Introduction to the Special Issue of Articles from the 2007 National Survey of Children’s Health

Families of children affected by birth defects suffer from a significant psychological burden across the lifespan, but there have been few studies on this topic in China. Our goal was to assess depression among mothers of children with birth defects (MCBD) and to explore factors influencing depression among MCBD in China. A total of 154 mothers of affected children aged 0–3 years old (MCBD) and 321 mothers of healthy children (MHC) in the same age range took part in the study. The Center for Epidemiologic Studies Depression Scale was used to assess maternal depression, and logistic regression models were used to explore the factors influencing depression among MCBD. MCBD were more depressed than MHC and birth defects were associated with maternal depression after demographic variables were controlled. Poverty was the most important predictor of depression among MCBD. Appropriate interventions for depressed mothers are essential and should focus on poor families.     

Oral Health Need and Access to Dental Services: Evidence from the National Survey of Children’s Health, 2007

This study examines associations between parents’ report of their children’s oral health and receipt of a dental visit for preventive care. We conducted a cross-sectional analysis of oral health status and receipt of a preventive dental visit among US children and youth, ages 1–17 years, using data from the 2007 National Survey of Children’s Health (n = 86,764). Survey-weighted logistic regression was used to estimate associations between perceived oral health status and receipt of a preventive dental health visit in the prior 12 months. Overall, 78 % of children and youth received at least one preventive dental health visit in the prior year. Among the youngest children, lower oral health status was associated with higher odds of receiving a preventive dental visit; among older children, lower oral health status was associated with lower odds of receiving a dental visit for preventive care. Use of preventive dental health care is below national target goals. Younger children in worse oral health are more likely, and older youth less likely, to receive preventive dental care. Public health efforts to educate parents to seek early and ongoing preventive oral health care, rather than services in response to problems, may yield oral health benefits later in childhood and over the life course.     

Characteristics of Children Eligible for Public Health Insurance but Uninsured: Data from the 2007 National Survey of Children’s Health

To describe the state variation, demographic and family characteristics of children eligible for public health insurance but uninsured. Using data from the National Survey of Children’s Health we selected a subset of children living in households with incomes <200 % of the federal poverty level, who are generally eligible for Medicaid or CHIP. We used multiple logistic regression to examine associations between insurance status among this group of eligible children and certain demographic factors, family characteristics, and state of residence. In adjusted models children aged 6–11 and 12–17 years were more likely to be eligible but uninsured compared to those aged 0–5 years (AOR 1.57; 95 % CI 1.15–2.16 and AOR 1.93; 95 % CI 1.41–2.64). Children who received school lunch (AOR 0.67; 95 % CI 0.52–0.86) and SNAP (AOR 0.33; 95 % CI 0.24–0.46) were less likely to be eligible but uninsured compared to those children not receiving those needs based services; however, a majority (58.7 %) of eligible uninsured children were enrolled in the school lunch program. Five states (Texas, California, Florida, Georgia, New York) accounted for 46 % of the eligible uninsured children. Vermont had the lowest adjusted estimate of eligible uninsured children (3.6 %) and Nevada had the highest adjusted estimate (35.5 %). Using nationally representative data we have identified specific state differences, demographic and household characteristics that could help guide federal and local initiatives to improve public health insurance enrollment for children who are eligible but uninsured.     

Weight and Mental Health Status in Massachusetts,National Survey of Children’s Health, 2007

This study explores how weight status is related to mental health status among Massachusetts children, aged 10–17 years. We used data from the 2007 National Survey of Children’s Health to examine the association between weight status (body mass index-for-age) and parent-reported mental health status among Massachusetts children (N = 827). Multivariable log binomial regression was performed to calculate the adjusted prevalence ratios (aPR) of three mental health outcomes (behavioral, emotional, and social) as related to weight status, after controlling for covariates including physical activity, sex, race/ethnicity, maternal education, poverty status, special health needs, and neighborhood safety. Almost one-third (32.5 %) of Massachusetts children were either overweight or obese. Sex was a significant effect modifier of the association between weight status and negative emotions. After stratifying by sex and controlling for covariates, the relationship between weight status and negative emotions remained significant among girls (aPR = 1.8, 95 % CI 1.3–2.6). Children who did not exercise at all were significantly more likely to exhibit negative behaviors (aPR = 1.3, 95 % CI 1.0–1.6), negative emotions (boys’ aPR = 3.3, 95 % CI 1.6–6.9; girls’ aPR = 2.6, 95 % CI 1.5–4.5), and fewer social skills (aPR = 1.9, 95 % CI 1.3–2.9) than those who exercised at least 20 min every day of the week. Overweight/obese children, especially girls, were more likely than children of normal weight to have parent-reported negative emotions, suggesting an association between weight status and mental health. Lower levels of physical activity were associated with negative mental health outcomes, supporting the benefits of physical activity for all children.     

