Asthma symptoms, morbidity, and antiinflammatory use in inner-city children.

BACKGROUND: Asthma is a major cause of morbidity that disproportionately affects inner-city children. For children with persistent asthma, defined as having asthma symptoms 3 or more days per week or 3 or more nights per month, national guidelines recommend the use of daily antiinflammatory agents. Despite these recommendations, antiinflammatory agents remain underused, particularly in inner-city children with high asthma morbidity. OBJECTIVES: The objectives of our study were to determine: 1) whether persistent asthma symptoms in inner-city children are related to acute care utilization and to the frequency of acute exacerbations; 2) whether children with persistent asthma are receiving recommended daily antiinflammatory agents; and 3) whether antiinflammatory medication use relates to sociodemographic factors, caretaker self-efficacy, the frequency of primary care visits, and/or measures of quality asthma care. DESIGN AND METHODS: A 64-item telephone survey was administered between July 1996 and June 1997 to 219 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center between January 1995 and February 1996. Persistent asthma symptoms were assessed by inquiring about the frequency of daily and nocturnal asthma symptoms over the last 4 weeks. Children's asthma severity was classified by applying the 1997 National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines' severity classification scheme based on the frequency of asthma symptoms. Asthma morbidity was defined as the frequency of acute asthma exacerbations, emergency department visits and hospitalizations. Daily antiinflammatory medication use was compared by sociodemographic factors, caretaker self-efficacy, frequency of primary care visits, and measures of quality asthma home management. RESULTS: In this sample, quantifying persistent asthma symptoms and applying the NAEPP symptom criteria identified 17% of the children with mild intermittent asthma, 27% with mild persistent asthma and 56% with moderate to severe persistent asthma. There were no differences in the age of the children in the 3 groups (mean age: 6 years). Asthma morbidity, as measured by the number of asthma exacerbations in the last 6 months, was significantly higher in the children with moderate to severe persistent asthma compared with children with mild intermittent asthma (9.8 vs 3.5) or mild persistent asthma (9.8 vs 4.5). In addition, there were significantly more emergency department visits in the moderate to severe group than in the mild persistent (3.05 vs 1.69) or mild intermittent group (3.05 vs 1.76). Lastly, as asthma symptom frequency increased, there were trends toward more hospitalizations and more days hospitalized. Overall, 35% of the 219 families reported giving daily antiinflammatory medications to their child (mostly cromolyn sodium). Of the 181 children (83%) who met NAEPP symptom criteria for persistent asthma, only 39% were receiving daily antiinflammatory treatment. Of the children with symptoms of moderate to severe asthma, only 15% were receiving inhaled steroids in contrast to the guidelines' recommendations. Use of antiinflammatory agents was not related to caretaker sociodemographic factors or self-efficacy scores. Measures of quality asthma home management, which included use of mattress covers, written plans, and peak flow meters, correlated positively with use of antiinflammatory agents. Children whose families reported using daily antiinflammatory medications had more primary care visits in the last 6 months than those children not receiving antiinflammatory medications. CONCLUSION: Questioning parents about the frequency of their child's asthma symptoms is an important, inexpensive, and readily accessible bedside and office tool that may aid in the detection of persistent symptoms and help direct therapy. Our study suggests that classifying asthma severity by quantifying persistent asthma symptoms, as defined in the NAEPP Guidelines, is a clinically useful tool that relates to asthma morbidity. In our sample of previously hospitalized children with asthma, 83% met 1997 NAEPP symptom criteria for persistent asthma, and yet only 35% were receiving daily antiinflammatory agents. Use of antiinflammatory agents correlated positively with other indicators of quality asthma home management. Additional work is necessary to increase appropriate use of antiinflammatory agents in this population, and in particular, to increase inhaled steroid use for children with moderate or severe symptoms.

Shortening the questionnaire for identifying children with chronic conditions: what is the consequence?

