Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders in Early Childhood — United States, 2011–2012

Sociodemographic, health care, family, and community attributes have been associated with increased risk for mental, behavioral, and developmental disorders (MBDDs) in children (1,2). For example, poverty has been shown to have adverse effects on cognitive, socio-emotional, and physical development (1). A safe place to play is needed for gross motor development, and accessible health care is needed for preventive and illness health care (3). Positive parenting and quality preschool interventions have been shown to be associated with prosocial skills, better educational outcomes, and fewer health risk behaviors over time (2). Protective factors for MBDDs are often shared (4) and conditions often co-occur; therefore, CDC considered MBDDs together to facilitate the identification of factors that could inform collaborative, multidisciplinary prevention strategies. To identify specific factors associated with MBDDs among U.S. children aged 2–8 years, parent-reported data from the most recent (2011–2012) National Survey of Children’s Health (NSCH) were analyzed. Factors associated with having any MBDD included inadequate insurance, lacking a medical home, fair or poor parental mental health, difficulties getting by on the family’s income, employment difficulties because of child care issues, living in a neighborhood lacking support, living in a neighborhood lacking amenities (e.g., sidewalks, park, recreation center, and library), and living in a neighborhood in poor condition. In a multivariate analysis, fair or poor parental mental health and lacking a medical home were significantly associated with having an MBDD. There was significant variation in the prevalence of these and the other factors by state, suggesting that programs and policies might use collaborative efforts to focus on specific factors. Addressing identified factors might prevent the onset of MBDDs and improve outcomes among children who have one or more of these disorders.

NSCH is a cross-sectional, nationally representative, random-digit–dialed telephone survey that collects information about U.S. children aged <18 years. The survey includes indicators of child health and well-being, access to quality health care, family characteristics, and school and neighborhood environment.* Participating parents or guardians completed interviews about one randomly selected child (N = 95,677) per household. The interview completion rates were 54.1% and 41.2% for landline and cell phone samples, respectively; the overall response rate was 23.0%.^† Data were weighted to account for unequal probability of selection of each household and child and for nonresponse. Weighted estimates reflect the population of noninstitutionalized children in the United States and within each state.

Parents were asked, “Has a doctor or other health care provider ever told you that [child] had [specified disorder]?” A child was considered to have an MBDD if the parent or guardian reported any of the following: attention-deficit/hyperactivity disorder (ADHD), depression, anxiety problems, behavioral or conduct problems such as oppositional defiant disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or speech or other language problems.

Analyses were restricted to the 35,121 U.S. children aged 2–8 years (defined by Healthy People 2020 as “early childhood”) with data for sex and each disorder. Weighted prevalence estimates of having any MBDD, and the associations with sociodemographic, health care, family, and community factors were calculated using statistical software to account for the complex sampling. Given previously documented associations between health care, family, and community factors, an exploratory regression model was also fit to determine which of the health care, family, or community factors that were independently associated with any MBDD remained significant after adjusting for the others. Sociodemographic factors were not included in the model.

Overall, among U.S. children aged 2–8 years, 15.4% had at least one diagnosed MBDD, by parent report (Table 1). Sociodemographic factors associated with report of having an MBDD included male sex, older age (aged 4–5 or 6–8 years compared with 2–3 years), being non-Hispanic white, and living in a household with a higher poverty level (i.e., <200% of federal poverty level) or where English was the primary language spoken.

Specific factors most strongly associated with MBDDs in early childhood were fair or poor parental mental health, difficulty getting by on the family’s income, child care problems (among parents of children aged 2–3 years), and lacking a medical home. Factors with the highest prevalence among children with MBDDs included lacking a medical home, living in a neighborhood lacking amenities, difficulty getting by on family income, and living in a neighborhood in poor condition. When adjusted for the other significant health care, family, and community factors, an exploratory multivariate model showed that only lacking a medical home and fair or poor parental mental health remained significantly associated with having an MBDD (Table 2).

The prevalence of MBDDs and health care, family, and community factors among U.S. children aged 2–8 years varied by state (supplemental table at http://stacks.cdc.gov/view/cdc/38108). Prevalence of having any disorder varied from 10.6% in California to 21.5% in Arkansas and Kentucky. More than 90% of children received preventive care (i.e., parent or guardian reported that in the past 12 months, the child saw a health care provider for preventive medical care such as a physical exam or well-child checkup at least once) in each state.

Among health care factors, inadequate insurance was highest in South Carolina (26.5%), and lacking a medical home was highest in Arizona (52.2%); Vermont had the lowest prevalence of both inadequate insurance (14.7%) and lacking a medical home (27%).

The prevalences of difficulty getting by on the family’s income and child care problems were both highest in Arizona (34.9% and 21.8%, respectively); income difficulties were lowest in North Dakota (18.5%), whereas child care problems were lowest in Nevada (2.6%^§). Fair or poor parental mental health prevalence was highest in the District of Columbia (19.1%) and lowest in Kansas (6.9%).

The District of Columbia had the highest prevalence of living in a neighborhood in poor condition (46.2%) but the lowest prevalence of living in a neighborhood without all of the reported amenities (26.7%); the lowest prevalence of living in a neighborhood in poor condition was 20% in Maryland, whereas the highest prevalence of living in a neighborhood without all of the reported amenities was 67.5% in Mississippi (67.5%). Finally, reported prevalence of lack of neighborhood support was highest in Arizona (32.9%) and lowest in North Dakota (7.9%).

Corresponding author: Rebecca Bitsko, dvk2@cdc.gov, 404-498-3556.

¹Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC; ²Office of Epidemiology and Research, Maternal and Child Health Bureau, Health Resources and Services Administration; ³Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, CDC.

