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ObjectivesPoverty is a common root cause of poor health and disrupts medical care. Clinically embedded antipoverty programs that address financial stressors may prevent missed visits and improve show rates. This pilot study evaluated the impact of clinic-based financial coaching on adherence to recommended preventive care pediatric visits and vaccinations in the first 6 months of life.MethodsIn this community-partnered randomized controlled trial comparing clinic-based financial coaching to usual care among low-income parent-infant dyads attending pediatric preventive care visits, we examined the impact of the longitudinal financial intervention delivered by trained coaches addressing parent-identified, strengths-based financial goals (employment, savings, public benefits enrollment, etc.). We also examined social needs screening and resource referral on rates of missed preventive care pediatric visits and vaccinations through the 6-month well-child visit.ResultsEighty-one parent-infant dyads were randomized (35 intervention, 46 control); nearly all parents were mothers and more than one-half were Latina. The rate of missed visits among those randomized to clinic-based financial coaching was half that of controls (0.46 vs 1.07 missed of 4 recommended visits; mean difference, 0.61 visits missed; P = .01). Intervention participants were more likely to have up-to-date immunizations each visit (relative risk, 1.26; P = .01) with fewer missed vaccinations by the end of the 6-month preventive care visit period (2.52 vs 3.8 missed vaccinations; P = .002).ConclusionsIn this pilot randomized trial, a medical-financial partnership embedding financial coaching within pediatric primary care improved low-income families’ adherence to recommended visits and vaccinations. Clinic-based financial coaching may improve care continuity and quality in the medical home.

With 2.3 million individuals incarcerated in the United States, incarceration remains a pressing social influence on health. While risk factors for incarceration are known, research has been slow to identify protective factors. Characterizing adolescent protective and risk factors for incarceration outcomes can inform interventions to prevent incarceration. Using survey data from the National Longitudinal Study of Adolescent to Adult Health, we tested the influence of adolescent risk and protective factors for incarceration of young people. We used ordinal logistic regressions, investigating the relationship between adolescent characteristics (wave I, grades 7–12) with two outcomes: incarceration onset (no incarceration, onset of incarceration as a juvenile, and onset of incarceration as an adult) and incarceration frequency (never incarcerated, incarcerated once, incarcerated more than once) during adolescence and into adulthood (N = 12,136, wave IV, ages 24–32). Adolescent protective factors against incarceration onset and higher incarceration frequency centered on education, including a higher grade point average and a higher likelihood of having future plans to attend college. Risk factors included disruptive behavior, physical or sexual abuse in childhood, parental incarceration, and living with a stepfather figure. Stratified analyses suggested that Latinos may have unique risk profiles compared to African American and White youth. The educational system may be a locus for protective interventions promoting academic achievement and educational aspirations. Understanding both incarceration risk and protective factors may allow interventions to be tailored appropriately.

ObjectiveTo evaluate the associations between parent confidence in avoiding hospitalization and subsequent hospitalization in children with medical complexity (CMC); and feasibility/acceptability of a texting platform, Assessing Confidence at Times of Increased Vulnerability (ACTIV), to collect repeated measures of parent confidence.Study designThis prospective cohort study purposively sampled parent-child dyads (n=75) in 1 of 3 complex care programs for demographic diversity to pilot test ACTIV for 3months. At random days/times every 2weeks, parents received text messages asking them to rate confidence in their child avoiding hospitalization in the next month, from 1 (not confident) to 10 (fully confident). Unadjusted and adjusted generalized estimating equations with repeated measures evaluated associations between confidence and hospitalization in the next 14days. Post-study questionnaires and focus groups assessed ACTIV's feasibility/acceptability.ResultsParents were 77.3% mothers and 20% Spanish-speaking. Texting response rate was 95.6%. Eighteen hospitalizations occurred within 14days after texting, median (IQR) 8 (2-10) days. When confidence was

