Parenting Stress, Community Support, and Unmet Health Care Needs of Children in the US.

OBJECTIVES: In 2018, approximately 2.3 million children in the United States had unmet healthcare needs (UHCN). To date, studies examining associations between UHCN and parent stress and support have had limited generalizability. This study aimed to investigate the relationship between children's UHCN and parenting stress and support using a nationally representative sample. Additionally, this study aimed to assess associations between unmet mental health needs and these parental well-being measures. METHODS: Households with children ages 0-17 and complete data on UHCN in the combined 2016, 2017, 2018, and 2019 cohorts of the National Survey of Children's Health (NSCH) met inclusion criteria. Logistic regressions were used to evaluate associations between overall UHCN and outcome measures of parental coping, aggravation, emotional support, and neighborhood support. Associations between mental UHCN and these outcome measures were analyzed in a subset limited to children with mental health conditions. Regressions were adjusted for potential confounders, including demographics, household income, medical home status, and health insurance (adequacy/type). RESULTS: In our sample of 131,299 children, overall UHCN were associated with poorer parental coping (aOR = 5.35, 95% CI: [3.60, 7.95]), greater parental aggravation (aOR = 3.35, 95% CI: [2.73, 4.12]), and non-supportive neighborhood (aOR = 2.22, 95% CI: [1.86, 2.65]). Mental UHCN were similarly associated with parental coping and aggravation and neighborhood support in the mental health subset. CONCLUSIONS FOR PRACTICE: Healthcare professionals must address the needs of children with UHCN and collaborate with community organizations and child advocates to promote coordinated and comprehensive care and adequately support caregivers.

Associations Between Bullying and Condition Severity Among Youth With Chronic Health Conditions.

PURPOSE: Children with chronic conditions are at increased risk of bullying involvement. In addition to examining associations between chronic health conditions and both victimization and perpetration, this study investigated whether condition severity is associated with bullying involvement. METHODS: A secondary analysis of the 2018-2019 National Survey of Children's Health was performed. Children ages six-17 (n = 42,716) were classified as perpetrators (if bullied others ≥one-two times/month), victims-only (if victimized ≥one-two times/month and not a perpetrator) or uninvolved in bullying (neither perpetrator nor victim-only). Survey-weighted multinomial logistic regressions were used to investigate associations between bullying involvement and 13 chronic medical and developmental/mental health conditions. For children with conditions associated with being a victim and/or perpetrator, multinomial logistic regressions were used to further investigate associations between condition severity and victimization or perpetration. RESULTS: All 13 conditions were associated with higher odds of victimization. Seven developmental/mental health conditions were associated with higher odds of perpetration. Condition severity was associated with at least one domain of bullying involvement for one chronic medical and six developmental/mental health conditions. Notably, among children with attention-deficit/hyperactivity disorder, learning disability, or anxiety, condition severity was associated with higher odds of being a victim or bully/bully-victim. DISCUSSION: Condition severity may be a risk-factor for bullying involvement for many developmental/mental health conditions. Future condition-specific analyses are needed that directly examine bullying involvement among children with varying severity of individual conditions like attention-deficit/hyperactivity disorder, learning disability, and anxiety, using a clear operational definition for bullying, objective measures of condition severity, and multiple informants of bullying involvement.

Sports Team Participation and Vaping Among High School Students: 2015-2019.

