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Objective Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. Methods Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. Results The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). Conclusions Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.

* Abbreviations: CDC — : Centers for Disease Control and Prevention COVID-19 — : coronavirus disease 2019 NYC — : New York City Although there are several accessible sources providing data on coronavirus disease 2019 (COVID-19) cases, hospitalizations, and deaths in the United States,1,2 little information has been reported on pediatric cases. However, information on COVID-19, categorized by age group, is publicly accessible on nearly all state health department Web sites. In a Centers for Disease Control and Prevention (CDC) report in April, it was reported that only 1.7% of confirmed COVID-19 cases were in children

Objective To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). Methods Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. Results Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care. Conclusions Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.

BACKGROUND: The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians. METHODS: We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics. RESULTS: Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less. CONCLUSIONS: Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Objective To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral. Methods Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics. Results Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer. Conclusions A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.

Objective To examine trends in pediatricians working part-time and residents seeking part-time work and to examine associated characteristics. Study design The American Academy of Pediatrics (AAP) Periodic Survey of Fellows and the AAP Annual Survey of Graduating Residents were used to examine part-time employment. Fourteen periodic surveys were combined with an overall response rate of 57%. Part-time percentages were compared for surveys conducted from 2006-2009 and 2010-2013. The AAP Annual Surveys of Graduating Residents (combined response rate = 60%) from 2006-2009 were compared with 2010-2013 surveys for residents seeking and obtaining part-time positions following training. Multivariable logistic regression models identified characteristics associated with part-time work. Results Comparable percentages of pediatricians worked part-time in 2006-2009 (23%) and 2010-2013 (23%). There was similarly no statistically significant difference in residents seeking part-time work (30%-28%), and there was a slight decline in residents accepting part-time work (16%-13%, aOR .75, 95% CI .56-.96). Increases in working part-time were not found for any subgroups examined. Women consistently were more likely than men to work part-time (35% vs 9%), but they showed different patterns of part-time work across age. Women in their 40s (40%) were more likely than other women (33%) and men in their 60s (20%) were more likely than other men (5%) to work part-time. Conclusions There has been a levelling off in the number of pediatricians working part-time and residents seeking part-time work. Overall, women remain more likely to work part-time, although 1 in 5 men over 60 work part-time.

Objectives To examine national trends in the percentage of children whose usual source of care is at a clinic, health center, or hospital outpatient department (hereafter "clinics") and whether trends differ by sociodemographic subpopulations. Study design Analysis of serial, cross-sectional, nationally representative in-person household surveys, the 1997-2013 National Health Interview Surveys, was conducted to identify children with a usual source of care (n = 190 571), and the percentage receiving that care in a clinic. We used joinpoint regression to identify changes in linear trends, and logistic regression with predictive margins to obtain per-year changes in percentages, both unadjusted and adjusted for sociodemographic factors. Interaction terms in logistic regressions were used to assess whether trends varied by sociodemographic subgroups. Results Of all children with a usual source of care, the percentage receiving that care in a clinic declined 0.44 percentage points per year ( P P Conclusions This study shows that, although the percentage of children with a usual source of care in a clinic declined between 1997 and 2002, it has steadily increased since that time.

OBJECTIVE: To examine how gradients in socioeconomic status (SES) impact US children’s reading and math ability at kindergarten entry and determine the contributions of family background, health, home learning, parenting, and early education factors to those gradients. METHODS: Analysis of 6600 children with cognitive assessments at kindergarten entry from the US Early Childhood Longitudinal Birth Cohort Study. A composite SES measure based on parent’s occupation, education, and income was divided into quintiles. Wald F tests assessed bivariate associations between SES and child’s cognitive ability and candidate explanatory variables. A decomposition methodology examined mediators of early cognitive gradients. RESULTS: Average reading percentile rankings increased from 34 to 67 across SES quintiles and math from 33 to 70. Children in lower SES quintiles had younger mothers, less frequent parent reading, less home computer use (27%–84%), and fewer books at home (26–114). Parent’s supportive interactions, expectations for their child to earn a college degree (57%–96%), and child’s preschool attendance (64%–89%) increased across quintiles. Candidate explanatory factors explained just over half the gradients, with family background factors explaining 8% to 13%, health factors 4% to 6%, home learning environment 18%, parenting style/beliefs 14% to 15%, and early education 6% to 7% of the gaps between the lowest versus highest quintiles in reading and math. CONCLUSIONS: Steep social gradients in cognitive outcomes at kindergarten are due to many factors. Findings suggest policies targeting levels of socioeconomic inequality and a range of early childhood interventions are needed to address these disparities.

BACKGROUND AND OBJECTIVE: Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children’s access to health services and whether trends vary by race/ethnicity and income. METHODS: Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income. RESULTS: Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators. CONCLUSIONS: Children’s access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.

OBJECTIVE: To examine current levels of educational debt among pediatric residents and the relationship between educational debt and career intentions. METHODS: Annual national random samples of 1000 graduating pediatric residents from 2006 through 2010 were surveyed. Responses were combined. We used t tests and 1-way analysis of variance to compare debt, linear regression to examine factors associated with educational debt, and logistic regression to assess the influence of debt on clinical practice goal. Response rate was 61%. RESULTS: Three in 4 residents reported having educational debt. The mean debt (in 2010 dollars) among all residents, which included spouse’s debt if married, increased 34% from $104 000 in 2006 to $139 000 in 2010. Among the subgroup who reported having any debt, the mean debt increased 24% from $146 000 in 2006 to $181 000 in 2010. Residents had varied clinical practice goals; 43% had goals that required fellowship training (subspecialty and combined primary-subspecialty) and 57% had goals not typically requiring fellowship training (primary care and hospitalist). In multivariate analyses, debt level (low, medium, high) remained an independent predictor of practice goal. Residents with medium debt (adjusted odds ratio: 1.46, 95% confidence interval: 1.16–1.84) and high debt (adjusted odds ratio: 1.51; 95% confidence interval: 1.20–1.90) had higher odds than residents with low debt of having a practice goal that does not typically require fellowship training. Other factors also had an independent association with career choice. CONCLUSIONS: Multiple factors shape decisions about careers. Higher educational debt is one factor that may push residents toward primary care or hospitalist practice, rather than pursuing fellowship training.