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.     

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children’s Health

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children’s Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

     

Racial/Ethnic Variation in Breastfeeding Across the US: A Multilevel Analysis from the National Survey of Children’s Health, 2007

We examined whether differences across states in race/ethnicity-specific breastfeeding rates are due solely to state differences in individual factors associated with breastfeeding or additionally, certain state “contextual” factors. Using data from the 2007 National Survey of Children’s Health, multilevel models examined whether state variability in race/ethnicity specific breastfeeding initiation and duration to 6 months were explained by (1) individual sociodemographic characteristics of women in states, and (2) an aggregate state measure of the availability of evidence-based maternity care services related to breastfeeding. Observed variability of race/ethnicity-specific breastfeeding rates was only minimally reduced after adjusting for sociodemographic characteristics (Median Odds Ratios (MOR), breastfeeding initiation: non-Hispanic White = 1.46, non-Hispanic Black = 2.26; Hispanic = 1.89. MOR, breastfeeding for 6 months: non-Hispanic White = 1.36, non-Hispanic Black = 1.84; Hispanic = 1.56). Overall variability in the degree of state gaps changed little in adjusted models (breastfeeding initiation: non-Hispanic Black σ² = 0.74, se 0.28, Hispanic σ² = 0.45, se 0.11; breastfeeding to 6-months: non-Hispanic Black σ² = 0.41, se 0.10, Hispanic σ² = 0.22, se 0.05). The measure of maternity care services was positively associated with breastfeeding overall but generally did not explain a substantial portion of between-state variability nor the overall variability in racial/ethnic gaps. Contextual sources of variation in state breastfeeding practices and disparities remain poorly understood. Differences in the socioeconomic makeup of states do not fully explain variability. The association of state breastfeeding rates and disparities with relevant policy and practice factors should be further investigated.     

Factors Associated with Forgone Care Among Children in the United States: An Analysis of the 2016-2018 National Survey of Children’s Health

Delaying or forgoing health care can have negative consequences for the health and well-being of children. In 2000, Paul Newacheck called for the continued monitoring of unmet health needs among children. While a handful of studies have been conducted since 2000, primarily among children with special healthcare needs (CSHCN), the redesigned National Survey of Children’s Health (NSCH) offers a unique opportunity to examine forgone care among all children ages 0-17. This study provides the most recent prevalence estimates of forgone care among children in the United States, by type of care, and identifies related sociodemographic and health factors. We used data from the combined 2016-2018 NSCH to examine sociodemographic and health factors associated with parent/caregiver-reported forgone care among children ages 0-17 years in the United States. We also examined the association of these factors with different types of forgone care and reasons for forgone care. Survey weighted bivariate and logistic regression analyses were conducted. 101,984 children ages 0-17 years. 3.1% of children (2.2 million) had forgone care in 2016-2018. Forgone dental care was most frequently reported (1.67%), followed by medical care (1.03%) and mental health care (0.83%). Cost was the most frequently reported reason for forgone care (1.83%), followed by problems getting an appointment (1.20%) and lack of eligibility (0.97%). Children, who were older, had greater number of health conditions, were CSHCN, were Hispanic or non-Hispanic black, were uninsured, and had family incomes < 100% of the federal poverty level (FPL) were significantly more likely to have any reported forgone care. Among children with forgone care, the factors associated with reporting different types of forgone care varied. After adjustment, insurance status was the only factor consistently associated with all types of care, except hearing services; CSHCN status, number of health conditions, and insurance status were associated with forgone dental care; race/ethnicity and insurance were associated with forgone vision care; age, number of health conditions, CSHCN status, and insurance were associated with forgone mental care; and FPL was associated with forgone hearing services. The factors associated with the different reasons for forgone care also varied. Insurance status and FPL were associated with forgone care due to lack of eligibility and issues with cost; CSHCN status was associated with services not available in the area; and insurance, CSHCN status, and race/ethnicity were associated with problems getting an appointment. Forgone care remains an issue for over 2.2 million children in the United States. However, the characteristics of children associated with different types of forgone care vary, as do those associated with different reasons for forgoing care. This suggests the need for diverse strategies, in addition to standing efforts to expand insurance coverage, to ensure timely access to needed healthcare services among US children. Efforts to reduce forgone care will need to address both financial and nonfinancial issues and will need to be tailored to address the factors associated with forgoing different types of care.     

