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.

The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children

BACKGROUND

There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses.

METHOD

This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP).

RESULTS

The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers.

CONCLUSIONS

Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

School Readiness among U.S. Children: Results from the 2022 National Survey of Children's Health

OBJECTIVE

Provide the latest national and state estimates, and correlates of the proportion of young children who are Healthy and Ready to Learn (HRTL) using a revised measure from the National Survey of Children's Health (NSCH).

METHODS

Data were analyzed for 11,121 children ages 3-5 years from the 2022 NSCH, an address-based, parent-completed survey on the health and well-being of children in the US. A total of 27 items across 5 domains (Early Learning Skills, Social Emotional Development, Self-Regulation, Motor Development and Health) were used to calculate domain-specific assessments scored as 'On Track', 'Emerging', or 'Needs Support' according to age-appropriate developmental expectations. Children 'On Track' in 4-5 domains with no domain that 'Needs Support' were considered HRTL.

RESULTS

In 2022, 63.6% of 3- to 5-year-old children were HRTL. The proportion of children 'On Track' ranged from just over two-thirds for Early Learning Skills and Motor Development to 88.9% for Health. One million children, or 9.0%, needed support in multiple domains. Being HRTL was associated with child, family, community factors including participation in early childhood education, special health care needs status/type, male sex, reading/singing/storytelling by family members, Adverse Childhood Experiences, parental mental health and education, food insufficiency, outdoor play, household language, neighborhood amenities, rural residence, medical home access.

CONCLUSIONS

Nearly two-thirds of young children are reported to be HRTL, meeting the Title V National Outcome Measure for School Readiness. Using a revised measure, modifiable factors are identified which offer a range of intervention opportunities at the child, family, and community levels.

WHAT'S NEW

Research on school readiness has identified contextual factors as more important than sociodemographic characteristics. Interventions addressing multiple factors and emphasizing quality and duration yield greater impacts, but only if meaningfully extended to families with diverse needs and experiences.

Family-Centered Care and Flourishing in Early Childhood

INTRODUCTION

Flourishing reflects a child's ability to cope with stress and have positive relationships, which are critical to health and well-being. Pediatricians may increase flourishing in children through family-centered care, which is perceived as sensitive and responsive to specific child needs and family circumstances. The purpose of this study was to examine the relationship between family-centered care and flourishing in young children.

METHODS

Data from the 2019-2020 National Survey of Children's Health were used to examine the relationship among children aged 1-5 years (n=17,826). The relationship was explored using chi-square tests and sequential logistic regression modeling, controlling for family socioeconomics and adversity, race/ethnicity, child health, and other measures of healthcare quality. Analyses were conducted in January 2022.

RESULTS

Approximately 82% of young children were flourishing. After adjusting for all variables, receipt of family-centered care was the only measure of quality health care associated with an increased likelihood of flourishing in young children (adjusted prevalence rate ratio=1.14; 95% CI=1.01, 1.29; p=0.02). Disparities in flourishing by child sex, race/ethnicity, parental education, income, and insurance type were mitigated after adjustment. However, a decreased likelihood of flourishing continued to be associated with having a special healthcare need (adjusted prevalence rate ratio=0.74; 95% CI=0.68, 0.82) and experiencing multiple adverse childhood experiences (adjusted prevalence rate ratio=0.78; 95% CI=0.66, 0.92).

CONCLUSIONS

Expanding receipt of family-centered care may support flourishing and help to reduce disparities in flourishing during early childhood. Future research should evaluate the strategies to overcome barriers to delivering and receiving family-centered care, especially among children with special healthcare needs and children who experienced multiple adverse childhood experiences.

State-Level Estimates of the Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016 to 2019

OBJECTIVE

To provide state-level estimates of diagnosed ADHD and associated treatment among children in the United States in 2016 to 2019.

METHOD

This study used the National Survey of Children's Health to produce national and state-level estimates of lifetime diagnosis and current ADHD among all children aged 3 to 17 years (n=114,476), and national and state-level estimates of medication and behavioral treatment use among children with current ADHD.

RESULTS

The state-level estimates of diagnosed ADHD ranged from 6.1% to 16.3%. Among children with current ADHD, state-level estimates of ADHD medication usage ranged from 37.8% to 81.4%, and state-level estimates of behavioral treatment ranged from 38.8% to 61.8%.

CONCLUSION

There was substantial state-level variation for indicators of ADHD diagnosis and associated treatment. These state-level results can be used by policymakers, public health practitioners, health care providers, and other stakeholders to help address the service needs of children with ADHD in their states.

Five-Year Trends in US Children's Health and Well-being, 2016-2020

IMPORTANCE

Ensuring the well-being of the 73 million children in the United States is critical for improving the nation's health and influencing children's long-term outcomes as they grow into adults.

OBJECTIVE

To examine recent trends in children's health-related measures, including significant changes between 2019 and 2020 that might be attributed to the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

Annual data were examined from the National Survey of Children's Health (2016-2020), a population-based, nationally representative survey of randomly selected children. Participants were children from birth to age 17 years living in noninstitution settings in all 50 states and the District of Columbia whose parent or caregiver responded to an address-based survey by mail or web. Weighted prevalence estimates account for probability of selection and nonresponse. Adjusted logistic regression models tested for significant trends over time.

MAIN OUTCOMES AND MEASURES

Diverse measures pertaining to children's current health conditions, positive health behaviors, health care access and utilization, and family well-being and stressors.

RESULTS

A total of 174 551 children were included (annual range = 21 599 to 50 212). Between 2016 and 2020, there were increases in anxiety (7.1% [95% CI, 6.6-7.6] to 9.2% [95% CI, 8.6-9.8]; +29%; trend P < .001) and depression (3.1% [95% CI, 2.9-3.5] to 4.0% [95% CI, 3.6-4.5]; +27%; trend P < .001). There were also decreases in daily physical activity (24.2% [95% CI, 23.1-25.3] to 19.8% [95% CI, 18.9-20.8]; -18%; trend P < .001), parent or caregiver mental health (69.8% [95% CI, 68.9-70.8] to 66.3% [95% CI, 65.3-67.3]; -5%; trend P < .001), and coping with parenting demands (67.2% [95% CI, 66.3-68.1] to 59.9% [95% CI, 58.8-60.9]; -11%; trend P < .001). In addition, from 2019 to 2020, there were increases in behavior or conduct problems (6.7% [95% CI, 6.1-7.4] to 8.1% [95% CI, 7.5-8.8]; +21%; P = .001) and child care disruptions affecting parental employment (9.4% [95% CI, 8.0-10.9] to 12.6% [95% CI, 11.2-14.1]; +34%; trend P = .001) as well as decreases in preventive medical visits (81.0% [95% CI, 79.7-82.3] to 74.1% [95% CI, 72.9-75.3]; -9%; trend P < .001).

CONCLUSIONS AND RELEVANCE

Recent trends point to several areas of concern that can inform future research, clinical care, policy decision making, and programmatic investments to improve the health and well-being of children and their families. More analyses are needed to elucidate varying patterns within subpopulations of interest.

The Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda

OBJECTIVES

In the United States, autistic individuals experience disproportionate physical and mental health challenges relative to non-autistic individuals, including higher rates of co-occurring and chronic conditions and lower physical, social, and psychological health-related quality of life. The Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multicenter research network for scientific collaboration and infrastructure that aims to increase the life expectancy and quality of life for autistic individuals, with a focus on underserved or vulnerable populations. The current paper describes the development of the AIR-P Research Agenda.

METHODS

Development of the research agenda involved an iterative and collaborative process between the AIR-P Advisory Board, Steering Committee, and Autistic Researcher Review Board. The methodology consisted of 3 phases: (1) ideation and design, (2) literature review and synthesis; and (3) network engagement.