Background "Asthma-related quality of life" (QOL) refers to the perceived impact that asthma has on the patient's QOL. Objective National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on QOL for use in future asthma clinical research. Methods We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing QOL instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study's aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011. Results Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data. Conclusions In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient's perception of the impact of asthma on all of the key dimensions of QOL, an important outcome that is not captured in other outcome measures.

BACKGROUND: Early identification of developmental delays is essential for optimal early intervention. An American Academy of Pediatrics (AAP) 2002 Periodic Survey of Fellows found OBJECTIVE: The goal of this study was to compare pediatricians' use of standardized screening tools from 2002 to 2009. METHODS: A national, random sample of nonretired US AAP members were mailed Periodic Surveys (2002: N = 1617, response rate: 55%; 2009: N = 1620, response rate: 57%). χ2 analyses were used to examine responses across survey years; a multivariate logistic regression model was developed to compare differences in using ≥1 formal screening tools across survey years while controlling for various individual and practice characteristics. RESULTS: Pediatricians' use of standardized screening tools increased significantly between 2002 and 2009. The percentage of those who self-reported always/almost always using ≥1 screening tools increased over time (23.0%–47.7%), as did use of specific instruments (eg, Ages & Stages Questionnaire, Parents' Evaluation of Developmental Status). No differences were noted on the basis of physician or practice characteristics. CONCLUSIONS: The percentage of pediatricians who reported using ≥1 formal screening tools more than doubled between 2002 and 2009. Despite greater attention to consistent use of appropriate tools, the percentage remains less than half of respondents providing care to patients younger than 36 months. Given the critical importance of developmental screening in early identification, evaluation, and intervention, additional research is needed to identify barriers to greater use of standardized tools in practice.

Provision of asthma education is associated with decreased hospitalizations and emergency department visits for patients with asthma. Our objective was to describe national trends in the provision of asthma education by primary care physicians in office settings.We used the National Ambulatory Medical Care Survey, a nationally representative dataset of patient visits to office-based physicians. We identified visits to primary care physicians for patients where asthma was a reason for the visit (asthma-related visits) or who had a diagnosis of asthma, but asthma was not a specific reason for the visit (asthma-unrelated visits) and estimated the percentage of visits where asthma education was provided. Data were available for asthma-related visits from 2001-2006 and from 2005-2006 only for asthma-unrelated visits. We examined time trends in asthma education and used multivariable logistic regression to identify independent patient and system-related factors that were predictors of asthma education.The percentage of asthma-related visits where asthma education was provided declined during the study period, from 50% in 2001-2002 to 38% in 2005-2006 (p = 0.03). Asthma education was provided less frequently during asthma-unrelated visits compared to asthma-related visits (12% vs. 38%, p0.0001). Independent predictors of providing asthma education included ageor = 18 years, receipt of a controller medication, incorporation of an allied health professional during the visit, longer visit duration and Northeast region.Asthma education is underused by primary care physicians and rates have declined from 2001-2006. Interventions designed to promote awareness and greater use of asthma education are needed.

OBJECTIVE: The content and systems surrounding well-child care have received increasing attention, and some propose that it is time to rethink both the delivery structure and central themes of well-child visits. A key, but largely missing perspective in these discussions has been that of parents, whose experiences and expectations are central to developing approaches responsive to family needs. In this study, we asked parents to address several core issues: why they attend well-child visits; aspects of well-child care that they find most valuable; and changes that could enhance the well-child care experience. METHODS: Twenty focus groups with parents (n = 131 [91% mothers]) were conducted by using a semistructured interview guide. Verbatim transcripts were coded for key words, concepts, and recurrent themes. RESULTS: Primary reasons for visit attendance included reassurance (child and parent) and an opportunity to discuss parent priorities. Families valued an ongoing relationship with 1 clinician who was child-focused and respected parental expertise, but continuity of provider was not an option for all participants. Suggestions for enhancement included improved promotion of well-child care, greater emphasis on development and behavior, and expanded options for information exchange. CONCLUSIONS: As the consumers of care, it is critical to understand parents' needs and desires as changes to the content and process of well-child care are considered. Taking into account the multifaceted perspectives of families suggests both challenges and opportunities for the rethinking discussion.

Background: Updated asthma guidelines stress the importance of obtaining patient-reported information about symptoms and limitations to develop effective treatment and education plans. In pediatrics, reporting has often relied on parent proxy but there is increasing recognition that children can provide input on their own health status. The Children’s Health Survey for Asthma (CHSA) has become a well-recognized tool for parent report of child asthma-related health status. To collect data directly from children and adolescents, we developed a companion pencil-and-paper instrument, the CHSA-Child Version (CHSA-C). Objective: Report statistical properties of the CHSA-C, a measure for children 7–16 years. Methods: The CHSA-C includes three scales—Physical Health, Child Activities, and Emotional Health (scoring 0–100; higher scores = better/more positive outcomes). We evaluated reliability (internal consistency; test–retest) and validity. Variations were examined by gender, income, and race/ethnicity. Results:...

Objective: To classify poisoning deaths of undetermined intent as either suicide or unintentional and to estimate the extent of underreported poisoning suicides. Methods: Based on 2002 statewide death certificate and medical examiner data in Utah, the authors randomly selected one half of undetermined and unintentional poisoning deaths for data abstraction and included all suicides. Bivariate analyses assessed differences in demographics, death characteristics, forensic toxicology results, mental health history, and other potentially contributing factors. Classification and regression tree (CART) analysis used information from unintentional and suicide poisoning deaths to create a classification tree that was applied to undetermined poisoning deaths. Results: The authors analyzed 41 unintentional, 87 suicide, and 84 undetermined poisonings. Undetermined and unintentional decedents were similar in the presence of opiates, physical health problems, and drug abuse. Although none of the undetermined decedents left a suicide note, previous attempt or intent to commit suicide was reported for 11 (13%) of these cases. CART analysis identified suicidal behavior, drug abuse, physical health problems, depressed mood, and age as discriminating between suicide and unintentional poisoning. It is estimated that suicide rates related to poisoning are underreported by approximately 30% and overall suicide rates by 10%. Unintentional poisoning death rates were underreported by 61%. Conclusions: This study suggests that manner of death determination relies on circumstance dependent variables that may not be consistently captured by medical examiners. Underreporting of suicide rates has important implications in policy development, research funding, and evaluation of prevention programs.