Assessing Child Health and Health Care in the U.S. Virgin Islands Using the National Survey of Children’s Health

Maternal and Child Health Journal - To characterize the health and health care experiences of children in the U.S. Virgin Islands (USVI), assess differences by household poverty status, and provide...     

Unmet Need for Therapy Among Children with Autism Spectrum Disorder: Results from the 2005–2006 and 2009–2010 National Survey of Children with Special Health Care Needs

Objectives We examined population-based trends in unmet need for therapy service in children with autism spectrum disorder (ASD) compared to other children with special health care needs (CSHCN), and identified factors associated with unmet need for therapy. Methods A pooled cross-sectional comparison of the 2005–2006 and 2009–2010 waves of the National Survey for Children with Special Health Care Needs (NS-CSHCN) was used. Weighted bivariate analyses were used to compare children ages 3–17 years with ASD (n = 5113) to other CSHCN (n = 71,294) on unmet need for therapy services. Survey weighted multivariate models were used to examine child, family, and contextual characteristics associated with unmet need. Results A greater percentage of children with ASD across both surveys were reported to need therapy than other children with CSHCN. Among children with a reported need, children with ASD were 1.4 times more likely to report an unmet need for therapy compared to other CSHCN (OR 1.42, 95 % CI 1.18–1.71). Variables significantly associated with unmet need for therapy services included not receiving a well-child visit in the past year (OR 5.81, CI 3.83–8.81), surveyed in 2009 (OR 1.42, CI 1.18–1.71), child being female (OR 1.27, CI 1.05–1.53), uninsured (OR 1.72, CI 1.15–2.56), and having greater functional limitation (OR 2.44, CI 1.80–3.34). Conclusions for Practice Children with ASD require supportive services such as occupational, physical, and speech therapy but are less likely to receive such services than other CSHCN. Receiving a well-child visit in the past year was strongly associated with receipt of needed therapy services.     

Perinatal Air Pollutant Exposures and Autism Spectrum Disorder in the Children of Nurses’ Health Study II Participants

Objective: Air pollution contains many toxicants known to affect neurological function and to have effects on the fetus in utero. Recent studies have reported associations between perinatal exposure to air pollutants and autism spectrum disorder (ASD) in children. We tested the hypothesis that perinatal exposure to air pollutants is associated with ASD, focusing on pollutants associated with ASD in prior studies.Methods: We estimated associations between U.S. Environmental Protection Agency–modeled levels of hazardous air pollutants at the time and place of birth and ASD in the children of participants in the Nurses’ Health Study II (325 cases, 22,101 controls). Our analyses focused on pollutants associated with ASD in prior research. We accounted for possible confounding and ascertainment bias by adjusting for family-level socioeconomic status (maternal grandparents’ education) and census tract–level socioeconomic measures (e.g., tract median income and percent college educated), as well as maternal age at birth and year of birth. We also examined possible differences in the relationship between ASD and pollutant exposures by child’s sex.Results: Perinatal exposures to the highest versus lowest quintile of diesel, lead, manganese, mercury, methylene chloride, and an overall measure of metals were significantly associated with ASD, with odds ratios ranging from 1.5 (for overall metals measure) to 2.0 (for diesel and mercury). In addition, linear trends were positive and statistically significant for these exposures (p < .05 for each). For most pollutants, associations were stronger for boys (279 cases) than for girls (46 cases) and significantly different according to sex.Conclusions: Perinatal exposure to air pollutants may increase risk for ASD. Additionally, future studies should consider sex-specific biological pathways connecting perinatal exposure to pollutants with ASD.     