RESULTS

Six core research priorities related to the health of autistic individuals were identified: (1) primary care services and quality, (2) community-based lifestyle interventions, (3) health systems and services, (4) gender, sexuality, and reproductive health, (5) neurology, and (6) genetics. Specific topics within each of these priorities were identified. Four cross-cutting research priorities were also identified: (1) neurodiversity-oriented care, (2) facilitating developmental transitions, (3) methodologically rigorous intervention studies, and (4) addressing health disparities.

CONCLUSIONS

The AIR-P Research Agenda represents an important step forward for enacting large-scale health-promotion efforts for autistic individuals across the lifespan. This agenda will catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health-promotion.

Parental Concerns About Child Weight Among 10-17-Year Olds With Overweight/Obesity: A Family Ecological Model

OBJECTIVES

The purpose of this study was to identify child, family/household, organization (provider), and neighborhood/community factors associated with parental concern about weight among children with overweight/obesity in order to inform effective interventions for improving health in this pediatric population.

METHODS

Prevalence of parental concern about child weight was estimated and factors identified within an adapted family ecological framework. Using cross-sectional data from the 2018 National Survey of Children's Health, we conducted bivariate and multivariable analyses of 10 to 17-year olds (N = 15,427) for whom height and weight information was reported by parents or primary caregivers.

RESULTS

There were 4287 children, aged 10 to 17 years, with overweight/obesity (31%). Approximately 34% of parents of children with overweight/obesity reported being concerned about their child's weight, with the remainder being not concerned. In adjusted analyses, 23% of children with overweight and 45% of children with obesity had parents who reported being concerned. Factors associated with parental concern among children with overweight/obesity included child weight status, female gender, peer social difficulties, the extent of the child's daily activities affected by health conditions, poorer parental coping, and having been told the child was overweight by a provider.

CONCLUSIONS

Only one in three parents of children with overweight/obesity reported being concerned about their child's weight, although parental concern was more common among children affected by obesity more so than overweight. A combination of child, family, and organization (provider) factors were associated with parental concern. Provider feedback about child overweight may improve parental awareness of a weight-related health issue.

Healthy and Ready to Learn: Prevalence and Correlates of School Readiness among United States Preschoolers

OBJECTIVE

To assess the national and state prevalence of being "Healthy and Ready to Learn" (HRL) and associated sociodemographic, health, family and neighborhood factors.

METHODS

Cross-sectional analysis of the 2016 National Survey of Children's Health, a nationally representative parent-reported survey administered by web and paper June 2016 to February 2017. Four domains were constructed from 18 items through confirmatory factor analyses: "Early Learning Skills", "Social-Emotional Development", "Self-Regulation", and "Physical Well-being and Motor Development." Each item and domain were scored according to age-specific standards as "On-Track", "Needs Support", and "At Risk" with overall HRL defined as "On-Track" in all domains for 7565 randomly selected children ages 3 to 5 years.

RESULTS

In 2016, 42.2% of children ages 3 to 5 years were considered HRL with the proportion considered "On-Track" ranging from 58.4% for Early Learning Skills to 85.5% for Physical Well-being and Motor Development"; approximately 80% of children were considered "On-Track" in Social-Emotional Development and Self-Regulation, respectively. Sociodemographic differences were mostly non-significant in multivariable analyses. Health, family, and neighborhood factors (ie, special health care needs status/type, parental mental health, reading, singing and storytelling, screen time, adverse childhood experiences, and neighborhood amenities) were associated with HRL. HRL prevalence ranged from 25.5% (NV) to 58.7% (NY), but only 4 states were significantly different from the U.S. overall.

CONCLUSIONS

Based on this pilot measure, only about 4 in 10 US children ages 3 to 5 years may be considered "Healthy and Ready to Learn." Improvement opportunities exist for multiple, modifiable factors to affect young children's readiness to start school.

Out-of-Pocket Health Care Expenditures Among United States Children: Parental Perceptions and Past-Year Expenditures, 2016 to 2017

OBJECTIVE

To examine the association between parental perceptions of out-of-pocket (OOP) health care costs for their child and the total amount of OOP health care expenditures for that child during the past year.

METHODS

We used data from the 2016 and 2017 National Surveys of Children's Health, cross-sectional, parent-reported, and nationally representative surveys of noninstitutionalized US children, ages 0 to 17 years. We conducted bivariate analyses to assess characteristics associated with the amount of OOP expenditures and parental perceptions of these costs. We estimated adjusted prevalence ratios for parental perceptions of OOP costs using logistic regression.

RESULTS

Based on parent report, nearly two thirds (65.7%) of children incurred some amount of past-year OOP expenditures, with 13.3% of children incurring expenditures of ≥$1000. Parents reported that costs were unreasonable for 35.3% of children with past-year expenditures. The amount of OOP spending was associated with parents' perceptions that costs were unreasonable, with 16.5% of those with $1 to 249 in expenditures reporting unreasonable costs compared to 77.5% of those with >$5,000 in expenditures (P < .05). In adjusted analyses, high OOP expenditures, non-Hispanic white race/ethnicity, lack of health insurance, low household income, parental education levels less than a college degree, and foreign-born nativity status were associated with reports of unreasonable costs (P < .05).

CONCLUSIONS

This study demonstrates an association between attitudinal and economic measures of health care expenditures for children while demonstrating differences in the perception of costs by measures of family economic vulnerability. Results may inform efforts to assess adequacy of health insurance coverage.

Bibliometric Analysis of Research Studies Based on Federally Funded Children's Health Surveys

OBJECTIVE

Bibliometric analyses are commonly used to measure the productivity of researchers or institutions but rarely used to assess the scientific contribution of national surveys/datasets. We applied bibliometric methods to quantify the contributions of the National Survey of Children's Health (NSCH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) to the body of pediatric health-related research. We also examined dissemination to nonresearch audiences by analyzing media coverage of statistics and research produced from the surveys.

METHODS

We conducted a search of the Web of Science database to identify peer-reviewed articles related to the NSCH and NS-CSHCN published between 2002 and 2019. We summarized information about citation counts, publishing journals, key research areas, and institutions using the surveys. We used the Lexis Advance database Nexis to assess media coverage.

RESULTS

The publication set included 716 NSCH/NS-CSHCN journal articles published between 2002 and June 2019. These publications have in turn been cited 22,449 times, including in 1614 review articles. Over 180 journals have published NSCH/NS-CSHCN articles, and the most commonly covered research areas are in pediatrics; public, environmental and occupational health; psychology; and health care sciences and services. Over 500 institutions have used NSCH/NS-CSHCN data to publish journal articles, and over 950 news media articles have cited statistics or research produced by the surveys.

CONCLUSIONS

NSCH/NS-CSHCN data are widely used by government, academic, and media institutions. Bibliometric methods provide a systematic approach to quantify and describe the contributions to the scientific literature made possible with these data.

Epidemiological Profile of Health and Behaviors in Middle Childhood

OBJECTIVES

In this study, we present an epidemiological profile of middle childhood (children aged 6-11 years) using the 2016-2017 National Survey of Children's Health.

METHODS

We used data from the 2016 and 2017 National Survey of Children's Health, a national cross-sectional, address-based survey administered annually. The study sample included 21 539 children aged 6 to 11 years. Survey items chosen to create this profile of middle childhood described sociodemographic and family characteristics, health status, and behaviors. Weighted descriptive and bivariate analyses were applied to examine the population and differences by subgroups.

