevalence, characteristics, and health-related outcomes of children with diagnosed health conditions and functional difficulties who do not meet criteria for having a special health care need based on the traditional scoring of the Children with Special Health Care Needs (CSHCN) Screener.

METHODS

Data come from the 2016 to 2021 National Survey of Children's Health (n = 225 443). Child characteristics and health-related outcomes were compared among 4 mutually exclusive groups defined by CSHCN Screener criteria and the presence of both conditions and difficulties.

RESULTS

Among children who do not qualify as children and youth with special health care needs (CYSHCN) on the CSHCN Screener, 6.8% had ≥1 condition and ≥1 difficulty. These children were more likely than CYSHCN to be younger, female, Hispanic, uninsured, privately insured, living in a household with low educational attainment, have families with more children and a primary household language other than English. After adjustment, non-CYSHCN with ≥1 conditions and ≥1 difficulty were less likely than CYSHCN, but significantly more likely than other non-CYSHCN, to have ≥2 emergency department visits, have unmet health care needs, not meet flourishing criteria, live in families that experienced child health-related employment impacts and frustration accessing services. Including these children in the calculation of CYSHCN prevalence increases the national estimate from 19.1% to 24.6%.

CONCLUSIONS

Approximately 4 million children have both a diagnosed health condition and functional difficulties but are not identified as CYSHCN. An expanded approach to identify CYSHCN may better align program and policy with population needs.

Pediatric Mental Health Care and Scope-of-Practice Expansions

To examine the association between psychologist and nurse practitioner scope-of-practice (SoP) regulations and pediatric mental health service access. A nationally representative sample of children with mental health needs was identified using 5 years of National Survey of Children's Health (2016-2020). Utilization was measured in two ways: (1) unmet mental health care needs and (2) receipt of mental health medication. Expanded SoP for psychologists and nurse practitioners was measured based on the child's state of residence and the year of the survey. The associations between both SoP expansion and both outcomes were assessed using logistic regression models adjusted for multiple covariates. The probability of having unmet mental health needs was 5.4 percentage points lower (95% CI - 0.102, - 0.006) for children living in a state with psychologist SoP expansion; however, there was no significant difference in unmet mental health needs between states with and without NP SoP expansion. The probability of receiving a mental health medication was 2.0 percentage points higher (95% CI 0.007, 0.034) for children living in a state with psychologist SoP expansion. Conversely, the probability of receiving a mental health medication was 1.5 percentage points lower (95% CI - 0.023, - 0.007) for children living in a state with NP SoP expansion. Expanded SoP for psychologists is associated with improved access to pediatric mental health care in terms of both unmet need and receiving medication. Expanded SoP for NPs, however, was not associated with unmet need and lower receipt of medication.

Association between Adverse Childhood Experiences and Unmet Health Care Needs among Children in the United States

Although studies have investigated and found an association between adverse childhood experiences and poor health and mental health outcomes, there is a dearth of studies investigating the association between adverse childhood experiences and unmet health care needs among children. The objective of this study is to examine the association between adverse childhood experiences and unmet health care needs after adjusting for predisposing, enabling, and need factors of health care service utilization. Data for this study came from the 2016-2017 National Survey of Children's Health. An analytic sample of 46,081 children (51.3% males; average age 11.5 years) was analyzed using negative binomial regression. Based on parent reports, about 3.5% of children had unmet health care needs, and half (50%) of the sample had experienced at least one childhood adversity. Controlling for other factors, children who experienced three or more childhood adversities had 4.51 times higher odds of having unmet health care needs (AOR = 4.51, p < .001, 95% CI = 3.15-6.45) when compared to their counterparts with no childhood adversity. Children with parents who have someone to turn to for everyday emotional support were 31% less likely to have unmet health care needs (AOR = .69, p < .01, 95% CI = .54-.89). Adverse childhood experiences have a detrimental effect on unmet health care needs. The findings of this study offer an important opportunity for further research on how best to prevent adverse childhood experiences and mitigate their impact on families.

Spending on public benefit programs and exposure to adverse childhood experiences

BACKGROUND

Adverse childhood experiences are associated with poverty, and public benefit programs are increasingly used as primary prevention for negative child outcomes.

OBJECTIVE

To estimate the association between spending on benefit programs and cumulative exposure to ACEs among children.

PARTICIPANTS AND SETTING

Children aged 0-17 years in the United States during 2016-17 as reported in National Survey of Children's Health.

METHODS

We examined the sum of state and federal spending on 5 categories of public benefit programs at the state-level. The primary exposure was mean annual spending per person living below the Federal poverty limit across 2010-2017 Federal fiscal years. The primary outcome was children <18 years old having ever been exposed to ≥ 4 ACEs.

RESULTS

Nationally, 5.7 % (95 % confidence interval [CI] 5.3 % - 6.0 %) of children had exposure to ≥ 4 ACEs. After adjustment for children's race and ethnicity, total spending on benefit programs was associated with lower exposure to ≥ 4 ACEs (odds 0.96 [95 % CI: 0.95, 0.97]; p < 0.001). Increased spending in each individual benefit category was also associated with decreased cumulative ACEs exposure (all p < 0.05). Inverse associations were largely consistent when children were stratified by race and ethnicity and income strata.

CONCLUSIONS

Investments in public benefit programs may not only decrease poverty but also have broad positive effects on near- and long-term child well-being beyond the programs' stated objectives. Findings support federal and state efforts to prioritize families' economic stability as part of a public health model to prevent ACEs.

Parent Gender and Assessment of Children's Health

Caregiver-reported data on children's health are typically provided by mothers. We investigated whether measures of children's health would significantly differ between mother and father respondents to a nationally representative survey. This study used de-identified data on children age 0 to 17 years from the 2016-2019 National Survey of Children's Health (NSCH). The primary exposure was whether the survey was completed by the child's father (cases) or mother (controls). Outcome variables included general health, special health care needs (SHCN), and unmet health care needs. We identified 85 191 children meeting inclusion criteria, of whom 35.1% had a father respondent. After propensity score matching, 27 738 children with a father respondent were matched to an equal size group of children with a mother respondent. On conditional logistic regression analysis of the matched sample, we found that poor health, SHCN, and unmet health care needs were less likely to be reported for children in the sample by father respondents.