Assessment of Environmental Health Children’s Population Living in Environmental Injustice Scenarios

We conducted a cross sectional study, involving 145 children randomly selected from three different socioeconomic locations. We selected social, environment and health indicators and measured the prevalence and prevalence odds ratios. Children from the brick producing site (segregation index 5), are exposed to high levels of multiple toxic agents, and showed the highest morbidity rates and malnutrition, anemia, dental fluorosis, and the lowest IQ, followed by children from municipal garbage dump (segregation index 4), where we detected the highest prevalence of dermatological and enteric diseases. Children from the Central Zone (segregation index 2) showed the lowest rates of malnutrition and higher IQ than the other two groups. A unified vision of social, health and environmental indicators opens the possibility of novel intervention programs and a legal framework that specifically protect children against environmental exposures.     

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.     

National Survey of State Children’s Mental Health Directors: Current Status and Future Directions

State agencies play a critical role in addressing the mental health needs of children and youth. Significant changes underway throughout the nation at the federal and state levels have led to questions about the role of state children’s mental health (CMH) agencies and the effects of these changes on children’s services. The purpose of this study was to examine the current status of state offices for CMH with regard to structure and responsibilities and to identify what state CMH directors express as opportunities and challenges for CMH at the state level. CMH directors or their representatives from 46 states, 1 US territory, and D.C. completed an online survey developed to address the specific aims of this study. Findings highlight the importance of a strong state structure to support CMH and opportunities for reform and system change, particularly related to the Affordable Care Act and expansion of Systems of Care.     

Prevalence of Children’s Mental Health Problems and the Effectiveness of Population-Level Family Interventions

The prevalence of mental health problems among children and adolescents is of growing importance. Intervening in children’s mental health early in life has been shown to be more effective than trying to resolve these problems when children are older. With respect to prevention activities in community settings, the prevalence of problems should be estimated, and the required level of services should be delivered. The prevalence of children’s mental health disorders has been reported for many countries. Preventive intervention has emphasized optimizing the environment. Because parents are the primary influence on their children’s development, considerable attention has been placed on the development of parent training to strengthen parenting skills. However, a public-health approach is necessary to confirm that the benefits of parent-training interventions lead to an impact at the societal level. This literature review clarifies that the prevalence of mental health problems is measured at the national level in many countries and that population-level parenting interventions can lower the prevalence of mental health problems among children in the community.Key words: child, mental health, prevalence, family intervention, evaluation     

Correlates of Overweight and Obesity Among American Indian/Alaska Native and Non-Hispanic White Children and Adolescents: National Survey of Children’s Health, 2007

Risk factors for overweight and obesity may be different for American Indian and Alaska Native (AI/AN) children compared to children of other racial/ethnic backgrounds, as obesity prevalence among AI/AN children remains much higher. Using data from the 2007 National Survey of Children’s Health, behavioral (child’s sport team participation, vigorous physical activity, television viewing, and computer use), household (parental physical activity, frequency of family meals, rules limiting television viewing, and television in the child’s bedroom), neighborhood (neighborhood support, perceived community and school safety, and presence of parks, sidewalks, and recreation centers in the neighborhood), and sociodemographic (child’s age and sex, household structure, and poverty status) correlates of overweight/obesity (body mass index ≥85th percentile for age and sex) were assessed among 10–17 year-old non-Hispanic white (NHW) and AI/AN children residing in Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota (n = 5,372). Prevalence of overweight/obesity was 29.0 % among NHW children and 48.3 % among AI/AN children in this sample. Viewing more than 2 h of television per day (adjusted odds ratio [aOR] = 2.0; 95 % confidence interval [CI] = 1.5–2.8), a lack of neighborhood support (aOR = 1.9; 95 % CI = 1.1–3.5), and demographic characteristics were significantly associated with overweight/obesity in the pooled sample. Lack of sport team participation was significantly associated with overweight/obesity only among AI/AN children (aOR = 2.7; 95 % CI = 1.3–5.2). Culturally sensitive interventions targeting individual predictors, such as sports team participation and television viewing, in conjunction with neighborhood-level factors, may be effective in addressing childhood overweight/obesity among AI/AN children. Longitudinal studies are needed to confirm these findings.     

Residential Mobility and Flourishing Among United States School-Age Children, 2011/2012 National Survey of Children’s Health

Maternal and Child Health Journal - Objectives To investigate the association of residential mobility with flourishing among school-age children. Methods Data from the 2011/2012 National Survey of...