Location of Usual Source of Care among Children and Adolescents in the United States, 1997-2013.

OBJECTIVES: To examine national trends in the percentage of children whose usual source of care is at a clinic, health center, or hospital outpatient department (hereafter "clinics") and whether trends differ by sociodemographic subpopulations. STUDY DESIGN: Analysis of serial, cross-sectional, nationally representative in-person household surveys, the 1997-2013 National Health Interview Surveys, was conducted to identify children with a usual source of care (n = 190,571), and the percentage receiving that care in a clinic. We used joinpoint regression to identify changes in linear trends, and logistic regression with predictive margins to obtain per-year changes in percentages, both unadjusted and adjusted for sociodemographic factors. Interaction terms in logistic regressions were used to assess whether trends varied by sociodemographic subgroups. RESULTS: Of all children with a usual source of care, the percentage receiving that care in a clinic declined 0.44 percentage points per year (P < .001) from 22.97% in 1997 to 19.31% in 2002. Thereafter, it increased approximately 0.57 percentage points per year (P < .001), reaching 26.1% in 2013. Trends for some sociodemographic subgroups varied from these overall trends. No changes were observed between 2003 and 2013 for non-Hispanic black and Medicaid/State Children's Health Insurance Program insured children. CONCLUSIONS: This study shows that, although the percentage of children with a usual source of care in a clinic declined between 1997 and 2002, it has steadily increased since that time.

A lifecourse approach to health development: implications for the maternal and child health research agenda.

Lifecourse-informed models of health fundamentally challenge simple biomedical models, introducing new ways of thinking about how diseases develop. This paper considers the broad implications of lifecourse theory for the maternal and child health (MCH) research agenda. The Lifecourse Health Development model provides an organizing framework for a synthesis of the existing literature on lifecourse health and identification of gaps in knowledge. Priority areas identified for MCH research in order to close these knowledge gaps include: epigenetic mechanisms and their potential mutability; peri-conception as a critical and sensitive period for environmental exposures; maternal health prior to pregnancy; the role of the placenta as an important regulator of the intra-uterine environment; and ways to strengthen early mother-child interactions. Addressing knowledge gaps will require an emphasis on longitudinal rather than cross-sectional studies, long-term (lifetime) rather than short-term perspectives, datasets that include socio-demographic, biologic and genetic data on the same subjects rather than discipline-specific studies, measurement and study of positive health as well as disease states, and study of multi-rather than single generational cohorts. Adoption of a lifecourse-informed MCH research agenda requires a shift in focus from single cause-single disease epidemiologic inquiry to one that addresses multiple causes and outcomes. Investigators need additional training in effective interdisciplinary collaboration, advanced research methodology and higher-level statistical modeling. Advancing a life course health development research agenda in MCH will be foundational to the nation's long-term health.

Lifecourse health development: past, present and future.

During the latter half of the twentieth century, an explosion of research elucidated a growing number of causes of disease and contributors to health. Biopsychosocial models that accounted for the wide range of factors influencing health began to replace outmoded and overly simplified biomedical models of disease causation. More recently, models of lifecourse health development (LCHD) have synthesized research from biological, behavioral and social science disciplines, defined health development as a dynamic process that begins before conception and continues throughout the lifespan, and paved the way for the creation of novel strategies aimed at optimization of individual and population health trajectories. As rapid advances in epigenetics and biological systems research continue to inform and refine LCHD models, our healthcare delivery system has struggled to keep pace, and the gulf between knowledge and practice has widened. This paper attempts to chart the evolution of the LCHD framework, and illustrate its potential to transform how the MCH system addresses social, psychological, biological, and genetic influences on health, eliminates health disparities, reduces chronic illness, and contains healthcare costs. The LCHD approach can serve to highlight the foundational importance of MCH, moving it from the margins of national debate to the forefront of healthcare reform efforts. The paper concludes with suggestions for innovations that could accelerate the translation of health development principles into MCH practice.

High-Deductible Health Plans for US Children: Trends, Health Service Use, and Financial Barriers to Care.

OBJECTIVE: Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. METHODS: Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. RESULTS: The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). CONCLUSIONS: Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.