OBJECTIVE: To determine whether a reduced item set can identify children who have chronic conditions with a level of at least 90% accuracy compared with the complete Questionnaire for Identifying Children With Chronic Conditions (QuICCC). BACKGROUND: The QuICCC was developed to operationalize a conceptually based, noncategorical definition of chronic conditions developed by Stein et al. It contains 39 item sequences administered to a parent that assess 3 types of consequences: functional limitations; reliance on compensatory mechanisms or assistance; and service use or need above usual for age. The QuICCC has been validated and widely adopted as a means of identifying children without using a diagnosis checklist, but there is considerable interest in shortening it. DESIGN/METHODS: Through secondary analyses of 3 data sets (Ns = 1265, 1388, and 4831), we identified a short list of items that identified >90% of children who were identified by the 39-item QuICCC. We administered these 16 items to 2 new samples of parents. In Study 1 we administered the 16 items in the shortened version first, followed by the other 23 items, and compared the results on the short and reordered long versions. In Study 2, the 39- and 16-item versions were each administered, one in person and the other by phone, in random order to the same respondent within a 2-week period. These data were analyzed to compare the short and longer versions at the 2 time points and within the single, longer 39-item format (simultaneous data). RESULTS: In Study 1 (N = 630) only 4 children were missed by the 16-item version who were identified by the longer version (sensitivity 98.6%; specificity 100%; positive predictive value 100%; negative predictive value 98.8% kappa 0.987). In Study 2 (N = 552), no children were missed by the 16-item subset of the 39 items when looking at the simultaneous data. When the two forms were administered 2 weeks apart, the 16-item version had a sensitivity of 87%, specificity of 90%, positive predictive value of 93%, negative predictive value of 82%, and kappa of 0.78 compared with the longer QuICCC. These results correspond exactly to the data obtained in a 2-week test-retest study for the QuICCC itself. The new form (the QuICCC-R) takes <2 minutes to administer on average (range 1-4 minutes) compared with 7 to 8 minutes for the full QuICCC. CONCLUSIONS: The results met our criteria for agreement, and we conclude that the QuICCC-R is a satisfactory alternative for screening populations. However, the full QuICCC has other applications beyond screening that may not apply to the QuICCC-R, the shorter version.

Access to care, unmet health needs, and poverty status among children with and without chronic conditions.

OBJECTIVES: To compare insurance coverage, access to care, and unmet health needs of children with and without chronic conditions in a national probability sample of the US population and to examine the role of poverty status in any demonstrated differences between the 2 groups. DESIGN: We analyzed parent-report data on children 0-17 years old from the 1994 National Health Interview Survey Disability Supplement (NHIS-D) and from the health insurance and access to care files of the 1994 Family Resources Supplement to the NHIS. In the NHIS-D, 4452 (14.8%) of the 30032 children were identified as having a chronic condition by a noncategorical method. We compared insurance coverage, access to care, and unmet needs of children with and without conditions overall and also compared them within 3 different income levels relative to the national poverty index: 1) below, 2) within 100%-200%, and 3) >200% above poverty level. RESULTS: In bivariate analyses, children with chronic conditions were more likely to be covered by some type of health insurance (odds ratio [OR], 1.3) and to have a usual provider both for medical ("sick") care (OR, 1.4) and for routine or preventive care (OR, 1.4). They also were more likely to have the same provider for medical care and routine or preventive care (OR, 1.2) and to have seen their health care provider in the last year (OR, 1.8) than children without chronic conditions (all P <.0001). Nonetheless, children with chronic conditions were twice as likely to have had at least 1 unmet need from a list of 4 services that included dental care, prescription medications, eyeglasses, and mental health services (OR, 2.0). They also were more likely to have more than 1 unmet need from the list (OR, 3.1), to have been unable to get needed medical care (OR, 3.1), and to have delayed obtaining medical care because of worry about its cost (OR, 1.8). Children with chronic conditions were at greater risk for unmet needs than were children without conditions across all income levels. The magnitude of the disparity between the groups increased with family income level. Differences persisted even after controlling for sociodemographic variables and insurance status. CONCLUSION: Despite higher levels of insurance coverage and greater access to regular providers of medical and routine care compared with healthy peers, children with chronic conditions are reported by their parents to be less likely than other children to receive the full range of needed health services. The magnitudes of the differences are small, yet the pattern of disadvantage in meeting health care needs among children with conditions compared with healthy peers is consistent across many different variables and it exists across income levels.

Exposure to violence among urban school-aged children: is it only on television?