RESULTS

Most children aged 6 to 11 years were in excellent or very good physical health (89%) and oral health (73%). More than 20% were considered to have special health care needs, and 20% had at least 2 health conditions. Allergies and asthma were the most prevalent physical conditions, whereas attention-deficit/hyperactivity disorder and behavioral or conduct problems were the most prevalent of emotional, behavioral, and/or developmental disorders. More than half of children participated in sports or other activities for at least 60 minutes per day, whereas more than one-third of children had ≥4 hours of parent-reported screen time per day, and nearly two-thirds received ≥9 hours of sleep per night. We found several significant differences in screen time and activity behaviors as children aged and by sex.

CONCLUSIONS

The middle-childhood population is generally healthy, yet several patterns observed with respect to age and sex indicate a need to examine the emergence and progression of select health-risk behaviors. In this study, we highlight opportunities to implement targeted interventions at earlier ages and different points along the life course.

Maternal and Child Health Bureau's Autism Research Program

OBJECTIVES

To provide an overview and quantitatively demonstrate the reach of the Health Resources and Services Administration's Maternal and Child Health Bureau autism research program.

METHODS

We reviewed program reports and internal data from 59 autism research grantees. The US federal Interagency Autism Coordinating Committee's strategic plan questions were used as a framework to highlight the contributions of the autism research program in advancing the field.

RESULTS

The autism research program grantees advance research in several ways. Grantees have strengthened the evidence for autism interventions by conducting 89 studies at 79 distinct research sites. A total of 212 708 participants have enrolled in autism research program studies and 361 researchers have contributed to furthering autism research. The program addresses topics that align with the majority of the Interagency Autism Coordinating Committee's priority topic areas, including advancements in treatments and interventions, services and supports, and identifying risk factors. Grantee products include 387 peer-reviewed publications, 19 tools, and 13 practice guidelines for improving care and intervention practices.

CONCLUSIONS

The autism research program has contributed to medical advances in research, leveraged innovative training platforms to provide specialized training, and provided access to health services through research-based screening and diagnostic procedures. Autism research program studies have contributed to the development of evidence-based practice guidelines, informed policy guidelines, and quality improvement efforts to bolster advancements in the field. Although disparities still exist, the Health Resources and Services Administration's Maternal and Child Health Bureau can reduce gaps in screening and diagnosis by targeting interventions to underserved populations including minority and rural communities.

Prevalence and Trends of Developmental Disabilities among Children in the United States: 2009-2017

OBJECTIVES

To study the national prevalence of 10 developmental disabilities in US children aged 3 to 17 years and explore changes over time by associated demographic and socioeconomic characteristics, using the National Health Interview Survey.

METHODS

Data come from the 2009 to 2017 National Health Interview Survey, a nationally representative survey of the civilian noninstitutionalized population. Parents reported physician or other health care professional diagnoses of attention-deficit/hyperactivity disorder; autism spectrum disorder; blindness; cerebral palsy; moderate to profound hearing loss; learning disability; intellectual disability; seizures; stuttering or stammering; and other developmental delays. Weighted percentages for each of the selected developmental disabilities and any developmental disability were calculated and stratified by demographic and socioeconomic characteristics.

RESULTS

From 2009 to 2011 and 2015 to 2017, there were overall significant increases in the prevalence of any developmental disability (16.2%-17.8%, P < .001), attention-deficit/hyperactivity disorder (8.5%-9.5%, P < .01), autism spectrum disorder (1.1%-2.5%, P < .001), and intellectual disability (0.9%-1.2%, P < .05), but a significant decrease for any other developmental delay (4.7%-4.1%, P < .05). The prevalence of any developmental disability increased among boys, older children, non-Hispanic white and Hispanic children, children with private insurance only, children with birth weight ≥2500 g, and children living in urban areas and with less-educated mothers.

CONCLUSIONS

The prevalence of developmental disability among US children aged 3 to 17 years increased between 2009 and 2017. Changes by demographic and socioeconomic subgroups may be related to improvements in awareness and access to health care.

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

Introduction Since 2001, the Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB) has funded and directed the National Survey of Children's Health (NSCH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN), unique sources of national and state-level data on child health and health care. Between 2012 and 2015, HRSA MCHB redesigned the surveys, combining content into a single survey, and shifting from a periodic interviewer-assisted telephone survey to an annual self-administered web/paper-based survey utilizing an address-based sampling frame. Methods The U.S. Census Bureau fielded the redesigned NSCH using a random sample of addresses drawn from the Census Master Address File, supplemented with a unique administrative flag to identify households most likely to include children. Data were collected June 2016-February 2017 using a multi-mode design, encouraging web-based responses while allowing for paper mail-in responses. A parent/caregiver knowledgeable about the child's health completed an age-appropriate questionnaire. Experiments on incentives, branding, and contact strategies were conducted. Results Data were released in September 2017. The final sample size was 50,212 children; the overall weighted response rate was 40.7%. Comparison of 2016 estimates to those from previous survey iterations are not appropriate due to sampling and mode changes. Discussion The NSCH remains an invaluable data source for key measures of child health and attendant health care system, family, and community factors. The redesigned survey extended the utility of this resource while seeking a balance between previous strengths and innovations now possible.

The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children

: media-1vid110.1542/5839990273001PEDS-VA_2017-4161Video Abstract OBJECTIVES: To estimate the national prevalence of parent-reported autism spectrum disorder (ASD) diagnosis among US children aged 3 to 17 years as well as their treatment and health care experiences using the 2016 National Survey of Children's Health (NSCH).

METHODS

The 2016 NSCH is a nationally representative survey of 50 212 children focused on the health and well-being of children aged 0 to 17 years. The NSCH collected parent-reported information on whether children ever received an ASD diagnosis by a care provider, current ASD status, health care use, access and challenges, and methods of treatment. We calculated weighted prevalence estimates of ASD, compared health care experiences of children with ASD to other children, and examined factors associated with increased likelihood of medication and behavioral treatment.

RESULTS

Parents of an estimated 1.5 million US children aged 3 to 17 years (2.50%) reported that their child had ever received an ASD diagnosis and currently had the condition. Children with parent-reported ASD diagnosis were more likely to have greater health care needs and difficulties accessing health care than children with other emotional or behavioral disorders (attention-deficit/hyperactivity disorder, anxiety, behavioral or conduct problems, depression, developmental delay, Down syndrome, intellectual disability, learning disability, Tourette syndrome) and children without these conditions. Of children with current ASD, 27% were taking medication for ASD-related symptoms, whereas 64% received behavioral treatments in the last 12 months, with variations by sociodemographic characteristics and co-occurring conditions.

CONCLUSIONS

The estimated prevalence of US children with a parent-reported ASD diagnosis is now 1 in 40, with rates of ASD-specific treatment usage varying by children's sociodemographic and co-occurring conditions.

Prevalence and Variation of Developmental Screening and Surveillance in Early Childhood

IMPORTANCE

Since 2001, the American Academy of Pediatrics has recommended universal developmental screening and surveillance to promote early diagnosis and intervention and to improve the outcomes of children with developmental delays and disabilities.

OBJECTIVE

To examine the current prevalence and variation of developmental screening and surveillance of children by various sociodemographic, enabling, and health characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis of the Health Resources and Services Administration's 2016 National Survey of Children's Health-a nationally representative survey of US children completed between June 2016 and February 2017-examined 5668 randomly selected children 9 through 35 months of age whose parent or caregiver responded to the address-based survey by mail or via a website. All analyses were weighted to account for the probability of selection and nonresponse and to reflect population counts of all noninstitutionalized US children residing in housing units.

MAIN OUTCOMES AND MEASURES

Developmental screening was measured through a validated set of 3 items indicating receipt in the past year of parent-completed screening from a health care professional with age-appropriate content regarding language development and social behavior. Surveillance was determined by an item capturing verbal elicitation of developmental concerns by a health care professional.

