Health Care, Family, and Community Factors Associated With Mental, Behavioral, and Developmental Disorders in Early Childhood — United States, 2011–2012

Rebecca H. Bitsko, PhD; Joseph R. Holbrook, PhD; Lara R. Robinson, PhD; Jennifer W. Kaminski, PhD; Reem Ghandour, DrPH; Camille Smith; EdS; Georgina Peacock, MD

Disclosures

Morbidity and Mortality Weekly Report. 2016;65(9):221-226. 

In This Article

Introduction

Sociodemographic, health care, family, and community attributes have been associated with increased risk for mental, behavioral, and developmental disorders (MBDDs) in children.[1,2] For example, poverty has been shown to have adverse effects on cognitive, socio-emotional, and physical development.[1] A safe place to play is needed for gross motor development, and accessible health care is needed for preventive and illness health care.[3] Positive parenting and quality preschool interventions have been shown to be associated with prosocial skills, better educational outcomes, and fewer health risk behaviors over time.[2] Protective factors for MBDDs are often shared[4] and conditions often co-occur; therefore, CDC considered MBDDs together to facilitate the identification of factors that could inform collaborative, multidisciplinary prevention strategies. To identify specific factors associated with MBDDs among U.S. children aged 2–8 years, parent-reported data from the most recent (2011–2012) National Survey of Children's Health (NSCH) were analyzed. Factors associated with having any MBDD included inadequate insurance, lacking a medical home, fair or poor parental mental health, difficulties getting by on the family's income, employment difficulties because of child care issues, living in a neighborhood lacking support, living in a neighborhood lacking amenities (e.g., sidewalks, park, recreation center, and library), and living in a neighborhood in poor condition. In a multivariate analysis, fair or poor parental mental health and lacking a medical home were significantly associated with having an MBDD. There was significant variation in the prevalence of these and the other factors by state, suggesting that programs and policies might use collaborative efforts to focus on specific factors. Addressing identified factors might prevent the onset of MBDDs and improve outcomes among children who have one or more of these disorders.

NSCH is a cross-sectional, nationally representative, random-digit–dialed telephone survey that collects information about U.S. children aged <18 years. The survey includes indicators of child health and well-being, access to quality health care, family characteristics, and school and neighborhood environment.* Participating parents or guardians completed interviews about one randomly selected child (N = 95,677) per household. The interview completion rates were 54.1% and 41.2% for landline and cell phone samples, respectively; the overall response rate was 23.0%. Data were weighted to account for unequal probability of selection of each household and child and for nonresponse. Weighted estimates reflect the population of noninstitutionalized children in the United States and within each state.

Parents were asked, "Has a doctor or other health care provider ever told you that [child] had [specified disorder]?" A child was considered to have an MBDD if the parent or guardian reported any of the following: attention-deficit/hyperactivity disorder (ADHD), depression, anxiety problems, behavioral or conduct problems such as oppositional defiant disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or speech or other language problems.

Analyses were restricted to the 35,121 U.S. children aged 2–8 years (defined by Healthy People 2020 as "early childhood") with data for sex and each disorder. Weighted prevalence estimates of having any MBDD, and the associations with sociodemographic, health care, family, and community factors were calculated using statistical software to account for the complex sampling. Given previously documented associations between health care, family, and community factors, an exploratory regression model was also fit to determine which of the health care, family, or community factors that were independently associated with any MBDD remained significant after adjusting for the others. Sociodemographic factors were not included in the model.

Overall, among U.S. children aged 2–8 years, 15.4% had at least one diagnosed MBDD, by parent report ( Table 1 ). Sociodemographic factors associated with report of having an MBDD included male sex, older age (aged 4–5 or 6–8 years compared with 2–3 years), being non-Hispanic white, and living in a household with a higher poverty level (i.e., <200% of federal poverty level) or where English was the primary language spoken.

Specific factors most strongly associated with MBDDs in early childhood were fair or poor parental mental health, difficulty getting by on the family's income, child care problems (among parents of children aged 2–3 years), and lacking a medical home. Factors with the highest prevalence among children with MBDDs included lacking a medical home, living in a neighborhood lacking amenities, difficulty getting by on family income, and living in a neighborhood in poor condition. When adjusted for the other significant health care, family, and community factors, an exploratory multivariate model showed that only lacking a medical home and fair or poor parental mental health remained significantly associated with having an MBDD ( Table 2 ).

The prevalence of MBDDs and health care, family, and community factors among U.S. children aged 2–8 years varied by state (supplemental table at http://stacks.cdc.gov/view/cdc/38108). Prevalence of having any disorder varied from 10.6% in California to 21.5% in Arkansas and Kentucky. More than 90% of children received preventive care (i.e., parent or guardian reported that in the past 12 months, the child saw a health care provider for preventive medical care such as a physical exam or well-child checkup at least once) in each state.

Among health care factors, inadequate insurance was highest in South Carolina (26.5%), and lacking a medical home was highest in Arizona (52.2%); Vermont had the lowest prevalence of both inadequate insurance (14.7%) and lacking a medical home (27%).

The prevalences of difficulty getting by on the family's income and child care problems were both highest in Arizona (34.9% and 21.8%, respectively); income difficulties were lowest in North Dakota (18.5%), whereas child care problems were lowest in Nevada (2.6%§). Fair or poor parental mental health prevalence was highest in the District of Columbia (19.1%) and lowest in Kansas (6.9%).

The District of Columbia had the highest prevalence of living in a neighborhood in poor condition (46.2%) but the lowest prevalence of living in a neighborhood without all of the reported amenities (26.7%); the lowest prevalence of living in a neighborhood in poor condition was 20% in Maryland, whereas the highest prevalence of living in a neighborhood without all of the reported amenities was 67.5% in Mississippi (67.5%). Finally, reported prevalence of lack of neighborhood support was highest in Arizona (32.9%) and lowest in North Dakota (7.9%).

*http://www.cdc.gov/nchs/slaits/nsch.htm and ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/slaits/nsch_2011_2012/01_Frequently_asked_questions/NSCH_2011_2012_FAQs.pdf.
The response rate is the percentage of households that completed interviews among all eligible households, including those that were not successfully contacted. The cooperation rate is the percentage of households that completed interviews among all eligible households that were contacted. NSCH attempts to minimize nonresponse bias by incorporating nonresponse adjustments in the development of the sampling weights.
§Relative standard error for Nevada = 38%; this estimate should be interpreted with caution.

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