Background. Racial/ethnic disparities in health care have received much national attention recently, but few studies have focused on disparities among children. We studied disparities in early childhood health and health care.Methods. We analyzed data for 2608 children, 4 to 35 months of age, from the 2000 National Survey of Early Childhood Health, a nationwide household survey. The overall response rate was 65.6%. Survey questions addressed health, health care, and interactions with health care providers.Results. Hispanic and black children were significantly less likely than whites to be in excellent/very good health (72%, 79%, and 90%, respectively) and were more likely to be uninsured (31%, 18%, and 9%, respectively). Only 60% of Hispanic and 77% of black parents would recommend their child's provider to others, compared with 84% of white parents. Minority parents more often reported that providers never or only sometimes understood their child-rearing preferences, and Hispanic parents most often reported that providers never or only sometimes understood their child's needs. Minority parents more often were asked about violence, smoking, drinking, and drug use. Hispanic and black parents averaged significantly fewer telephone calls to doctors' offices than did whites (2.0, 3.1, and 4.3 calls, respectively). Providers significantly less often referred Hispanic and black children to specialists (11% and 17%, respectively, compared with 22% for whites). Most disparities persisted in multivariate analyses, and several disparities were found between children with parents who completed surveys in Spanish and those with parents who completed surveys in English.Conclusion. Young minority children experience multiple disparities in health status, insurance coverage, topics discussed during pediatric visits, parents feeling understood by providers, parental satisfaction, and referrals to specialists.

Objective.—Accurately measuring the health of the increasingly diverse population of US children requires instruments that are comparable and valid across cultures, economic background, and language. This paper asks: Has the field of pediatric health status measures reached this level of comprehensiveness? Methods.—Children's health status and quality of life measures commonly used in the United States were reviewed to assess how they have included racial/ethnic minority and low-income groups. Four generic and 2 condition-specific instruments (asthma) were examined for total sample size, percent of sample from racial/ethnic and low-income groups, language availability, translation methods for US-Spanish, reading level, and separately reported psychometric findings and outcomes/scores. Results.—Most measures have included minority groups, usually African American or Hispanic children, although with little information by Hispanic subgroup. Children's measures have generally been tested on relatively small samples, without separate analyses by subgroups. When done, tests of reliability and validity find few differences from the general population. Some studies report information on health by racial or ethnic group, but the findings are inconclusive. Economic status is usually measured in some way, but rarely are psychometric findings examined separately by income. When differences in health outcome are reported by income, lower income children usually have poorer health. Conclusions.—Much has been accomplished in advancing health status measures for children. Next-generation issues include the influence of race, ethnicity, and income on health and health reports.

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.

Objectives. The National Survey of Early Childhood Health (NSECH) is a new survey that was designed to provide nationally representative data on the health and development of children and to fill an information gap in the pediatric literature on parents’ views of the delivery of health care to their young children.Design. The selection of topics was guided by previous studies conducted to examine parents’ expectations and needs in child health supervision visits. The NSECH is a random-digit-dial telephone survey of a nationally representative sample of 2068 children aged 4 to 35 months. This sample includes an oversample of black and/or Hispanic children so that results for these minority groups could be estimated with greater precision. The sampling frame for NSECH is from the State and Local Area Integrated Telephone Survey (SLAITS), which is a program of surveys conducted by the National Center for Health Statistics that makes economical use of the large sampling frame of the National Immunization Survey (NIS). SLAITS takes advantage of the NIS screening effort by fielding interviews on other health topics with households screened for the NIS. The respondent was the parent or guardian identified as the person most responsible for the sampled child’s medical care. Spanish-language interviews composed 19% of all completed interviews. The Council of American Survey Research Organizations response rate was 65.6%.Conclusion. The NSECH provides a unique data set that allows a well-rounded picture of the health, health care utilization, health care content, and interpersonal quality of health services received by young children in the United States. It also contains important information about family characteristics, patterns of health-promoting behaviors, and family routines that are associated with promoting the developmental health of young children. NSECH results can also help national policy makers understand the health needs of families with young children and how well the health system is meeting those needs.

Background. Insurance status has been shown to have an impact on children’s use of preventive and acute health services. The objective of this study was to determine the relationship between insurance status and vaccination coverage among US preschool children aged 19 to 35 months.Methods. We linked data from 2 national telephone surveys, the National Immunization Survey and the National Survey of Early Childhood Health, conducted during the first half of 2000. Children were considered up to date (UTD) when they had received at least 4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 MMR vaccine, 3 Haemophilus influenza vaccines, and 3 hepatitis B vaccines at the time the interview was conducted.Results. Among the 735 children in our study sample, 72% were UTD. The vast majority (94%) reported some type of health insurance at the time of the survey. Children with private insurance were more likely to be UTD (80%) than those with public insurance (56%) or no insurance (64%). In a multivariate analysis that controlled for child’s race/ethnicity; household income; maternal age/marital status/educational level; location of usual care; and Special Supplemental Nutrition Program for Women, Infants, and Children participation, insurance was no longer an independent predictor of vaccination.Conclusions. The disparity in vaccination coverage among publicly, privately, and uninsured children is dramatic, underscoring its importance as a marker for underimmunization, despite the multivariate findings. The Vaccines for Children Program, a partnership between public health and vaccination providers who serve uninsured children and those enrolled in Medicaid, is well suited to target and improve vaccination coverage among these vulnerable children.

