Seizures in Children and Adolescents Aged 6–17 Years — United States, 2010–2014
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Seizures in Children and Adolescents Aged 6–17 Years — United States, 2010–2014

Wanjun Cui, PhD1; Rosemarie Kobau, MPH1; Matthew M. Zack, MD1; Sandra Helmers, MD1; Marshalyn Yeargin-Allsopp, MD2

A seizure is a brief change in normal electrical brain activity resulting in alterations in awareness, perception, behavior, or movement. Seizures affect persons of all ages, but are particularly common in childhood. There are many causes of seizures in children, including epilepsy; high fever (febrile seizures); head injuries; infections (e.g., malaria, meningitis, and gastrointestinal illness); metabolic, neurodevelopmental, and cardiovascular conditions; and complications associated with birth (13). Outcomes associated with single or recurring seizures in children vary by seizure type (febrile compared with nonfebrile) and multiple risk factors (age, illness, family history, and family context). Outcomes range from no complications to increased risk for behavioral problems, epilepsy, or sudden unexpected death (36). No nationally representative estimates have been reported for the number of U.S. children and adolescents with seizures, co-occurring conditions, or health service utilization. To address these information gaps, CDC analyzed combined data on children and adolescents aged 6–17 years from the National Health Interview Survey (NHIS) for the period 2010–2014. Overall, 0.7% of children and adolescents (weighted national estimate = 336,000) were reported to have had at least one seizure during the preceding year. Compared with children and adolescents without seizures, a higher percentage of those with seizures were socially and economically disadvantaged. Children and adolescents with seizures had higher prevalences of various mental, developmental, physical, and functional co-occurring conditions than those without seizures; however, only 65.6% of those with seizures had visited a medical specialist (defined as a medical doctor who specializes in a particular medical disease or problem, other than an obstetrician/gynecologist, psychiatrist, or ophthalmologist) during the preceding 12 months. Public health agencies can work with other health and human service agencies to raise awareness about childhood seizures, implement strategies to prevent known causes and risk factors for seizures, study the associations between sociodemographic characteristics and seizure incidence, and ensure linkages for children with seizures to appropriate clinical and community providers.

NHIS is an ongoing annual, nationally representative multistage household survey of the U.S. civilian noninstitutionalized population (http://www.cdc.gov/nchs/nhis/about_nhis.htm). CDC analyzed combined 2010–2014 NHIS data from the Sample Child component (questions asked about one randomly selected child from each family in the NHIS), with an average final response rate of 70%. Because these data do not distinguish the relatively large proportion of young children who experience usually benign febrile seizures* from those who have seizures of other etiologies (7), only children and adolescents aged 6–17 years were selected for analysis. Those whose parents provided a "Yes" answer to the survey question, "During the past 12 months, has [your child] had any of the following conditions?" and indicated "seizures" were identified as respondents with seizures.

Multiple outcomes reported by parents of those with and without seizures were examined, including indicators of food insecurity; co-occurring conditions (e.g., neurodevelopmental disabilities, recent infectious illnesses), functional limitations, and taking prescription medications; barriers to care, represented by delaying getting care and being unable to afford care in the past 12 months; access to care or health service utilization in the past 12 months; and the number of missed school days associated with any illness or injury.

Multiple logistic regression was used to calculate the prevalences and 95% confidence intervals (CI) of co-occurring conditions and barriers and access to care, adjusted by sex, race/ethnicity, family poverty income ratio, and mother's highest level of education, for children with and without seizures. Statistical software was used to account for the NHIS complex survey design and sample child weights. Prevalences were considered statistically significantly different if their CIs did not overlap.

During 2010–2014, parents of 0.7% of children and adolescents aged 6–17 years (weighted national estimate = 336,000) reported that their child had seizures during the past 12 months (Table 1). Children and adolescents with seizures were significantly more likely than those without seizures to live in poverty and low-income families or households (41.6% compared with 28.6%), and were less likely to have mothers or fathers with a bachelor's degree or higher (20.4% compared with 30.6% and 22.4% compared with 34.0%, respectively), or to live in nuclear families or households§ (30.3% compared with 41.9%). Parents of children with seizures also were more likely than parents of children without seizures to report worrying that food would run out (34.5% compared with 22.9%) or that food they bought would not last until they had money to get more (30.9% compared with 19.2%).