Gaps in the Vision Screening Pathway for School-Aged US Children

This cross-sectional study uses a nationally representative survey of the US pediatric population to identify gaps in the vision screening pathway.

Psychometrics of psychosocial behavior items under age 6 years: Evidence from Nebraska, USA

Because healthy psychosocial development in the first years of life is critical to lifelong well-being, governmental, and nongovernmental organizations are increasingly interested in monitoring psychosocial behaviors among populations of children. In response, the World Health Organization is developing the Global Scales of Early Development Psychosocial Form (GSED PF) to facilitate population-level psychosocial monitoring. Once validated, the GSED PF will be an open-access, caregiver-reported measure of children's psychosocial behaviors that is appropriate for infants and young children. This study examines the psychometric validity evidence from 45 items under consideration for inclusion in the GSED PF. Using data from N = 836 Nebraskan (USA) children aged 180 days to 71 months, results indicate that scores from 44 of the 45 (98%) items exhibit positive evidence of validity and reliability. A bifactor model with one general factor and five specific factors best fit the data, exhibited strong reliability, and acceptable model fit. Criterion associations with known predictors of children's psychosocial behaviors were in the expected direction. These findings suggest that measurement of children's psychosocial behaviors may be feasible, at least in the United States. Data from more culturally and linguistically diverse settings is needed to assess these items for global monitoring.

Adverse Social Determinants of Health and Gaps in Care Coordination Among Children

Gaps in care coordination (CC) can have detrimental impacts on children's health. It is unclear how much adverse social determinants of health (SDoH) may affect CC gaps. We determined whether exposure to adverse SDoH is associated with experiencing more gaps in CC using a representative national sample of children. Children with inadequate or no health insurance (adjusted odds ratio [aOR] = 2.41; 95% confidence interval [CI], 2.19-2.66) and living in disadvantaged neighborhoods (aOR = 1.53; 95% CI, 1.33-1.75) have a higher likelihood of having gaps in CC, as do those with higher counts of adverse SDoH (aOR = 2.17; 95% CI, 1.85-2.53). Thus, interventions to improve CC for children should consider adverse SDoH.

Childcare Disruptions and Parental Stress During the COVID-19 Pandemic

OBJECTIVE

Families in the United States experienced tremendous disruptions during the COVID-19 pandemic. This study evaluated the relationship of parental stress during the pandemic with interruptions in availability of services (childcare, after-school activities, and medical appointments) for children.

METHODS

We analyzed data from 2 waves of the Measuring the Impact of Violence Against Children and Women During a Pandemic survey 1 to develop a multivariable logistic regression model of the association between caregivers' stress and pandemic-related disruptions in children's lives. Caregivers' past experiences of childhood abuse, recommended stress-relieving activities, and responses to the statement "helping my child(ren) with their education, including remote schoolwork, has been very stressful and/or has resulted in increased tension at home" were included as covariates. Demographic and socioeconomic variables were examined as potential confounders.

RESULTS

In total, 3479 (73.3%) of 4659 respondents reported feeling stressed since the start of the pandemic. For every one-item increase in the number of COVID disruptions in children's lives, the odds of feeling stressed increased by 20% (OR 1.20: p value < 0.0001, 95% confidence interval [CI], 1.14-1.27). Compared with men, women had 60% higher odds of feeling stressed (odds ratio [OR] 1.60: p value < 0.0001, 95% CI, 1.32-1.93). The covariates listed earlier were all statistically significant.

CONCLUSION

Pandemic-related disruptions in children's lives were significantly associated with caregiver stress. Women were more likely to feel stressed than men. Sex, education, marital status, and family income were also associated with parental stress. These results suggest that childcare continuity and parental support should be part of disaster planning.

Family Support Services and Reported Parent Coping Among Caregivers of Children with Emotional, Behavioral, or Developmental Disorders

OBJECTIVE

Caregivers of children with special health care needs (CSHCN) experience substantial strain caring for their child's special needs because of high needs for health and other support services. Caregivers of CSHCN with emotional, behavioral, or developmental problems (EBDPs) report stress and poor mental health at higher rates than caregivers of other CSHCN. Although family support services are associated with caregiver mental health and well-being among families of CSHCN, the association of these factors with caregiver coping has been underexamined.

METHOD

Using the Double ABCX Model of Family Adaptation to guide variable selection, this study uses 2016 to 2019 data from the National Survey of Children's Health. Univariate, bivariate, and multivariate logistic analyses examined the association between caregivers' receipt of adequate care coordination and emotional support services and their reported coping with the day-to-day strains of parenting. These relationships are compared between caregivers of CSHCN with and without EBDPs.

RESULTS

Receipt of adequate care coordination was associated with higher rates of caregiver-reported positive coping for all caregivers of CSHCN who have no source of emotional support. Receipt of emotional support services was associated with increased reports of positive coping for caregivers for all CSHCN as well. Caregivers reporting only informal sources of emotional support, however, also reported higher rates of positive coping when compared with caregivers with no source of emotional support.

CONCLUSION

Mobilization of resources that can aid caregivers in coordinating care and provide emotional support may play a key role in positive caregiver coping for families of CSHCN.

Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design

IMPORTANCE

Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER-Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads.

METHODS

RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators.

DISCUSSION

RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero.

CLINICAL TRIALS.GOV IDENTIFIER

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.