Family income gradients in the health and health care access of US children.

This study sought to examine the shape and magnitude of family income gradients in US children's health, access to care, and use of services. We analyzed cross-sectional data from the 2003 National Survey of Children's Health, a telephone survey of 102,353 parents of children aged 0-17 years. Associations between family income [Below 100% Federal Poverty Level (FPL), 100-199% FPL, 200-299% FPL, 300-399% FPL, 400% FPL or Greater] and a set of 32 health and health care indicators were examined using linear polynomial testing and multivariate logistic regression. The percentage of children in better health increased with family income for 15 health outcomes. In multivariate logistic regression models that controlled for health insurance coverage and socio-demographic confounders, odds ratios >2 comparing the lowest to the highest income groups were noted for health conditions across both physical and developmental domains (diabetes, headaches, ear infections, learning disabilities, behavior/conduct problems, speech problems). Parent-reported global child health status, activity limitation, and oral health status showed steeper gradients than specific chronic and acute conditions. Ten measures of health care access and utilization were associated with family income in multivariate logistic regression models. Income gradients are pervasive across many health indicators at an early age. Social and health policy interventions are needed to address the multitude of factors that can affect children's health and initiate disparities in development.

Why social determinants?

There is overwhelming evidence that social factors have profound influences on health. Children are particularly sensitive to social determinants, especially in the early years. Life course models view health as a developmental process, the product of multiple gene and environment interactions. Adverse early social exposures become programmed into biological systems, setting off chains of risk that can result in chronic illness in mid-life and beyond. Positive health-promoting influences can set in motion a more virtuous and health-affirming cycle, leading to more optimal health trajectories. Mounting an effective response to social determinants will involve both direct social policy initiatives designed to eliminate poverty and inequality, and indirect approaches focused on disrupting pathways between social risks and poor health outcomes. To be effective, these indirect strategies will require nothing short of a transformation of existing child health systems. Parents and professionals must work together from the ground up, raising public awareness about social determinants of health and implementing cross-sector place-based initiatives designed to promote positive health in childhood.

Sleep, Physical Activity, and General Health Status: US Pediatricians and the General US Adult Population.

OBJECTIVE: To examine US pediatricians and US adults on 3 self-reported health measures (sleep, physical activity, and general health status) and to assess factors related to these measures for each group. METHODS: Pediatrician data were collected through a 2012 American Academy of Pediatrics Periodic Survey (response rate = 64.0%). US population data originated from the 2012 National Health Interview Survey (response rate = 61.2%). Analytic samples included those currently working and ≥30 years old and were restricted to post-trainees (pediatricians; n = 854) and US adults with at least a bachelor's degree (n = 5447). Accounting for sample demographic differences, predicted probabilities compared the proportions reporting ≥7 hours of sleep, meeting physical activity recommendations, and reporting very good or excellent health. Multivariable logistic regression examined characteristics associated with health measures for pediatricians and US adults separately. RESULTS: When the US population demographic profile was adjusted to resemble the pediatrician sample, 7 in 10 pediatricians (71.2%; confidence interval [CI], 68.0-74.5) and US adults (69.9%; CI, 67.8-72.0) reported ≥7 hours of sleep. Pediatricians were more likely than US adults to meet physical activity recommendations (71.4%; CI, 68.0-74.8 vs. 62.9%; CI, 60.6-65.2) and less likely to report very good or excellent health (74.3%; CI, 71.2-77.3 vs. 80.2%; CI, 78.3-82.1). In pediatrician and US population multivariable models, self-identified Asians and those working ≥50 hours were less likely to get ≥7 hours of sleep (P < .05). CONCLUSIONS: Most US pediatricians and US adults reported getting the recommended amounts of sleep and physical activity and rated their health as very good or excellent. Those working fewer hours reported more sleep. Organization-directed approaches may be needed to help physicians maintain and improve their health.

Unmet mental health need and access to services for children with special health care needs and their families.