OBJECTIVE: To measure exposure to different types of violence among school-aged children in a primary care setting. DESIGN: Child interviews using an instrument measuring 4 types of exposure (direct victimization, witnessing, hearing reports, media). Violent acts measured include being beaten up, chased/threatened, robbed/mugged, stabbed/shot, killed. SETTING: Pediatric primary care clinic of large urban hospital. PATIENTS: Convenience sample of 175 children 9-12 years old and their mothers. A total of 53% of the children were boys, 55% were Hispanic, and 40% received public assistance. RESULTS: All children had been exposed to media violence. A total of 97% (170/175) had been exposed to more direct forms of violence; 77% had witnessed violence involving strangers; 49% had witnessed violence involving familiar persons; 49% had been direct victims; and 31% had witnessed someone being shot, stabbed, or killed. Exposure to violence was significantly associated with being male. CONCLUSION: Most school-aged children who visited a pediatric primary care clinic of a large urban hospital had directly experienced violence as witnesses and/or victims.

Characteristics and outcome of children with carbon monoxide poisoning with and without smoke exposure referred for hyperbaric oxygen therapy.

OBJECTIVES: To describe the clinical characteristics and outcome of children with carbon monoxide (CO) poisoning with and without smoke exposure referred for hyperbaric oxygen therapy (HBOT), and to determine the association between any of these characteristics and death. SETTING: Regional hyperbaric referral center. PATIENTS: The medical records of 150 children with CO poisoning (COP) who were treated with HBOT between August 92 and September 95 were reviewed. MEASUREMENTS/MAIN RESULTS: COP was defined as a history of probable exposure to CO, with either a carboxyhemoglobin level (COHb) > 25, or COHb < 25 with neurological, respiratory, or cardiac compromise. Major cutaneous burns were described as second degree burns over greater than 20% of the patient's total body surface area (TBSA), or third degree burns over greater than 10% of the patient's TBSA. Children extracted from a closed-space fire who had airway soot, singed facial hair/facial burns, or respiratory distress were defined as having smoke inhalation and carbon monoxide poisoning (CO/SI). CO/SI occurred in 40.1% of patients. Compared to children with COP alone, those with CO/SI were significantly more likely to have a depressed mental status upon arrival to an ED (76.3 % vs 13.6 %, P < 0.001), lower mean initial GCS (6.7 vs 14.7, P < 0.001), lower mean initial pH (7.2 vs 7.4, P < 0.001), respiratory arrest at the scene (68.5% vs 0%, P < 0.001), and cardiac arrest at the scene (25.9% vs 0%, P < 0.001). Children with CO/SI were significantly more likely to have a poor outcome (death) than children with COP alone (22.6% vs. 0%, P < 0.001). Comparing children with CO/SI who died versus survivors, there were significant differences in mean initial COHb (38.3 vs 24.3, P = 0.03), mean initial temperature upon arrival in an ED (94.9 degrees F vs 98.2 degrees, P < 0.006), respiratory arrest at the scene (92% vs 59.6%, P = 0.04), and cardiac arrest at the scene (66.7% vs 13.5%, P < 0.001). Sixty percent of children died who had a combination of risk factors of smoke inhalation, low temperature, high COHb level, and respiratory and cardiac arrest in the field. CONCLUSIONS: These preliminary data suggest that children with COP alone who are treated with HBOT are at low risk for dying regardless of initial COHb level. Children with CO/SI have a significantly higher risk of dying than those children with COP alone. A combination of smoke inhalation, low temperature, high COHb level, respiratory arrest, and cardiac arrest is highly associated with death. Prospective studies are needed to confirm and further define these associations.

Cervical papanicolaou smear abnormalities and Chlamydia trachomatis in sexually active adolescent females.