Objectives. This study uses the first national data on well-child care for young children to 1) assess how many children have a specific clinician for well-child care; 2) identify the health insurance, health care setting, and child and family determinants of having a specific clinician; and 3) assess how parents choose pediatric clinicians.Methods. Data from the National Survey of Early Childhood Health (NSECH), a nationally representative survey of health care quality for young children fielded by the National Center for Health Statistics in 2000, were used to describe well-child care settings for children aged 4 to 35 months. Parents reported the child’s usual setting of well-child care, whether their child has a specific clinician for well-child care, and selection method for those with a clinician. Bivariate and logistic regression analyses are used to identify determinants of having a specific clinician and of provider selection method, including health care setting, insurance, managed care, and child and family characteristics.Results. Nearly all young children aged 4 to 35 months in the United States (98%) have a regular setting, but only 46% have a specific clinician for well-child care. The proportion of young children who have a single clinician is highest among privately insured children (51%) and lowest among publicly insured children (37%) and uninsured children (28%). In multivariate logistic regression including health care and sociodemographic factors, odds of having a specific clinician vary little by health care setting. Odds are lower for children who are publicly insured (odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.45–0.97) and for Hispanic children with less acculturated parents (OR: 0.6; 95% CI: 0.39–0.91). Odds are higher for children in a health plan with gatekeeping requirements (OR: 1.4; 95% CI: 1.02–1.88). Approximately 13% of young children with a specific clinician were assigned to that provider. Assignment rather than parent choice is more frequent for children who are publicly insured, in managed care, cared for in a community health center/public clinic, Hispanic, and of lower income and whose mother has lower education. In multivariate logistic regression, only lack of health insurance, care in a community health center, and managed care participation are associated with lack of choice.Conclusions. Anticipatory guidance is the foundation of health supervision visits and may be most effective when there is a continuous relationship between the pediatric provider and the parent. Only half of young children in the United States are reported to have a specific clinician for well-child care. Low rates of continuity are found across health care settings. Furthermore, not all parents of children with a continuous relationship exercised choice, particularly among children in safety net health care settings. These provisional findings on a new measure of primary care continuity for children raise important questions about the prevalence and determinants of continuity.

BACKGROUND: Over the past half century the prevalence of childhood disability increased dramatically, coupled with notable increases in the prevalence of mental health and neurodevelopmental conditions. This study provides a detailed assessment of recent trends in childhood disability in relation to health conditions and sociodemographic factors. METHODS: Secondary data analysis of National Health Interview Survey (NHIS) datasets 2001–2002, 2004–2005, 2007–2008, and 2010–2011 (N = 198 888) was conducted to calculate the prevalence, rate of change, severity, and sociodemographic disparities of parent-reported childhood disability. RESULTS: The prevalence of childhood disability has continued to increase, growing by 15.6% between 2001–2002 and 2010–2011. Nearly 6 million children were considered disabled in 2010–2011. Children living in poverty experienced the highest rates of disability, 102.6 cases per 1000 population in 2010–2011, but unexpectedly, children living in households with incomes ≥400% above the federal poverty level experienced the largest increase (28.4%) over this 10-year period. The percentage of disability cases related to any physical health condition declined 11.8% during the decade, whereas cases related to any neurodevelopmental or mental health condition increased by 20.9%. CONCLUSIONS: Over the past decade, parent-reported childhood disability steadily increased. As childhood disability due to physical conditions declined, there was a large increase in disabilities due to neurodevelopmental or mental health problems. For the first time since the NHIS began tracking childhood disability in 1957, the rise in reported prevalence is disproportionately occurring among socially advantaged families. This unexpected finding highlights the need to better understand the social, medical, and environmental factors influencing parent reports of childhood disability.

The Chicago Housing Authority's (CHA) notorious high-rise developments are among the most dangerous public housing in America. In the early 1990s, the CHA launched an ambitious attack on crime, a comprehensive and collaborative crime prevention program known as the Anti-Drug Initiative (ADI). From 1994 to 1996 we tracked conditions in three of the CHA's high-rise developments, assessing the agency's success in implementing the ADI programs in each site as well as tracking other, related interventions. Using a combination of surveys and qualitative research methods, we examined the impact of these programs through the eyes of the residents and other key actors, looking at various outcome measures related to crime and disorder. Our findings indicate some positive results, but follow-up research conducted in 1996 documented the fragility of these changes and their vulnerability to gang influence.

The objective of this study was to determine the annual incidence of fatal motor vehicle crashes involving street racing and to describe the characteristics of these crashes compared to other fatal crashes in the United States. The National Highway Traffic Safety Administration Fatality Analysis Reporting System data for 1998-2001 were used for the analyses. There were 149 568 fatal crashes and 315 (0.21%) involved street racing and 399 fatalities occurred in these crashes. In contrast to other fatal crashes, street racing fatal crashes were more likely to occur on urban roadways and were nearly six times more likely to occur at travel speedsor = 65 mph. Compared with other drivers involved in fatal crashes, street racers were more likely to be teenagers, male, and have previous crashes and driving violations. Street racing involves risky driving behaviors and warrants further attention.

This observational study explores the tensions and negative consequences of record construction for patients and front-line staff in a public clinic providing services to poor women and children. For emphasis, it is possible to say that the routine of the clinic is record driven, not service driven. More is accomplished in clinic work than producing records; patients certainly do receive needed health care. However, tight regulations filtered through heavy paperwork requirements stifle the effective delivery of comprehensive, flexible services especially needed by disadvantaged families. Clinic staff may be motivated to attend to individual patient concerns, but accounting demands generally circumscribe their work and create barriers for patients. The record has a life of its own as a socially constructed artifact in the process of caregiving in bureaucratic settings, where actual services often respond not to the client, but to the countable, accountable mandates of management.

Crime and disorder have been prevalent in public housing developments since the 1960s. Various attempts, ranging from physical design modifications to intensive law enforcement strategies, have been made to combat these problems. The Chicago Housing Authority's Public Housing Drug Elimination Program (PHDEP), an extensive anticrime initiative, involves sweeping buildings for drugs and weapons, improving security, removing unauthorized tenants, responding to residents' needs for services and maintenance, and implementing drug prevention and intervention programs. This study surveyed respondents' perceptions of PHDEP's effects on drugs and crime in two housing developments chosen for their preexisting differences in crime rates and population stability. Overall, respondents in the better organized development reported more favorable perceptions of PHDEP's impact. We discuss the implications of these findings for research and public policy.

Background Little is known about the current state of residency education with respect to counseling parents about media usage and whether trainees consider it to be adequate. Methods A national survey of graduating pediatric residents was conducted in the United States to determine the amount of training they receive on traditional and new media, their perceptions of its quality, and their self-reported practices regarding talking to families about media usage. Results A 58% response rate was achieved with no evidence of response bias based on age or gender. Only 38% rated their residency program as "very good" or "excellent" in preparing them to provide anticipatory guidance on the effects of media on children and adolescents. In logistic regression analyses, controlling for demographic characteristics, more training on media issues was a significant predictor for usually/always advising families on traditional, passive media (adjusted odds ratio=3.29; 95% confidence interval 2.26–4.81) and usually/always advising families on new, interactive media use (adjusted odds ratio=3.96; 95% confidence interval 2.61–6.00) during well-child visits. Conclusions The majority of residents believe their training on children in media is inadequate. Enhanced training on media is needed in US pediatric residencies.