Co-occurring conditions were generally more frequently reported by parents of children and adolescents with seizures than by those without seizures (Table 2). Children with seizures had higher reported prevalences of mental or developmental co-occurring conditions, including learning disabilities (43.7% compared with 8.2%); other types of developmental delay (32.3% compared with 4.3%); intellectual disability (22.9% compared with 1.0%); and attention deficit hyperactivity disorder/attention deficit disorder (19.3% compared with 10.3%) than did children without seizures. Parents of children with seizures more frequently reported that their children had headaches or migraines (23.7% compared with 7.0%), hay fever (19.0% compared with 11.2%), and stuttering or stammering (11.3% compared with 1.6%). In addition, children with seizures were more frequently reported to have an impairment or health problem that limited their abilities to crawl, walk, run, or play (23.7% compared with 1.9%); to require special equipment because of impairment or health problems (21.4% compared with 1.1%); and to have taken prescription medication for ≥3 months (68.7% compared with 15.6%) (Table 2).

A significantly higher percentage of parents of children and adolescents with seizures reported delays in getting health care than did parents of children without seizures (14.4% compared with 8.8%) (Table 3). Children and adolescents with seizures were significantly more likely to see different types of health care providers, but 34.4% had not seen a medical specialist during the past 12 months. During the same time period, 41.0% of children and adolescents with seizures visited an emergency department, compared with 15.4% of children and adolescents without seizures. Children and adolescents with seizures reportedly missed six or more school days associated with any illness or injury significantly more frequently than did children and adolescents without seizures (41.9% compared with 14.3%) (Table 3).

Discussion

Seizures in children and adolescents vary by cause, severity, and impact. The risk for some seizures can be prevented or reduced by eliminating their causes, such as ensuring proper prenatal and perinatal care and preventing head injuries. The findings in this report indicate that seizures affect 0.7% of children and adolescents aged 6–17 years, and, relative to the general population, children and adolescents with seizures are socially and economically disadvantaged, more likely to have co-occurring conditions, and more likely to face barriers to care.

The higher observed prevalence of co-occurring conditions is consistent with previous research that has shown a higher prevalence of neurodevelopmental conditions and behavior problems among some children with seizures (36). In this analysis, approximately two in five children and adolescents with seizures were reported to have a learning disability and 20%–30% of them had an intellectual disability, attention deficit hyperactivity disorder/attention deficit disorder, or other developmental disorder. Associations between seizures and these conditions might be bidirectional, sharing some common pathophysiological mechanisms (8). Headaches, including migraines, hay fever, and functional disabilities also reportedly affected about one in five children and adolescents with seizures.

Although most children and adolescents with seizures had recently seen a general doctor, they frequently require the care of a specialist, such as a neurologist, and parents of approximately one third of those with seizures reported that they had not recently seen or talked to a medical specialist. Parents reported delays in obtaining care associated with cost and other factors, such as lack of transportation. Higher rates of home care might be associated with severity of co-occurring conditions or transportation barriers. Higher rates of emergency department use might reflect seizure severity, or associated conditions, barriers to routine health care, or other unmet caregiver needs. For example, caregivers might not understand seizure symptoms, or they might be uncomfortable with providing appropriate seizure response.

Overall, parents of children and adolescents with seizures reported higher prevalences of co-occurring conditions; these and the health care utilization patterns and social disadvantages reported by parents of children and adolescents with seizures highlight unmet needs and gaps in care. Children and adolescents with seizures might need coordinated care that ensures accurate diagnosis of seizures and any co-occurring conditions, and that links caregivers with other community organizations to improve health outcomes (9,10).

The findings in this study are subject to at least four limitations. First, the percentage of children and adolescents with seizures was ascertained through parent reports, which were not corroborated by other sources, and might be subject to misclassification or response biases. Second, this study might inadvertently include children and adolescents with febrile seizures. However, because febrile seizures usually occur in children aged 6 months–5 years (7), limiting analyses to children and adolescents aged 6–17 years should have excluded almost all children with febrile seizures. Third, because NHIS data are cross-sectional, causal relationships between seizures and some of the variables cannot be established. Finally, because NHIS does not ask about seizure type and frequency in children and adolescents, it is not possible to confirm whether children and adolescents with reported seizures had epilepsy, or to determine the etiology of the seizure or seizures.