Immediate Caregiving Environment of Young Children with Autism: Findings from the U.S. National Survey of Children's Health

Autism spectrum disorder (ASD) is a complex neurodevelopmental disability that negatively affects children's learning, motor behavior, social communication, and interaction. It was estimated that, in 2020, 1 in 36 children aged 8 years in the United States had ASD. Caring for children with ASD might exert significant psychological and emotional distress on parents. Receiving parental emotional support and fostering positive parent-child interactions at home have been identified as beneficial for the immediate caregiving environment for children with ASD. The current secondary analysis of the 2019-2020 National Survey of Children's Health examined parent-child interactions and accessible sources of emotional support for parents caring for 3-5-year-old children diagnosed with ASD (N = 243). Children with the following characteristics had higher odds of having ASD: male gender; having no private insurance or uninsured; and having less than excellent general health. Among parents, higher odds of caring for children with ASD were associated with accessing emotional support from various sources, especially from healthcare professionals and peers, and spending more time telling stories and/or singing to their children. Given these significant health disparities, educational interventions and strategies are needed to foster a positive home caregiving environment for young children with ASD, including equitable access to parent resources.

Association Between Socioeconomic Status and Prevalence of Hypersensitivity Diseases and Autism: A Nationwide Study of Children

OBJECTIVE

Prior research suggests that children with a low socioeconomic status (SES) background are at an increased risk for special healthcare needs. Conversely, for hypersensitivity-related diseases, many studies reported a lower risk among children with lower SES according to the hygiene hypothesis. We aimed to evaluate the association between SES and several hypersensitivity diseases and autism in a representative American sample.

METHODS

We used data from the 2016, 2017 and 2018 US National Survey of Children's Health. A total of 102,341 children aged 0-17 years were included. The dependent variables were doctor-diagnosed allergies, arthritis, asthma, diabetes, and autism. The main SES indicators were family poverty levels, highest education of the reported adults and difficulty in family income. Our analysis used logistic regression that accounted for the survey sampling design.

RESULTS

The sample had a mean age of 9.4 ± 5.3 years. The weighted prevalence for allergies was 24.4%, 0.3% for arthritis, 11.9% for asthma, 0.5% for diabetes and 2.6% for autism. Children with adults reporting higher educational levels had greater odds of allergies (adjusted odds ratio and 95% CI: 1.48, 1.23-1.78) than those with lower educational levels. But for all other diseases, most findings suggested that a higher odds of disease was associated with lower SES instead of higher SES.

CONCLUSIONS

A low SES background remains an important risk factor for hypersensitivity diseases in children. Most of our results suggested that children with low SES were associated with a higher risk of hypersensitivity diseases and autism.

Health Insurance Coverage Gaps Among Children With a History of Adversity

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

Resilience in development: Neighborhood context, experiences of discrimination, and children's mental health

An understanding of child psychopathology and resilience requires attention to the nested and interconnected systems and contexts that shape children's experiences and health outcomes. In this study, we draw on data from the National Survey of Children's Health, 2016 to 2021 (n = 182,375 children, ages 3- to 17 years) to examine associations between community social capital and neighborhood resources and children's internalizing and externalizing problems, and whether these associations were moderated by experiences of racial discrimination. Study outcomes were caregiver-report of current internalizing and externalizing problems. Using logistic regression models adjusted for sociodemographic characteristics of the child and household, higher levels of community social capital were associated with a lower risk of children's depression, anxiety, and behaviors. Notably, we observed similar associations between neighborhood resources and child mental health for depression only. In models stratified by the child's experience of racial/ethnic discrimination, the protective benefits of community social capital were specific to those children who did not experience racial discrimination. Our results illustrate heterogeneous associations between community social capital and children's mental health that differ based on interpersonal experiences of racial/ethnic discrimination, illustrating the importance of a multilevel framework to promote child wellbeing.

Factors associated with unmet pediatric health care needs during the coronavirus pandemic

PURPOSE

To examine risk factors for unmet pediatric health care needs during the coronavirus pandemic in a national sample of US children under 17 years of age.

DESIGN AND METHODS

In this cross-sectional study, we used data from the 2021 National Survey of Children's Health (n = 50,892). Unmet pediatric health care needs were assessed as follows: "during the past 12 months, was there any time when this child needed health care but it was not received?". Logistic regression with multiple imputations was used to evaluate bivariate and multivariable associations between predisposing, enabling, and need factors of health care services use and unmet pediatric health care needs.

RESULTS

Approximately 3.6% of children had unmet health care needs, with significant differences by sample characteristics. Unmet health care needs were notably prevalent among select groups, including children with difficulty covering basic needs (10.6%) and those with ≥2 health conditions (8.9%). In multivariable analyses, factors associated with unmet pediatric health care needs included predisposing factors such as older age, ≥2 children with special health care needs in the household, primary language other than English or Spanish, and poor caregiver health; enabling factors such as difficulty covering basic needs, no insurance, and no personal doctor or nurse; and need factors such as poor perceived or evaluated child health. Reasons for unmet needs included financial, nonfinancial, and accessibility barriers.

CONCLUSIONS

Several factors were associated with unmet health care needs.

PRACTICE IMPLICATIONS

We identified children who would benefit from targeted interventions aimed at promoting health care services use.

Positive Early Childhood Experiences and School Readiness among US Preschoolers

OBJECTIVES

To characterize the relationship between positive early childhood experiences (PECEs) and school readiness, and assess whether the PECEs-school readiness relationship was robust to and/or differed across levels of adverse childhood experiences (ACEs).

METHODS

We analyzed national data on children ages 3-5 from 2016 to 2020 (n = 26 871) to examine associations between key PECE domains (nurturing relationships, home learning opportunities, safe and stable environments, and family routines) with being on track for school readiness, defined using a pilot, multidimensional measure called "healthy and ready to learn". Weighted univariate, bivariate, and multivariable analyses were conducted to generate nationally representative estimates. Multivariable models adjusted for sociodemographic factors and were assessed both with and without cumulative ACE exposure.

RESULTS

Two-fifths of children were healthy and ready to learn. Exposure to PECEs was associated with higher school readiness, irrespective of relative ACE exposure. Compared with those with low PECEs, children with moderate (aOR, 2.19; 95% CI, 1.86-2.58) and high (aOR, 4.37; 95% CI, 3.58-5.34) PECEs had greater odds for being healthy and ready to learn, net of both sociodemographic factors and ACE exposure. Significant associations were robust across demographic groups (eg, race and ethnicity), ACE levels, and ACE types (eg, parental incarceration).

