Child health status and parental employment.

OBJECTIVE: To understand the relationship between several measures of child health status and the employment of parents. DESIGN: A cross-sectional study using 1994 National Health Interview Survey on Disability data. PARTICIPANTS: A nationally representative sample of children and their parents. OUTCOME MEASURES: Maternal and paternal employment (measured separately). INTERVENTION: We use a series of logistic regression models with maternal and paternal employment as the dependent variables and the health status of the child with the poorest health status in the family as the primary independent variable. Models additionally include sociodemographic correlates of employment. RESULTS: Having a child with poor health status, as measured by general reported health, hospitalizations, activity limitations, and chronic condition or disability status, is associated with reduced employment of mothers and fathers. For example, the odds ratios of being employed for having a child with an activity limitation are 0.75 for mothers (95% confidence interval, 0.67-0.85) and 0.66 for fathers (95% confidence interval, 0.53-0.82). CONCLUSIONS: Having a child with poor health status is associated with reduced maternal and paternal employment. Further studies are needed to determine whether poor child health status causes reductions in parental labor force participation. If such a causal relationship exists, it has important implications for social policy, employment policy, and clinical anticipatory guidance.

Who cares for medicaid-enrolled children with chronic conditions?

OBJECTIVE: To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use. METHODS: We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care. RESULTS: Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI. CONCLUSIONS: Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.

Switching to gatekeeping: changes in expenditures and utilization for children.

BACKGROUND: Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. OBJECTIVE: To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. DESIGN: We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. RESULTS: Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. CONCLUSION: Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

The child with ADHD: using the AAP Clinical Practice Guideline. American Academy of Pediatrics.

The American Academy of Pediatrics developed an evidence-based clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). This guideline, the first of two guidelines to provide recommendations on this condition, is intended for use by primary care clinicians. The second set of guidelines will address the treatment of children with ADHD. The guideline contains six recommendations for the diagnosis of ADHD: (1) in a child six to 12 years of age who presents with inattention, hyperactivity, impulsivity, academic underachievement or behavior problems, primary care clinicians should initiate an evaluation for ADHD; (2) the diagnosis of ADHD requires that a child meet the criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders; (3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms and degree of functional impairment; (4) the assessment of ADHD also requires evidence directly obtained from a teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment and associated conditions; (5) evaluation of the child with ADHD should include assessment for coexisting conditions; and (6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of coexisting conditions.

Social influences on health-risk behaviors among minority middle school students.

PURPOSE: To determine whether parent social influences are associated with health-risk behaviors more than peer social influences among young minority adolescents. METHODS: We conducted a cross-sectional survey of seventh-grade students in a public urban magnet middle school using a survey instrument adapted from the Centers for Disease Control and Prevention Youth Risk Behavior Survey. The sample consisted of all seventh-grade students in the school, and the survey was part of a needs assessment for a school-based health education program. We measured four health-risk behaviors: use of (a) tobacco, (b) alcohol, (c) onset of sexual activity, and (d) marijuana use; and five social influences: (a) parent disapproval of health-risk behaviors, (b) parent modeling of health-risk behaviors, (c) parent monitoring of health-risks, (d) peer disapproval of health risks, and (e) peer modeling of health-risk behaviors. The analyses included measures of the prevalence of health-risk behaviors, bivariate analyses to evaluate relationships between health-risk behaviors and social influences, and regressions analyses to determine the independent associations of the social influences with the four health-risk behaviors. RESULTS: Twenty percent of respondents reported using tobacco, over 50% used alcohol in the past year, 13.3% were sexually active, and 12% reported marijuana use. Parent influences were associated with differences in alcohol use, whereas peer influences were associated with differences in all measured health-risk behaviors: tobacco and alcohol use, sexual activity, and marijuana use. Regression analyses demonstrated that peer social influences were the only measures independently associated with abstinence from tobacco (p < .05), alcohol (p < .01), sexual activity (p < .05), and marijuana use (p < .05). In all analyses, peers emerged as the most consistent social influence on health-risk behavior. CONCLUSION: This study suggests peers and peer group behavior may be better predictors of adolescent health-risk behaviors than parental social influences among young adolescents.

Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings.

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.

A report card on quality improvement for children's health care.

OBJECTIVE: Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research. METHODS: To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program. RESULTS: We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults. CONCLUSIONS: Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

Utility of psychosocial screening at a school-based health center.

School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents' mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.

Impact of expanding SSI on Medicaid expenditures of disabled children.