We sought to understand the role of parent engagement in overcoming barriers to care for youth re-entering the community following incarceration. For this mixed methods study, we conducted quantitative surveys on healthcare needs and access with youth (n = 50) at 1-month post-incarceration, and semi-structured interviews with a subset of these youth (n = 27) and their parents (n = 34) at 1, 3, and 6-months post-incarceration (total 94 interviews). Differences by race/ethnicity and gender were assessed using Chi square test of proportions. We performed thematic analysis of interview transcripts to examine the role of parent engagement in influencing youths' access to healthcare during reentry. Most youth were from racial/ethnic minority groups and reported multiple ACEs. Girls, compared to boys, had higher ACE scores (p = 0.03), lower family connectedness (p = 0.03), and worse general health (p = 0.02). Youth-identified barriers to care were often parent-dependent and included lack of: affordable care (22%), transportation (16%), and accompaniment to health visits (14%). Two major themes emerged from the qualitative interviews: (1) parents motivate youth to seek healthcare during reentry and (2) parents facilitate the process of youth seeking healthcare during reentry. Parents are instrumental in linking youth to healthcare during reentry, dispelling prevailing myths that parents of incarcerated youth are inattentive and that youth do not want their help. Efforts that support and enhance parent engagement in access to care during reentry, such as by actively involving parents in pre-release healthcare planning, may create stronger linkages to care.

Supplemental Material, Barnert_18-08-0041_Appendix_2 for Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review by Elizabeth Barnert, Ava Sun, Laura S. Abrams and Paul J. Chung in Journal of Correctional Health Care

Supplemental Material, Online_Appendix_1 for Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review by Elizabeth Barnert, Ava Sun, Laura S. Abrams and Paul J. Chung in Journal of Correctional Health Care

ObjectivesNewborns hospitalized with unconjugated hyperbilirubinemia without critical comorbidities may receive intensive phototherapy (IP) in non-ICU levels of care, such as a mother-newborn unit, or ICU levels of care. Our aim was to compare outcomes between each level.MethodsUsing hospital discharge data from 2005 to 2011 in New York's State Inpatient Database, we performed multivariate analyses to compare outcomes that included total cost of hospitalization, length of stay, 30-day readmission rate after IP, and the number of cases of death, exchange transfusion, and γ globulin infusion. We included term newborns treated with IP in their first 30 days of life and without diagnosis codes for other critical illnesses. Explanatory variables included level of care, sex, race, insurance type, presence or absence of hemolysis, hospital, volume of IP performed at each hospital, and year of hospitalization.ResultsNinety-nine percent of IP was delivered in non-ICU levels of care. Incidence of major complications was rare (≤0.1%). After adjusting for confounders, ICU level of care was not associated with difference in length of stay (relative risk: 1.2; 95% confidence interval [CI]: 0.91 to 1.15) or 30-day readmission rate (odds ratio: 0.74; 95% CI: 0.50 to 1.09) but was associated with 1.51 (95% CI: 1.47 to 1.56) times higher costs.ConclusionsFor otherwise healthy term newborns with jaundice requiring IP, most received treatment in a non-ICU level of care, and those in intensive care had no difference in outcomes but incurred higher costs. IP guideline authors may want to be more prescriptive about IP level of care to improve value.

Importance:Although school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown. Objective:To test whether exposure to high-performing schools is associated with risky adolescent health behaviors. Design, Setting, and Participants:This natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018. Exposures:Schools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades). Main Outcomes and Measures:Primary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students' social networks) were also examined. Results:Among the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P

media-1vid110.1542/5789654354001PEDS-VA_2018-0023Video Abstract BACKGROUND AND OBJECTIVES: Adverse childhood experiences (ACEs) include stressful and potentially traumatic events associated with higher risk of long-term behavioral problems and chronic illnesses. Whether parents' ACE counts (an index of standard ACEs) confer intergenerational risk to their children's behavioral health is unknown. In this study, we estimate the risk of child behavioral problems as a function of parent ACE counts. METHODS:We obtained retrospective information on 9 ACEs self-reported by parents and parent reports of their children's (1) behavioral problems (using the Behavior Problems Index [BPI]), (2) attention-deficit/hyperactivity disorder diagnosis, and (3) emotional disturbance diagnosis from the 2013 Panel Study of Income Dynamics (PSID) core interview and the linked PSID Childhood Retrospective Circumstances Study and 2014 PSID Child Development Supplement. Multivariate linear and logistic regression models were used to estimate child behavioral health outcomes by parent retrospective ACE count. RESULTS:Children of parents with a history of 4 or more ACEs had on average a 2.3-point (95% confidence interval [CI]: 1.3-3.2) higher score on the BPI, 2.1 times (95% CI: 1.1-3.8) higher odds of hyperactivity, and 4.2 times (95% CI: 1.7-10.8) higher odds of an emotional disturbance diagnosis than children of parents with no ACEs. Maternal ACEs revealed a stronger association with child behavior problems than paternal ACEs. Relationships between parents' 9 component ACEs individually and children's BPI scores revealed consistently positive associations. Mediation by parent emotional distress and aggravation were observed. CONCLUSIONS:Parents with greater exposure to ACEs are more likely to have children with behavioral health problems.

