Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders and Poverty Among Children Aged 2–8 Years — United States, 2016

Childhood mental, behavioral, and developmental disorders (MBDDs) are associated with adverse outcomes that can persist into adulthood (1,2). Pediatric clinical settings are important for identifying and treating MBDDs (3). Early identification and treatment of MBDDs can promote healthy development for all children (4), especially those living in poverty who are at increased risk for MBDDs (3,5) but might have reduced access to care (6). CDC analyzed data from the 2016 National Survey of Children’s Health (NSCH) on MBDDs, risk factors, and use of federal assistance programs (e.g., Supplemental Nutrition Assistance Program [SNAP]) to identify points to reach children in poverty. In line with previous research (3,6), compared with children in higher-income households, those in lower-income households more often had ever received a diagnosis of an MBDD (22.1% versus 13.9%), and less often had seen a health care provider in the previous year (80.4% versus 93.8%). Among children living below 200% of the federal poverty level (FPL) who did not see a health care provider in the previous year, seven of 10 were in families receiving at least one public assistance benefit. Public assistance programs might offer collaboration opportunities to provide families living in poverty with information, co-located screening programs or services, or connection to care.

Childhood mental, behavioral, and developmental disorders (MBDDs) are associated with adverse outcomes that can persist into adulthood (1,2).Pediatric clinical settings are important for identifying and treating MBDDs (3).Early identification and treatment of MBDDs can promote healthy development for all children (4), especially those living in poverty who are at increased risk for MBDDs (3,5) but might have reduced access to care (6).CDC analyzed data from the 2016 National Survey of Children's Health (NSCH) on MBDDs, risk factors, and use of federal assistance programs (e.g., Supplemental Nutrition Assistance Program [SNAP]) to identify points to reach children in poverty.In line with previous research (3,6), compared with children in higher-income households, those in lower-income households more often had ever received a diagnosis of an MBDD (22.1% versus 13.9%), and less often had seen a health care provider in the previous year (80.4% versus 93.8%).Among children living below 200% of the federal poverty level (FPL) who did not see a health care provider in the previous year, seven of 10 were in families receiving at least one public assistance benefit.Public assistance programs might offer collaboration opportunities to provide families living in poverty with information, co-located screening programs or services, or connection to care.
NSCH is a national, cross-sectional, web-based and paperbased survey funded and directed by the Health Resources and Services Administration's Maternal and Child Health Bureau that is representative of noninstitutionalized children aged 0-17 years in the United States.*The U.S. Census Bureau conducted the 2016 NSCH using address-based sampling and created weights to account for oversampling and potential MBDDs (1,3), including household income, health insurance, components of a medical home, difficulty getting by on the family's income, parent emotional support, neighborhood condition (e.g., litter or vandalism), neighborhood amenities (e.g., sidewalks or parks), and parental mental or physical health, as well as whether they received public assistance (e.g., SNAP; Women, Infants, and Children [WIC]; free or reduced price meals at school; or cash assistance).§  Parents of 50,212 children participated in the survey, resulting in an interview completion rate of 69.7% and a weighted response rate of 40.7%.Analyses were restricted to children aged 2-8 years with nonmissing data on MBDD diagnosis and age (16,912 children).Data missing on race (0.3%), ethnicity (0.5%), sex (0.1%), and FPL (16.6%) were imputed using hot-deck imputation (a method for handling missing data in which missing values are replaced with observed responses from "similar" units) and regression methods.¶ Differences in demographic, health care, family, and community factors by MBDD status were assessed using weighted prevalence estimates, prevalence ratios (PRs), 95% confidence intervals (CIs), and Wald chi-square tests.Prevalence of MBDDs, health care, family, and community factors were compared by FPL category.Weighted prevalence estimates, PRs, and 95% CIs § https://www.census.gov/programs-surveys/nsch/technical-documentation/codebooks.html.¶ https://census.gov/content/dam/Census/programs-surveys/nsch/techdocumentation/methodology/2016-NSCH-Methodology-Report.pdf.
were calculated.To further explore whether federal assistance programs are possible points to reach children living in poverty, 4,410 children living below 200% of the FPL who had and had not seen a health care provider in the past year, both with and without MBDDs, were compared by whether their families received public assistance.Statistical software was used to account for the complex survey design.
Overall, 17.4% of children aged 2-8 years had at least one MBDD (Table 1 income level decreased), with the exception that inadequate insurance was less often reported for children in the lower income levels than for those in the highest level.
Among children living at <200% of FPL, 82.6% saw a health care provider in the past year, and 73.4% received public assistance (Table 3).Among the children who did not see a health care provider in the past year, 69.0% received public assistance and 19.2% had a diagnosed MBDD.Among children who did not see a health care provider in the past year and had a diagnosed MBDD, 81.7% received public assistance.Of children who did not see a health care provider in the past year and did not have a diagnosed MBDD, 66.0% received public assistance.