Background Patient adherence, the level of asthma self-management skills, exposure to stress, and depression can have considerable influence on a wide range of asthma outcomes and thus are considered asthma outcome mediators. Objective National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures for 7 domains of asthma clinical research outcomes measures. Although the review of mediators of these outcomes was not within the scope of any specific outcome topic, a brief summary is presented so that researchers might consider potential mediators. Methods We prepared a summary of key mediators of asthma outcomes based on expertise and knowledge of the literature. Results The rationale for including measures of adherence, self-management skills, and exposures to stress in asthma clinical research is presented, along with a brief review of instruments for collecting this information from clinical research participants. Conclusions Appropriate measurement of adherence, self-management skills, and exposures to stress will enhance characterization of study participants and provide information about the potential impact these factors can have on mediating the effects of treatment interventions.

BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). RESULTS: One-third (33.6%) of parents reported spending ≤10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5–3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7–6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5–26.5) higher odds of having enough time to ask questions. CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

OBJECTIVE: The objective of this study was to track trends in part-time employment among pediatricians from 2000 to 2006 and to examine differences within subgroups of pediatricians. METHODS: As part of the Periodic Survey of Fellows, national random samples of American Academy of Pediatrics members were surveyed in 2000, 2003, and 2006. These surveys shared questions concerning working part-time and other practice characteristics. Roughly 1600 pediatricians were included in each random sample. Totals of 812 (51%), 1020 (63%), and 1013 (62%) pediatricians completed the surveys in 2000, 2003, and 2006, respectively. Analyses were limited to nonretired, posttrainee pediatricians. RESULTS: The number of pediatricians who reported that they work part-time increased from 15% in 2000, to 20% in 2003, to 23% in 2006. The pattern of increased part-time work from 2000 to 2006 held for many subgroups, including men, women, pediatricians who were younger than 40 years, pediatricians who were aged ≥50 years, pediatricians who worked in an urban inner city, pediatricians who worked in suburban areas, general pediatricians, and subspecialist pediatricians. Those who were working part-time were more satisfied within their professional and personal activities. Part-time pediatricians worked on average 14.3 fewer hours per week in direct patient care. CONCLUSIONS: Increases in part-time work are apparent throughout pediatrics. The possible continued growth of part-time is an important trend within the field of pediatrics that will need to be monitored.

OBJECTIVE: To assess perspectives about the practice of well-child care among pediatric clinicians, especially in the areas of child development and behavior. METHODS: Thirty-one focus groups (282 pediatricians and 41 pediatric nurse practitioners) in 13 cities addressed current practices, priorities used to determine content of well-child care visits, and changes to improve visit quality and outcomes. RESULTS: Although most clinicians were positive about their practice of well-child care, they reported areas of concern and suggested ideas for improvements. Establishing a therapeutic relationship and individualizing care were viewed as significant contributions to quality of care. Participants agreed about the importance of eliciting parent concerns as the first priority for all well-child care visits. Community resources outside the office setting were seen as both a major influence on and, in some communities, a limitation to pediatric care. The challenges of early recognition of developmental and behavior problems through standardized questionnaires and effective interviewing were viewed as a priority to improve pediatric effectiveness in monitoring and treatment. To enhance primary care practices in developmental and behavioral pediatrics, participants suggested innovations in practice organization, community linkages, information technology, and integration of existing innovative programs. Education for pediatricians and enhanced resident training in developmental and behavioral pediatrics were endorsed. CONCLUSIONS: Pediatric clinicians' support a vision of preventive care that is comprehensive, family centered, and developmentally relevant, both for children with greater risk to long-term healthy development and for families with more normative child-rearing concerns.

BACKGROUND. Attention-deficit/hyperactivity disorder, the most common childhood behavioral condition, is one that pediatricians think they should identify and treat/manage. OBJECTIVE. Our goals were to explore the relationships between pediatricians' self-reports of their practice behaviors concerning usually inquiring about and treating/managing attention-deficit/hyperactivity disorder and (1) attitudes regarding perceived responsibility for attention-deficit/hyperactivity disorder and (2) personal and practice characteristics. METHODS. We analyzed data from the 59th Periodic Survey of the American Academy of Pediatrics for the 447 respondents who practice exclusively in general pediatrics. Bivariate and logistic regression analyses were used to identify attitudes and personal and practice characteristics associated with usually identifying and treating/managing attention-deficit/hyperactivity disorder. RESULTS. A total of 67% reported that they usually inquire about and 65% reported that they usually treat/manage attention-deficit/hyperactivity disorder. Factors positively associated with usually inquiring about attention-deficit/hyperactivity disorder in adjusted multivariable analyses include perceived high prevalence among current patients, attendance at a lecture/conference on child mental health in the past 2 years, having patients who are assigned or can select a specific pediatrician, practicing in suburban communities, practicing for ≥10 years, and being female. Pediatricians' attitudes about responsibility for identification of attention-deficit/hyperactivity disorder were not associated with usually inquiring about attention-deficit/hyperactivity disorder in either unadjusted or adjusted analyses. Attitudes about treating/managing attention-deficit/hyperactivity disorder were significantly associated with usually treating/managing attention-deficit/hyperactivity disorder in unadjusted and adjusted analyses. Those who perceived that pediatricians should be responsible for treating/managing had almost 12 times the odds of reporting treating/managing attention-deficit/hyperactivity disorder, whereas those who believe physicians should refer had threefold decreased odds of treating/managing. Other physician/practice characteristics significantly associated with the odds of usually treating/managing attention-deficit/hyperactivity disorder include belief that attention-deficit/hyperactivity disorder is very prevalent among current patients, seeing patients who are assigned or can select a specific pediatrician, and practice location. CONCLUSIONS. Taking responsibility for treating attention-deficit/hyperactivity disorder and practice characteristics seem to be important correlates of pediatrician self-reported behavior toward caring for children with attention-deficit/hyperactivity disorder.