Public health agencies can work with other health and human service agencies to raise awareness about seizures in children and adolescents (e.g., educate parents and school personnel), implement strategies to prevent known causes and risk factors for seizures (e.g., head injuries), study the associations between sociodemographic characteristics and seizure incidence, and ensure linkages to appropriate clinical and community providers for children and adolescents who experience seizures.


1Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2National Center on Birth Defects and Developmental Disabilities, CDC.

Corresponding author: Wanjun Cui, wtd9@cdc.gov, 770-488-5853.

References

  1. Martin ET, Kerin T, Christakis DA, et al. Redefining outcome of first seizures by acute illness. Pediatrics 2010;126:e1477–84.
  2. Fox CK, Glass HC, Sidney S, Lowenstein DH, Fullerton HJ. Acute seizures predict epilepsy after childhood stroke. Ann Neurol 2013;74:249–56.
  3. Yeargin-Allsopp M, Boyle C, van Naarden-Braun K, Trevathan E. The epidemiology of developmental disabilities. In: Accardo PJ, ed. Capute and Accardo's neurodevelopmental disabilities in infancy and childhood. Baltimore, MD: Paul H. Brookes Publishing Co; 2008:61–104.
  4. Austin JK, Perkins SM, Johnson CS, et al. Behavior problems in children at time of first recognized seizure and changes over the following 3 years. Epilepsy Behav 2011;21:373–81.
  5. Hesdorffer DC, Crandall LA, Friedman D, Devinsky O. Sudden unexplained death in childhood: A comparison of cases with and without a febrile seizure history. Epilepsia 2015;56:1294–300.
  6. Fastenau PS, Johnson CS, Perkins SM, et al. Neuropsychological status at seizure onset in children: risk factors for early cognitive deficits. Neurology 2009;73:526–34.
  7. Vestergaard M, Christensen J. Register-based studies on febrile seizures in Denmark. Brain Dev 2009;31:372–7.
  8. Stafstrom CE, Benke TA. Autism and epilepsy: exploring the relationship using experimental models. Epilepsy Curr 2015;15:206–10.
  9. Kenney MK, Mann M. Assessing systems of care for US children and adolescents with epilepsy/seizure disorder. Epilepsy Res Treat 2013;
    2013:825824.
  10. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee, 2014. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics 2014;133:e1451–60.

* Febrile seizures usually occur in children aged 6 months–5 years and affect about 2%–5% of children in that age range. Febrile seizures are usually benign and children with uncomplicated febrile seizures rarely go on to develop epilepsy (7).

A ratio of the family's income to the appropriate federal poverty threshold. Each person or family is assigned one out of 48 possible poverty thresholds. Thresholds vary according to family size and ages of family members. If total family income is less than the threshold appropriate for that family, the family is in poverty.

§ A nuclear family consists of one or more children living with two parents who are married to one another and are each biological or adoptive parents to all children in the family.

For example, a genetic mutation might disrupt neuronal development, resulting in seizures, autism spectrum disorder, or both, enhancing the progression of negative outcomes associated with either condition (8).


Summary

What is already known on this topic?

Children and adolescents with seizures can have more associated mental, developmental, and behavioral problems than children and adolescents without seizures. No nationally representative estimates of seizure burden and health service utilization for children and adolescents aged 6–17 years in the United States have been reported.

What is added by this report?

According to 2010–2014 NHIS data, seizures affected 0.7% of children and adolescents aged 6–17 years and, relative to the general population, those with seizures were socially and economically disadvantaged, more likely to have co-occurring conditions, and more likely to face barriers to care.

What are the implications for public health practice?

Public health agencies can work with other health and human service agencies to raise awareness about seizures that occur in children and adolescents (e.g., educate parents and school personnel), implement strategies to prevent known causes and risk factors for seizures (e.g., head injuries), study the associations between sociodemographic characteristics and seizure incidence, and ensure linkages for those with seizures to appropriate clinical and community providers.