STUDY OBJECTIVE: To examine the effect of cervical Chlamydia trachomatis infection on the prevalence of Papanicolaou (Pap) smear abnormalities in adolescent females. DESIGN: Retrospective study performed by examination of previously obtained cervical C. trachomatis cultures and Pap smear results. SETTING: Urban adolescent health care clinic in the Bronx, New York. PARTICIPANTS: Sexually active females, aged 13 to 23 (mean age: 17.9 years), attending the clinic for evaluation of sexually transmitted diseases. INTERVENTION: Patients who had undergone a gynecological examination with performance of cervical Pap smears and culture for C. trachomatis were enrolled in the study. MAIN OUTCOME MEASURE: Determine the prevalence of cervical C. trachomatis infection and compare cervical smear abnormalities in those with and without infection. RESULTS: Of a study population of 257 females, 24 patients (9.3%) were culture positive for C. trachomatis and 58 patients (22.6%) had significant cervical smear abnormalities, i.e., atypical squamous cells of undetermined significance (ASCUS), low grade squamous intraepithelial lesion (LGSIL), or high grade squamous intraepithelial lesion (HGSIL). The 24 patients infected with C. trachomatis showed the following cervical smear abnormalities: within normal limits-37.5%, benign cellular changes-41.7%, ASCUS-12. 5%, and LGSIL-8.3%. A total of 233 patients (90.7%) were culture negative for C. trachomatis and showed the following cervical smear abnormalities: within normal limits-37.3%, benign cellular changes-39.9%, ASCUS-13.3%, LGSIL-8.6%, and HGSIL-.9%. Statistical analysis suggested no significant differences between the two groups (P >.9 by the Kruskal-Wallace test). CONCLUSIONS: The isolation of C. trachomatis from the cervix of sexually active adolescent females at a single point in time does not impact on the prevalence of significant cervical smear abnormalities.

Brief report: psychological symptoms in healthy female siblings of adolescents with and without chronic conditions.

OBJECTIVE: To examine the psychological impact of having a sibling with a chronic condition on healthy adolescent females and to explore the potential moderating role of birth order on this relationship. METHOD: We compared selected Brief Symptom Index subscales (anxiety, depression, interpersonal sensitivity, hostility) and global severity scores (GSI) in two groups of healthy, inner-city female adolescents matched for sibling age, gender, birth order, and age spacing: 34 sisters of males and females ages 13-19 years with chronic health conditions (ILLSIBS) and 34 sisters of males and females in the same age range without conditions (WELLSIBS). RESULTS: ILLSIBS generally had more symptoms than WELLSIBS. MANOVA yielded significant three-way interactions of sibling illness status, birth order, and gender for the anxiety, hostility, and GSI. A similar pattern was nonsignificant for the two other subscales. Among younger sisters in general and among older sisters of males only, ILLSIBS had higher scores; however, ILLSIBS who were older sisters of females did not differ significantly in symptom levels from the comparable group of WELLSIBS. CONCLUSIONS: Psychological symptoms in sisters of inner-city, male and female adolescents are related to sibling health status. However, the combination of sibling gender and birth order may modify this relationship and should be considered when evaluating psychological risk or designing interventions.

Do pediatricians recognize mothers with depressive symptoms?

OBJECTIVE: To determine whether pediatric health care providers recognize maternal depressive symptoms and to explore whether maternal, provider, and visit characteristics affect pediatric providers' ability to recognize inner-city mothers with depressive symptoms. DESIGN: A cross-sectional study was conducted at a hospital-based, inner-city, general pediatric clinic. Two groups of participants completed questionnaires, each unaware of the other's responses: 1) mothers who brought their children ages 6 months to 3 years for health care maintenance or a minor acute illness and 2) pediatric health care providers (attending pediatricians, pediatric trainees, and nurse practitioners). The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Pediatric providers assessed child, maternal, and family functioning and documented maternal depressive symptoms. Criteria for positive identification of a mother by the pediatric health care provider were met if the provider reported one or more maternal symptoms (from a 10-item list of depressive symptoms), a rating of 4 or less on a scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression. RESULTS: Of 338 mothers who completed the questionnaire, 214 (63%) were assessed by 1 of 60 pediatric providers. Seventy-seven percent of surveys were completed by the child's designated pediatric provider. The mean visit length was 23 minutes. Mothers primarily were single, were black or Hispanic, and had a mean age of 26 years (15-45 years). Almost 25% of mothers were living alone with their children. Eighty-six (40%) mothers scored >/=20 on the PSI, representing high symptom levels. Of these, 25 were identified by pediatric providers (sensitivity = 29%). A total of 104 of 128 mothers with a PSI score <20 were identified as such by providers (specificity = 81%). Pediatric providers were more likely to identify mothers who were <30 years old, living alone, and on public assistance. Also, mothers who were assessed by the child's own primary provider or by an attending pediatrician were more likely to be identified accurately than were mothers whose children were seen by a pediatric trainee or a nurse practitioner. CONCLUSIONS: Pediatric health care providers did not recognize most mothers with high levels of self-reported depressive symptoms. Pediatricians may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for developing depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.