Supplemental Security Income (SSI) expansions for disabled children in the early 1990s provoked criticism that eligibility criteria were too lax and motivated the subsequent retraction of benefits for many children. However, little evidence exists on whether the clinical needs of SSI children declined during this period. The authors used Medicaid data to examine changes in average expenditures between 1989 and 1992, using an Aid to Families with Dependent Children (AFDC) comparison group to control for confounding time trends (e.g., in access). Results showed declines in average expenditures in Georgia and Tennessee but increases in California and Michigan, which are thought to have started with more liberal eligibility policies.

American Academy of Pediatrics. Committee on Children With Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs.

Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. Care coordination often is complicated because there is no single entry point to multiple systems of care, and complex criteria determine the availability of funding and services among public and private payers. Economic and sociocultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care pediatricians have a vital role in the process of care coordination, in concert with the family.

Employment, child care, and mental health of mothers caring for children assisted by technology.

OBJECTIVE: This study examines 1) the way that children with chronic conditions are cared for at home and assisted by technology affects maternal employment and child care; 2) the social and clinical factors associated with the decision of a mother to quit employment to care for a child at home; and 3) the way in which care at home and the decision of a mother to quit a job affects maternal mental health. DESIGN: The 6-month postdischarge status of 70 mothers of children assisted by technology (study group) was compared with the 6-month postdischarge status of 58 mothers of children (matched for age and gender) hospitalized for acute illnesses (comparison group). Between January and December 1993, we gathered information on sociodemographic status, employment status and changes in employment, severity of the child's condition, child care and nursing services at home, family support, and maternal mental health. RESULTS: One third of mothers in the study group reported that they quit employment to take care of a child at home with only 37.1% remaining employed outside the home, compared with 69.0% of comparison group mothers. Single caretakers were 15 times more likely to quit employment compared with mothers in two-parent families. Availability of child care had an independent effect on a mother's decision to quit a job, whereas the severity of the child's condition did not. Child care hours were significantly lower in study group families and were provided mostly by relatives compared with day-care facilities and regular babysitters in comparison families. Family support was highest among employed mothers in both the study and the comparison groups and lowest in study group mothers who were neither employed currently nor before the child's illness or who had quit employment to care for the child. Family income was significantly lower in families with a child assisted by technology. Families in the study group had 20-fold higher uncompensated health care costs than did the comparison group. Mothers caring for a child assisted by technology reported less good mental health than did comparison group mothers, and employment seems to mediate this relationship. CONCLUSIONS: Caring for a child assisted by technology seems to create barriers to maternal employment diminishing family resources at a time when financial needs actually may increase. Lack of family support and child care services increase the likelihood that mothers of children assisted by technology will stay out of the labor force. Remaining employed buffers the negative effects of care at home on maternal mental health. Health policies for children with chronic health problems should address issues of financial burdens and the labor force participation of their caretakers.

Changing patterns of conditions among children receiving Supplemental Security Income disability benefits.

OBJECTIVE: To determine the relative growth of types of chronic health conditions among children and adolescents receiving Supplemental Security Income (SSI) benefits before and after major SSI program changes, including changes in definitions of childhood disability and outreach to identify eligible children. DESIGN: Retrospective analysis of Medicaid claims from California, Georgia, Michigan, and Tennessee. PARTICIPANTS: All children (aged < or = 21 years) newly enrolled in SSI programs in these states from July 1989 (n=21 222) to June 1992 (n=38 789). METHODS: Medicaid data indicate eligibility status and diagnoses for services rendered. For children newly enrolled before (time 1, July 1989 to June 1990), during (time 2, July 1990 to June 1991), and after (time 3, July 1991 to June 1992) the program changes, we used claims for the first 6 months of enrollment to determine rates of chronic conditions in general and rates of asthma, attention-deficit/hyperactivity disorder (ADHD), and mental retardation specifically. We also followed up time 1 enrollees during the study period to determine the likelihood of a chronic condition claim at any time. MAIN OUTCOME MEASURE: Presence of claims for chronic conditions. RESULTS: New SSI enrollees almost doubled during the study period. Increasing numbers of new enrollees had chronic condition claims in their first 6 months (from 29% to 36%); 58% of time 1 enrollees had such claims during any study month. Rates of chronic physical conditions other than asthma increased 14% (time 1 to time 3); asthma rates increased 73%. Rates of mental health conditions other than mental retardation and ADHD increased 63%; rates of mental retardation decreased 29%, while rates of ADHD increased almost 3-fold. CONCLUSIONS: The number of children with chronic conditions receiving SSI benefits experienced rapid growth from 1989 to 1992. Growth was particularly marked for children with diagnoses of asthma and ADHD.