Objective To examine the benefits of having a medical home among Latino and Black school-aged children, both with and without special health care needs (CSHCN). Methods Data from the 2011-2012 National Survey of Children's Health (NSCH) were analyzed to examine the associations of preventive dental and medical care, unmet dental or medical care, or missed school days with having a medical home among Latino and Black children compared to White children. Multivariate logistic regression with survey weights was used to adjust for child, parent, home, and geographic characteristics and an interaction term to estimate differences in outcomes among Black or Latino children receiving care in a medical home compared to White children with a medical home. Results Approximately 35% of Latino CSHCN and Latino non-CSHCN ages 6-17years of age had a medical home. In the adjusted model comparing the effectiveness of the medical home by race and ethnicity, Latino non-CSHCN compared to White non-CSHCN were associated with lower odds of having one or more preventive dental visit in the last 12months (OR 0.66; 95% CI 0.46-0.95) and no other associations between having a medical home and outcomes were found among Latinos compared to Whites regardless of non-CSHCN or CHSCN status. Meanwhile, having a medical home among Black non-CHSCN and CHSCN, compared to their White counterparts, showed potential benefits in regards to unmet medical care needs after adjusting for covariates, (OR 0.15; 95% CI 0.06-0.35; OR 0.16; 95% CI 0.05-0.55). Conclusions Medical homes may not be effective in delivering health services to the majority of Latino children but provide some benefit to Black children with and without CSHCN. Alternatively, the medical home may function differently for Latinos due to the specific medical home components measured by NSCH.

Objective"What do you want to be when you grow up?" is a simple, commonly asked question that might provide insight into adolescent well-being. Career aspirations might reflect an adolescent's sense of identity, hope for the future, and self-efficacy, all of which are critical to identifying at-risk youth and intervening on risky behaviors. However, there are no studies on whether career aspirations are associated with adolescent emotional and health behavior outcomes.MethodsWe analyzed cross-sectional surveys of 929 ninth to 12th grade low-income minority adolescents in Los Angeles assessing career aspirations and its association with hopelessness, self-efficacy, substance use, violence, and risky sexual activity. We used Department of Labor statistics to categorize career aspirations according to amount of education required, income, and prestige. Generalized estimating equations accounted for sociodemographic characteristics, school type, academic performance, and clustering at the school level.ResultsGrades, standardized test scores, and health behaviors varied according to career type. Adolescents with higher career aspirations, measured according to career-related education, income, and prestige reported less hopelessness and more self-efficacy. After adjusting for confounders, aspirations requiring high levels of education were associated with decreased odds of alcohol use, at-school substance use, and risky sexual activity, and higher prestige scores were associated with decreased odds of other drug use.ConclusionsCareer aspirations might be a marker for adolescent health and well-being. Adults might consider asking a teen what they want to be when they grow up to gain insight into their levels of hopelessness and self-efficacy and provide context for counseling on healthy behavior change.

ImportanceHealth care spending on children in the United States continues to rise, yet little is known about how this spending varies by condition, age and sex group, and type of care, nor how these patterns have changed over time.ObjectiveTo provide health care spending estimates for children and adolescents 19 years and younger in the United States from 1996 through 2013, disaggregated by condition, age and sex group, and type of care.Evidence reviewHealth care spending estimates were extracted from the Institute for Health Metrics and Evaluation Disease Expenditure 2013 project database. This project, based on 183 sources of data and 2.9 billion patient records, disaggregated health care spending in the United States by condition, age and sex group, and type of care. Annual estimates were produced for each year from 1996 through 2013. Estimates were adjusted for the presence of comorbidities and are reported using inflation-adjusted 2015 US dollars.FindingsFrom 1996 to 2013, health care spending on children increased from $149.6 (uncertainty interval [UI], 144.1-155.5) billion to $233.5 (UI, 226.9-239.8) billion. In 2013, the largest health condition leading to health care spending for children was well-newborn care in the inpatient setting. Attention-deficit/hyperactivity disorder and well-dental care (including dental check-ups and orthodontia) were the second and third largest conditions, respectively. Spending per child was greatest for infants younger than 1 year, at $11 741 (UI, 10 799-12 765) in 2013. Across time, health care spending per child increased from $1915 (UI, 1845-1991) in 1996 to $2777 (UI, 2698-2851) in 2013. The greatest areas of growth in spending in absolute terms were ambulatory care among all types of care and inpatient well-newborn care, attention-deficit/hyperactivity disorder, and asthma among all conditions.Conclusions and relevanceThese findings provide health policy makers and health care professionals with evidence to help guide future spending. Some conditions, such as attention-deficit/hyperactivity disorder and inpatient well-newborn care, had larger health care spending growth rates than other conditions.