References

1. Evans GW, Kim P. Childhood poverty, chronic stress, self-regulation, and coping. Child Dev Perspect 2013;7:43–8. CrossRef
2. National Research Council and Institute of Medicine. Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Washington, DC: The National Academic Press; 2009.
3. Council on Community Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children’s health. Pediatrics 2013;131:623–8. CrossRef
4. Durlak JA. Common risk and protective factors in successful prevention programs. Am J Orthopsychiatry 1998;68:512–20. CrossRef PubMed
5. Abraído-Lanza AF, Armbrister AN, Flórez KR, Aguirre AN. Toward a theory-driven model of acculturation in public health research. Am J Public Health 2006;96:1342–6. CrossRef PubMed
6. Bradley RH, Corwyn RF. Socioeconomic status and child development. Annu Rev Psychol 2002;53:371–99. CrossRef PubMed
7. Houtrow AJ, Larson K, Olson LM, Newacheck PW, Halfon N. Changing trends of childhood disability, 2001–2011. Pediatrics 2014;134:530–8. CrossRef PubMed
8. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health 2010;100:590–5. CrossRef PubMed
9. Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. J Public Health Manag Pract 2008;14(Suppl):S8–17. CrossRef PubMed
10. Heckman JJ. Skill formation and the economics of investing in disadvantaged children. Science 2006;312:1900–2. CrossRef PubMed

TABLE 1. Prevalence of ever having any mental, behavioral, or developmental disorder (MBDD)* by parent report, among children aged 2–8 years, by selected characteristics — National Survey of Children’s Health, United States, 2011–2012

Abbreviation: CI = confidence interval.
* Including parent report of whether they were ever told by a health care professional that the child had attention-deficit/hyperactivity disorder (ADHD), depression, anxiety problems, behavioral or conduct problems such as oppositional defiant disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or speech or other language problems.
^† Includes American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, and Asian.
^§ Federal poverty level is based on family income and family size and composition using federal poverty thresholds that are updated annually by the U.S. Census Bureau using the change in the average annual consumer price index for all urban consumers. Imputed income was used for 9.3% of children aged 2–8 years without reported household income.
^¶ Based on the education of adult parents or respondents.

TABLE 2. Prevalence of ever having any mental, behavioral, or developmental disorder (MBDD)* by parent report, among children aged 2–8 years, by health care, family, and community factors — National Survey of Children’s Health, United States, 2011–2012

Abbreviation: CI = confidence interval.
* Including parent report of whether they were ever told by a health care professional that the child had attention-deficit/hyperactivity disorder (ADHD), depression, anxiety problems, behavioral or conduct problems such as oppositional defiant disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or speech or other language problems.
^† A regression model was fit to determine which of the health care, family, and community factors that were independently associated with MBDD remained significant after adjusting for the others. Child care problems were not included because these were limited to children aged 2–3 years. Having at least one parent with fair or poor mental health was included in the model rather than individual paternal and maternal mental health indicators.
^§ Based on a negative response to one of four variables included in the following five questions: 1) whether the child has current health insurance coverage; 2) whether the coverage is sufficient to meet the child’s needs; 3) whether the family pays out-of-pocket expenses, and if yes, 4) whether these expenses are usually or always reasonable; and 5) whether insurance allows the child to see needed health care providers.
^¶ Based on a response of “none” to the question, “During the past 12 months, how many times did [child name] see a doctor, nurse, or other health care provider for preventive medical care such as a physical exam or well–child checkup?”
** Based on five component variables (personal doctor or nurse, usual source for sick and well care, family-centered care, problems getting needed referrals, and effective care coordination when needed) drawn from 19 survey items. To have a medical home, children must have a personal doctor or nurse, usual source of care, and family-centered care; children needing referrals or care coordination must also have those criteria met.
^†† Based on responses of “fair or poor” (i.e., compared with excellent, very good, or good) to questions about maternal and paternal mental health. Maternal question: “In general, what is the status of [child name’s [mother’s/your] mental and emotional health?” Paternal question: “In general, what is the status of [child name]’s [father’s/your] mental and emotional health?”
^§§ Based on responses of “very often” or “somewhat often” (i.e., compared with rarely or never) to “Since [the child] was born, how often has it been very hard to get by on your family’s income, for example, it was hard to cover the basics like food or housing?”
^¶¶ Based on responses of “no” to “Is there someone that you can turn to for day-to-day emotional help with [parenthood/raising children]?”
*** Regarding children aged 2–3 years, based on responses of “yes” to “During the past 12 months, did you or anyone in the family have to quit a job, not take a job, or greatly change your job because of problems with child care for [the child]?”
^††† Based on responses of “no” to at least one of the following statements: “Please tell me if the following places and things are available to children in your neighborhood, even if [the child] does not actually use them”: 1) sidewalks or walking paths; 2) a park or playground area; 3) a recreation center, community center, or boys’ or girls’ club; 4) a library or bookmobile.
^§§§ Based on responses of “yes” to any of the following three questions: “In your neighborhood, is there litter or garbage on the street or sidewalk? How about poorly kept or rundown housing? How about vandalism such as broken windows or graffiti?”
^¶¶¶ Based on responses of “definitely agree, somewhat agree, somewhat disagree, or definitely disagree” were scored for the following four statements about their neighborhood or community: “People in this neighborhood help each other out; we watch out for each other’s children in this neighborhood; there are people I can count on in this neighborhood; if my child were outside playing and got hurt or scared, there are adults nearby who I trust to help my child.” Responses were scored 1–4 and an average score was calculated; averages less than 2.25 indicated a “lack of support.”
**** Based on responses of “never” or “sometimes” (i.e., compared with usually or always) to the question, “How often do you feel [the child] is safe in your community or neighborhood?”