TABLE 1. Number and weighted percentage of children and adolescents aged 6–17 years with seizures and without seizures, by selected characteristics — National Health Interview Survey, 2010–2014

Characteristic

With seizures

Without seizures

No. in sample

Weighted % (95% CI)

No. in sample

Weighted % (95% CI)

Total

298

0.7

41,711

99.3

Sex

Male

147

46.9 (39.8–54.1)

21,552

51.2 (50.6–51.8)

Female

151

53.1 (45.9–60.2)

20,159

48.8 (48.2–49.4)

Race/Ethnicity

White, non-Hispanic

125

50.7 (43.0–58.3)

18,761

54.8 (53.7–55.9)

Black, non-Hispanic

54

16.3 (11.5–22.7)

6,445

13.8 (13.1–14.4)

Hispanic

85

23.3 (17.7–29.9)

12,145

22.7 (21.7–23.7)

Other

34

9.7 (6.5–14.2)

4,360

8.7 (8.3–9.2)

Family poverty income ratio*

≤129%

123

41.6 (34.4–49.1)

12,168

28.6 (27.7–29.5)

130%–349%

111

37.0 (29.8–44.7)

16,257

38.1 (37.4–38.8)

≥350%

64

21.5 (16.2–27.9)

13,286

33.3 (32.3–34.4)

Mother's education

Less than high school diploma

48

16.4 (11.7–22.4)

6,486

15.2 (14.5–16.0)

High school

65

25.7 (19.5–33.1)

8,606

21.7 (21.1–22.3)

Some college

103

37.5 (30.6–45.0)

12,108

32.5 (31.8–33.3)

Bachelor's degree or higher

57

20.4 (14.9–27.4)

10,501

30.6 (29.6–31.6)

Father's education

Less than high school diploma

37

19.3 (13.2–27.4)

5,066

15.3 (14.5–16.1)

High school

43

24.5 (17.3–33.3)

7,135

24.2 (23.4–25.1)

Some college

55

33.8 (25.6–43.1)

7,351

26.4 (25.6–27.2)

Bachelor's degree or higher

34

22.4 (16.1–30.4)

8,503

34.0 (32.9–35.3)

Family structure

Single-parent family

74

23.1 (17.6–29.8)

8,180

17.9 (17.3–18.4)

Nuclear family

80

30.3 (24.0–37.4)

15,333

41.9 (41.1–42.8)

Blending or cohabiting family

43

16.5 (11.8–22.6)

4,746

12.7 (12.2–13.2)

Extended family/Other

101

30.0 (24.1–36.8)

13,422

27.6 (27.0–28.1)

Worried food would run out before had money to buy more (only asked in 2011–2014)

Often true or sometimes true

79

34.5 (27.1–42.6)

8,246

22.9 (22.1–23.6)

Never true

157

65.5 (57.4–72.9)

26,143

77.1 (76.4–77.9)

Food did not last before had money to get more (only asked in 2011–2014)

Often true or sometimes true

74

30.9 (23.3–39.5)

6,945

19.2 (18.5–19.8)

Never true

162

69.1 (60.5–76.7)

27,445

80.8 (80.2–81.5)

Could not afford to eat balanced meals (only asked in 2011–2014)

Often true or sometimes true

63

24.3 (18.4–31.4)

5,552

14.9 (14.3–15.4)

Never true

173

75.7 (68.6–81.6)

28,832

85.1 (84.6–85.7)

Insurance status

Private

129

46.4 (39.2–53.7)

22,134

56.3 (55.3–57.3)

Medicaid/Medicare

124

36.1 (29.8–42.8)

11,317

26.1 (25.3–27.0)

Not covered

14

§

3,591

7.4 (7.1–7.8)

Other

30

12.7 (8.3–19.0)

4,492

10.2 (9.7–10.7)

Abbreviation: CI = confidence interval.

* A ratio of the family's income to the appropriate federal poverty threshold. Each person or family is assigned one out of 48 possible poverty thresholds. Thresholds vary according to family size and ages of family members. If total family income is less than the threshold appropriate for that family, the family is in poverty.

Estimate is statistically significantly different (p<0.01) from the "Without seizures" group for the same condition/variable.

§ Estimate suppressed because relative standard error was ≥30%.

Estimate has a relative standard error of ≥20% and <30%.