Current recommendations emphasize developmental screening and surveillance to identify developmental delays (DDs) for referral to early intervention (EI) services. Many young children without DDs, however, are at high risk for poor developmental and behavioral outcomes by school entry but are ineligible for EI. We developed models for 2-year-olds without DD that predict, at kindergarten entry, poor academic performance and high problem behaviors. Data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), were used for this study. The analytic sample excluded children likely eligible for EI because of DDs or very low birth weight. Dependent variables included low academic scores and high problem behaviors at the kindergarten wave. Regression models were developed by using candidate predictors feasibly obtainable during typical 2-year well-child visits. Models were cross-validated internally on randomly selected subsamples. Approximately 24% of all 2-year-old children were ineligible for EI at 2 years of age but still had poor academic or behavioral outcomes at school entry. Prediction models each contain 9 variables, almost entirely parental, social, or economic. Four variables were associated with both academic and behavioral risk: parental education below bachelor's degree, little/no shared reading at home, food insecurity, and fair/poor parental health. Areas under the receiver-operating characteristic curve were 0.76 for academic risk and 0.71 for behavioral risk. Adding the mental scale score from the Bayley Short Form-Research Edition did not improve areas under the receiver-operating characteristic curve for either model. Among children ineligible for EI services, a small set of clinically available variables at age 2 years predicted academic and behavioral outcomes at school entry.

ObjectiveIndividual academic achievement is a well-known predictor of adult health, and addressing education inequities may be critical to reducing health disparities. Disparities in school quality are well documented. However, we lack nationally representative studies evaluating the impact of school quality on adult health. We aim to determine whether high school quality predicts adult health outcomes after controlling for baseline health, socio-demographics and individual academic achievement.MethodsWe analyzed data from 7037 adolescents who attended one of 77 high schools in the Unites States and were followed into adulthood from the National Longitudinal Study of Adolescent to Adult Health. Selected school-level quality measures-average daily attendance, school promotion rate, parental involvement, and teacher experience-were validated based on ability to predict high school graduation and college attendance. Individual adult health outcomes included self-rated health, diagnosis of depression, and having a measured BMI in the obese range.ResultsLogistic regressions controlling for socio-demographics, baseline health, health insurance, and individual academic performance demonstrated that school quality significantly predicted all health outcomes. As hypothesized, attending a school with lower average daily attendance predicted lower self-rated health (Adjusted Odds Ratio (AOR) 1.59, p=0.003) and higher odds of depression diagnosis (AOR 1.35, p=0.03); and attending a school with higher parent involvement predicted lower odds of obesity (AOR 0.69, p=0.001). However, attending a school with higher promotion rate also predicted lower self-rated health (AOR1.20, p&nbsp

ObjectiveChild health is strongly influenced by social determinants. Little is known about the opinions of primary caregivers regarding the physicians' role in addressing social needs. Our objective was to examine caregivers' opinions about that role and any associations between those opinions, previous exposure to screening for needs by pediatric residents, and socioeconomic status (SES).MethodsCross-sectional survey study of caregivers of hospitalized children. The survey collected information on caregiver opinion regarding their ability to ask physicians for help with social needs, whether physicians know how to help with those needs, and whether physicians should ask about social needs. The chi square test was used to identify associations between caregiver opinions, prior screening by a resident at admission, and SES (determined by census tract median household income).ResultsSurveys were completed by 143 caregivers (79% participation). Most respondents agreed that they could ask their physician for help (54.5%), that their physician knows how to help (64.3%), and that physicians should ask about social needs (71.3%). Previously screened caregivers had more favorable opinions about asking for help (76.2% vs 45.5%, P < .01), whether their physician knows how to help (81.0% vs 57.4%, P = .02), and physician screening for unmet needs (85.7% vs 65.3%, P = .03). There were no SES differences in opinion.ConclusionsCaregivers have favorable opinions of the physician's role in addressing the social determinants of health, especially after being screened. Physicians should be confident in the acceptability of screening families for social needs.