OBJECTIVES: Studies suggest that children with disabilities or serious health conditions are vulnerable to mental health problems due to adjustment and limitation problems. The aim of this study was to examine rates and predictors of unmet mental health need among children with special health care needs (CSHCN) and their family members and to determine if race/ethnicity and language are associated with unmet need for the child and family members who have a mental health need attributed to the child's special needs. METHODS: Data are from the 2001 National Survey of Children with Special Health Care Needs, a nationally representative sample of CSHCN. RESULTS: Rates of unmet need were higher for CSHCN and family members of CSHCN with a chronic emotional, behavioral, or developmental problem (EBDP) compared to CSHCN with a mental health need but not a chronic EBDP. In multivariate analysis controlling for condition impact and demographics, among CSHCN with a chronic EBDP, African-American children had greater odds of unmet need (OR 1.60, 95% CI, 1.12-2.28), and family members of Hispanic children with a Spanish language parent interview had greater odds of unmet need compared to others (OR 4.48, 95% CI, 1.72-11.63). Lacking a personal doctor or nurse was associated with higher odds of unmet need for CSHCN with and without a chronic EBDP. CONCLUSION: Parents reported prevalent mental health needs of CSHCN as well as family members. Given the importance of family members to the care of CSHCN, research on racial/ethnic disparities in access to perceived needs should focus on children and their family members.

Income Inequality and the Differential Effect of Adverse Childhood Experiences in US Children.

OBJECTIVE: Adverse childhood experiences (ACEs) can affect health and development across the life course. Despite a general understanding that adversity is associated with lower income, we know less about how ACEs manifest at different income levels and how these income-related patterns affect children's health and development. METHODS: Data from the 2011 to 2012 National Survey of Children's Health were used to examine the prevalence of 9 ACEs in US children, across 4 levels of household income, and in relationship to 5 parent-reported measures of child health. Bivariate analyses and multivariable logistic regression models were used to examine the associations between number of ACEs and children's health outcomes on the basis of the 4 income groups. RESULTS: When partitioned according to income strata, the proportion of children who experienced ACEs showed a steep income gradient, particularly for children who experienced ≥4 ACEs. The linear gradient across income groups was less pronounced for each specific ACE, with several ACEs (experience of divorce, drug and alcohol exposure, parental mental illness) showing high reported prevalence in all but the highest income group. Multivariate analysis showed a consistent income-related gradient for each of the health outcomes. However, higher income was not necessarily found to be a protective factor against ACEs. CONCLUSIONS: ACEs are distributed across the income ladder and not just concentrated below the poverty level. This suggests that a more comprehensive policy strategy that includes targeted as well as universal interventions is warranted.

Trends in Access to Health Care Services for US Children: 2000-2014.

BACKGROUND AND OBJECTIVE: Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children's access to health services and whether trends vary by race/ethnicity and income. METHODS: Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income. RESULTS: Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators. CONCLUSIONS: Children's access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.

Predictors of Poor School Readiness in Children Without Developmental Delay at Age 2.

BACKGROUND AND OBJECTIVES: Current recommendations emphasize developmental screening and surveillance to identify developmental delays (DDs) for referral to early intervention (EI) services. Many young children without DDs, however, are at high risk for poor developmental and behavioral outcomes by school entry but are ineligible for EI. We developed models for 2-year-olds without DD that predict, at kindergarten entry, poor academic performance and high problem behaviors. METHODS: Data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), were used for this study. The analytic sample excluded children likely eligible for EI because of DDs or very low birth weight. Dependent variables included low academic scores and high problem behaviors at the kindergarten wave. Regression models were developed by using candidate predictors feasibly obtainable during typical 2-year well-child visits. Models were cross-validated internally on randomly selected subsamples. RESULTS: Approximately 24% of all 2-year-old children were ineligible for EI at 2 years of age but still had poor academic or behavioral outcomes at school entry. Prediction models each contain 9 variables, almost entirely parental, social, or economic. Four variables were associated with both academic and behavioral risk: parental education below bachelor's degree, little/no shared reading at home, food insecurity, and fair/poor parental health. Areas under the receiver-operating characteristic curve were 0.76 for academic risk and 0.71 for behavioral risk. Adding the mental scale score from the Bayley Short Form-Research Edition did not improve areas under the receiver-operating characteristic curve for either model. CONCLUSIONS: Among children ineligible for EI services, a small set of clinically available variables at age 2 years predicted academic and behavioral outcomes at school entry.