High-expenditure children with Supplemental Security Income.

OBJECTIVE: To examine the clinical characteristics and health service use of children with high Medicaid expenditures. METHODOLOGY: We examined 1992 Medicaid claims and eligibility files from four states (California, Georgia, Michigan, Tennessee) for children with at least $10000 billed to Medicaid who obtained Medicaid through the Supplemental Security Income (SSI) Program and a comparison group (matched by age group and gender) of children receiving Medicaid for other reasons. We compared mean expenditures, examined expenses by category, and examined diagnoses associated with at least $10000 in expenses. RESULTS: In 1992, Medicaid paid on average approximately $1000 for children with non-SSI Medicaid enrollment. Expenditures for children with SSI were 2.9 to 9.4 times higher, but once the approximately 10% of children with high expenditures were excluded, SSI average expenditures were only 1.5 to 2.7 times higher than the non-SSI average. Children with high expenditures are likely to use hospitals and long-term care, and these services account for more than half of the average expenditures. Children with high expenditures and SSI are more likely to have chronic medical conditions than are their peers enrolled in Medicaid but not through SSI. CONCLUSIONS: A small proportion of children, even on SSI, account for very large proportions of Medicaid expenditures. Most children with SSI, despite having relatively severe mental health, physical, or developmental disabilities, have relatively modest Medicaid expenditures.

Assessing managed care for children with chronic conditions.

This paper reviews opportunities to monitor managed care for children and adolescents with chronic conditions and considers how well the Health Plan Employer Data and Information Set, version 3.0 (HEDIS 3.0), assesses care for these children. We propose four steps to strengthen the applicability of HEDIS to children with chronic conditions: (1) develop methods of identifying and monitoring groups of children with chronic conditions; (2) report HEDIS indicators for these children separately from those for other children; (3) develop and implement consumer and provider surveys that elicit information specific to these populations; and (4) develop specific structure, process, and outcomes indicators for children with chronic conditions.

Impact of long-term care of children assisted by technology on maternal health.

This study examines the health outcomes of mothers of children assisted by technology and their associations with condition severity and family and social support. The 6-month postdischarge status of 65 mothers of children assisted by technology was compared with that of 54 mothers of children (matched for age and sex) hospitalized for acute illnesses. We measured maternal health, emotional well-being (Center for Epidemiologic Studies Depression Scale), severity of the child's condition, family functioning, social support, and sociodemographic data. Mothers in the study group reported impaired health related to pain, vitality, social functioning, and mental health and substantially more depressive symptoms than mothers in the control group (p < .001), with almost half having scores suggesting clinical depression. Family supportiveness and opportunities for recreational and cultural activities were significantly lower in families with children assisted by technology. After controlling for sociodemographic variables, high condition severity (p < .01), lack of family support (p = .05), low social support appraisal (p < .01), and high levels of receipt of social support (p < .01) were associated with more depressive symptoms of mothers in the study group. Six months after diagnosis or major hospitalization, the severity of the condition was highly associated with maternal emotional well-being, with family support and social support appraisal having moderate independent positive effects. The receipt of social support indicated need rather than support and was negatively associated with well-being. Discharge planning and support systems need to focus on both the child and the prevention of secondary social and psychological morbidity of caretakers.

An epidemiologic profile of children with special health care needs.

OBJECTIVE: To present an epidemiologic profile of children with special health care needs using a new definition of the population developed by the federal Maternal and Child Health Bureau. METHODS: We operationalized the new definition using the recently released 1994 National Health Interview Survey on Disability. Estimates are based on 30 032 completed interviews for children <18 years old. The overall response rate was 87%. RESULTS: Eighteen percent of US children <18 years old in 1994, or 12.6 million children nationally, had a chronic physical, developmental, behavioral, or emotional condition and required health and related services of a type or amount beyond that required by children generally. This estimate includes children with existing special health care needs but excludes the at-risk population. Prevalence was higher for older children, boys, African-Americans, and children from low-income and single-parent households. Children with existing special health care needs had three times as many bed days and school absence days as other children. An estimated 11% of children with existing special health care needs were uninsured, 6% were without a usual source of health care, 18% were reported as dissatisfied with one or more aspects of care received at their usual source of care, and 13% had one or more unmet health needs in the past year. CONCLUSIONS: A substantial minority of US children were identified as having an existing special health care need using national survey data. Children with existing special health care needs are disproportionately poor and socially disadvantaged. Moreover, many of these children face significant barriers to health care.