© 2015 Academic Pediatric Association. Abstract Objective To describe how minority parents help their young children navigate issues of race and racism and discuss implications this racial socialization may have for school readiness. Methods Sixteen focus groups were conducted among 114 African American, English language-primary Latino, Spanish language-primary Latino, and Korean language-primary Korean parents of children ages 0 to 4 years old. Transcripts were coded for major themes and subsequently compared across the 4 language-ethnicity groups. Parents also shared demographic and parenting data by survey, from which group-specific proportions provide context for identified themes. Results In this sample, nearly half of surveyed parents had already talked to their young child about unfair treatment due to race. The proportion of such conversations ranged from one-fifth of Korean parents to two-thirds of Spanish language-primary parents. In focus groups, Korean parents reported fewer experiences with racism than African American and Latino parents. Within each language-ethnicity group, fewer fathers than mothers reported addressing race issues with their young children. All focus groups endorsed messages of cultural pride, preparation for bias, and a strong focus on the individual. The majority of parents viewed racial socialization as an important part of school readiness. Conclusions Racial socialization was believed to be salient for school readiness, primarily practiced by mothers, and focused at the individual level. The smaller role of fathers and systems-based approaches represent opportunities for intervention. These results may inform the development of culturally tailored parenting interventions designed to decrease the race-based achievement gap and associated health disparities.

Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small, independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called "Community Advisory Boards" [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate follow-up, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non-face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign.

The authors investigated perceptions of parents with children in the Head Start program about the processes of detection and intervention for developmental concerns.Descriptive, qualitative study.A large, urban Head Start agency, operating 14 centers and annually serving more than 1200 predominantly Latino children. During 2008-2009, a collaborative partnership with academicians from UCLA was created to evaluate their model of developmental screening and referrals. PARTICIPANTS AND PROCEDURES: We conducted 5 focus groups with a total of 30 parents of Head Start children with developmental concerns. Parents were asked about where they go for information when they have concerns, how they perceived the developmental screening process and services, and how children and families have changed after being in the Head Start program. Focus groups were recorded, transcribed and translated into English, then coded in ATLAS.ti using the domains above and sorted into themes for analysis.Parents perceived the screening process as both diagnostically and therapeutically important, with multiple benefits ranging from closer parent-teacher relationships to improved parenting and understanding of developmental interventions. Families focused their discussion on the importance of social-emotional and behavioral development, with school readiness and improved expressive language as important but secondary outcomes.For families of children with developmental and behavioral risks or concerns, a structured developmental screening process in a preschool setting, such as that provided by Head Start, may serve as a vital gateway for identifying and addressing concerns and promoting social-emotional learning, parent engagement, language development and school readiness.

OBJECTIVE: To examine the prevalence of parent–provider discussions of family and community health risks during well-child visits and the gaps between which issues are discussed and which issues parents would like to discuss. METHODS: Data came from the National Survey of Early Childhood Health, a nationally representative sample of parents of 2068 children aged 4 to 35 months. The outcome measures were 1) the reported discussions with pediatric clinicians about 7 family and community health risks and 2) whether the parent believes that pediatric clinicians should ask parents about each risk. RESULTS: Most parents believe that pediatric providers should discuss topics such as smoking in the household, financial difficulties, and emotional support available to the parent. However, with the exception of “household smoking,” fewer than half of parents have been asked about these topics by their child’s clinician. Parents of black and Hispanic children were more likely than parents of white children to be asked about several of these issues, as were parents of the youngest children and those with publicly financed health insurance. The greatest gap between parents’ views and their reports of discussion with the clinician occur for parents of white children and older children. Among parents who hold the view that a topic should be discussed, parents of white and older children are less likely than others to report discussing some or all family and community health risks. CONCLUSION: The low frequency of discussions for many topics indicates potential unmet need. More universal surveillance of parents with young children might ensure that needs are not missed, particularly given that strong majorities of parents view family and community topics, with the exception of community violence, as appropriate for discussion in clinic visits.