BACKGROUND AND OBJECTIVES: Electronic vapor products (EVPs) have gained popularity among adolescents despite the health risks. This study aimed to evaluate whether sports team participation, a well-established protective factor against cigarette use, is similarly associated with decreased EVP use. METHODS: This cross-sectional study analyzed the 2015-2019 Youth Risk Behavior Survey cohorts. Survey-weighted logistic regressions investigated associations between sports team participation and past 30-day exclusive cigarette use, exclusive EVP use, and dual cigarette/EVP use among US high school students, adjusting for sex, grade, and survey year. RESULTS: The analytic cohort included 16 790 sports team participants (1.7% exclusive cigarette users, 18.3% exclusive EVP users, 5.5% dual users) and 13 972 nonparticipants (3.1% exclusive cigarette users, 13.4% exclusive EVP users, 7.6% dual users). Sports team participation was associated with lower odds of cigarette use (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.48-0.71) and dual use (aOR, 0.74; 95% CI, 0.63-0.88) and higher odds of EVP use (aOR, 1.39; 95% CI, 1.25-1.54). Among exclusive cigarette users and exclusive EVP users, sports team participation was associated with lower odds of frequent (≥20 days in the past month) than intermittent (1-19 days in the past month) cigarette use (aOR, 0.30; 95% CI, 0.19-0.49) and EVP use (aOR, 0.74; 95% CI, 0.61-0.91), respectively. CONCLUSIONS: Our findings suggest that risk profiles for cigarette and EVP use differ with respect to sports team participation. Given the health risks associated with EVP use, aggressive efforts must be taken to educate student athletes about the health risks of EVP use.

Health care provider support and factors associated with breastfeeding beyond infancy: A cross-national study.

BACKGROUND: Breastfeeding beyond infancy (12 months) remains atypical in the United States, United Kingdom, Canada, and Australia, and the role of health care providers is unclear. The objective of this study was to compare women's perceptions of provider support and other factors affecting breastfeeding beyond infancy across countries, among women who had each successfully breastfed at least one child that long. METHODS: Women completed an online questionnaire distributed via La Leche League, USA (2013), about sources and ratings of support for breastfeeding for their oldest child who was breastfed at least 12 months and participant demographics. Multivariable log-binomial regression was used to compare ratings of health care provider support and the importance of 13 factors by country. RESULTS: Some similarities and many differences were observed across countries in support received from providers, whereas modest or no differences were observed in the importance women placed on factors like health benefits and enjoyment of breastfeeding. Of 59 581 women, less than half discussed their decision to breastfeed beyond infancy with their child's provider. United Kingdom women rated their comfort in discussing breastfeeding beyond 12 months with their providers and the support received as lower than United States women. Canadian women gave lower ratings than United States women, but inconsistently. Australian women rarely differed from United States women in their responses. Providers' recommendations were not important to the decision to breastfeed beyond infancy, especially for United Kingdom women. DISCUSSION: Rates of breastfeeding beyond infancy are low in these countries; improving provider support may help achieve global breastfeeding goals.

Impact of Medication on Performance of Household Chores by Children with ADHD.

OBJECTIVE: To investigate associations between ADHD medication and household chore performance by children with ADHD. METHODS: A parent questionnaire collected information about the adequacy and quality of their child's performance of two self-care and six family-care chores. Parent perceptions of ADHD medication effect duration were used to identify children with after-school medication benefits (ASMB). Mann-Whitney U tests compared children with and without ASMB across measures of chore performance. RESULTS: A total of 565 parents of children with ADHD that regularly take medication completed the questionnaire. Children with ASMB were more likely to meet parental expectations for five of eight household chores and were more likely to be able to independently complete both self-care and family-care chores than those without ASMB. No differences were noted regarding their need for reminders or assistance with chores. CONCLUSION: Improvement in chore performance may be an additional consideration with respect to medication selection for children with ADHD.

The COVID-19 pandemic and its potential enduring impact on children.

PURPOSE OF REVIEW: The COVID-19 pandemic has ushered in great and rapid change in our society. Although children are somewhat less likely to get infected or have severe symptoms from COVID-19, they are being adversely affected by this global public health emergency in many direct and indirect ways. This review focuses on the major areas in which children and adolescents are suffering, and how pediatricians can anticipate and optimize child healthcare and support as the COVID-19 pandemic and its aftermath continues. RECENT FINDINGS: This review provides preliminary insights into the physical, psychological, educational, developmental, behavioral, and social health implications of the pandemic on the pediatric population, highlighting both the pandemic's current and potential future impact on children. SUMMARY: The COVID-19 pandemic has and will likely continue to adversely affect many different aspects of children's health and well-being. It is important for pediatricians to be aware of these consequences of COVID-19 and take steps to help their patients now and in the future. Because the virus continues to ravage many parts of the world, continued research is needed to identify and evaluate any additional COVID-related challenges and concerns that adversely impact the growth and development of children.