RESULTS

Of the estimated 9.0 million children aged 9 through 35 months, an estimated 30.4% (95% CI, 28.0%-33.0%) were reported by their parent or guardian to have received a parent-completed developmental screening and 37.1% (95% CI, 34.4%-39.8%) were reported to have received developmental surveillance from a health care professional in the past year. Characteristics associated with screening and/or surveillance that remained significant after adjustment included primary household language, family structure, household education, income, medical home, past-year preventive visit, child health status, and special health care needs. Having health care that meets medical home criteria was significantly associated with both developmental screening (adjusted rate ratio, 1.34; 95% CI, 1.13-1.57) and surveillance (adjusted rate ratio, 1.24; 95% CI, 1.08-1.42), representing an 8 to 9 absolute percentage point increase. State-level differences spanned 40 percentage points for screening (17.2% in Mississippi and 58.8% in Oregon) and surveillance (19.1% in Mississippi and 60.8% in Oregon), with approximately 90% of variation not explained by child and family characteristics.

CONCLUSIONS AND RELEVANCE

Despite more than a decade of initiatives, rates of developmental screening and surveillance remain low. However, state-level variation indicates continued potential for improvement. Systems-level quality improvement efforts, building on the medical home, will be necessary to achieve recommended screening and surveillance goals.

Title V Maternal and Child Health Services Block Grant Priority Needs and Linked Performance Measures: Current Patterns and Trends (2000-2015)

Objective As part of the Title V Maternal and Child Health (MCH) Services Block Grant, administered by the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau (MCHB), states are required to conduct a comprehensive needs assessment identifying MCH priorities every 5 years. The most current needs assessment (2015) occurred after a transformation of the program, in which a new performance measurement framework was created. This analysis examined current patterns and trends in state MCH priorities and selected performance measures to identify changing needs and inform technical support. Methods Multiple coders categorized: (1) state priority needs from 2000 to 2015 into focus areas and subcategories for examination of current, diminishing, and emerging needs; and (2) the selection of linked national and state performance measures in 2015 for all 59 states and jurisdictions. Results Between 2000 and 2015, the proportion of states with a need around pre- and inter-conception care increased from 19% to 66%. More states had needs in the breastfeeding subcategory (42%) compared with 20% of states or less in previous years. Fewer states had needs around data capacity than in past years. Emerging needs included supporting families/relationships. The most commonly selected national performance measures (NPMs) were around breastfeeding and well-woman visits. The state performance measures (SPMs) analysis also emphasized assets, with measures around community/context and positive development. Teen births and postpartum depression were areas where multiple states had SPMs. Conclusions for practice Increasing and emerging needs may help to inform technical assistance and future national measures for the Title V program.

Widening Disparities In Infant Mortality And Life Expectancy Between Appalachia And The Rest Of The United States, 1990-2013

Appalachia-a region that stretches from Mississippi to New York-has historically been recognized as a socially and economically disadvantaged part of the United States, and growing evidence suggests that health disparities between it and the rest of the country are widening. We compared infant mortality and life expectancy disparities in Appalachia to those outside the region during the period 1990-2013. We found that infant mortality disparities widened for both whites and blacks, with infant mortality 16 percent higher in Appalachia in 2009-13, and the region's deficit in life expectancy increased from 0.6 years in 1990-92 to 2.4 years in 2009-13. The association between area poverty and life expectancy was stronger in Appalachia than in the rest of the United States. We found wide health disparities, including a thirteen-year gap in life expectancy among black men in high-poverty areas of Appalachia, compared to white women in low-poverty areas elsewhere. Higher mortality in Appalachia from cardiovascular diseases, lung cancer, chronic lower respiratory diseases or chronic obstructive pulmonary disease, diabetes, nephritis or kidney diseases, suicide, unintentional injuries, and drug overdose contributed to lower life expectancy in the region, compared to the rest of the country. Widening health disparities were also due to slower mortality improvements in Appalachia.

Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016

The purpose of this study is to estimate the national prevalence of parent-reported attention deficit/hyperactivity disorder (ADHD) diagnosis and treatment among U.S. children 2-17 years of age using the 2016 National Survey of Children's Health (NSCH). The NSCH is a nationally representative, cross-sectional survey of parents regarding their children's health that underwent a redesign before the 2016 data collection. It included indicators of lifetime receipt of an ADHD diagnosis by a health care provider, whether the child currently had ADHD, and receipt of medication and behavioral treatment for ADHD. Weighted prevalence estimates were calculated overall and by demographic and clinical subgroups (n = 45,736). In 2016, an estimated 6.1 million U.S. children 2-17 years of age (9.4%) had ever received an ADHD diagnosis. Of these, 5.4 million currently had ADHD, which was 89.4% of children ever diagnosed with ADHD and 8.4% of all U.S. children 2-17 years of age. Of children with current ADHD, almost two thirds (62.0%) were taking medication and slightly less than half (46.7%) had received behavioral treatment for ADHD in the past year; nearly one fourth (23.0%) had received neither treatment. Similar to estimates from previous surveys, there is a large population of U.S. children and adolescents who have been diagnosed with ADHD by a health care provider. Many, but not all, of these children received treatment that appears to be consistent with professional guidelines, though the survey questions are limited in detail about specific treatment types received. The redesigned NSCH can be used to annually monitor diagnosis and treatment patterns for this highly prevalent and high-impact neurodevelopmental disorder.

Age of Parental Concern, Diagnosis, and Service Initiation Among Children With Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) require substantial support to address the core symptoms of ASD and co-occurring behavioral/developmental conditions. This study explores the early diagnostic experiences of school-aged children with ASD using survey data from a large probability-based national sample. Multivariate linear regressions were used to examine age when parent reported developmental concern to doctor, received ASD diagnosis, and first obtained services. Children whose parents had concerns about their child's verbal communication reported earlier ages for all outcomes when compared to children of parents who did not have verbal communication concerns. Children whose parents had concerns about their child's nonverbal communication or unusual gestures/movements received an earlier diagnosis than children whose parents did not have these specific concerns.

A new performance measurement system for maternal and child health in the United States

Objective

The Title V Maternal and Child Health (MCH) Block Grant is the linchpin for US MCH services. The first national performance measures (NPMs) for MCH were instituted in 1997. Changing trends in MCH risk factors, outcomes, health services, data sources, and advances in scientific knowledge, in conjunction with budgetary constraints led the Maternal and Child Health Bureau (MCHB) to design a new performance measurement system.

Methods

A workgroup was formed to develop a new system. The following guiding principles were used: (1) Afford States more flexibility and reduce the overall reporting burden; (2) Improve accountability to better document Title V’s impact; (3) Develop NPMs that encompass measures in: maternal and women’s health, perinatal health, child health, children with special health care needs, adolescent health, and cross-cutting areas.

Results

A three-tiered performance measurement system was proposed with national outcome measures (NOMs), NPMs and evidence-based/informed strategy measures (ESMs). NOMs are the ultimate goals that MCHB and States are attempting to achieve. NPMs are measures, generally associated with processes or programs, shown to affect NOMs. ESMs are evidence-based or informed measures that each State Title V program develops to affect the NPMs. There are 15 NPMs from which States select eight, with at least one from each population area. MCHB will provide the data for the NOMs and NPMs, when possible.

Conclusions

The new performance measurement system increases the flexibility and reduces the reporting burden for States by allowing them to choose 8 NPMs to target, and increases accountability by having States develop actionable ESMs.

Significance

The new national performance measure framework for maternal and child health will allow States more flexibility to address their areas of greatest need, reduce their data reporting burden by having the Maternal and Child Health Bureau provide data for the National Outcome and Performance Measures, yet afford States the opportunity to develop measurable strategies to address their selected performance measures.

