Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders and Poverty Among Children Aged 2–8 Years — United States, 2016

1NSCH is a national, cross-sectional, web-based and paper-based survey funded and directed by the Health Resources and Services Administration’s Maternal and Child Health Bureau that is representative of noninstitutionalized children aged 0–17 years in the United States.* The U.S. Census Bureau conducted the 2016 NSCH using address-based sampling and created weights to account for oversampling and potential nonresponse biases.† Parents were asked, “Has a doctor or other health care provider ever told you that this child has (specified MBDDs)?” A child was considered to have ever had an MBDD if their parent reported one or more of the following: anxiety problems, depression, attention-deficit/hyperactivity disorder, behavioral or conduct problems, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay, or language problems. Parents also responded to questions related to factors associated with MBDDs, including household income, health insurance, components of a medical home, difficulty getting by on the family’s income, parent emotional support, neighborhood condition (e.g., litter or vandalism), neighborhood amenities (e.g., sidewalks or parks), and parental mental or physical health, as well as whether they received public assistance (e.g., SNAP; Women, Infants, and Children [WIC]; free or reduced price meals at school; or cash assistance).§

2Parents of 50,212 children participated in the survey, resulting in an interview completion rate of 69.7% and a weighted response rate of 40.7%. Analyses were restricted to children aged 2–8 years with nonmissing data on MBDD diagnosis and age (16,912 children). Data missing on race (0.3%), ethnicity (0.5%), sex (0.1%), and FPL (16.6%) were imputed using hot-deck imputation (a method for handling missing data in which missing values are replaced with observed responses from “similar” units) and regression methods.¶ Differences in demographic, health care, family, and community factors by MBDD status were assessed using weighted prevalence estimates, prevalence ratios (PRs), 95% confidence intervals (CIs), and Wald chi-square tests. Prevalence of MBDDs, health care, family, and community factors were compared by FPL category. Weighted prevalence estimates, PRs, and 95% CIs were calculated. To further explore whether federal assistance programs are possible points to reach children living in poverty, 4,410 children living below 200% of the FPL who had and had not seen a health care provider in the past year, both with and without MBDDs, were compared by whether their families received public assistance. Statistical software was used to account for the complex survey design.

3Overall, 17.4% of children aged 2–8 years had at least one MBDD (Table 1). Child sex, age, and race/ethnicity varied by MBDD status. Compared with children without MBDDs, those with MBDDs more often lived in the lowest income category (<100% of FPL; PR = 1.4) and less often in the highest category (≥400% of FPL; PR = 0.8). Prevalences of most risk factors (e.g., child care problems, and lack of support in neighborhood) were higher among children with MBDDs than among those without MBDDs.

4Prevalence of MBDDs was higher in each consecutive decreasing income level compared with the highest level (≥400% of FPL) (Table 2); estimates of MBDDs ranged from 13.9% among those in the highest income level (≥400% of FPL) to 22.1% among those in the lowest level (<100% of FPL). A lower percentage of children in lower-income households saw a health care provider in the past 12 months (80.4%) and a higher percentage did not receive needed care (5%), compared with children in the highest income level (93.8% and 0.8%, respectively). Similar patterns across income levels were found for most health care, family, and community factors (e.g., increasing prevalences of the risk factors as household income level decreased), with the exception that inadequate insurance was less often reported for children in the lower income levels than for those in the highest level.

5Among children living at <200% of FPL, 82.6% saw a health care provider in the past year, and 73.4% received public assistance (Table 3). Among the children who did not see a health care provider in the past year, 69.0% received public assistance and 19.2% had a diagnosed MBDD. Among children who did not see a health care provider in the past year and had a diagnosed MBDD, 81.7% received public assistance. Of children who did not see a health care provider in the past year and did not have a diagnosed MBDD, 66.0% received public assistance.

6Consistent with previous studies, this study found that children living in lower-income households had higher prevalences of a parent-reported diagnosis of an MBDD and other health care, family, and community risk factors associated with MBDDs than did children living in higher-income households. Most children had seen a health care provider in the past year regardless of income level; therefore, the American Academy of Pediatrics recommendation to screen for MBDDs and family and socioeconomic risk factors during primary care visits appears to be theoretically feasible.

7Screening**,†† in health care settings can be challenging in practice, and MBDDs might be underdiagnosed even among children who have recently seen a health care provider. Children living in lower-income households had lower prevalences of having seen a health care provider in the past year and of receiving needed health care compared with children living in higher-income households. Approximately one in five children living at <200% of FPL who did not see a health care provider in the past year had a diagnosed MBDD. This, coupled with families with lower incomes reporting greater difficulty receiving needed health care, raises concern that MBDDs might be undertreated in this population. Additionally, families living in poverty were more likely to experience a range of risk factors related to MBDDs; therefore, connections to health care services are especially relevant for this population.

8Public assistance programs might provide opportunities to connect families living in poverty to services, in line with the American Academy of Pediatrics call for collaboration between public health professionals and pediatricians. Where treatment resources are available, education or early identification programs could be embedded within services families are already accessing. For example, CDC’s Learn the Signs. Act Early program connects WIC staff members with resources for parents about early identification of developmental delays and helps staff with referrals to primary care.§§ Similar approaches to promoting parental awareness of MBDDs and the value of pediatric screening, if carefully designed to minimize stigmatization, could be implemented within other public assistance programs. Identification of MBDDs and associated risk factors (e.g., poor parental mental health or lack of support) and connection to services can be challenging for families, even among those with primary care. Therefore, expanded co-location of developmental and behavioral health services in public assistance programs, as well as other sites that would reach additional families (e.g., schools or early-learning settings, federally qualified health centers,¶¶ or federal partnerships***), might help to eliminate barriers to care for families living in poverty.†††, §§§

9The findings in this report are subject to at least three limitations. First, data are cross-sectional, so it was not possible to ascertain temporal associations or causality. Second, the sampling weights used to calculate nationally representative estimates might not completely compensate for nonresponse bias. Finally, indicators rely on parental report and might be subject to recall or social desirability bias.

10Early identification and treatment of MBDDs could positively impact a child’s functioning and reduce the need for costly interventions over time. Public assistance programs hold potential for increasing developmental monitoring and connection to treatment for MBDDs for families living in poverty by collaborating to distribute resources, implementing co-located screening services, or facilitating connections to appropriate treatment and care.

11Poverty, as well as health care, family, and community factors are associated with mental, behavioral, and developmental disorders (MBDDs) in children.

12Parent-reported data from 2016 showed that a higher percentage of children in lower-income households had ever received a diagnosis of an MBDD and a lower percentage had seen a health care provider in the previous year, compared with children in higher-income households. Most children in lower-income households were in families receiving public assistance benefits.

13Public assistance programs might offer collaboration opportunities for public health and pediatrics to provide information, implement co-located screening programs or services, or facilitate connection to care.