Perceived role restriction and depressive symptoms in mothers of children with chronic health conditions.

This study examined role restriction in 365 inner-city mothers of 5- to 8-year-old children with chronic health conditions and tested whether it could account for a previously reported relationship between children's functional limitations and maternal psychological distress. Functional limitations in the children were related to maternal role restriction with sociodemographic factors controlled. Children's functional limitations also independently predicted maternal Depression subscale scores in a regression model. Adding role restriction to this model significantly increased explained variance in Depression scores, indicating that it also is directly related to maternal distress symptoms. However, adding role restriction only slightly reduced the impact of functional limitations in the model, suggesting that it plays a small role, if any, in explaining the relationship between the other two variables. Because perceived role restriction independently predicts maternal depressive symptoms and represents a potentially modifiable risk factor, it warrants attention as a useful target for intervention.

Sociodemographic and condition-related characteristics associated with conduct problems in school-aged children with chronic health conditions.

OBJECTIVE: To examine whether sociodemographic and condition-related characteristics are associated with conduct problems in children with chronic health conditions. DESIGN: Cross-sectional survey. PARTICIPANTS: Mothers of children 5 to 8 years old with diverse chronic health conditions who received care at 2 large urban medical centers. MEASURES: Mothers responded to a face-to-face structured interview that included the Eyberg Child Behavior Inventory, the Psychiatric Symptom Index, and questions about sociodemographic and health condition-related characteristics. RESULTS: Of the 356 children assessed, 138 (38.8%) had conduct problems as defined by criteria of the Eyberg Child Behavior Inventory. In logistic regression analyses, conduct problems were associated with younger child age, mother having a husband or partner unrelated to her child, poorer perceived prognosis, child having a learning disability, and maternal self-report of high emotional distress on the Psychiatric Symptom Index. Conduct problems were not related to child sex, maternal ethnicity or education, family receiving welfare, or a wide range of condition-related factors, including age at diagnosis, visibility to others, need to watch for sudden changes, presence of mobility or sensory-communication problems, using medication or equipment, annual hospitalizations, or physician visits. CONCLUSIONS: Conduct problems in children with chronic health conditions appear to be associated more closely with their sociodemographic and family characteristics than with condition-related risk factors. Additional research remains to be done on the ways that maternal adjustment, diagnosis-specific condition characteristics, and other risk factors influence children's behavior.

Cervical Papanicolaou smear abnormalities in inner city Bronx adolescents: prevalence, progression, and immune modifiers.

BACKGROUND: The aim of this study was to quantify the prevalence of cervical smear abnormalities in sexually active adolescents and identify the effect of immune-modifying conditions. METHODS: Two hundred seventy-one females ages 13-22 years attending a clinic for sexually transmitted disease (STD) evaluation had cervical Papanicoloau (Pap) smears and completed sexual history questionnaires. Results of all follow-up Pap smears were obtained. Medical charts were available for 54 patients with cytologic follow-up and were reviewed for the presence of immune-modifying conditions. Follow-up smear results for patients with and without immune-modifying conditions were compared. Abnormality rates for all cervical smears seen in 1995 at Montefiore Medical Center were also obtained. RESULTS: The smear abnormality rate for adolescents was 20. 7% (abnormal squamous cells of undetermined significance [ASCUS], 12. 2%; low grade squamous intraepithelial lesion [LGSIL], 7.7%; high grade squamous intraepithelial lesion [HGSIL], 0.7%) compared with all adult females, for whom the rate was 13.2% (ASCUS, 9.9%; LGSIL, 2.5%; HGSIL, 0.6%; carcinoma 0.2%) (P < 0.0002). Of 20 initial ASCUS patients, 6 (30%) showed LGSIL or HGSIL on follow-up. Chart review allowed the clinical immune status of 54 patients to be determined. Of 14 patients with an immune-modifying condition (9 HIV positive patients, 3 receiving oral steroids, 1 liver transplant patient receiving steroids, and 1 with intestinal lymphangiectasia), 11 (78. 6%) developed or maintained an abnormality on cytologic follow-up. Of 40 patients with no identifiable immune-modifying condition, 11 (27.5%) developed or maintained an abnormality on cytologic follow-up (P < 0.00082). CONCLUSIONS: Sexually active adolescents are at higher risk of developing a significant cervical smear abnormality, especially LGSIL. Patients with an atypical Pap smear or immune-modifying condition require more attentive gynecologic monitoring. Cancer (Cancer Cytopathol)