Prevalence of cerebral palsy and intellectual disability among children identified in two U.S. National Surveys, 2011-2013

PURPOSE

Cerebral palsy (CP) and intellectual disability (ID) are developmental disabilities that result in considerable functional limitations. There are few recent and nationally representative prevalence estimates of CP and ID in the United States.

METHODS

We used two U.S. nationally representative surveys, the 2011-2012 National Survey of Children's Health (NSCH) and the 2011-2013 National Health Interview Survey (NHIS), to determine the prevalence of CP and ID based on parent report among children aged 2-17 years.

RESULTS

CP prevalence was 2.6 (95% confidence interval [CI]: 2.1-3.2) per 1000 in the NSCH and 2.9 (95% CI: 2.3-3.7) in the NHIS. ID prevalence was 12.2 (95% CI: 10.7-13.9) and 12.1 (95% CI: 10.8-13.7) in NSCH and NHIS, respectively. For both conditions, the NSCH and NHIS prevalence estimates were similar to each other for nearly all sociodemographic subgroups examined.

CONCLUSIONS

Despite using different modes of data collection, the two surveys produced similar and plausible estimates of CP and ID and offer opportunities to better understand the needs and situations of children with these conditions.

Geographic, Racial/Ethnic, and Sociodemographic Disparities in Parent-Reported Receipt of Family-Centered Care among US Children

This study examined geographic, racial/ethnic, and sociodemographic disparities in parental reporting of receipt of family-centered care (FCC) and its components among US children aged 0-17 years. We used the 2011-2012 National Survey of Children's Health to estimate the prevalence and odds of not receiving FCC by covariates. Based on parent report, 33.4% of US children did not receive FCC. Children in Arizona, Mississippi, Nevada, California, New Jersey, Virginia, Florida, and New York had at least 1.51 times higher adjusted odds of not receiving FCC than children in Vermont. Non-Hispanic Black and Hispanic children had 2.11 and 1.58 times higher odds, respectively, of not receiving FCC than non-Hispanic White children. Children from non-English-speaking households had 2.23 and 2.35 times higher adjusted odds of not receiving FCC overall and their doctors not spending enough time in their care than children from English-speaking households, respectively. Children from low-education and low-income households had a higher likelihood of not receiving FCC. The clustering of children who did not receive FCC and its components in several Southern and Western US states, as well as children from poor, uninsured, and publicly insured and of minority background, is a cause for concern in the face of federal policies to reduce health care disparities.

Prevalence and impact of unhealthy weight in a national sample of US adolescents with autism and other learning and behavioral disabilities

We estimated the prevalence of obesity, overweight, and underweight among US adolescents with and without autism and other learning and behavioral developmental disabilities (DDs) and assessed the health consequences of obesity among adolescents with DDs. From the 2008 to 2010 National Health Interview Survey, we selected 9,619 adolescents ages 12-17 years. Parent respondents reported weight, height, presence of DDs and health conditions. We calculated body mass index (BMI) and defined obesity, overweight, and underweight as ≥95th, ≥85th to <95th, and <5th percentiles, respectively, using established criteria. We created mutually-exclusive DD subgroups using the following order of precedence: autism; intellectual disability; attention-deficit-hyperactivity-disorder; learning disorder/other developmental delay. We compared BMI outcomes among adolescents in each DD group versus adolescents without DDs using multivariable logistic regression. Socio-demographic factors and birthweight were included as confounders. Estimates were weighted to reflect the US population. Both obesity and underweight prevalences were higher among adolescents with than without DDs [adjusted prevalence ratios (aPR) 1.5 (1.25-1.75) and 1.5 (1.01-2.20), respectively]. Obesity was elevated among adolescents with all DD types, and was highest among the autism subgroup [aPR 2.1 (1.44-3.16)]. Adolescents with either a DD or obesity had higher prevalences of common respiratory, gastrointestinal, dermatological and neurological conditions/symptoms than nonobese adolescents without DDs. Adolescents with both DDs and obesity had the highest estimates for most conditions. Obesity is high among adolescents with autism and other DDs and poses added chronic health risks. Obesity prevention and management approaches for this vulnerable population subgroup need further consideration.

Diagnosis lost: Differences between children who had and who currently have an autism spectrum disorder diagnosis

Autism spectrum disorder diagnoses sometimes change due to misdiagnosis, maturation, or treatment. This study uses a probability-based national survey-the Survey of Pathways to Diagnosis and Services-to compare currently diagnosed (n = 1420) and previously diagnosed (n = 187) children aged 6-17 years based on retrospective parental reports of early concerns about their children's development, responses to those concerns by doctors and other healthcare providers, the type of provider who made the first autism spectrum disorder diagnosis, and the autism spectrum disorder subtype diagnoses received (if any). Propensity score matching was used to control for differences between the groups on children's current level of functioning and other current characteristics that may have been related to diagnosis loss. Approximately 13% of the children ever diagnosed with autism spectrum disorder were estimated to have lost the diagnosis, and parents of 74% of them believed it was changed due to new information. Previously diagnosed children were less likely to have parents with early concerns about verbal skills, nonverbal communication, learning, and unusual gestures or movements. They were also less likely to have been referred to and diagnosed by a specialist. Previously diagnosed children were less likely to have ever received a diagnosis of Asperger's disorder or autistic disorder.

Assessing systems quality in a changing health care environment: the 2009-10 national survey of children with special health care needs

To provide a national, population-based assessment of the quality of the health care system for children and youth with special health care needs using a framework of six health care system quality indicators. 49,242 interviews with parents of children with special health care needs from the 2009-10 National Survey of Children with Special Health Care Needs (NS-CSHCN) were examined to determine the extent to which CSHCN had access to six quality indicators of a well-functioning system of services. Criteria for determining access to each indicator were established and applied to the survey data to estimate the proportion of CSHCN meeting each quality indicator by socio-demographic status and functional limitations. 17.6% of CSHCN received care consistent with all six quality indicators. Results for each component of the system quality framework ranged from a high of 70.3% of parents reporting that they shared decision-making with healthcare providers to a low of 40% of parents reporting receipt of services needed for transition to adult health care. Attainment rates were lower for CSHCN of minority racial and ethnic groups, those residing in households where English was not the primary language, those in lower income households, and those most impacted by their health condition. Only a small proportion of CSHCN receive all identified attributes of a high-quality system of services. Moreover, significant disparities exist whereby those most impacted by their conditions and those in traditionally disadvantaged groups are served least well by the current system. A small proportion of CSHCN appear to remain essentially outside of the system, having met few if any of the elements studied.

Age at Autism Spectrum Disorder (ASD) Diagnosis by Race, Ethnicity, and Primary Household Language Among Children with Special Health Care Needs, United States, 2009-2010

We examined prevalence of diagnosed autism spectrum disorder (ASD) and age at diagnosis according to child's race/ethnicity and primary household language. From the 2009-2010 National Survey of Children with Special Health Care Needs, we identified 2729 3-17-year-old US children whose parent reported a current ASD diagnosis. We compared ASD prevalence, mean diagnosis age, and percentage with later diagnoses (≥5 years) across racial/ethnic/primary household language groups: non-Hispanic-white, any language (NHW); non-Hispanic-black, any language (NHB); Hispanic-any-race, English (Hispanic-English); and Hispanic-any-race, other language (Hispanic-Other). We assessed findings by parent-reported ASD severity level and adjusted for family sociodemographics. ASD prevalence estimates were 15.3 (NHW), 10.4 (NHB), 14.1 (Hispanic-English), and 5.2 (Hispanic-Other) per 1000 children. Mean diagnosis age was comparable across racial/ethnic/language groups for 3-4-year-olds. For 5-17-year-olds, diagnosis age varied by race/ethnicity/language and also by ASD severity. In this group, NHW children with mild/moderate ASD had a significantly higher proportion (50.8 %) of later diagnoses than NHB (33.5 %) or Hispanic-Other children (18.0 %). However, NHW children with severe ASD had a comparable or lower (albeit non-significant) proportion (16.4 %) of later diagnoses than NHB (37.8 %), Hispanic-English (30.8 %), and Hispanic-Other children (12.0 %). While NHW children have comparable ASD prevalence and diagnosis age distributions as Hispanic-English children, they have both higher prevalence and proportion of later diagnoses than NHB and Hispanic-Other children. The diagnosis age findings were limited to mild/moderate cases only. Thus, the prevalence disparity might be primarily driven by under-representation (potentially under-identification) of older children with mild/moderate ASD in the two minority groups.