CONCLUSIONS

Increasing PECEs correspond with greater likelihood of possessing capacities key for school functioning, even amidst ACEs. In concert with efforts to ameliorate early life trauma, caregivers, health care providers, educators, and systems can consider boosting PECEs to foster healthy development in childhood and beyond.

The association between parent-child quality time and children's flourishing level

PURPOSE

Few studies have examined the association between parental quality time and flourishing measures in young children. This study explored the association between parental quality time and children's flourishing in a national sample of USA children 1-5 years of age.

DESIGN AND METHODS

A cross sectional study using data from the 2019-2020 National Survey of Children's Health (N = 17,855). Flourishing was measured with a composite score (values 0-4) derived from 4 questions on attachment with parent, resilience, learning, and contentment with life. Having all 4 items was optimal. Parent-child quality time per week was measured with 3 items: singing or storytelling, reading to child, and family meal with child; using a 4-point scale: 0 days, 1-3 days, 4-6 days, and every day/week. Multivariable logistic regression models were conducted to assess the odds of lower flourishing in SAS 9.4.

RESULTS

After controlling for confounding, only the lack of singing and storytelling were negatively associated with greater odds of lower levels of flourishing (0-2 items OR = 5.06, 95% CI 2.11-12.14; 3 items OR = 2.92, 95% CI 1.73-4.93).

CONCLUSIONS

Insufficient parent-child quality time is associated with lower flourishing levels. Fostering parental opportunities to engage in weekly quality time with their children should be a priority of child health programs seeking to improve child flourishing.

PRACTICE IMPLICATIONS

Nurses should provide guidance to parents on ways to nurture quality family time and promote children's psychosocial, environmental, and physical well-being. Nurses can advocate for programmatic and policy changes to ensure familial work/life balance and licensing/accreditation of all child centers.

Vision Testing for Adolescents in the US

Importance

Untreated refractive error contributes to the racial, ethnic, and socioeconomic disparities in visual function of adolescent children in the US.

Objective

To describe patterns in vision testing as a function of age among US adolescents and identify sociodemographic factors associated with vision testing.

Design, Setting, and Participants

This cross-sectional study used data from the National Survey of Children's Health (2018-2019), a nationally representative survey of the noninstitutionalized US pediatric population. A total of 24 752 adolescent children (aged 12 to <18 years) were included. Data were analyzed from March 22 to August 11, 2023.

Main Outcomes and Measures

The primary outcome was the caregiver report of vision testing within the last 12 months. Linear regression was used to describe the patterns in reported vision testing as a function of participant age. Logistic regression was used to describe the association of sociodemographic factors with the report of vision testing in each setting.

Results

Among 24 752 adolescents, the median (IQR) age was 14 (13-16) years; 12 918 (weighted, 51%) were male. Vision testing in any setting within the previous year was reported by caregivers of 18 621 adolescents (weighted, 74%). Vision testing was reported to have occurred at an eye clinic in 13 323 participants (weighted, 51%), at a primary care clinic in 5230 participants (weighted, 22%), at a school in 2594 participants (weighted, 11%), and at a health center in 635 participants (weighted, 4%). The percentage of adolescents reported to have vision tested decreased with age (-1.3% per year; 95% CI, -2.5% to 0% per year) due to a decrease in testing in primary care and school settings. After adjusting for age and sex, there were lower odds of vision testing reported for adolescents who were uninsured vs insured (adjusted odds ratio [AOR], 0.81; 95% CI, 0.76-0.87), had caregivers with less than vs greater than high school education (AOR, 0.89; 95% CI, 0.84-0.95), and were from a family born outside vs inside the US (AOR, 0.90; 95% CI, 0.82-0.98).

Conclusions and Relevance

In this cross-sectional study, vision testing in adolescents decreased as a function of age due to fewer reported tests performed in primary care and school-based settings. Relative to children in socioeconomically advantaged families, those from disadvantaged families were less likely to report receiving vision testing in clinical settings. Efforts to expand the role of school-based vision testing for older adolescents from disadvantaged backgrounds may enable opportunities to address disparities in untreated refractive error.

Parents' Perspectives in Accessing Psychiatric Residential Treatment for Children and Youth: Differential Experiences by Funding Source

Objective

There are well-documented disparities in access to mental health care for children and youth with significant behavioral health needs. Few studies that explored the differential experiences of families who use private vs public sources of financing (i.e., insurance and funding) in accessing residential treatment (RT) for children and youth. This study aimed to examine the lived experiences of families accessing psychiatric residential treatment (RT) and contextualize these experiences based on source of financing.

Methods

Twenty parents completed two interviews about their experiences with RT including the process for gaining access, length of stay, and aftercare. Parents were also asked about barriers (e.g., custody relinquishment), and facilitators (e.g., policies in the state) to accessing RT. Data were analyzed using content analysis.

Results

There were three distinct groups of families in the study. The first group includes lower income families whose children had public health coverage before needing RT. The second group comprises middle-income families whose children had private coverage but lived in states where there were no RTs that accepted private insurance or private payment and who did not have the means to send their child to RT in another state. The final group included higher income families with private insurance and enough private resources to overcome the limitations of insurance and state policies. This study illuminates key barriers and hardships for families accessing RT: 1) waiting long waiting periods and navigating complex systems; 2) inadequate lengths of stay; and 3) inadequate aftercare and support in the community transition.

Conclusions

This study is among the first to examine how access to RT differs by whether a family has access to public or private resources. Taken together, these findings support the importance of insurance and financing for families accessing RT for their children and the need for systemic changes in policies and practices to reduce disparities in access.

A window of opportunity: Adverse childhood experiences and time alone with a provider in the United States

BACKGROUND

To date, there is limited literature on the relationship between Adverse Childhood Experiences (ACEs) and the quality of health care provider encounters. This is key, as people with a history of ACEs have a greater burden of illness.

METHODS

This study uses data from the 2020-2021 National Survey of Children's Health to examine relationships between ACEs and (1) spending less than ten minutes with a health care provider, and (2) spending time alone with a health care provider.