How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? National Heart, Lung, and Blood Institute.

OBJECTIVES: 1) To describe the asthma morbidity, primary care practices, and asthma home management of inner-city children with asthma; 2) to determine the responses of parental caretakers to asthma exacerbations in their child; and 3) to compare these responses to the recommendations of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of asthma. DESIGN AND METHODS: A 64-item telephone survey was administered between July 1996 and June 1997 to 220 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center from January, 1995 to February, 1996. Sociodemographics, primary care practices, asthma morbidity, and asthma home management were assessed. Parents were asked what they would do if their child "began wheezing and breathing faster than usual." RESULTS: Morbidity measures indicated that there were an average of 2.5 +/- 4.5 emergency department visits for asthma in the last 6 months, 1.6 +/- 2.2 hospitalizations for asthma in the last 12 months, and 18.1 +/- 17.9 asthma-related school absences in the previous school year. Most, but not all, of the families had primary care providers and most had phone access to them. Half of the families (51%) reported having been given a written asthma action plan. Only 30% of families with children age 5 years and older had peak flow meters. In contrast, almost all families (97%) had equipment for inhalation of beta-agonists. Only 39% of the 181 children with persistent symptoms were receiving daily antiinflammatory agents as recommended in the guidelines of the NHLBI. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan, only 1 caretaker would measure peak flow and 36% would give beta-agonists. Two percent would give oral steroids initially, and 1 additional person would do so if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinician. Reports of actual practice differed from the scenario responses in that more people began beta-agonists and oral steroids in response to an exacerbation in the past 6 months than said they would in response to the scenario. CONCLUSION: In this population of previously hospitalized inner-city children with asthma, the NHLBI guidelines for the home management of asthma exacerbations are not being followed. Interventions are needed to affect both clinician and caretaker practices.

Operationalizing a conceptually based noncategorical definition: a first look at US children with chronic conditions.

OBJECTIVE: To apply a conceptually based noncategorical definition in the analysis of a nationally representative sample of US children to determine the prevalence and sociodemographic characteristics of US children with chronic conditions. DESIGN: Data on 30032 children, aged 0 through 17 years, from the 1994 National Health Interview Survey Disability Supplement were analyzed using a noncategorical conceptual definition of chronic conditions and a method that parallels that outlined in the development of the Questionnaire for Identifying Children with Chronic Conditions. We determined the percentages of children with chronic conditions overall and in 3 conceptual domains: (1) functional limitations, (2) dependence on compensatory mechanisms, and (3) service use or need beyond routine care for age. RESULTS: Content that corresponded to 35 of 39 items on the Questionnaire for Identifying Children with Chronic Conditions assessing consequences was available in the National Health Interview Survey Disability Supplement data set. An estimated 10.3 million children (14.8%) had chronic conditions; 7.0% of the children met enrollment criteria in a single conceptual domain, 5.2% in 2 domains, and 2.6% in all 3 domains. Significant sociodemographic correlates of having a chronic condition were being school-aged or older, male, white, living with a responsible adult with less than a college education, and having a family income below the poverty index (all P<.01). CONCLUSIONS: We established the feasibility of operationalizing a noncategorical conceptual definition by using a large-scale data set and provided an estimate of the prevalence of chronic conditions among US children. We confirmed that several sociodemographic correlates of chronic conditions in samples identified through diagnostic checklists were related to the presence of chronic conditions among these children.