Wandering behavior in children with autism spectrum disorder and other developmental disabilities.

PURPOSE OF REVIEW: Approximately one in four children with autism spectrum disorder (ASD) 'elope' or wander away from supervision each year; however, many caregivers do not receive adequate information on how to address wandering behavior. The purpose of this review is to summarize the available research on elopement frequency, wandering patterns, and interventions to provide pediatricians and other childcare professionals with appropriate strategies to address wandering behavior. RECENT FINDINGS: Despite the high prevalence of wandering by children with ASD or other developmental disabilities, there is relatively limited research in this area. Recent research has identified common patterns and factors associated with risk of elopement and elopement frequency. SUMMARY: Pediatricians should counsel families on the common issues and intervention strategies related to elopement. By increasing awareness of wandering in children with ASD, caregivers can feel better prepared to make informed decisions regarding their child's wellbeing and safety.

Electronic Vapor Product Use and Sexual Risk Behaviors in US Adolescents.

BACKGROUND AND OBJECTIVES: Adolescent electronic vapor product (EVP) usage continues to increase and is associated with heightened engagement in other risk behaviors. However, there is limited research on associations between youth EVP use and sexual risk behaviors (SRBs). In this study, we examined how current youth EVP and/or cigarette usage, as well as EVP usage frequency, is related to several SRBs. METHODS: Respondents (N = 12 667) of the 2017 National Youth Risk Behavior Survey were categorized by previous 30-day EVP and/or cigarette usage: nonuse, EVP use only, cigarette use only, or dual use. Separately, respondents were categorized by previous 30-day EVP usage frequency: 0, 1 to 9, 10 to 29, or 30 days. Ten SRBs were identified as dependent variables. Adjusted prevalence ratios were calculated by using modified Poisson regression to determine associations between SRBs and both current EVP and/or cigarette usage and EVP usage frequency. Linear contrasts compared adjusted prevalence ratios across usage and frequency categories. RESULTS: Youth EVP-only users and dual users were more likely than nonusers to engage in 9 of 10 SRBs. Prevalence proportions did not differ between EVP-only users and dual users for 7 of 10 behaviors. Occasional EVP users were more likely than nonusers to engage in 9 of 10 SRBs and were similarly as likely as frequent and daily users to engage in all 10 SRBs. CONCLUSIONS: EVP usage among US high school students, with or without concurrent cigarette use, was associated with heightened engagement in several SRBs. Prevalence of engagement in most SRBs did not differ among occasional, frequent, and daily EVP users.

School Readiness of Young Children Enrolled in Preschool in the United States.

OBJECTIVE: As preschool enrollment increases, it is important to know whether children enrolled in preschool are more likely to be "healthy and ready to learn (HRTL)." Our objective was to assess whether there are detectable school readiness differences between children enrolled in preschool and those who are not in a large, cross-sectional, nationally representative US sample. METHODS: Caregivers of 4931 3- to 4-year-old children in the 2016 National Survey of Children's Health indicated whether their child had started school and completed questions forming the "HRTL" School Readiness National Outcome Measure and its domains: early learning skills, self-regulation, social-emotional development, and physical health/motor development. Propensity score-matched logistic regression models estimated prevalence ratios (PRs) comparing children in versus not in preschool. RESULTS: 49.1% of children had started preschool. After matching, children in preschool did not differ from children not in preschool on the composite (PR = 1.21; 95% confidence interval [CI]: 0.92-1.58) or any domains. Children in preschool were more likely to be "on track" with rhyming words (PR = 1.48; 95% CI: 1.11-1.96), writing their name (PR = 2.36; 95% CI: 1.82-3.08), and holding a pencil (PR = 1.55; 95% CI: 1.12-2.14) but less likely with explaining things they have seen/done (PR = 0.59; 95% CI: 0.44-0.79) and overall health (PR = 0.57; 95% CI: 0.33-0.97). Some associations were sex specific. CONCLUSION: The largely null findings of this study underscore the need for further research that incorporates information regarding the extent and quality of preschool exposure when evaluating the developmental benefits of preschool on a national level.