Cognitive ability at kindergarten entry and socioeconomic status.

OBJECTIVE: To examine how gradients in socioeconomic status (SES) impact US children's reading and math ability at kindergarten entry and determine the contributions of family background, health, home learning, parenting, and early education factors to those gradients. METHODS: Analysis of 6600 children with cognitive assessments at kindergarten entry from the US Early Childhood Longitudinal Birth Cohort Study. A composite SES measure based on parent's occupation, education, and income was divided into quintiles. Wald F tests assessed bivariate associations between SES and child's cognitive ability and candidate explanatory variables. A decomposition methodology examined mediators of early cognitive gradients. RESULTS: Average reading percentile rankings increased from 34 to 67 across SES quintiles and math from 33 to 70. Children in lower SES quintiles had younger mothers, less frequent parent reading, less home computer use (27%-84%), and fewer books at home (26-114). Parent's supportive interactions, expectations for their child to earn a college degree (57%-96%), and child's preschool attendance (64%-89%) increased across quintiles. Candidate explanatory factors explained just over half the gradients, with family background factors explaining 8% to 13%, health factors 4% to 6%, home learning environment 18%, parenting style/beliefs 14% to 15%, and early education 6% to 7% of the gaps between the lowest versus highest quintiles in reading and math. CONCLUSIONS: Steep social gradients in cognitive outcomes at kindergarten are due to many factors. Findings suggest policies targeting levels of socioeconomic inequality and a range of early childhood interventions are needed to address these disparities.

Changing trends of childhood disability, 2001-2011.

BACKGROUND: Over the past half century the prevalence of childhood disability increased dramatically, coupled with notable increases in the prevalence of mental health and neurodevelopmental conditions. This study provides a detailed assessment of recent trends in childhood disability in relation to health conditions and sociodemographic factors. METHODS: Secondary data analysis of National Health Interview Survey (NHIS) datasets 2001-2002, 2004-2005, 2007-2008, and 2010-2011 (N = 198888) was conducted to calculate the prevalence, rate of change, severity, and sociodemographic disparities of parent-reported childhood disability. RESULTS: The prevalence of childhood disability has continued to increase, growing by 15.6% between 2001-2002 and 2010-2011. Nearly 6 million children were considered disabled in 2010-2011. Children living in poverty experienced the highest rates of disability, 102.6 cases per 1000 population in 2010-2011, but unexpectedly, children living in households with incomes ≥ 400% above the federal poverty level experienced the largest increase (28.4%) over this 10-year period. The percentage of disability cases related to any physical health condition declined 11.8% during the decade, whereas cases related to any neurodevelopmental or mental health condition increased by 20.9%. CONCLUSIONS: Over the past decade, parent-reported childhood disability steadily increased. As childhood disability due to physical conditions declined, there was a large increase in disabilities due to neurodevelopmental or mental health problems. For the first time since the NHIS began tracking childhood disability in 1957, the rise in reported prevalence is disproportionately occurring among socially advantaged families. This unexpected finding highlights the need to better understand the social, medical, and environmental factors influencing parent reports of childhood disability.

Parental divorce and adult longevity.

OBJECTIVE: Life course research has established associations between adverse childhood events and later life health. We examine the relationship of experiencing parental divorce before the age of 16 and survival across 34 years of adulthood. METHODS: Analysis of panel data from a USA-based survey of 6,928 adults residing in Alameda County, California in 1965. Cox regression was used to examine associations between parental divorce and longevity. RESULTS: Controlling for age, race/ethnicity, gender, and childhood socioeconomic position, respondents who recalled a parental divorce during childhood had increased risk of mortality compared to those with no separation. The association was stronger for premature mortality and deaths due to cardiovascular disease. Divorce in childhood was also associated with lowered adult education, fewer social network ties, more depression, and worse health practices. These factors appeared to explain the association with longevity. CONCLUSION: Parental divorce in childhood is associated with lowered well-being in adulthood and long-term survival. Early prevention and health promotion efforts may be warranted for children who experience parental divorce or discord as a means of supporting enhanced trajectories of health and well-being.

Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17.

OBJECTIVE: This large population-based study of US children considered the association of obesity with a broad range of comorbidities. This study examined relationships between weight status and health for US children. METHODS: We performed cross-sectional analysis of data on 43,297 children aged 10 to 17 from the 2007 National Survey of Children's Health. Weight status was calculated from parent report of child height and weight. Logistic regression models assessed associations between weight status and 21 indicators of general health, psychosocial functioning, and specific health disorders, adjusting for sociodemographic factors. RESULTS: Using body mass index (BMI) percentiles for age and sex, 15% of US children were considered overweight (BMI 85th to <95th percentile), and 16% were obese (BMI ≥95th percentile). Compared with children classified as not overweight, obese children were more likely to have reported good/fair/poor health (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI] 1.76-2.69), activity restrictions (AOR 1.39, 95% CI 1.10-1.75), internalizing problems (AOR 1.59, 95% CI 1.04-2.45), externalizing problems (AOR 1.33, 95% CI 1.07-1.65), grade repetition (AOR 1.57, 95% CI 1.24-1.99), school problems, and missed school days. Attention deficit/hyperactivity disorder, conduct disorder, depression, learning disability, developmental delay, bone/joint/muscle problems, asthma, allergies, headaches, and ear infections were all more common in obese children. CONCLUSIONS: Obese children have increased odds of worse reported general health, psychosocial functioning, and specific health disorders. Physicians, parents, and teachers should be informed of the specific comorbidities associated with childhood obesity to target interventions that could enhance well-being. Future research should examine additional comorbidities and seek to confirm associations using longitudinal data and clinical measures of height and weight.

A national profile of childhood epilepsy and seizure disorder.

OBJECTIVE: To determine sociodemographics, patterns of comorbidity, and function of US children with reported epilepsy/seizure disorder. METHODS: Bivariate and multivariable cross-sectional analysis of data from the National Survey of Children's Health (2007) on 91 605 children ages birth to 17 years, including 977 children reported by their parents to have been diagnosed with epilepsy/seizure disorder. RESULTS: Estimated lifetime prevalence of epilepsy/seizure disorder was 10.2/1000 (95% confidence interval [CI]: 8.7-11.8) or 1%, and of current reported epilepsy/seizure disorder was 6.3/1000 (95% CI: 4.9-7.8). Epilepsy/seizure disorder prevalence was higher in lower-income families and in older, male children. Children with current reported epilepsy/seizure disorder were significantly more likely than those never diagnosed to experience depression (8% vs 2%), anxiety (17% vs 3%), attention-deficit/hyperactivity disorder (23% vs 6%), conduct problems (16% vs 3%), developmental delay (51% vs 3%), autism/autism spectrum disorder (16% vs 1%), and headaches (14% vs 5%) (all P < .05). They had greater risk of limitation in ability to do things (relative risk: 9.22; 95% CI: 7.56-11.24), repeating a school grade (relative risk: 2.59; CI: 1.52-4.40), poorer social competence and greater parent aggravation, and were at increased risk of having unmet medical and mental health needs. Children with prior but not current seizures largely had intermediate risk. CONCLUSIONS: In a nationally representative sample, children with seizures were at increased risk for mental health, developmental, and physical comorbidities, increasing needs for care coordination and specialized services. Children with reported prior but not current seizures need further study to establish reasons for their higher than expected levels of reported functional limitations.

The changing landscape of disability in childhood.