Depressive symptoms in inner-city mothers of young children: who is at risk?

OBJECTIVE: To identify factors associated with depressive symptoms in inner-city mothers of young children. DESIGN: A cross-sectional survey was administered to a convenience sample of English-speaking mothers attending a well-child visit for a child aged 6 months to 3 years in a hospital-based, inner-city, general pediatric clinic. The maternal interview collected data on sociodemographic characteristics, and mothers' health and financial status. Mothers completed the Psychiatric Symptom Index (PSI), a 29-item checklist shown to have very good validity and reliability in a multicultural population. A total score of >/=20 represents high levels of symptoms; scores >/=30 strongly suggest major depression. RESULTS: Two hundred seventy-nine mothers completed the PSI. Mothers ranged in age from 14 to 48 years (mean, 27 years). Seventy-one percent were unmarried; 57% received public assistance. Forty-two percent of mothers were Hispanic, 40% black, 9% white, and 10% mixed or other races. Forty-eight percent were foreign-born. Twenty-four percent reported having a medical condition; 6% had activity limitation because of illness. The mean PSI score was 19; 18% of mothers had a PSI score >/=30 and 39% scored >/=20. PSI scores did not vary by age, race, birthplace, educational level, employment, marital status, or family composition. PSI scores were higher for mothers receiving public assistance (21 vs 17), with self-reports of poor or fair financial status (22 vs 15) and poor health status (52 vs 17). Mothers with activity limitations because of illness had significantly higher PSI scores (34 vs 18). Multiple regression analyses confirmed the independent relationships of these maternal characteristics to high PSI scores. CONCLUSIONS: Depressive symptoms in inner-city mothers of young children are common. In this population of women with many risk factors, traditional sociodemographic risk factors did not successfully identify those who are depressed. However, mothers' self-reports of poor financial status, health status, or activity limitation because of illness were associated with higher levels of depressive symptoms. These findings may assist clinicians in distinguishing which mothers are likely to be depressed when almost all are at high risk.

Burden of wheezing illness among U.S. children reported by parents not to have asthma.

We examined the 12-month prevalence of asthma and wheezing among U.S. children and compared the illness-related burden of children who wheezed with and without an asthma diagnosis. Data were obtained in a cross-sectional telephone survey that tested the performance of a health interview designed to identify children with chronic health conditions. Respondents were 712 primary caretakers of 1388 children under 18 years old in a national probability sample selected by random-digit dialing. Although 51 children identified with asthma and wheezing had more episodes, sleep disturbances, and attacks that limited speech, and received more medical treatment for wheezing than 69 children with wheezing alone, the "undiagnosed" children appeared to be only somewhat less affected by their wheezing. Repeat episodes and burden experienced by children with wheezing alone suggest that the asthma prevalence may be underestimated if based only on the diagnostic label.

Comparison of adjustment of school-age children with and without chronic conditions: results from community-based samples.

We assessed whether children in the 1990s who were identified as having chronic conditions by using a new noncategorical technique (the Questionnaire for Identifying Children with Chronic Conditions) were as well adjusted as children without chronic conditions, and whether selection factors or sociodemographic variables accounted for any observed differences. Random-digit-dial telephone surveys were conducted using two separate samples: one consisting of 1275 children in 654 inner-city households and the other of 1388 children in a national sample of 712 households. Children with chronic conditions had poorer parent-reported functioning on the Personal Adjustment and Role Skills Scale total score and three of its six subscales (Hostility, Dependency, and Productivity). Differences in two other subscales (Withdrawal and Anxiety/Depression) were significant only for the inner-city sample. The results were consistent when controlling for other potentially confounding factors. These findings demonstrate that mental health risks continue to occur among contemporary community-based samples of children with chronic health conditions who are identified by using noncategorical techniques. These risks have implications for the care of those children.

Implications for estimates of disability in children: a comparison of definitional components.