Transformation of the title V maternal and child health services block grant

This paper describes the transformation of the Title V Maternal and Child Health (MCH) Services Block Grant. The Maternal and Child Health Bureau of the Health Resources and Services Administration led a 21-month visioning process to engage input from MCH stakeholders and other national, state and local MCH leaders, families and other partners to improve, innovate, and transform the Title V MCH Services Block Grant. The process has helped inform the development of a new grant guidance for the next 5-year cycle beginning in fiscal year 2016. The triple aims of the transformation are to reduce burden, maintain flexibility, and increase accountability. State reporting burden is reduced by aligning and streamlining the needs assessment, annual report and application, reducing the number of forms States have to fill out, eliminating Health Systems Capacity Indicators, and prepopulating the annual report and application with State data using national data sources. State flexibility is maintained through the needs assessment process whereby State needs and priorities drive the selection of National Performance Measures and State-specific Performance Measures, and the development of State Action Plan and Evidence-based/informed Strategy Measures. Accountability is increased through the new three-tiered performance measurement framework, which will help States tell a more coherent and compelling story about the impact of Title V on the health of the Nation's mothers, children, and families. The ultimate success of the transformation will be measured by how much the transformed Title V program moves the needle in MCH in the States and for the Nation.

Contributors to excess infant mortality in the U.S. South

BACKGROUND

Infant mortality rates (IMRs) are disproportionally high in the U.S. South; however, the proximate contributors that could inform regional action remain unclear.

PURPOSE

To quantify the components of excess infant mortality in the U.S. South by maternal race/ethnicity, underlying cause of death, and gestational age.

METHODS

U.S. Period Linked Birth/Infant Death Data Files 2007-2009 (analyzed in 2013) were used to compare IMRs between the South (U.S. Public Health Regions IV and VI) and all other regions combined.

RESULTS

Compared to other regions, there were 1.18 excess infant deaths per 1000 live births in the South, representing about 1600 excess infant deaths annually. New Mexico and Texas did not have elevated IMRs relative to other regions; excess death rates among other states ranged from 0.62 per 1000 in Kentucky to 3.82 per 1000 in Mississippi. Racial/ethnic compositional differences, generally the greater proportion of non-Hispanic black births in the South, explained 59% of the overall regional difference; the remainder was mostly explained by higher IMRs among non-Hispanic whites. The leading causes of excess Southern infant mortality were sudden unexpected infant death (SUID; 36%, range=12% in Florida to 90% in Kentucky) and preterm-related death (22%, range= -71% in Kentucky to 51% in North Carolina). Higher rates of preterm birth, predominantly <34 weeks, accounted for most of the preterm contribution.

CONCLUSIONS

To reduce excess Southern infant mortality, comprehensive strategies addressing SUID and preterm birth prevention for both non-Hispanic black and white births are needed, with state-level findings used to tailor state-specific efforts.

Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011

OBJECTIVE

Data from the 2003 and 2007 National Survey of Children's Health (NSCH) reflect the increasing prevalence of parent-reported attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment by health care providers. This report updates these prevalence estimates for 2011 and describes temporal trends.

METHOD

Weighted analyses were conducted with 2011 NSCH data to estimate prevalence of parent-reported ADHD diagnosis, current ADHD, current medication treatment, ADHD severity, and mean age of diagnosis for U.S. children/adolescents aged 4 to 17 years and among demographic subgroups. A history of ADHD diagnosis (2003-2011), as well as current ADHD and medication treatment prevalence (2007-2011), were compared using prevalence ratios and 95% confidence intervals.

RESULTS

In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011.

CONCLUSIONS

Approximately 2 million more U.S. children/adolescents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011. This suggests an increasing burden of ADHD on the U.S. health care system. Efforts to further understand ADHD diagnostic and treatment patterns are warranted.

Financial and nonfinancial burden among families of CSHCN: changes between 2001 and 2009-2010

OBJECTIVE

We use the latest data to explore multiple dimensions of financial burden among children with special health care needs (CSHCN) and their families in 2009-2010 and changes since 2001.

METHODS

Five burden indicators were assessed using the 2001 and 2009-2010 National Surveys of CSHCN: past-year health-related out-of-pocket expenses of ≥$1,000 or ≥ 3% of household income; perceived financial problems; changes in family employment; and >10 hours of weekly care provision/coordination. Unadjusted and adjusted prevalence estimates were used to assess burden in 2009-2010 and calculate absolute and relative measures of change since 2001. Prevalence rate ratios for each burden type in 2009-2010 compared to 2001 were estimated by logistic regression.

RESULTS

Nearly half of CSHCN and their families experienced some form of burden in 2009-2010. The percentage of CSHCN living in families that paid ≥$1,000 or ≥ 3% of household income out of pocket for health care rose 120% and 35%, respectively, between 2001 and 2009-2010, while the prevalence of caregiving and employment burdens declined. Relative to 2001, in 2009-2010, CSHCN who were privately insured or least affected by their conditions were 1.7 times as likely to live in families that paid ≥ 3% of household income out of pocket, while publicly insured children were 20% less likely to do so and those most severely affected were 12% more likely to do so.

CONCLUSIONS

Over the past decade, increases in financial burden and declines in employment and caregiving burdens were observed for CSHCN families. Public insurance expansions may have buffered increases in financial burden, yet disparities persist.

Health, chronic conditions, and behavioral risk disparities among U.S. immigrant children and adolescents

OBJECTIVE

We examined differentials in the prevalence of 23 parent-reported health, chronic condition, and behavioral indicators among 91,532 children of immigrant and U.S.-born parents.

METHODS

We used the 2007 National Survey of Children's Health to estimate health differentials among 10 ethnic-nativity groups. Logistic regression yielded adjusted differentials.

RESULTS

Immigrant children in each racial/ethnic group had a lower prevalence of depression and behavioral problems than native-born children. The prevalence of autism varied from 0.3% among immigrant Asian children to 1.3%-1.4% among native-born non-Hispanic white and Hispanic children. Immigrant children had a lower prevalence of asthma, attention deficit disorder/attention deficit hyperactivity disorder; developmental delay; learning disability; speech, hearing, and sleep problems; school absence; and ≥ 1 chronic condition than native-born children, with health risks increasing markedly in relation to mother's duration of residence in the U.S. Immigrant children had a substantially lower exposure to environmental tobacco smoke, with the odds of exposure being 60%-95% lower among immigrant non-Hispanic black, Asian, and Hispanic children compared with native non-Hispanic white children. Obesity prevalence ranged from 7.7% for native-born Asian children to 24.9%-25.1% for immigrant Hispanic and native-born non-Hispanic black children. Immigrant children had higher physical inactivity levels than native-born children; however, inactivity rates declined with each successive generation of immigrants. Immigrant Hispanic children were at increased risk of obesity and sedentary behaviors. Ethnic-nativity differentials in health and behavioral indicators remained marked after covariate adjustment.