RESULTS

In general, our results suggested most ACEs were associated with higher odds of a provider spending <10 min with a child during their last preventative care visit, while ACEs were inconsistently related to spending time alone with a provider. Each additional ACE was found to be associated with higher odds of both outcomes.

CONCLUSIONS

This work emphasizes the importance of ACEs screening in a health care setting and may set the groundwork for future research investigating mechanisms within these associations. Given the established link between health care quality and patient-provider trust, and health outcomes, intervention work is needed to develop healthcare practices that may encourage the length and quality of health care provider visits.

Geographic variation and trends in prevalence of obesity among US adolescents, 2016-2021

OBJECTIVE

Recent updates of geographic variations, trends, and sociodemographic disparities in obesity prevalence among US adolescents are limited. The study aimed to fill those research gaps.

STUDY DESIGN

Serial cross-sectional analysis of the US nationally representative study.

METHODS

Data from six cycles of the National Survey of Children's Health (2016, 2017, 2018, 2019, 2020, and 2021) with information on physical health at the national and state level were used. A total of 107,274 adolescents aged 10-17 years old were included with sociodemographic data (age, sex, race/ethnicity, parental education level, and family income) and state of residence. Logistic regression models were used to estimate the odds ratios (ORs) associated with obesity across sociodemographic groups. In addition, ORs were calculated to compare obesity rates between the pandemic period (2020-2021) and the pre-pandemic period (2018-2019) overall and by sociodemographic subgroups. Survey analysis procedures were used to account for complex survey designs to derive representative estimates.

RESULTS

From 2016 to 2021, obesity prevalence increased from 16.1% (95% confidence interval [CI], 14.9%-17.4%) to 17.6% (95% CI, 16.4%-18.9%) (P-trend = 0.04). The combined prevalence of obesity varies substantially by state, from 9.34% (95% CI, 6.96%-12.4%; Colorado) to 27.1% (95% CI, 23.1%-31.5%; Mississippi) for adolescents aged 10-13 years and ranged from 9.86% (95% CI, 7.63%-12.7%; Utah) to 22.4% (95% CI, 19.0%-26.1%; West Virginia) for adolescents aged 14-17 years. Except for subgroups male gender and parents with college degrees or above, the prevalence of obesity showed stable trends across sociodemographic subgroups. Compared to the pre-pandemic period, the multivariable-adjusted ORs of obesity were 1.18 (95% CI, 1.06-1.32) for male adolescents, 1.16 (95% CI, 1.04-1.28) for non-Hispanic White adolescents, 1.81 (95% CI, 1.15-2.84) for non-Hispanic Asian adolescents, 1.26 (95% CI, 1.05-1.52) for adolescents whose parents had a high school education, and 1.15 (95% CI, 1.0-1.33) for adolescents whose parents had a college degree or higher.

CONCLUSIONS

The prevalence of obesity among US adolescents increased significantly between 2016 and 2021. The prevalence of obesity was relatively high in southern states. Those with low household income, low parental education, or being non-Hispanic Black or Hispanic were also more likely to be obese. Compared to the pre-pandemic period, several groups of adolescents increased their likelihood of obesity during the pandemic period.

Understanding the Impact of Insufficient Sleep in Children with Behavior Problems on Caregiver Stress: Results from a U.S. National Study

Research indicates strong connections between child ADHD, child ODD/CD, and sleep. Children experiencing these concerns also have caregivers who report feeling more stress. However, no studies have examined how child ADHD and ODD/CD interact together and with insufficient sleep to potentially exacerbate caregiver stress. Data were acquired from the 2018/2019 National Survey of Children's Health, a nationally representative survey of parents or caregivers conducted across the United States (U.S.). The current study used data for children 6-17 years old with a final analytic sample size of 41,541, representing a total of 47,357,862 U.S. youth. Overall child ADHD and ODD/CD were each uniquely associated with increased caregiver stress, while adequate child sleep duration was related to decreased caregiver stress. However, these findings were qualified by a significant two-way interaction that revealed that caregiver stress among children with comorbid ADHD and ODD/CD was not significantly greater than that of children with ODD/CD alone. Significant interactions between sleep and ODD/CD on caregiver stress were generally not observed, except potentially in females with ADHD. Our findings underscore the importance of considering strategies to reduce both youth symptoms and caregiver stress simultaneously. Additionally, ensuring adequate sleep for all children is recommended.

Socioecologic Factors Associated With Obesity in Adolescents With Epilepsy in the United States

BACKGROUND

Obesity among youth with epilepsy has multifactorial etiology, yet socioecologic obesity risk factors (eg, neighborhood factors) have not been examined in this population. This study examined (1) the prevalence of obesity adjusting for relevant covariates and (2) socioecologic correlates of obesity in adolescents with epilepsy aged 10-17 years.

METHODS

This cross-sectional study used 2017-2018 National Survey of Children's Health data (total n = 27,094; epilepsy n = 184). Chi-square tests compared weighted prevalence of obesity with relevant covariates among all adolescents and adolescents with epilepsy. Weighted multiple logistic regression models were conducted to adjust for covariates.

RESULTS

The prevalence of obesity in adolescents with epilepsy was 27.8% (95% confidence interval [CI] 15.4%-40.3%) vs 15.1% (95% CI 14.1%-16.2%) for the non-epilepsy group. Adolescents with epilepsy also had higher odds of obesity after adjusting for age, gender, race/ethnicity, household income, physical activity, and medical home (odds ratio [OR] 2.1, 95% CI 1.2-3.8). Adjusting for sociodemographics, anxiety (OR 4.5, 95% CI 1.3-15.6), 2 or more adverse childhood experiences (OR 7.3, 95% CI 1.6-33.4), neighborhood detracting elements (eg, OR 5.2, 95% CI 1.5-18.5 for 1 detracting element), and forgone care (ie, unmet health care needs) (OR 22.4, 95% CI 3.8-132.8) were associated with obesity in adolescents with epilepsy. Adjusting for multiple comparisons, neighborhood detracting elements (P < .0001) and forgone care (P < .0007) remained significant.