TABLE 2. Adjusted* prevalences of selected co-occurring health conditions for children and adolescents aged 6–17 years, with and without seizures — National Health Interview Survey, 2010–2014

Condition

With seizures

Without seizures

No. in sample

Weighted % (95% CI)

No. in sample

Weighted % (95% CI)

Learning disability

138

43.7 (36.6–51.2)

3,498

8.2 (7.9–8.6)

Intellectual disability

70

22.9 (17.5–29.4)

475

1.0 (0.9–1.2)

Other developmental delay

96

32.3 (25.6–39.8)

1,724

4.3 (4.1–4.6)

Attention deficit hyperactivity disorder/Attention deficit disorder

69

19.3 (14.2–25.5)

4,227

10.3 (9.9–10.7)

Cerebral palsy

31

15.0 (9.9–22.1)§

78

0.2 (0.1–0.3)

Autism spectrum disorder

18

8.1 (4.8–13.5)§

405

1.2 (1.0–1.3)

Asthma

62

19.0 (14.1–25.0)

7,137

16.4 (15.8–16.9)

Hay fever, past 12 mos.

51

19.0 (13.4–26.3)

4,565

11.2 (10.7–11.7)

Respiratory allergy, past 12 mos.

51

16.1 (11.6–21.9)

5,047

12.3 (11.9–12.8)

Food/Digestive allergy, past 12 mos.

30

10.5 (6.9–15.7)§

2,202

5.5 (5.3–5.9)

Eczema/skin allergy, past 12 mos.

43

14.0 (9.5–20.0)

4,688

11.7 (11.3–12.1)

Diarrhea/colitis, past 12 mos.

23

8.1 (4.9–13.4)§

521

1.3 (1.1–1.4)

Anemia, past 12 mos.

17

5.8 (3.2–10.0)§

433

0.9 (0.8–1.1)

Had three or more ear infections, past 12 mos.

25

8.2 (5.2–12.6)§

1,370

3.3 (3.1–3.5)

Had frequent headaches/migraines, past 12 mos.

76

23.7 (18.3–30.2)

3,033

7.0 (6.6–7.3)

Had head/chest cold, past 2 wks.

40

12.2 (8.3–17.5)

5,220

12.8 (12.4–13.3)

Had stomach illness with vomiting/diarrhea, past 2 wks.

26

7.5 (4.7–11.7)§

1,980

5.1 (4.9–5.4)

Stuttered/stammered, past 12 mos.

44

11.3 (7.7–16.2)

707

1.6 (1.5–1.8)

Trouble seeing

37

12.4 (8.1–18.6)§

1,373

3.2 (3.0–3.4)

Need special equipment due to impairment/health problem

56

21.4 (16.0–28.0)

464

1.1 (1.0–1.3)

Impairment/Health problem limiting crawl/walk/run/play

71

23.7 (18.0–30.5)

795

1.9 (1.7–2.1)

Taken prescription medication for ≥3 mos.

197

68.7 (61.4–75.3)

6,361

15.6 (15.1–16.1)

Hearing status without hearing aid or other listening device

Excellent

145

70.3 (62.5–77.1)

25,875

80.0 (79.3–80.6)

Good

61

20.7 (14.9–27.9)

6,148

17.6 (17.0–18.2)

Trouble hearing/deaf

26

9.0 (5.5–14.5)§

762

2.4 (2.2–2.7)

Health condition compared with 12 mos. ago

Better

81

26.0 (19.9–33.3)

8,347

18.2 (17.7–18.7)

Worse

32

10.7 (7.0–16.0)§

588

1.4 (1.2–1.6)

Same

184

63.2 (55.8–70.1)

32,755

80.4 (79.9–80.9)

Abbreviation: CI = confidence interval.

* Adjusted for sex, race/ethnicity, family poverty income ratio, and mother's education.

Estimate is statistically significantly different (p<0.01) from the "Without seizures" group for the same condition/variable.

§ Estimate has a relative standard error of ≥20% and <30%.


TABLE 3. Adjusted* prevalences of barriers and access to health care variables for children and adolescents aged 6–17 years, with and without seizures — National Health Interview Survey, 2010–2014

Barrier/Variable

With seizures

Without seizures

No. in sample

Weighted % (95% CI)

No. in sample

Weighted % (95% CI)

Delayed getting care for any reason, past 12 mos.

45

14.4 (10.1–20.1)§

3,736

8.8 (8.4–9.2)

Didn't get something needed because you couldn't afford it, past 12 mos.