Objective: This study examines whether having a regular clinician for preventive care is associated with quality of care for young children, as measured by interpersonal quality ratings and content of anticipatory guidance. Data Source: The National Survey of Early Childhood Health (NSECH), a nationally representative parent survey of health care quality for 2068 young US children fielded by the National Center for Health Statistics (NCHS). Study Design: Bivariate and multivariate analyses evaluate associations between having a regular clinician for well child care and interpersonal quality, the content of anticipatory guidance, and timely access to care. Principal Findings: In bivariate analysis, parents of children with a regular clinician for preventive care reported slightly higher interpersonal quality (69 vs. 65 on a 0-100 scale, P = 0.01). Content of anticipatory guidance received was slightly greater for children with a regular clinician (82 vs. 80 on a 0-100 scale, P = 0.03). In bivariate analysis, a regular clinician was associated with interpersonal quality only among African American and Hispanic children. In multivariate analyses, controlling for factors that could independently influence self-reports of experiences with care, interpersonal quality but not anticipatory guidance content was higher for children with a regular clinician. Conclusions: Having a regular primary care clinician is embraced in pediatrics, although team care among physicians is also widely practiced. For young children, having a regular clinician is associated with modest gains in interpersonal quality and no differences in content of anticipatory guidance. The benefit of having a regular clinician may primarily occur in interpersonal quality for subgroups of young children.

The new Bright Futures Guidelines for the Health Supervision of Infants, Children, and Adolescents, third edition, provide an important pathway that will carry practitioners and families forward. Preventive care in pediatrics has a very proud history, but there is more to be learned and more to be done to translate best practices across diverse communities and practice environments. ABOUT THE AUTHORS Lynn M. Olson, PhD, is with Department of Research, American Academy of Pediatrics, Elk Grove VIllage, Illinois. J. Lane Tanner, MD, FAAP, is with Division of Developmental and Behavioral Pediatrics, Children’s Hospital and Research Center at Oakland, Oakland, California. Martin T. Stein, MD, FAAP, is with Department of Pediatrics, University of California San Diego Medical Center, San Diego, California. Linda Radecki, MS, is with Department of Research, American Academy of Pediatrics. Address correspondence to: Lynn M. Olson, PhD, Department of Research, American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007, e-mail LOlson@aap.org. Dr. Olson, Dr. Tanner, Dr. Stein, and Ms. Radecki have disclosed no relevant financial relationships. This work is supported in part by a grant from the Commonwealth Fund. The views expressed are those of the authors and not the organizations where they work. EDUCATIONAL OBJECTIVES Describe the basic components of health supervision visits. Identify major challenges encountered providing preventive care for children. Discuss the changing demographics of children in the United States and the impact this has on the delivery of effective and culturally competent care.

OBJECTIVE. The goal was to monitor the number of pediatric residents seeking part-time employment after graduation and to examine the difficulty of their job searches, compared with residents seeking full-time employment. METHODS. As part of the American Academy of Pediatrics Graduating Resident Survey, national random samples of 500 graduating, categorical pediatrics residents were surveyed from 2003 through 2005, between May and August of each year. Responses were pooled to examine resident interest in and experience with part-time employment. Totals of 308 (62%), 307 (61%), and 281 (56%) residents completed the survey in 2003, 2004, and 2005, respectively. Analyses focused on residents who applied for nonfellowship jobs. RESULTS. A total of 51% of residents applied for nonfellowship jobs. Of those who applied for such jobs, 38% reported that they applied for part-time positions and 21% actually accepted part-time positions. Residents who applied for part-time positions were more likely to report moderate or considerable job search difficulty (part-time: 36%; full-time: 25%). The average starting salary for residents who accepted part-time jobs was almost $34000 less than that for residents working full-time (part-time: $71615; full-time: $105598). Residents who accepted part-time positions expected to work 15 hours less per week in practice (38 vs 23 hours) and were more likely to accept a position in the same city/area as their residency (part-time: 60%; full-time: 47%). CONCLUSIONS. Approximately 4 of 10 pediatric residents seek part-time employment after graduation, and 2 of 10 accept part-time positions. Strong interest in part-time positions is likely to continue, and this important trend has implications for the pediatric workforce.

Motor vehicle crashes are a leading cause of death for young people in the United States. Assessing which drivers are at a high risk of experiencing a crash is important for the implementation of traffic regulations. Illegal street racing has been associated with a high rate of motor vehicle crashes. In this study, we link Utah statewide driver license citations and motor vehicle crash data to evaluate the rate of crashes for drivers with street racing citations relative to other drivers. Using a zero-inflated negative binomial model we found that drivers with no citations are approximately three times more likely to be at zero risk of a crash compared to drivers with street racing citations. Moreover, among drivers at non-negligible risk of crash, cited street racers are more likely to be involved in a crash compared to drivers without citations or those cited for violations other than street racing. However, drivers with increased numbers of non-street-racing citations experience crash risks approaching those of the cited street racers.

Background: Injuries from small arms are of concern internationally. The health perspective is an emerging aspect of international work to reduce these injuries. This aspect has been evident in US firearm injury prevention work for over a decade, exhibited by strong statements from the American Academy of Pediatrics (AAP) to remove firearms from children’s environments. Objectives: To assess trends among US pediatricians related to firearm injury prevention counseling practices and attitudes toward gun legislation. Design: National random sample, mailed surveys of AAP members: (1) 1994 (response rate = 68.9%, n = 982); (2) 2000 (response rate = 62.4%, n = 922). χ 2 Tests were used to assess bivariate relationships and logistic regression to assess multivariate relationships regarding counseling practices. Results: Respondents in both years believed that violence prevention should be a priority for pediatricians (91.4% and 92.0%) and reported always or sometimes recommending handgun removal from the home (46.2% and 55.9%, respectively). In 2000, 74% of the respondents were comfortable discussing firearm safety; fewer thought they had sufficient training (32.7%) or time (27.5%) to discuss firearms. In 1994 and 2000, the likelihood of counseling on handgun removal was positively related to recent experience treating a gun injury, female sex and not owning a gun. In both years, >80% of pediatricians thought that gun control legislation or regulations would reduce injury and death. Conclusions: US pediatricians continue to adopt policies promoting gun injury prevention. The practices and attitudes of pediatricians may be important for public education strategies regarding firearm injury prevention in the US and internationally.