CONCLUSION

Variables related to mental health, family functioning, built environment, and forgone care were associated with obesity in adolescents with epilepsy, but the association was not fully explained by these factors. Obesity interventions for this population should consider multiple levels of influence including the community and special health care needs of this population.

Adverse Childhood Experiences and Family-Centered Care

Adverse Childhood Experiences (ACEs) include experiences of child maltreatment and household dysfunction. Prior work has shown that children with ACEs may have suboptimal utilization of preventive health care, including annual well-visits, however little is known about the relationship between ACEs and quality of patient care. Using data from the 2020 National Survey of Children's Health (N = 22,760) a series of logistic regression models estimated associations between ACEs, both individually and cumulatively, and five components of family-centered care. Most ACEs were consistently associated with lower odds of family-centered care (e.g. financial hardship was associated with doctors always spend enough time with children, AOR = 0.53; 95% CI = 0.47, 0.61), except for having a parent or guardian die, which was associated with higher odds. Cumulative ACE score was also associated with lower odds of family-centered care (e.g. doctors always listened carefully to the parent, AOR = 0.86; 95% CI = 0.81, 0.90). These findings emphasize the importance of the consideration of ACEs in the context of family-centered care, and support the need for ACEs screening in the clinical setting. Future work should focus on mechanisms explaining the observed associations.

The Children, Caregivers, and Community (C3) study of together growing strong: A protocol for an observational, place-based initiative in Sunset Park, Brooklyn

Reaching population-level impact for families in poverty requires moving beyond a sole focus on individuals, to a wider focus on interactions between individuals and their broader environmental contexts. Place-based initiatives have emerged as a policy response to promote community-level change around these broader interactions between individuals and their local communities through addressing long-standing disparities in housing, employment, education, and health. Together Growing Strong (TGS) is one such place-based initiative focused on transforming the health, wellbeing, and development of young children and their families in Sunset Park, Brooklyn. The Children, Caregivers, and Community (C3) Study is an outcomes-based study designed to assess the trajectories of children and families in Sunset Park along indicators such as family health and wellbeing and child development in relation to TGS program participation. The aims, scope, and protocol of the C3 Study are the subjects of this paper.

Emotional Support Among Parents of Children With Adverse Childhood Experiences

INTRODUCTION

We assess the association between a child's exposure to adverse childhood experiences (ACEs) and the parent's current experiences of emotional support.

METHOD

This study used pooled cross-sectional data from the National Survey of Children's Health (N = 129,988). Emotional support for the parent was classified by the presence (any emotional support, no emotional support) and type (any formal support or only informal support). All models were adjusted for relevant predisposing, enabling, and need factors.

RESULTS

Having two or more ACEs was associated with a higher probability of any emotional support (average marginal effect = 0.017; 95% confidence interval = 0.002-0.032) and a higher probability of formal support (average marginal effect = 0.049; 95% confidence interval = 0.028-0.069). Several individual ACEs were associated with the presence and type of emotional support.

DISCUSSION

Parents of children with higher ACEs are likelier to have emotional support, especially formal support.

Scaling Family Voices and Engagement to Measure and Improve Systems Performance and Whole Child Health: Progress and Lessons from the Child and Adolescent Health Measurement Initiative

BACKGROUND

The 1997 legislation authorizing the United States Child Health Insurance Program sparked progress to measure and publicly report on children's healthcare services quality and system performance. To meet the moment, the national Child and Adolescent Health Measurement Initiative (CAHMI) public-private collaboration was launched to put families at the center of defining, measuring and using healthcare performance information to drive improved services quality and outcomes.

METHODS

Since 1996 the CAHMI followed an intentional path of collaborative action to (1) articulate shared goals for child health and advance a comprehensive, life-course and outcomes-based healthcare performance measurement and reporting framework; (2) collaborate with families, providers, payers and government agencies to specify, validate and support national, state and local use of dozens of framework aligned measures; (3) create novel public-facing digital data query, collection and reporting tools that liberate data findings for use by families, providers, advocates, policymakers, the media and researchers (Data Resource Center, Well Visit Planner); and (4) generate field building research and systems change agendas and frameworks (Prioritizing Possibilities, Engagement In Action) to catalyze prevention, flourishing and healing centered, trauma-informed, whole child and family engaged approaches, integrated systems and supportive financing and policies.

CONCLUSIONS

Lessons call for a restored, sustainable family and community engaged measurement infrastructure, public activation campaigns, and undeterred federal, state and systems leadership that implement policies to incentivize, resource, measure and remove barriers to integrated systems of care that scale family engagement to equitably promote whole child, youth and family well-being. Population health requires effective family engagement.

Infant feeding practices and autism spectrum disorder in US children aged 2-5 years: the national survey of children's health (NSCH) 2016-2020

OBJECTIVE

To investigate the relationship between infant feeding practices and autism spectrum disorder (ASD) among children aged 2-5 years in the United States (US).

METHODS

Data from the 2016-2020 National Survey of Children's Health, a nationally representative cross-sectional survey, were utilized for this study. Questionnaires were administered to parents of children aged 2-5 years to gather information on ASD diagnosis, infant feeding practices, and demographic factors (e.g., child sex, ethnic group, and maternal age at birth). Logistic regression with sample weights was employed to assess the association between infant feeding practices and ASD, while controlling for demographic variables. Polynomial regression models were used to examine trends in exclusive breastfeeding and ever breastfeeding rates among children with and without ASD.

RESULTS

A total of 35,050 children aged 2-5 years were analyzed, including 616 diagnosed with ASD, after excluding participants with missing information on breastfeeding and ASD diagnosis. Of these children with ASD, 76.6% (n = 472) had a breastfeeding history, with 67.5% (n = 416) engaged in partial breastfeeding and 9.1% (n = 56) exclusively breastfed. Adjusted odds ratios for each additional month of breastfeeding compared to never being breastfed were 0.98 (95% CI, 0.96-1.01). The adjusted odds ratios for breastfeeding durations of > 0-6 months, > 6-12 months, > 12-24 months, and > 24 months were 0.81 (95% CI, 0.50-1.31), 0.65 (95% CI, 0.36-1.18), 0.81 (95% CI, 0.44-1.49), and 0.48 (95% CI, 0.23-1.01), respectively. Compared to children who were never breastfed, the adjusted odds ratio for children who were ever breastfed was 0.74 (95% CI, 0.47-1.18). Among children with ASD, the proportion of ever breastfeeding declined from 82.0% in 2017 to 64.3% in 2020, while exclusive breastfeeding decreased from 12.0% in 2016 to 4.2% in 2020.