CONCLUSIONS

Immigrant patterns in child health and health-risk behaviors vary substantially by ethnicity, generational status, and length of time since immigration. Public health programs must target at-risk children of both immigrant and U.S.-born parents.

Immigrant health inequalities in the United States: use of eight major national data systems

Eight major federal data systems, including the National Vital Statistics System (NVSS), National Health Interview Survey (NHIS), National Survey of Children's Health, National Longitudinal Mortality Study, and American Community Survey, were used to examine health differentials between immigrants and the US-born across the life course. Survival and logistic regression, prevalence, and age-adjusted death rates were used to examine differentials. Although these data systems vary considerably in their coverage of health and behavioral characteristics, ethnic-immigrant groups, and time periods, they all serve as important research databases for understanding the health of US immigrants. The NVSS and NHIS, the two most important data systems, include a wide range of health variables and many racial/ethnic and immigrant groups. Immigrants live 3.4 years longer than the US-born, with a life expectancy ranging from 83.0 years for Asian/Pacific Islander immigrants to 69.2 years for US-born blacks. Overall, immigrants have better infant, child, and adult health and lower disability and mortality rates than the US-born, with immigrant health patterns varying across racial/ethnic groups. Immigrant children and adults, however, fare substantially worse than the US-born in health insurance coverage and access to preventive health services. Suggestions and new directions are offered for improvements in health monitoring and for strengthening and developing databases for immigrant health assessment in the USA.

Healthy people 2010 leading health indicators: how children with special health care needs fared

OBJECTIVES

We compared estimates for children with and without special health care needs (SHCN) at 2 time periods for national health objectives related to the Healthy People 2010 leading health indicators (LHIs).

METHODS

Data were from the 2003 and 2007 National Surveys of Children's Health. Seven survey items were relevant to the LHIs and available in both survey years: physical activity, obesity, household tobacco use, current insurance, personal health care provider, past-month depressive symptoms, and past-year emergency department visits.

RESULTS

In 2003 and 2007, children with SHCN fared worse than those without SHCN with respect to physical activity, obesity, household tobacco exposure, depressive symptomology, and emergency department visits, but fared better on current insurance and having a personal health care provider. Physical activity and access to a personal health care provider increased for all children, whereas the absolute disparity in personal provider access decreased 4.9%.

CONCLUSIONS

Significant disparities exist for key population health indicators between children with and without SHCN. Analyses illustrated how population-based initiatives could be used to frame health challenges among vulnerable populations.

All-cause and cause-specific mortality among US youth: socioeconomic and rural-urban disparities and international patterns

We analyzed international patterns and socioeconomic and rural-urban disparities in all-cause mortality and mortality from homicide, suicide, unintentional injuries, and HIV/AIDS among US youth aged 15-24 years. A county-level socioeconomic deprivation index and rural-urban continuum measure were linked to the 1999-2007 US mortality data. Mortality rates were calculated for each socioeconomic and rural-urban group. Poisson regression was used to derive adjusted relative risks of youth mortality by deprivation level and rural-urban residence. The USA has the highest youth homicide rate and 6th highest overall youth mortality rate in the industrialized world. Substantial socioeconomic and rural-urban gradients in youth mortality were observed within the USA. Compared to their most affluent counterparts, youth in the most deprived group had 1.9 times higher all-cause mortality, 8.0 times higher homicide mortality, 1.5 times higher unintentional-injury mortality, and 8.8 times higher HIV/AIDS mortality. Youth in rural areas had significantly higher mortality rates than their urban counterparts regardless of deprivation levels, with suicide and unintentional-injury mortality risks being 1.8 and 2.3 times larger in rural than in urban areas. However, youth in the most urbanized areas had at least 5.6 times higher risks of homicide and HIV/AIDS mortality than their rural counterparts. Disparities in mortality differed by race and sex. Socioeconomic deprivation and rural-urban continuum were independently related to disparities in youth mortality among all sex and racial/ethnic groups, although the impact of deprivation was considerably greater. The USA ranks poorly in all-cause mortality, youth homicide, and unintentional-injury mortality rates when compared with other industrialized countries.

State-based and demographic variation in parent-reported medication rates for attention-deficit/hyperactivity disorder, 2007-2008

Medication is the most effective treatment of attention-deficit/hyperactivity disorder (ADHD), a common neurobehavioral disorder of childhood. We used data from the 2007-2008 National Survey of Children’s Health to calculate weighted estimates of parent-reported ADHD and medication treatment among US children aged 4 to 17 years, by state and sex-stratified age. State-based rates of ADHD medication treatment ranged from 33% in Nevada to 79% in Mississippi; rates of medicated ADHD were higher among boys than girls at every age. State-based investigations of ADHD medication treatment factors are needed, and our findings may inform these public health efforts.

Mental health surveillance among children--United States, 2005-2011

Mental disorders among children are described as "serious deviations from expected cognitive, social, and emotional development" (US Department of Health and Human Services Health Resources and Services Administration, Maternal and Child Health Bureau. Mental health: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, and National Institutes of Health, National Institute of Mental Health; 1999). These disorders are an important public health issue in the United States because of their prevalence, early onset, and impact on the child, family, and community, with an estimated total annual cost of $247 billion. A total of 13%-20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994-2011 has shown the prevalence of these conditions to be increasing. Suicide, which can result from the interaction of mental disorders and other factors, was the second leading cause of death among children aged 12-17 years in 2010. Surveillance efforts are critical for documenting the impact of mental disorders and for informing policy, prevention, and resource allocation. This report summarizes information about ongoing federal surveillance systems that can provide estimates of the prevalence of mental disorders and indicators of mental health among children living in the United States, presents estimates of childhood mental disorders and indicators from these systems during 2005-2011, explains limitations, and identifies gaps in information while presenting strategies to bridge those gaps.

Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011-2012

OBJECTIVES

This report presents data on the prevalence of diagnosed autism spectrum disorder (ASD) as reported by parents of school-aged children (ages 6-17 years) in 2011-2012. Prevalence changes from 2007 to 2011-2012 were evaluated using cohort analyses that examine the consistency in the 2007 and 2011-2012 estimates for children whose diagnoses could have been reported in both surveys (i.e., those born in 1994-2005 and diagnosed in or before 2007).

DATA SOURCES

Data were drawn from the 2007 and 2011-2012 National Survey of Children's Health (NSCH), which are independent nationally representative telephone surveys of households with children. The surveys were conducted by the Centers for Disease Control and Prevention's National Center for Health Statistics with funding and direction from the Health Resources and Services Administration's Maternal and Child Health Bureau.

RESULTS

The prevalence of parent-reported ASD among children aged 6-17 was 2.00% in 2011-2012, a significant increase from 2007 (1.16%). The magnitude of the increase was greatest for boys and for adolescents aged 14-17. Cohort analyses revealed consistent estimates of both the prevalence of parent-reported ASD and autism severity ratings over time. Children who were first diagnosed in or after 2008 accounted for much of the observed prevalence increase among school-aged children (those aged 6-17). School-aged children diagnosed in or after 2008 were more likely to have milder ASD and less likely to have severe ASD than those diagnosed in or before 2007.

CONCLUSIONS

The results of the cohort analyses increase confidence that differential survey measurement error over time was not a major contributor to observed changes in the prevalence of parent-reported ASD. Rather, much of the prevalence increase from 2007 to 2011-2012 for school-aged children was the result of diagnoses of children with previously unrecognized ASD.