OBJECTIVE. This study examined psychometric properties and feasibility issues surrounding child-reported asthma health status data.METHODS. In separate interviews, parents and children completed 3 visits. Child questionnaires were interviewer administered. The primary instrument was the Children's Health Survey for Asthma–Child Version, used to compute 3 scales (physical health, activities, and emotional health). The following were assessed: reliability (internal consistency and test-retest reliability), validity (general health status, symptom burden, and lung function), and feasibility (completion time, missing data, and inconsistent responses).RESULTS. A total of 414 parent-child pairs completed the study (mean child age: 11.5 years). Reliability estimates for the activities and emotional health scales were >.70 in all but 1 age category; 5 of 9 age groups had acceptable internal consistency ratings (≥.70) for the physical health scale. Cronbach's α tended to increase with child age. In general, test-retest correlations between forms and intraclass correlation coefficients were strong for all ages but tended to increase with child age. Correlations between forms ranged from .57 (7-year-old subjects, physical health) to .96 (14-year-old subjects, activities). Intraclass correlation coefficients ranged from .76 (13-year-old subjects, emotional health) to .94 (15–16-year-old subjects, physical health). Children with less symptom burden reported higher mean Children's Health Survey for Asthma–Child Version scores (indicating better health status) for each scale, at significant levels for nearly all age groups. Children's Health Survey for Asthma–Child Version completion times decreased from 12.9 minutes at age 7 to 6.9 minutes at age 13.CONCLUSIONS. This research indicates that children with asthma as young as 7 may be dependable and valuable reporters of their health. Data quality tends to improve with age.

Estimates of the number of uninsured people in the United States usually exclude those with discontinuous coverage. The effects of gaps in insurance coverage for children on access to and use of ambulatory care are poorly understood.We analyzed a sample of 26,955 children under 18 years of age from the 2000 and 2001 National Health Interview Surveys. Children with discontinuous health insurance coverage were compared with those who were uninsured all year and with those who had public or private full-year coverage.During the last 12 months before they were interviewed, 6.6 percent of children in the United States had no insurance and an additional 7.7 percent had gaps in insurance. Children who had full-year insurance coverage (private or public) had low rates of unmet health care needs and good access to care (delayed care, unmet medical care, and unfilled prescriptions were reported in3 percent, and5 percent had no usual place of care). Access to care was much worse for children who were uninsured for part of the year and for those who were uninsured for the full year (delayed care, 20.2 percent and 15.9 percent, respectively; unmet medical care, 13.4 percent and 12.6 percent, respectively; unfilled prescriptions, 9.9 percent and 10.0 percent, respectively; P0.01 for all comparisons with children with full-year, private insurance coverage). In multivariate analyses adjusting for age, income, race or ethnic group, region, citizenship, family structure, parental employment, and health status, the differences in access to care persisted. As compared with the parents of children with full-year, private insurance, parents of children uninsured for the full year were far more likely to report delaying care (adjusted odds ratio, 12.65; 95 percent confidence interval, 9.45 to 16.94), as were parents of children uninsured for part of the year (adjusted odds ratio, 13.65; 95 percent confidence interval, 10.41 to 17.90).Children with gaps in health insurance coverage commonly do not seek medical care, including preventive visits, and do not get prescriptions filled. These findings are important for both research and policy and point to the need for more encompassing and sensitive measures of the situation of being uninsured.

Background: Little is known about whether racial/ ethnic differences exist in household family activities, safety practices, and educational opportunities known to impact young children’s healthy development and school success. Objective: To examine whether racial/ethnic disparities exist in early childhood home routines, safety measures, and educational practices/resources. Methods: The 2000 National Survey of Early Childhood Health is a telephone survey of a nationwide sample of parents of 2608 children aged 4 to 35 months. Differences in family activities, safety measures, and educational practices/resources were examined for white, black, and Hispanic children. Results: Minority children are less likely than white children to have consistent daily mealtimes and bedtimes, and more frequently never eat lunch or dinner with their family. Minority parents are less likely to install stair gates or cabinet safety locks and to turn down hot water settings. Minority parents less often read daily to their child, Hispanic parents more often never read to their child, and minority households average fewer children’s books. Black children average more hours watching television daily. Disparities persisting in multivariate analyses included: minority children having increased odds of never eating lunch or dinner with their family, black children not having regular mealtimes (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) and watching 1 more hour of television daily, black parents not installing cabinet locks, minority parents having twice the odds of not installing stair gates and not reading to their child daily, and minority homes having fewer children’s books (black homes, �30; and Hispanic homes, �20). Children whose parents completed surveys in Spanish also experienced several disparities. Conclusions: Young minority children experience multiple disparities in home routines, safety measures, and educational practices/resources that have the potential to impede their healthy development and future school success. Such disparities might be reduced or eliminated through targeted education and intervention by pediatric providers. Arch Pediatr Adolesc Med. 2005;159:158-165

To describe the content of anticipatory guidance provided to parents of infants and toddlers and to identify primary areas of unmet need as reported by both parents and pediatricians.Parent data were obtained from the National Survey of Early Childhood Health, a nationally representative sample of parents of 2068 US children aged 4 to 35 months. Pediatrician data were obtained from the Periodic Survey of Fellows, a national survey of members of the American Academy of Pediatrics.Parents and pediatricians tend to agree on the relative ranking of which topics are most frequently addressed. Parents and pediatricians both report that the traditional topics of preventive care--immunizations, feeding issues, and sleep patterns--are most frequently discussed, whereas topics that were more recently introduced into pediatric care related to developmental needs and family context are less commonly addressed. Parent-reported discussion of these topics include reading (discussed for 61% of children 19-35 months) and child care (discussed for 26% of children 19-35 months). Parent reports of some unmet need--defined as topics not discussed that the parent believes would have been helpful to them--affect 36% of children aged 4 to 9 months and 56% of children aged 10 to 35 months and are highest for the topics of discipline strategies and toilet training. Other specific areas of unmet need reported by at least 15% of parents are burn prevention, child care, reading, vocabulary development, and social development. Rates of unmet need vary with family characteristics and health system factors, including maternal education, race/ethnicity, and length of well-child visits.Parents and pediatricians report high rates of discussion on many topics that are critical to healthy development in the first years of life. They also identify areas of need that largely address health supervision on developmental topics. Findings indicate that additional research is needed to understand issues related to specific topic areas as well as the dynamics of personal and system factors that determine what is discussed.

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.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.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.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.

