Anne W. Riley

Evidence That School-Age Children Can Self-Report on Their Health

The value of obtaining childrens reports about their health from questionnaires is a topic of considerable debate in clinical pediatrics and child health research. Evidence from the following areas can inform the debate: 1) studies of parent-child agreement or concordance about the childs health state, 2) basic research on the development of childrens cognitive abilities, 3) cognitive interviewing studies of childrens abilities to respond to questionnaires and of influences on their responses, 4) psychometric studies of child-report questionnaires, and 5) longitudinal research on the value of childrens reports. This review makes a case for the utility of child rather than parent-proxy reports for many, though not all, applications. The review summarizes evidence in terms of the value and limitations of child questionnaire reports. Research demonstrates adequate understanding and reliability and validity of child reports of their health even at age 6, which increases after age 7 in general populations. The reliability of reports by children 8-11 years old is quite good on health questionnaires developed especially for this age group. Childrens personal reports provide a viable means of monitoring internal experiences of health and distress during childhood and adolescence, which can enhance understanding about trajectories of health and development of illnesses.

The adolescent child health and illness profile: A population-based measure of health

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11–17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

Social class gradients in health during adolescence

Study objective: To review existing data on social class gradients in adolescent health and to examine whether such gradients exist in new data concerning US adolescents. Design: Review of relevant publications and unpublished data; regression analyses using adolescent self reported health status data to determine whether there are gradients by social class, using three classes categorised by adolescent reported parental work status and education. Participants: Adolescents of ages 11–17. Main results: Findings from the literature indicate the presence of social class gradients in some but not all aspects of adolescent health. Results from new data showed social class gradients in several domains of health and in profiles of health. The likelihood of being satisfied with ones health, of being more resilient (better family involvement, better problem solving, more physical activity, better home safety), having higher school achievement, and of being in the best health profiles were significantly and progressively greater as social class rose. Moreover, the probability of being in the poorest health profile type group was progressively higher as social class declined. Conclusions: The review of existing data and the new findings support the existence of social class gradients in satisfaction with ones health, in resilience to health threats, in school achievement, and in being in the best health overall (as manifested by the health profiles composed of four major domains of health). The study had two especially notable findings: (1) the paucity of studies using the same or similar indicators, and (2) the consistent existence of social class gradients in characteristics related to subsequent health, particularly intake of nutritional foods and physical activity. The sparseness of existing data and the different aspects of health investigated in the relatively few studies underscore the need for (1) the development of conceptual models specifically focused on adolescent health and social class; (2) additional inquiry into the measurement of social class and adolescent perceptions of class; (3) inclusion of contextual variables in study design; and (4) longitudinal cohort studies to better understand the specific determinants of health during adolescence.

Elementary school-aged children's reports of their health: A cognitive interviewing study

There are no standard methods for assessing the quality of young childrens perceptions of their health and well-being and their ability to comprehend the tasks involved in reporting their health. This research involved three cross-sectional studies using cognitive interviews of 5–11-year-old children (N = 114) to determine their ability to respond to various presentations of pictorially illustrated questions about their health. The samples had a predominance of children in the 5–7-year-old range and families of lower and middle socio-economic status. The research questions in Study 1 involved childrens ability to convert their health experiences into scaled responses and relate them to illustrated items (n = 35); Study 2 focused on the type of response format most effectively used by children (n = 19); and Study 3 involved testing childrens understanding of health-related terms and use of a specific recall period (n = 60). The results of Study 1 showed that children identified with the cartoon drawing of a child depicted in the illustrated items, typically responding that the child was at or near their own age and of the same gender, with no differences related to race. Study 2 results indicated that children responded effectively to circles of graduated sizes to indicate their response and preferred them to same-size circles or a visual analogue scale. Tests of three-, four-, and five-point response formats demonstrated that children could use them all without confusion. In Study 3, expected age-related differences in understanding were obtained. In fact, the 5-year-old children were unable to understand a sufficient number of items to adequately describe their health. Virtually all children 8 years of age and older were able to fully understand the key terms and presentation of items, used the full five-point range of response options, and accurately used a 4-week recall period. Six- and seven-year-olds were more likely than older children to use only the extreme and middle responses on a five-point scale. No pattern of gender differences in understanding or in use of response options was found. We conclude that children as young as eight are able to report on all aspects of their health experiences and can use a five-point response format. Children aged 6–7 had difficulty with some health-related terms and tended to use extreme responses, but they understood the basic task requirements and were able to report on their health experiences. These results provide the guidance needed to develop and test a pediatric health status questionnaire for children 6–11 years old.

Children's health care use: a prospective investigation of factors related to care-seeking.

Objectives.To determine the best predictors of the amount of children’s health care use. Research Design. Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use. Subjects.367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO. Measures.Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers’ Mental Health and Health Care Use. Results.The volume of a child’s past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother’s retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children’s past use of health care. In this model the mother’s worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model. Conclusions.This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child’s health, most notably maternal functioning.