Parent-reported prevalence of autism spectrum disorders in US-born children: an assessment of changes within birth cohorts from the 2003 to the 2007 National Survey of Children's Health

The prevalence of autism spectrum disorders (ASD) from the 2007 National Survey of Children's Health (NSCH) was twice the 2003 NSCH estimate for autism. From each NSCH, we selected children born in the US from 1990 to 2000. We estimated autism prevalence within each 1-year birth cohort to hold genetic and non-genetic prenatal factors constant. Prevalence differences across surveys thus reflect survey measurement changes and/or external identification effects. In 2003, parents were asked whether their child was ever diagnosed with autism. In 2007, parents were asked whether their child was ever diagnosed with an ASD and whether s/he currently had an ASD. For the 1997-2000 birth cohorts (children aged 3-6 years in 2003 and 7-10 years in 2007), relative increases between 2003 autism estimates and 2007 ASD estimates were 200-600 %. For the 1990-1996 birth cohorts (children aged 7-13 years in 2003) increases were lower; nonetheless, differences between 2003 estimates and 2007 "ever ASD" estimates were >100 % for 6 cohorts and differences between 2003 estimates and 2007 "current ASD" estimates were >80 % for 3 cohorts. The magnitude of most birth cohort-specific differences suggests continuing diagnosis of children in the community played a sizable role in the 2003-2007 ASD prevalence increase. While some increase was expected for 1997-2000 cohorts, because some children have later diagnoses coinciding with school entry, increases were also observed for children ages ≥ 7 years in 2003. Given past ASD subtype studies, the 2003 "autism" question might have missed a modest amount (≤ 33 %) of ASDs other than autistic disorder.

Diagnostic history and treatment of school-aged children with autism spectrum disorder and special health care needs

Data from the 2011 Survey of Pathways to Diagnosis and Services The median age when school-aged children with special health care needs (CSHCN) and autism spectrum disorder (ASD) were first identified as having ASD was 5 years. School-aged CSHCN identified as having ASD at a younger age (under age 5 years) were identified most often by generalists and psychologists, while those identified later (aged 5 years and over) were identified primarily by psychologists and psychiatrists. Nine out of 10 school-aged CSHCN with ASD use one or more services to meet their developmental needs. Social skills training and speech or language therapy are the most common, each used by almost three-fifths of these children. More than one-half of school-aged CSHCN with ASD use psychotropic medication.

Medical home access among American Indian and Alaska Native children in 7 states: National Survey of Children's Health

To describe the prevalence of medical home among American Indian and Alaska Native children (AIAN) compared to non-Hispanic white (NHW) children and identify areas for improvement in the provision of care within a medical home. Prevalence of medical home, defined as family-centered, comprehensive, coordinated, compassionate, culturally effective care, including a personal doctor or nurse and usual care location, was estimated using 2007 National Survey of Children's Health data. Analyses included 1-17 year-olds in states reporting AIAN race as a distinct category (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota, n = 9,764). Associations between medical home and demographic (child's age, household education and income, and state) and health-related [child's insurance status, special health care need status, and past year Indian Health Service (IHS) utilization] characteristics were assessed among AIAN children. Overall, the prevalence of medical home was 27 % lower among AIAN children (42.6, 95 % CI = 34.4-50.8) than NHW children (58.3, 95 % CI = 56.2-60.4). Child's age (adjusted OR [aOR] = 2.7, 95 % CI = 1.3-5.6) was significantly associated with medical home. IHS utilization was associated with medical home among AIAN children with private insurance (aOR = 0.2, 95 % CI = 0.1-0.4), but not among uninsured or publicly insured children. Care coordination and family-centered care were noted areas for improvement among AIAN children. Less than half of AIAN children had a medical home. Future studies should further examine the intersection between insurance and IHS to determine if enhanced coordination is needed for this population, which is often served by multiple federally-funded health-related programs.

Factors associated with exclusive breastfeeding in the United States

OBJECTIVES

To estimate the proportions of US infants who were breastfed exclusively for 6 months, according to characteristics of the mother, child, and household environment, and to compare associations between those characteristics and exclusive breastfeeding with associations between those characteristics and breastfeeding initiation.

METHODS

Data were obtained from the 2007 National Survey of Children's Health, a nationally representative, cross-sectional survey. Multivariate logistic regression was used to calculate the adjusted odds ratios for breastfeeding among all infants and for breastfeeding exclusively for 6 months among infants who had initiated breastfeeding. All analyses were limited to children aged 6 months through 5 years for whom breastfeeding data were available (N = 25 197).

RESULTS

Of the nearly 75% of children in the study who had ever been breastfed, 16.8% had been breastfed exclusively for 6 months. Non-Hispanic black children were significantly less likely to have ever been breastfed compared with their non-Hispanic white counterparts (adjusted odds ratio: 0.54 [95% confidence interval: 0.44-0.66]). However, no significant differences in the odds of exclusive breastfeeding according to race were observed. Children with birth weights of <1500 g were most likely to have ever been breastfed and least likely to have been breastfed exclusively. Maternal age was significantly associated with exclusive breastfeeding; however, maternal age was not associated with breastfeeding initiation.

CONCLUSIONS

In the United States, the prevalence of exclusive breastfeeding for 6 months remains low among those who initiate breastfeeding. Factors associated with breastfeeding exclusively for 6 months differ from those associated with breastfeeding initiation.

Association between parental nativity and autism spectrum disorder among US-born non-Hispanic white and Hispanic children, 2007 National Survey of Children's Health

BACKGROUND

Limited studies suggest the prevalence of autism spectrum disorders (ASD) varies by whether maternal and child birth country are discordant.

OBJECTIVE/HYPOTHESIS

We explored associations between ASD and maternal and paternal nativity in a sample of US-born non-Hispanic white (NHW, n = 37,265) and US-born Hispanic (n = 4,690) children in the 2007 National Survey of Children's Health (NSCH).

METHODS

We assessed ASD prevalence within race-ethnicity and parental nativity subgroups. Prevalence ratios (aPR), comparing each group to NHW children with 2 US-born parents, were adjusted for child age, sex, and receipt of care in a medical home. Estimates were weighted to reflect US noninstitutionalized children. Standard errors were adjusted to account for the complex sample design.

RESULTS

In NHW children with 2 US-born parents, ASD prevalence was 1.19%; estimates were similar for NHW children with a foreign-born mother or father. There was a striking heterogeneity between Hispanic children with 2 US-born versus 2 foreign-born parents (ASD prevalence 2.39% versus 0.31%, p = .05). Even after adjustment, PRs comparing ASD prevalence in Hispanic versus NHW children were vastly different for Hispanic subgroups, suggesting a substantially lower prevalence for Hispanic children with both parents foreign-born (aPR 0.2, 95% confidence interval 0.1-0.5) and a higher prevalence for Hispanic children with both parents US-born (aPR 2.0 [0.8-4.6]).

CONCLUSIONS

Previous studies comparing ASD prevalence between NHW and Hispanic children based on a composite Hispanic grouping without consideration of parental nativity likely missed important differences between these racial-ethnic groups. Continuing efforts toward improving early identification in Hispanic children are needed.

Neighborhood socioeconomic conditions, built environments, and childhood obesity

We examine the impact of neighborhood socioeconomic conditions and "built environments" on obesity and overweight prevalence among U.S. children and adolescents using the 2007 National Survey of Children's Health. The odds of a child's being obese or overweight were 20-60 percent higher among children in neighborhoods with the most unfavorable social conditions such as unsafe surroundings; poor housing; and no access to sidewalks, parks, and recreation centers than among children not facing such conditions. The effects were much greater for females and younger children; for example, girls ages 10-11 were two to four times more likely than their counterparts from more favorable neighborhoods to be overweight or obese. Our findings can contribute to policy decisions aimed at reducing health inequalities and promoting obesity prevention efforts such as community-based physical activity and healthy diet initiatives.