The National Survey of Early Childhood Health (NSECH) is a new survey that was designed to provide nationally representative data on the health and development of children and to fill an information gap in the pediatric literature on parents' views of the delivery of health care to their young children.The selection of topics was guided by previous studies conducted to examine parents' expectations and needs in child health supervision visits. The NSECH is a random-digit-dial telephone survey of a nationally representative sample of 2068 children aged 4 to 35 months. This sample includes an oversample of black and/or Hispanic children so that results for these minority groups could be estimated with greater precision. The sampling frame for NSECH is from the State and Local Area Integrated Telephone Survey (SLAITS), which is a program of surveys conducted by the National Center for Health Statistics that makes economical use of the large sampling frame of the National Immunization Survey (NIS). SLAITS takes advantage of the NIS screening effort by fielding interviews on other health topics with households screened for the NIS. The respondent was the parent or guardian identified as the person most responsible for the sampled child's medical care. Spanish-language interviews composed 19% of all completed interviews. The Council of American Survey Research Organizations response rate was 65.6%.The NSECH provides a unique data set that allows a well-rounded picture of the health, health care utilization, health care content, and interpersonal quality of health services received by young children in the United States. It also contains important information about family characteristics, patterns of health-promoting behaviors, and family routines that are associated with promoting the developmental health of young children. NSECH results can also help national policy makers understand the health needs of families with young children and how well the health system is meeting those needs.

Insurance status has been shown to have an impact on children's use of preventive and acute health services. The objective of this study was to determine the relationship between insurance status and vaccination coverage among US preschool children aged 19 to 35 months.We linked data from 2 national telephone surveys, the National Immunization Survey and the National Survey of Early Childhood Health, conducted during the first half of 2000. Children were considered up to date (UTD) when they had received at least 4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 MMR vaccine, 3 Haemophilus influenza vaccines, and 3 hepatitis B vaccines at the time the interview was conducted.Among the 735 children in our study sample, 72% were UTD. The vast majority (94%) reported some type of health insurance at the time of the survey. Children with private insurance were more likely to be UTD (80%) than those with public insurance (56%) or no insurance (64%). In a multivariate analysis that controlled for child's race/ethnicity; household income; maternal age/marital status/educational level; location of usual care; and Special Supplemental Nutrition Program for Women, Infants, and Children participation, insurance was no longer an independent predictor of vaccination.The disparity in vaccination coverage among publicly, privately, and uninsured children is dramatic, underscoring its importance as a marker for underimmunization, despite the multivariate findings. The Vaccines for Children Program, a partnership between public health and vaccination providers who serve uninsured children and those enrolled in Medicaid, is well suited to target and improve vaccination coverage among these vulnerable children.

Objective. To determine the proportion of children aged 10 to 35 months who were reported ever to have received a developmental assessment (DA) and to examine characteristics of the child, family, and health care setting associated with the receipt of a DA.Methods. The National Survey of Early Childhood Health, conducted in 2000, is a survey of 2068 parents of children 4 to 35 months of age. Children were classified as having received a DA in response to 2 questions: whether the child’s pediatric provider ever told parents that he or she was doing a “developmental assessment” and/or parents recalled explicit components of a DA, such as stacking blocks or throwing a ball. Parent-reported receipt of a DA was assessed in relationship to child and family, health care access, other measures of health care content and process, and measures of quality and satisfaction.Results. Approximately 57% of children 10 to 35 months of age ever received a DA. Forty-two percent of parents recalled ever being told by their child’s pediatric provider that a DA was being done. Thirty-nine percent recalled their child’s being asked to perform specific tasks routinely included in a DA. Bivariate analysis indicates that receipt of a DA is not associated with child or family sociodemographic characteristics such as maternal education and household income, with the exception of race/ethnicity. Less acculturated Hispanic parents reported a DA more frequently than parents in other racial/ethnic groups (66% vs 56%). A smaller proportion of parents whose children who used community health centers reported their child’s ever having received a DA compared with children who use other settings (51% vs 60%). Compared with other children, parents whose child ever received a DA reported more frequently than other parents that the time spent with the child’s provider during the last well-child visit was adequate (94% vs 80%). They also reported longer visits (19 minutes vs 16 minutes), higher family-centered care ratings (mean: 71 vs 59), and higher satisfaction with well-child care (8.9 vs 8.4). Receipt of a DA is also associated with the content of developmentally focused anticipatory guidance received. For each health supervision topic analyzed, frequency of discussion is higher for children who ever received a DA. In multivariate analysis, odds of receiving a DA are higher for children with longer visits with the provider (odds ratio: 1.03; 95% confidence interval: 1.01–1.05) and lower for children in community health clinics compared with a private office (odds ratio: 0.61; 95% confidence interval: 0.39–0.96), even accounting for total well-child visits to the pediatric provider.Conclusion. Although guidelines endorse the routine provision of DAs, parents of many children do not report receiving DAs. Children who receive assessments are more likely to receive other developmental services, and their parents are more likely to report greater satisfaction with care and rate the interpersonal quality of well-child care more favorably. The substantial number of children who do not receive these routinely recommended services raises important questions about the quality of care received.

Background. Because children uninsured for less than a full year are often reported as insured, they receive less attention in health policy debates than do the full-year uninsured and are underrecognized as potential users of public insurance programs. Objective. The purpose of this study is to assess the impact on estimates of how many US children are uninsured when alternatives to the full-year uninsured definition are used. Methods. Monthly health insurance coverage data collected from children through age 18 in the 1999 Medical Expenditure Panel Survey were analyzed to estimate prevalence of health insurance gaps among children in terms of the size of part-year and full-year uninsured child population, duration of uninsured gaps, and aggregate uninsured spells. Results. Although 6.6 million ([M] 8.4%) children in the United States were uninsured throughout 1999, an additional 11.4M (14.4%) were uninsured for part of the year. Part-year uninsured gaps accounted for 41.7% of a total of 130M months of missing coverage experienced by all children. Conclusions. Different definitions and measures of who are uninsured can project radically different pictures of the magnitude of the problem. As this study shows, including the part-year uninsured more than doubled the estimated uninsured child population for 1999, and increased the estimated aggregate uninsured months by 71%. As potential users of public coverage, children who have no insurance for part of the year should be included when evaluating challenges to and accomplishments by the State Children’s Health Insurance Program and other public programs. Their significant numbers and the potential burden they place on the health care delivery system argue for them to be counted and for the causes and consequences of short-term uninsured spells to be better understood.

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U.S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.