Breastfeeding Is Associated with a Reduced Risk of Attention-Deficit/Hyperactivity Disorder Among Preschool Children.

BACKGROUND: Breastfeeding has been associated with a lower risk of attention-deficit/hyperactivity disorder (ADHD). However, most studies examining this association have focused on small samples outside the United States or were likely subject to substantial residual confounding. Our objectives were to investigate, in a nationally representative sample of preschool children in the United States, the associations between ADHD and both age of breastfeeding cessation and age of formula introduction, as well as associations between ADHD and exclusive breastfeeding duration. METHODS: Analysis of data from children aged 3 to 5 years in the 2011/12 National Survey of Children's Health (n = 12,793). Logistic regressions were used to model current medical diagnosis of preschool ADHD as a function of breastfeeding duration, breastfeeding exclusivity, and the timing of formula introduction with adjustment for 12 potential confounders using propensity scores, including sex, age, race, household income, prematurity, insurance, and medical home. RESULTS: After adjustment for potential confounders, exclusive breastfeeding for at least 6 months was associated with substantially reduced odds of ADHD (adjusted prevalence odds ratio [aPOR] = 0.38; 95% confidence interval [CI], 0.15-0.99). Breastfeeding duration was also associated with ADHD, with 8% reduced odds of ADHD for each additional month of breastfeeding (aPOR = 0.92; 95% CI, 0.86-0.99). The results for exclusive breastfeeding duration were similar, but the confidence interval included the null (aPOR = 0.92; 95% CI, 0.85-1.00). The age of formula introduction was not associated with ADHD (aPOR = 0.92; 95% CI, 0.81-1.05). CONCLUSION: In a nationally representative sample of preschool children, breastfeeding was associated with a lower prevalence of ADHD. These findings provide evidence in support of the neurodevelopmental benefits of breastfeeding.

Impact of ADHD on Household Chores.

Objective: To assess the relationship between ADHD and performance of household chores. Method: A 72-question online questionnaire was developed to collect demographic/clinical information as well as parents' assessment of their child's performance of self-care (SC) and family-care (FC) chores. Results: The sample consists of 797 primary caregivers of children with ADHD. The overwhelming majority of parents believed that ADHD to some extent affected their child's ability to independently and satisfactorily complete SC and FC chores. An inverse relationship was noted between parent ratings of a child's ability to do chores independently and satisfactorily and the likelihood they believed ADHD affected chore performance. There was no difference in chore performance between children with or without co-morbid oppositional defiant disorder. Conclusion: Given that household routines, including chores, play an important role in children's development and psychosocial adjustment, clinicians must be sensitive to the adverse impact that ADHD may have in this regard.

Sex Differences in Gender-Diverse Expressions and Identities among Youth with Autism Spectrum Disorder.

A growing body of evidence supports a potential link between autism spectrum disorder (ASD) and gender dysphoria, yet few studies have looked at sex differences in the co-occurrence of gender diversity and ASD. The aim of this study was to characterize sex differences in gender-diverse expressions and identities, as well as gender-related concerns, in youth with ASD. Parents of youth with ASD ages 6-21 (n = 163) completed an online questionnaire about their child's gender expression and identity. Sex-typed behaviors during childhood were measured using the Gender Identity Questionnaire (GIQ). Semi-partial Kendall correlations and chi-square tests were used to compare gender non-conformity, gender-diverse identities, and gender-related concerns between sexes. Sex-based differences in mean GIQ score and individual GIQ items were evaluated using a linear regression and semi-partial Kendall correlations, respectively. All regressions and correlations controlled for child age. Parents of girls were more likely to report child appearances and mannerisms that were less concordant with their child's birth sex. Based on parent-report, girls had lower mean GIQ scores, indicating greater cross-gendered/fewer same-gendered behaviors in childhood. Lastly, parents of girls with ASD were more likely to report that their daughters experienced anxiety due to gender-related concerns and discomfort during puberty than parents of boys. These findings suggest that girls with ASD seem more likely have gender-diverse preferences, mannerisms, and appearances that fall outside of traditional gender norms. Gender-related concerns appear to be a source of real distress in girls with ASD, highlighting the need for individualized support, especially during puberty. LAY SUMMARY: Despite evidence of a potential link between autism and gender diversity, few studies have explored differences in gender identity/expression between boys and girls with autism. Based on parent responses, we found that girls with autism are more likely than boys to have appearances and mannerisms, as well as behaviors during childhood, that fall outside of the traditional gender role. The unique profile of girls with autism and their elevated distress over gender-related concerns call for individualized support during adolescence.