49

15.6 (11.1–21.6)

4,144

11.5 (11.1–12.0)

Saw/talked to eye doctor, past 12 mos.

123

40.3 (33.7–47.2)§

13,225

32.2 (31.5–32.9)

Saw/talked to foot doctor, past 12 mos.

25

8.7 (5.3–13.8)**

1,020

2.4 (2.2–2.6)

Saw/talked to therapist (PT/OT/etc.), past 12 mos.

100

34.4 (27.6–41.8)§

2,648

6.8 (6.4–7.1)

Saw/talked to a NP/PA, past 12 mos.

94

38.1 (30.7–46.0)§

6,112

16.3 (15.7–16.9)

Saw/talked to mental health professional, past 12 mos.

72

22.7 (17.1–29.6)§

3,638

8.5 (8.1–8.8)

Saw/talked to a medical specialist, past 12 mos.††

172

65.6 (58.6–72.0)§

5,703

14.4 (13.9–14.8)

Saw/talked to a general doctor, past 12 mos.

265

92.4 (88.7–95.0)§

32,885

81.2 (80.6–81.8)

Saw/talked to a doctor who treats both children and adults (asked among those who saw/talked to a general doctor)

123

43.4 (35.8–51.4)

13,955

39.7 (38.7–40.7)

Saw/talked to doctor for emotional/behavioral problem (asked among those who saw/talked to a general doctor)

50

16.8 (11.9–23.3)§

2,135

6.3 (5.9–6.6)

Had well-child checkup, past 12 mos.

241

81.5 (75.1–86.5)

31,284

77.5 (76.8–78.1)

Received home care from health professional, past 12 mos.

25

10.5 (6.6–16.2)**

212

0.5 (0.4–0.6)

Number of times in emergency department, past 12 mos.

None

161

59.1 (51.3–66.4)§

35,036

84.7 (84.1–85.2)

1

63

21.1 (15.7–27.7)§

4,419

10.5 (10.0–10.9)

≥2

72

19.9 (14.7–26.2)§

2,036

4.9 (4.6–5.2)

Total number of office visits, past 12 mos.

None or 1

37

12.8 (8.5–18.8)**

15,704

36.2 (35.5–36.8)

2–3

71

21.2 (15.9–27.6)§

15,397

38.1 (37.4–38.7)

4–5

53

17.7 (12.9–23.7)

5,247

13.3 (12.9–13.8)

6–7

42

16.0 (11.0–22.7)§

1,904

4.8 (4.5–5.1)

8–12

46

15.4 (10.9–21.4)§

1,775

4.6 (4.3–4.9)

≥13

46

17.0 (11.9–23.6)§

1,255

3.1 (2.9–3.4)

Time since last saw/talked to health professional

≤6 months

260

89.3 (84.2–92.9)§

28,697

70.7 (70.1–71.3)

>6 months or never

36

10.7 (7.1–15.8)**

12,627

29.3 (28.7–29.9)

School days missed due to illness/injury, past 12 mos.

Didn't go to school or none

60

20.7 (14.9–28.1)§

13,007

29.6 (29.0–30.3)

1–2 days

44

16.5 (11.8–22.7)§

11,877

29.8 (29.2–30.4)

3–5 days

66

20.8 (15.2–27.9)

10,642

26.3 (25.7–27.0)

6–10 days

50

17.9 (12.8–24.5)§

3,941

9.8 (9.4–10.2)

≥11 days

73

24.0 (18.5–30.5)§

1,885

4.5 (4.2–4.8)

Abbreviations: CI = confidence interval; NP/PA = nurse practitioner/physician's assistant; PT/OT = physical therapist/occupational therapist.

* Adjusted for sex, race/ethnicity, family poverty-income ratio, and mother's education.

Including the following reasons: couldn't get through on the phone, couldn't get appointment soon enough, wait was too long in doctor's office, not open when able to go, and no transportation.

§ Estimate is statistically significantly different (p<0.01) from the "Without seizures" group for the same condition/variable.

Including the following situations: prescription medicine, follow-up care (only asked in 2011–2014), seeing a specialist (only asked in 2011–2014), receiving mental health care/counseling, dental care, and eyeglasses.

** Estimate has a relative standard error ≥20% and <30%.

†† A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist).



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