Americans' perceptions of childhood disability have changed dramatically over the past century, as have their ideas about health and illness, medical developments, threats to children's health and development, and expectations for child functioning. Neal Halfon, Amy Houtrow, Kandyce Larson, and Paul Newacheck examine how these changes have influenced the risk of poor health and disability and how recent policies to address the needs of children with disabilities have evolved. The authors examine the prevalence in the United States of childhood disability and of the conditions responsible for impairment, as well as trends in the prevalence of chronic conditions associated with disability. They find that childhood disability is increasing and that emotional, behavioral, and neurological disabilities are now more prevalent than physical impairments. They stress the importance of, and lack of progress in, improving socioeconomic disparities in disability prevalence, as well as the need for better measures and greater harmonization of data and data sources across different child-serving agencies and levels of government. They call on policy makers to strengthen existing data systems to advance understanding of the causes of childhood disabilities and guide the formulation of more strategic, responsive, and effective policies, programs, and interventions. The authors offer a new and forward-looking definition of childhood disability that reflects emerging and developmentally responsive notions of childhood health and disability. They highlight the relationship between health, functioning, and the environment; the gap in function between a child's abilities and the norm; and how that gap limits the child's ability to engage successfully with his or her world. Their definition also recognizes the dynamic nature of disability and how the experience of disability can be modified by the child's environment.

Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007.

OBJECTIVE: To determine patterns of comorbidity, functioning, and service use for US children with attention-deficit/hyperactivity disorder (ADHD). METHODS: Bivariate and multivariable cross-sectional analyses were conducted on data from the 2007 National Survey of Children's Health on 61 779 children ages 6 to 17 years, including 5028 with ADHD. RESULTS: Parent-reported diagnosed prevalence of ADHD was 8.2%. Children with ADHD were more likely to have other mental health and neurodevelopmental conditions. Parents reported that 46% of children with ADHD had a learning disability versus 5% without ADHD, 27% vs 2% had a conduct disorder, 18% vs 2% anxiety, 14% vs 1% depression, and 12% vs 3% speech problems (all P < .05). Most children with ADHD had at least 1 comorbid disorder: 33% had 1, 16% had 2, and 18% had 3 or more. The risk for having 3 or more comorbidities was 3.8 times higher for poor versus affluent children (30% vs 8%). Children with ADHD had higher odds of activity restriction (odds ratio: 4.14 [95% confidence interval: 3.34-5.15]), school problems (odds ratio: 5.18 [95% confidence interval: 4.47-6.01]), grade repetition, and poor parent-child communication, whereas social competence scores were lower and parent aggravation higher. Functioning declined in a stepwise fashion with increasing numbers of comorbidities, and use of health and educational services and need for care coordination increased. CONCLUSIONS: Clinical management of ADHD must address multiple comorbid conditions and manage a range of adverse functional outcomes. Therapeutic approaches should be responsive to each child's neurodevelopmental profile, tailored to their unique social and family circumstances, and integrated with educational, mental health and social support services.

Duration of a well-child visit: association with content, family-centeredness, and satisfaction.

BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). RESULTS: One-third (33.6%) of parents reported spending ≤ 10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5-3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7-6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5-26.5) higher odds of having enough time to ask questions. CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

Factors associated with discipline counseling for parents of infants and young children.

OBJECTIVE: The aim of this study was to identify and better understand the factors associated with discipline counseling at health visits and how parents' needs for discipline counseling are being met. METHODS: Cross-sectional data analyses from the 2000 National Survey of Early Childhood Health. Participants were 1216 parents of children aged between 10 and 35 months. Main outcome measures were parents' reports that their health care provider discussed discipline practices with them in the previous year, and if not, whether this would have been helpful (an unmet need). RESULTS: Discipline counseling was more common when the health care provider discussed other developmental and psychosocial topics, did a developmental assessment, received higher ratings of family centered care and provided longer visits, and when parents indicated having the opportunity to ask all their questions. However, parents who reported less support for child rearing and parents who reported greater use of spanking were less likely to receive discipline counseling. Spanish-speaking Hispanic parents and parents who reported less support were more likely to report an unmet need for discipline counseling. Higher income respondents were less likely to report an unmet need for discipline counseling. CONCLUSION: Discipline counseling at health visits is associated with a family-centered orientation and the delivery of other developmental and psychosocial services. However, many parents who might have benefited from discipline counseling were less likely to receive it and more likely to report this as an unmet need. These data suggest that discipline counseling may be more accurately tailored to parents most likely to benefit.