CONCLUSIONS AND RELEVANCE

Although no significant association was found between infant feeding practices and ASD among US children aged 2-5 years, the rates of breastfeeding, particularly exclusive breastfeeding, were suboptimal among children with ASD. This highlights the need for specific policies and practices to promote and support breastfeeding among parents of children with ASD or those at high risk of having a child with ASD.

Socioeconomic and Racial/Ethnic Disparities in Recovery from Childhood Behavioral or Conduct Problems: Evidence from a Nationally Representative Sample of 3-17 Years Old US Children

Our study provides nationally-generalizable evidence on the racial/ethnic and socioeconomic disparities in diagnosis and recovery from childhood behavioral or conduct problems. We pooled data from 4 years (2016-2019) of the National Survey of Children's Health (NSCH) for 3 to 17 years old US children (N = 114,476). We performed several logistic regression models using complex survey data analysis statistical methodologies to estimate nationally representative and generalizable results in the Stata MP 16 program. About 20.1% of 3-17 years old US children previously diagnosed with behavioral or conduct problems no longer had the current diagnosis (were recovered). Hispanic children [Odds ratio (OR) 0.77, 95% Confidence Interval (CI) 0.65-0-95], immigrant children or children of immigrant parents (first or second generation immigrant children), and children from high-income families [200-399% Federal Poverty Level (FPL)] were about 23%, 38%, and 21% less likely than non-Hispanic White children, children of US native parents, and children with a family income of below 100% FPL to be currently diagnosed with behavioral or conduct problems, respectively. Conversely, Non-Hispanic Black and Hispanic children were about 50% and 40% more likely than non-Hispanic White children to recover from a past diagnosis. Moreover, children from higher-income families (at or above 300% of FPL) were between 1.59 to 1.79 times more likely than those from low-income families (below 100% FPL) to recover from a past diagnosis. Racial/ethnic and socioeconomic disparities in diagnosing appear to persist in recovering from behavioral or conduct problems.

Parent Ratings of Health Insurance Adequacy for Children with Emotional, Behavioral, or Developmental Problems

OBJECTIVE

Parents of children with special health care needs (CSHCN) report that private insurance is less adequate than public health coverage. Parents of CSHCN with emotional, behavioral, or developmental problems (EBDPs) may perceive private insurance to be especially inadequate due to higher need for a wider array of non-medical services and supports. This study's objective is to assess differences in parent ratings of insurance adequacy for public versus private health coverage between non-CSHCN, CSHCN, and CSHCN with EBDPs.

METHODS

This study pooled publicly available data from the 2016 through 2019 National Survey of Children's Health. Multivariable fixed effects logistic regression models estimated the association between insurance type, CSCHN and EBDP status, and parent ratings of their child's insurance adequacy. Marginal effects were calculated for insurance type, CSHCN and EBDP status, and their interactions to estimate the size of the association.

RESULTS

Among all subgroups, consistently more parents with publicly insured children rated their insurance as adequate compared to those with private insurance. Parents of privately insured CSHCN with EBDPs rated their insurance as adequate at significantly lower rates than any other group of parents (55%)-including those with privately insured children without EBDPs (non-CSHCN= 67%; CSHCN = 63%) and all other parents with publicly insured children (non-CSHCN = 87%; CSHCN = 83%; CSHCN with EBDPs = 84%).

CONCLUSIONS

Future research should investigate if perceptions of insurance adequacy among families whose CSHCN has an EBDP aligns with reports of service access and unmet health care needs.

Racial and ethnic disparities in insufficient sleep among US in infants and preschoolers

OBJECTIVE

To examine racial and ethnic disparities and associated factors of insufficient sleep among children from infancy to preschool-aged.

METHODS

We analyzed parent-reported data on US children ages 4 months-5 years (n = 13,975) from the 2018 and 2019 National Survey of Children's Health. Children who slept less than the age-specific minimum hours recommended by the American Academy of Sleep Medicine were classified as having insufficient sleep. Logistic regression was used to estimate unadjusted and adjusted odds ratios (AOR).

RESULTS

An estimated 34.3% of children from infancy to preschool-aged experienced insufficient sleep. Socioeconomic factors (poverty [AOR] = 1.5, parents' education level [AORs] from 1.3 to 1.5); parent-child interaction variables (AORs from 1.4 to 1.6); breast feeding status (AOR = 1.5); family structure (AORs from 1.5 to 4.4); and weeknight bedtime regularity (AORs from 1.3 to 3.0) were significantly associated with having insufficient sleep. Non-Hispanic Black (OR = 3.2) and Hispanic children (OR = 1.6) had significantly higher odds of insufficient sleep compared to non-Hispanic White children. Racial and ethnic disparities in insufficient sleep between non-Hispanic White children and Hispanic children were largely attenuated by adjusting for social economic factors. However, the difference in insufficient sleep between non-Hispanic Black and non-Hispanic White children remains (AOR = 1.6) after adjusting socioeconomic and other factors.

CONCLUSIONS

More than one-third of the sample reported insufficient sleep. After adjusting for socio-demographic variables, racial disparities in insufficient sleep decreased but persistent disparities existed. Further research is warranted to examine other factors and develop interventions to address multilevel factors and improve sleep health among racial and ethnic minority group children.

Researching COVID to enhance recovery (RECOVER) pregnancy study: Rationale, objectives and design

Importance

Pregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER- Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads.

Methods

RECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators.

Discussion

RECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero.

Registration

NCT05172024.