Reporting of child maltreatment during the SARS-CoV-2 pandemic in New York City from March to May 2020.

BACKGROUND: School closures and other public health responses have decreased the extent that children interact with mandated reporters and other professionals trained to detect child maltreatment. OBJECTIVE: To assess associations between the pandemic public health response and the number of allegations of child abuse or neglect. METHODS: This study analyzed monthly data from New York City of the number of child maltreatment allegations, stratified by reporter type (e.g., mandated reporter, education personnel, healthcare personnel), as well as the number of Child Protective Services (CPS) investigations warranting child welfare preventative services. SARIMA models were trained using data from January 2015 to February 2020 to predict expected values for March, April, and May 2020. Observed values were compared against predicted values at an alpha of .05. RESULTS: Substantially fewer allegations of child maltreatment were reported than expected in March (-28.8 %, deviation: 1848, 95 % CI: [1272, 2423]), April (-51.5 %, deviation: 2976, 95 % CI: [2382, 3570]), and May 2020 (-46.0 %, deviation: 2959, 95 % CI: [2347, 3571]). Significant decreases in child maltreatment reporting were also noted for all reporter subtypes examined for March, April, and May 2020. Fewer CPS investigations warranted preventative services than expected in March 2020 (-43.5 %, deviation: 303, 95 % CI: [132, 475]). CONCLUSIONS: Precipitous drops in child maltreatment reporting and child welfare interventions coincided with social distancing policies designed to mitigate COVID-19 transmission. In light of these findings, educators and healthcare providers must be especially vigilant when engaging online with children and their families for signs of child abuse and/or neglect.

Patterns and Outcomes of Diagnosis Disclosure to Youth with Autism Spectrum Disorder.

OBJECTIVE: Although the benefits of diagnosis disclosure have been recognized for a number of pediatric medical conditions, there is a paucity of research about the process by which youth with autism spectrum disorder (ASD) are informed about their diagnosis. The aim of this study was to systematically characterize the antecedents, correlates, and outcomes of diagnosis disclosure to youth with ASD. METHODS: In this cross-sectional study, parents and guardians of youth with ASD (ages 8-25) completed a detailed online questionnaire about their experiences with diagnosis disclosure. The perceived impact of disclosure on affected youth was also assessed. RESULTS: Five hundred seventy-five parents of youth with ASD (mean age: 14 years) completed the questionnaire, of whom 81% reported their affected child had been told that he or she had ASD. Most youth who had been told about their diagnosis (86%) were currently aware that they had ASD, according to the parent report. Youth awareness of the diagnosis was reported to be associated with improved self-advocacy skills (60%), enhanced self-awareness of personal strengths (69%) and weaknesses (68%), and other benefits. Youth who had sought information about ASD from support groups and other individuals with ASD had better outcomes regarding self-esteem [adjusted odds ratio = 2.73, 95% confidence interval: (1.34, 3.98)] and acceptance of the diagnosis (p = 0.001) than those who exclusively learned about ASD from other sources. CONCLUSION: Given the numerous potential benefits of diagnosis disclosure, there is a need for physicians and other professionals to support parents in educating youth with ASD about their diagnosis.

Family Well-being in Grandparent- Versus Parent-Headed Households.