Discussion
Consistent with previous studies (3,5,7), this study found that children living in lower-income households had higher prevalences of a parent-reported diagnosis of an MBDD and other health care, family, and community risk factors associated with MBDDs than did children living in higher-income households.Most children had seen a health care provider in the past year regardless of income level; therefore, the American Academy of Pediatrics recommendation to screen for MBDDs (8) and family and socioeconomic risk factors (4) during primary care visits appears to be theoretically feasible.Screening** , † † in health care settings can be challenging in practice, and MBDDs might be underdiagnosed even among ** https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/default.aspx.† † https://eclkc.ohs.acf.hhs.gov/publication/birth-5-watch-me-thrivecompendium-screening-measures-young-children.
children who have recently seen a health care provider (9).Children living in lower-income households had lower prevalences of having seen a health care provider in the past year and of receiving needed health care compared with children living in higher-income households.Approximately one in five children living at <200% of FPL who did not see a health care provider in the past year had a diagnosed MBDD.This, coupled with families with lower incomes reporting greater difficulty receiving needed health care, raises concern that MBDDs might be undertreated in this population.Additionally, families living in poverty were more likely to experience a range of risk factors related to MBDDs; therefore, connections to health care services are especially relevant for this population.2) 1.0 (0.9-1.0) ¶ 89.4 (87.8-90.9)0.9 (0.9-1.0) ¶ 87.9 (85.5-90.0)0.9 (0.9-1.0) ¶ 90.8 (90.1-91.5)Large rural Abbreviations: CI = confidence interval; PR = prevalence ratio.* Federal poverty level is based on family income and family size and composition using federal poverty thresholds that are updated annually by the U.S. Census Bureau using the change in the average annual consumer price index for all urban consumers.Imputed income was used for 16.6% of children aged 2-8 years with MBDD status and sex reported, but without reported household income, using regression methods.† Percentages are weighted.Column percentages might not sum to 100% because of rounding.§ Based on a response of "yes" to whether "a doctor or other health care provider ever told you that this child has" one or more of the following disorders: "anxiety problems, depression, attention-deficit/hyperactivity disorder, behavioral or conduct problems, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or speech or other language disorder." ¶ Statistically significant difference from the referent group.** Based on a negative value for any of four variables based on these questions: 1) "Is this child currently covered by any kind of health insurance or health coverage plan?" 2) "How often does this child's health insurance offer benefits or cover services that meet this child's needs?" 3) "Does the family pays out-of-pocket expenses, " and if yes, "How often are these costs reasonable?" and 4) "How often does this child's health insurance allow him or her to see the health care providers he or she needs?"† † Based on a response of "yes" to having "Medicaid, Medical Assistance, or any kind of government assistance plan for those with low incomes or a disability." § § Based on five component variables (personal doctor or nurse, usual source for sick and well care, family-centered care, problems getting needed referrals, satisfaction with communication, and effective care coordination when needed), derived from 16 survey items.To have a medical home, the child must have a personal doctor or nurse, usual source of care, and familycentered care; children needing referrals or care coordination must also have those criteria met.¶ ¶ Based on a response of "yes" to the following question: "During the past 12 months, did this child see a doctor, nurse, or other health care professional for sick-child care, well-child check-ups, physical exams, hospitalizations or any other kind of medical care?" *** Based on a response of "yes" to the following question: "During the past 12 months, was there any time when this child needed health care but it was not received?By health care, we mean medical care as well as other kinds of care like dental care, vision care, and mental health services." † † † Estimate has a relative standard error >30% and might be unreliable.§ § § Based on whether either parent reported "fair" or "poor" (i.e., compared with "excellent, " "very good, " or "good") to the question: "In general, how is your mental or emotional health?"¶ ¶ ¶ Based on whether either parent reported "fair" or "poor" (i.e., compared with "excellent, " "very good, " or "good") to the question "In general, how is your physical health?"**** Based on an answer of "very often" or "somewhat often" (i.e., compared with "never" or "rarely") to the question "Since this child was born, how often has it been very hard to get by on your family's income (hard to cover the basics like food or housing)?"† † † † Based on a response of "yes" to the question "During the past 12 months, was there someone that you could turn to for day-to-day emotional support with parenting or raising children?" § § § § Based on a response of "yes" to the question: "During the past 12 months, did you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for (child)?Note: This question was asked for children aged 0-5 years only.¶ ¶ ¶ ¶ Based on a response of "no" to any of the following four questions: "In your neighborhood, is/are there: 1) sidewalks or walking paths?2) a park or playground? 3) a recreation center, community center, or boys' and girls' club? 4) a library or bookmobile?" ***** Based on a response of "yes" to any of the following three questions: "In your neighborhood, is/are there: 1) Litter or garbage on the street or sidewalk?2) Poorly kept or rundown housing? 3) Vandalism such as broken windows or graffiti?"† † † † † Based on a response of "definitely disagree" or "somewhat disagree" (i.e., compared with "definitely agree" or "somewhat agree") to any of the following three questions: "To what extent do you agree with these statements about your neighborhood or community?1) People in this neighborhood help each other out, 2) We watch out for each other's children in this neighborhood, 3) When we encounter difficulties, we know where to go for help in our community." § § § § § Based on a response of "definitely disagree" or "somewhat disagree" (i.e., compared with "definitely agree" or "somewhat agree") to the following question: "To what extent do you agree with these statements about your neighborhood or community?1) This child is safe in our neighborhood." ¶ ¶ ¶ ¶ ¶ Urban and rural designations were determined using a four-category classification based on 2010 rural-urban community area codes (RUCAs), a census tract-based classification system.Urban areas (RUCA codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1) include metropolitan areas and surrounding towns from which commuters flow to an urban area; large rural areas (RUCA codes 4.0, 5.0, and 6.0) include large towns (micropolitan areas) with populations of 10,000-49,999 and their surrounding areas; small rural areas (RUCA codes 7.0, 7.2, 8.0, 8.2, and 9.0) include small towns with populations of 2,550-9,999 and up to 50% secondary flow to a large urban cluster of up to 50,000; isolated areas (RUCA codes 10.0, 10.2, and 10.3) with less than 2,500 population and up to 50% secondary flow to a large or small urban cluster (population up to 10,000).(https://www.census.gov/geo/reference/ua/urbanrural-2010.html).
, increasing prevalences of the risk factors as household US Department of Health and Human Services/Centers for Disease Control and Prevention See table footnotes on the next page.