The Australian Child Maltreatment Study (ACMS), a national survey of the prevalence of child maltreatment and its correlates: methodology

OBJECTIVES

To describe the aims, design, methodology, and respondent sample representativeness of the Australian Child Maltreatment Study (ACMS).

DESIGN, SETTING

Cross-sectional, retrospective survey; computer-assisted mobile telephone interviewing using random digit dialling (computer-generated), Australia, 9 April - 11 October 2021.

PARTICIPANTS

People aged 16 years or more. The target sample size was 8500 respondents: 3500 people aged 16-24 years and 1000 respondents each from five further age groups (25-34, 35-44, 45-54, 55-64, 65 years or more).

MAIN OUTCOME MEASURES

Primary outcomes: Emotional abuse, neglect, physical abuse, sexual abuse, exposure to domestic violence during childhood, assessed with the Juvenile Victimization Questionnaire-R2 Adapted Version (Australian Child Maltreatment Study).

SECONDARY OUTCOMES

selected mental disorder diagnoses (Mini International Neuropsychiatric Interview, MINI), selected physical health conditions, health risk behaviours, health service use.

RESULTS

The demographic characteristics of the ACMS sample were similar to those of the Australian population in 2016 with respect to gender, Indigenous status, region and remoteness category of residence, and marital status, but larger proportions of participants were born in Australia, lived in areas of higher socio-economic status, had tertiary qualifications, and had income greater than $1250 per week. Population weights were derived to adjust for these differences. Associations between the number of calls required to recruit participants and maltreatment rates and health outcomes were not statistically significant.

CONCLUSIONS

The ACMS provides the first reliable estimates of the prevalence of each type of child maltreatment in Australia. These estimates, and those of associated mental health and health risk behaviours reported in this supplement can inform policy and practice initiatives for reducing the prevalence of child maltreatment and its consequences. Our benchmark study also provides baseline data for repeated waves of the ACMS that will assess the effectiveness of these initiatives.

Did mental and emotional health of SNAP families' children improve during the COVID-19 pandemic?

The onset of the COVID-19 pandemic disproportionately affected low-income households in the United States. As part of the government's response to the pandemic, households with children participating in the Supplemental Nutrition Assistance Program (SNAP) benefited from several temporary provisions. This study examines whether the mental/emotional well-being of children in SNAP families was influenced by the SNAP temporary provisions, overall and across subpopulations by race/ethnicity and school meal programs (SMP) participation status of children. Cross-sectional data from the 2016-2020 National Survey of Children Health (NSCH) were used to study the occurrence of mental, emotional, developmental, or behavioral (MEDB) health of children (6-17 years) in SNAP families. Difference-in-Differences (DID) analyses were conducted to assess the association between MEDB health of children in SNAP families and the implementation of the SNAP provisions. Overall, finding show that between 2016 and 2020, children in SNAP families were more likely to face adverse MEDB conditions than children in non-SNAP families (p < 0.05). DID analyses indicate that children's MEDB health was not statistically affected following the first year of SNAP temporary provisions (p > 0.1). Additionally, no differential results were found by race/ethnicity of children or SMP participation (p > 0.1). Results are robust to the use of different well-being measures. These results suggest that SNAP provisions may have been associated with the reduction of the adverse effects of the pandemic on children's well-being.

Adverse Childhood Experiences Are Associated With Seizures in Children: A Cross-sectional Analysis

Background and Objective

To assess the relationship between adverse childhood experiences (ACE/ACEs) and epilepsy.

Methods

We performed a cross-sectional retrospective cohort analysis using population-based data from the 2018 and 2019 National Survey of Children's Health to examine caregiver-reported ACE exposures and their relationship to caregiver-reported physician diagnoses of epilepsy or seizure disorder in children. ACEs elicited in the survey included questions about experience of violence, household dysfunction, and food and housing insecurity. Adjusting for age, race, and income level, we used logistic regression to test the relationships between cumulative ACE score and current seizure disorder or epilepsy diagnosis and to examine which specific ACEs were individually associated with current seizure disorder or epilepsy diagnosis.

Results

The study population consisted of 59,963 participants; 52.2% were female, and 47.8% were male. Participant ages ranged from 0 to 17 years. A current diagnosis of epilepsy or seizure disorder was reported in 377 (0.63%) participants, and 22,749 (37.9%) participants had one or more ACE exposures. As the number of ACEs increased, odds of current epilepsy or seizure disorder diagnosis increased by 1.14 (95% confidence interval 1.07-1.22). Five ACE exposures demonstrated a high association with a current diagnosis of epilepsy or seizure disorder: food/housing insecurity, witnessing domestic violence, household mental illness, neighborhood violence, and parent/guardian incarceration.

Discussion

Multiple ACE exposures were individually associated with reporting a diagnosis of epilepsy or seizure disorder. An increase in cumulative ACE exposures increased odds of having current diagnosis of epilepsy or seizure disorder.

Over a Century of Leadership for Maternal and Child Health in the United States: An Updated History of the Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) is the only federal agency solely focused on improving the health and well-being of all of America's mothers, children, and families. Founded in 1912 as the Children's Bureau, the Bureau has evolved over 110 years in response to the changing needs of MCH populations and shifting legislative and administrative priorities. The Bureau's role in promoting and protecting maternal and child health has grown, spurred by landmark legislation including the Sheppard-Towner Maternity and Infancy Care Act, Title V of the Social Security Act, and multiple programmatic authorizations. Emerging issues in the field-ranging from deficiencies in access and coverage for health care to the emergence of new infectious diseases-have resulted in additional roles and responsibilities for the Bureau; these include convening state and national partners, providing leadership on priority topics, developing guidelines for care, and implementing new programs. Throughout its history, the Bureau has partnered with other federal government agencies, states, communities, and families to improve outcomes for mothers, children, and families. Previous reports have documented the founding of the Children's Bureau and the growth of federal legislation and programs through 1990. This updated history builds on those works and describes the multiple new programs and legislative authorities assigned to the Bureau since the Title V reforms of the 1980s, the Bureau's response to emerging issues, and the contemporary structure and function of MCHB.