BACKGROUND AND OBJECTIVES: Little is known about the 2% of US children being raised by their grandparents. We sought to characterize and compare grandparent- and parent-headed households with respect to adverse childhood experiences (ACEs), child temperament, attention-deficit/hyperactivity disorder (ADHD), and caregiver aggravation and coping. METHODS: Using a combined data set of children ages 3 to 17 from the 2016, 2017, and 2018 National Survey of Children's Health, we applied survey regression procedures, adjusted for sociodemographic confounders, to compare grandparent- and parent-headed households on composite and single-item outcome measures of ACEs; ADHD; preschool inattention and restlessness; child temperament; and caregiver aggravation, coping, support, and interactions with children. RESULTS: Among 80 646 households (2407 grandparent-headed, 78 239 parent-headed), children in grandparent-headed households experienced more ACEs (ß = 1.22, 95% confidence interval [CI]: 1.07 to 1.38). Preschool-aged and school-aged children in grandparent-headed households were more likely to have ADHD (adjusted odds ratio = 4.29, 95% CI: 2.22 to 8.28; adjusted odds ratio = 1.72, 95% CI: 1.34 to 2.20). School-aged children in these households had poorer temperament (ßadj = .25, 95% CI: -0.63 to 1.14), and their caregivers experienced greater aggravation (ßadj = .29, 95% CI: 0.08 to 0.49). However, these differences were not detected after excluding children with ADHD from the sample. No differences were noted between grandparent- and parent-headed households for caregiver coping, emotional support, or interactions with children. CONCLUSIONS: Despite caring for children with greater developmental problems and poorer temperaments, grandparent caregivers seem to cope with parenting about as well as parents.

Clinical correlates of laterality among school-age children in the United States.

Researchers have long been interested in whether lateral preference is associated with giftedness, season of birth, and/or ADHD constructs (short attention span, high level of activity, and impulsivity). The objective of this study was to examine these associations in a large, longitudinal sample of U.S. children (National Collaborative Perinatal Project (CPP), 1959-1973). Children born to women in this pregnancy cohort underwent a neonatal exam and an exam at age 7 years to assess lateral preference of the hand and eye, IQ on the Wechsler Intelligence Scale for Children (WISC), and ADHD symptoms. Children with perinatal/neonatal risk factors for neurologic impairment or early signs of neurological abnormality were excluded from our analyses. The final sample included 25,385 children. Associations between laterality and IQ were examined using linear and logistic regression models adjusted for sex, race, and socioeconomic status. Associations between laterality and ADHD symptoms and between season of birth and laterality were estimated using multivariable logistic regression. In this large, longitudinal study of neurologically healthy children, modest associations were observed between hand/eye preference and IQ and hyperactivity only.

Wandering by Children with Autism Spectrum Disorders: Impact of Electronic Tracking Devices on Elopement Behavior and Quality of Life.

OBJECTIVE: Half of US children with autism spectrum disorder (ASD) have attempted to elope from adult supervision at least once, elevating their risk for serious injury/death. This study aimed to assess, in a sample of children with ASD aged 4 to 18 years who had previously wandered, whether electronic tracking device (ETD) use is associated with changes in the elopement behavior and household quality of life (QOL). METHODS: An anonymous, online questionnaire assessing elopement interventions, elopement behavior, household QOL, attitudes toward ETDs, and sociodemographics was distributed via US autism-related organizations to caregivers of children with ASD. Differences in retrospective estimates of elopement behavior and household QOL before ETD use and during ETD use were evaluated using Wilcoxon signed-rank tests. RESULTS: A total of 2563 participants completed the questionnaire; 1459 participants met the inclusion criteria. For the current (n = 361) and past (n = 96) ETD users, ETD use was associated with decreased frequency and duration of elopement and decreased risk for serious injury because of elopement (all p < 0.001). ETD use was similarly associated with improvements across all 5 measures of QOL. Among the past ETD users, reasons for discontinuation included device discomfort/fit (33.3%), burden of use (27.1%), and financial cost (14.6%). Among the non-ETD users (n = 1002), common barriers to ETD use were cost (47.5%) and lack of awareness of ETD technology (18.8%). CONCLUSION: Electronic tracking devices represent a promising technology to help safeguard the well-being of children with ASD while reducing the emotional toll that elopement imposes on families. Cost concerns, burden of use, and lack of awareness seem to limit the widespread adoption of ETDs.