The national prevalence of parent-reported asthma, attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) is on the rise in the United States, as are accompanying comorbid disorders, but poverty influences the prevalence of each of these conditions differently, according to a longitudinal analysis of the National Survey of Children's Health (NSCH). The study was published online February 13 in Pediatrics.
"[W]e conducted a data analysis using the 3 waves of the [NSCH] from 2003 through 2012," Christian Pulcini, MD, from the Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center in Pennsylvania, and colleagues write. "Within this study's time period, there was a rise in parent-reported lifetime prevalence of all 3 target disorders."
Specifically, between 2003 and 2011-2012, the relative increase in lifetime prevalence of asthma was 18%, it was 44% for ADHD, and it was almost 400% for ASD.
Table. Lifetime Prevalence of Three Target Conditions
|2003||2007||2011 - 2012|
However, "the increases in lifetime prevalence of these disorders were differentially influenced by poverty status," investigators write.
For example, increases in asthma prevalence were highest among poor children. Among those who were living under the federal poverty level (FPL), there was a 25.8% increase in asthma prevalence between 2003 and 2011-2012. In comparison, there was only a 13.4% increase in childhood asthma among children living in households with incomes 400% or higher above the FPL.
Asthma was also far more likely to affect uninsured children: it increased by 57.9% for uninsured vs 9.4% among privately insured children.
A similar pattern was seen with ADHD. Specifically, children who were living under the FPL had a 43.2% relative increase in the prevalence of ADHD between 2003 and 2011-2012 compared with a 33.4% increase among children who lived in the wealthiest households. Among uninsured children, there was a relative increase of 42.7% in the prevalence of ADHD vs a 37.5% increase among children who were privately insured across the same survey interval.
"In contrast, increases in the lifetime prevalence of ASD were more prominent among the groups with more financial resources...and those with private insurance," investigators observe.
For example, between 2007 and 2011-2012, there was a 36.0% relative increase in the lifetime prevalence of ASD in children living in the wealthiest households compared with only about a 13.3% increase in children living below the FPL.
There was also a 50.0% relative increase in the prevalence of ASD among children covered by private insurance vs a zero percent increase among the uninsured.
"The rise in the extent of parent-reported comorbid conditions for these target conditions also was differentially influenced by poverty status," the investigators continue.
For example, parental reports of poor or near-poor children with asthma having one or more comorbid conditions rose by almost one quarter over the study period, they note. This was also true for poor and near-poor children with ADHD, such that the prevalence of two or more parent-reported comorbid conditions increased by 32.4% and 48.7%, respectively, across the same years of the survey analysis.
Interestingly, most children with ASD had at least two comorbid conditions at all times across the NCHS analysis; in 2011-2012, parents reported their ASD child had, on average, four comorbid conditions. For each of the three target conditions surveyed, the most common parental-reported comorbid disorders included learning disabilities and speech and language disorders.
"These findings underscore the importance of increased clinician awareness of higher risk for comorbid conditions when caring for children with asthma and ADHD who are living in impoverished households," the investigators conclude.
"Our data reinforce the importance of clinicians to remain steadfast in their evaluation of all children with ASD because comorbidities are exceedingly common in all income groups." they add.
Do No Harm
In an accompanying editorial, Bernard Dreyer, MD, immediate past president, American Academy of Pediatrics (AAP), and professor of pediatrics at New York University School of Medicine in New York City, acknowledges it is well established that poor children are more likely to suffer from poor health and chronic conditions. "They are also at greater risk for poor social, emotional, and behavioral problems, including disobedience, impulsivity, and anxiety," Dr. Dreyer writes. "Behavioral and mental health problems are common comorbidities of chronic conditions in children living in poverty."
As he notes, many children are currently covered by some form of health insurance, usually Medicaid and the Children's Health Insurance Program. However, the Affordable Care Act (ACA), now in danger of repeal by the Trump administration, did serve to cover some children whose parents signed up for it when the ACA became available.
Given the current Congressional debate surrounding the ultimate fate of the ACA, changes to this act may well affect children very badly, especially poor children, Dr. Dryer argues. "We in the AAP, and pediatricians throughout the country, urge Congress to take a "do no harm to children" standard," Dr. Dreyer writes. "Any changes in the ACA must not leave children worse off than they are today; there must be no structural changes to Medicaid; and CHIP must be reauthorized and strengthened. As described in the AAP Blueprint for Children, anything less will leave the most vulnerable children, who have an increased burden of chronic disease, without access to the essential, comprehensive health services they need to survive and thrive."
The authors and Dr. Dreyer have disclosed no relevant financial relationships.
Pediatrics. Published online February 13, 2017.
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