OBJECTIVE: To test how prevalence estimates and characteristics of children vary by the way that disability is defined. Specifically, to determine 1) the proportions of children identified as disabled by one particular operationalization of disability based on parental reports of three types of consequences (i.e., functional limitations [FL]), dependence on compensatory mechanisms (CD), and service use or need beyond routine [SU/N]), and 2) whether children identified as disabled by these three types of consequences differ by type of disorder or condition, age, socioeconomic status, or race. METHOD: We analyzed a national dataset representing a random sample of 712 households with 1388 children. The Questionnaire for Identifying Children with Chronic Conditions (QuICCC) was used to identify children with disabling conditions. We divided the QuICCC items into three discrete sets, reflecting three definitional components of disability, and compared the proportions and characteristics of children fitting these components separately and in combination. RESULTS: Using the QuICCC definition of disability, SU/N identified the largest proportion of children (72%), followed by CD (55%) and FLs (49%). Forty-four percent of children were identified by only one component, 36% by two components in any combination, and 20% by all three components. The type of disorder or condition generally did not vary by the three definitional components, although the FL component may be more effective at identifying children with sensory impairments. Children identified by two or more components were more likely to have multiple conditions and had more pervasive disorders than those identified by only one component. The youngest children (0 to 3 years old) may be less likely to be identified as disabled than children of other ages, especially by FLs. FLs also were more likely to identify children from the poorest and least educated families. CONCLUSIONS: Although the specific findings reported here pertain to a single definitional approach (the QuICCC), the data highlight that who will be classified as disabled (and who will not) may be dependent on how disability is defined. The implications of using different definitions and definitional components on both the prevalence and the characteristics of children with disabilities need to be considered before data can be applied responsibly and appropriately.

Relationship of parental psychological distress to consequences of chronic health conditions in children.

OBJECTIVE: To assess whether parents' self-reported psychological distress was related to consequences of chronic health conditions in their children as reflected by three domains: functional limitations, reliance on compensatory mechanisms, and service use above routine care. METHODS: We used telephone survey data on children's health and parents' psychiatric symptoms from an inner-city community sample (n = 380) and a population-based national sample (n =398). RESULTS: In the national sample, parents of children with functional limitations were more distressed than parents whose children experienced other types of condition consequences or none. In the inner-city sample, presence of a health condition was associated with greater parental distress, but there were no significant effects by consequence type. CONCLUSION: Research needs to determine if parents of children with functional limitations represent a high-risk group and to identify the factors associated with their elevated distress.

Content validity of the Psychiatric Symptom Index, CES-depression Scale, and State-Trait Anxiety Inventory from the perspective of DSM-IV.

We compared the item content of three commonly used scales of psychiatric symptoms [the broad-band Psychiatric Symptom Index (Ilfeld) and two narrow-band scales, the Center for Epidemiologic Studies-Depression Scale (Radloff) and the State-Trait Anxiety Inventory (Spielberger)], with diagnostic criteria and criterion-based symptoms for Major Depressive Episode and Generalized Anxiety Disorder as they appeared in DSM-IV. The Psychiatric Symptom Index and the Center for Epidemiologic Studies-Depression Scale each measured 7 of 9 criterion-based symptoms of Major Depressive Episode. The Psychiatric Symptom Index and State-Trait Anxiety Inventory each measured 5 of 8 domains for Generalized Anxiety Disorder. The Psychiatric Symptom Index had comparable content validity to the narrow-band measures. All met a majority of DSM-IV criteria for depression and anxiety, supporting their applicability for current research.

Perception of the impact of a child's chronic illness: does it predict maternal mental health?

Longitudinal data were used to investigate direct and indirect effects of demographic factors, parameters of chronic health conditions, service use variables, and perception of family impact of illness on mental health of 169 mothers of children with diverse chronic health conditions. Bivariate analyses indicated that baseline assessments of demographic factors, condition parameters, and service use were: (1) generally unrelated to maternal mental health at 1 year and (2) modestly related to maternal perception of the condition's impact on the family 1 year later. Perceived impact and maternal mental health themselves were moderately related. Multivariate analyses indicated that the need to watch for changes in the child's condition, the presence of communication or speech problems, and the number of hospitalizations in the previous year predicted maternal perceptions of the impact of the condition 1 year later. Mothers perception of impact had a direct effect on mothers' mental health after accounting for condition parameters. Results suggest that condition parameters and service use can affect maternal mental health through mothers' perceptions of the impact of the condition on family life. Implications for interventions to prevent maternal health problems are discussed.