Developmental Epidemiology of the Disruptive Behavior Disorders

Epidemiology is both a scientific discipline and a powerful set of investigative methods that have been adopted by other fields, including the fields that study the behavior problems of children and adolescents. The discipline of epidemiology was developed to study the etiology of diseases, and the methods of epidemiology evolved in service of that aim. Because the mental health disciplines also seek to understand the origins of disorders, it has been to our advantage to adopt many of the methods of epidemiology.

The Parent Report Form of the Chip–child Edition: Reliability and Validity

BackgroundValid, comprehensive instruments to describe, monitor, and evaluate health from childhood through adolescence are almost nonexistent, but are critical for health resource planning, evaluation of policy, preventive, and clinical interventions, and understanding trajectories of health during this important period of life. ObjectivesThe objectives of this study were to describe the development, testing, and final versions of the Parent Report Form of the Child Health and Illness Profile–Child Edition (CHIP-CE/PRF), designed to measure the health of children 6 to 11 years old from the caregiver perspective. MethodsParents (N = 1049) completed a version of the CHIP-CE/PRF in 4 locations in the United States, either in clinic waiting rooms or their homes. They differed in race/ethnicity, socioeconomic level, and native language. ResultsThe Parent CHIP-CE is feasible; parents with a 5th-grade reading level complete the 76-item PRF in 20 minutes. Its domains (Satisfaction, Comfort, Risk Avoidance, Resilience, and Achievement) measure structurally distinct, interrelated aspects of health. Domain reliability is high: internal consistency = 0.79–0.88; retest reliability (ICC) = 0.71–0.85. Validity is supported. The scale scores are sensitive to predicted age, gender, and socioeconomic status differences in health. ConclusionThe CHIP–Child Edition/Parent Report Form is a psychometrically sound, conceptually based measure of child health that works well in diverse populations. It produces scores that parallel those of children on the CHIP-CE/CRF and adolescents on the CHIP-AE and allows health to be consistently assessed from childhood through adolescence. It should meet many needs for describing, monitoring, and understanding child health and evaluating outcomes of interventions.

The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy

Young children who experience toxic stress are at high risk for a number of health outcomes in adulthood, including cardiovascular disease, cancers, asthma, and depression. The American Academy of Pediatrics has recently called on pediatricians, informed by research from molecular biology, genomics, immunology, and neuroscience, to become leaders in science-based strategies to build strong foundations for children’s life-long health. In this report, we provide an overview of the science of toxic stress. We summarize the development of the neuroendocrine-immune network, how its function is altered by early life adversity, and how these alterations then increase vulnerability to disease. The fact that early environments shape and calibrate the functioning of biological systems very early in life is both a cautionary tale about overlooking critical periods in development and reason for optimism about the promise of intervention. Even in the most extreme cases of adversity, well-timed changes to children’s environments can improve outcomes. Pediatricians are in a unique position to contribute to the public discourse on health and social welfare by explaining how factors that seem distal to child health may be the key to some of the most intractable public health problems of our generation. We consider the challenges and opportunities for preventing toxic stress in the context of contemporary pediatric practice.

Determinants of children's health care use: An investigation of psychosocial factors.

Factors related to the amount of health care used by 5− to 11-year-old children in a health maintenance organization (HMO) were investigated using a comprehensive multivariate model that assessed the contribution of child health need, mental health, and social functioning; maternal mental health, social support and health care utilization; and family functioning and life events. Mothers reported on the 450 participating children. Health care visits for a two-year retrospective period were obtained from the computerized encounter system.Child health need and maternal patterns of health care use were powerful predictors of the overall amount of health care used, and these factors discriminated high users from low users of care. Family conflict was associated with a higher volume of care, while childrens depressive symptoms and non-white race were related to lower use. Maternal social support, mental health, and life events were not predictive of use in either full multivariate model. Enabling factors were held relatively constant by participation of all families in a prepaid HMO. The multiple regression model explained 33% of the variance in use, slightly more than in previous studies of childrens health care use.When included in a comprehensive analysis, child and family psychosocial characteristics help to explain childrens health care use beyond what is possible using simple health and illness variables. The implications of these findings in the development of further research and to the practice of routine pediatric care are discussed. Key words: childrens health care; pediatrics; utilization; psychosocial factors. (Med Care 1993; 31:767–783)

The Validity of Measures of Socioeconomic Status of Adolescents.

This study examines the validity of measures of socioeconomic status (SES) as reported by adolescents. Adolescents completed a self-administered questionnaire that included eight measures of SES. Mothers also reported on selected measures of SES. Supporting criterion validity, adolescents and mothers had relatively high agreement on the SES measures. Older adolescents, those less involved in risk behaviors, and those who do better in school gave more accurate SES reports and/or were less likely to have missing SES data. Those in households without fathers were less likely to know fathers’ information. Income was not asked of the adolescents. However, most adolescent-reported SES questions varied systematically and in the expected direction with mothers’income report. In terms of construct validity, the SES measures related to adolescent health measures in the predicted way—that is, those with higher SES were more likely to report better physical and emotional health.