Deborah A. Frank

Maternal Depression, Changing Public Assistance, Food Security, and Child Health Status

OBJECTIVE To examine the association of positive report on a maternal depression screen (PDS) with loss or reduction of welfare support and foods stamps, household food insecurity, and child health measures among children aged < or =36 months at 6 urban hospitals and clinics. METHODS A convenience sample of 5306 mothers, whose children <36 months old were being seen in hospital general clinics or emergency departments (EDs) at medical centers in 5 states and Washington, District of Columbia, were interviewed from January 1, 2000 until December 31, 2001. Questions included items on sociodemographic characteristics, federal program participation and changes in federal benefits, child health status rating, childs history of hospitalizations since birth, household food security status, and a 3-question PDS. For a subsample interviewed in the ED, whether the child was admitted to the hospital that day was recorded. RESULTS PDS status was associated with loss or reduction of welfare support and food stamps, household food insecurity, fair/poor child health rating, and history of child hospitalization since birth but not low child growth status measures or admission to the hospital at the time of ED visit. After controlling for study site, maternal race, education, and insurance type as well as child low birth weight status, mothers with PDS were more likely to report fair/poor child health (adjusted odds ratio [AOR]: 1.58; 95% confidence interval [CI]: 1.33-1.88) and hospitalizations during the childs lifetime (AOR: 1.20; 95% CI: 1.03-1.39), compared with mothers without PDS. Controlling for the same variables, mothers with PDS were more likely to report decreased welfare support (AOR: 1.52; 95% CI: 1.03-2.25), to have lost food stamps (AOR: 1.56; 95% CI: 1.06-2.30), and reported more household food insecurity (AOR: 2.69; 95% CI: 2.33-3.11) than mothers without PDS. CONCLUSION Positive maternal depression screen status noted in pediatric clinical samples of infants and toddlers is associated with poorer reported child health status, household food insecurity, and loss of federal financial support and food stamps. Although the direction of effects cannot be determined in this cross-sectional survey, child health providers and policy makers should be aware of the potential impact of maternal depression on child health in the context of welfare reform.

Effect of parents' wartime deployment on the behavior of young children in military families.

OBJECTIVE To describe the effect of wartime military deployments on the behavior of young children in military families. DESIGN Cross-sectional study. SETTING Childcare centers on a large Marine base. PARTICIPANTS Parents and childcare providers of children aged 1(1/2) to 5 years enrolled in on-base childcare centers. Main Exposure Parental deployment. OUTCOME MEASURES Mean externalizing, internalizing, and total symptom scores on the Child Behavior Checklist (CBCL) (1(1/2)-5 years) and the CBCL-Teacher Report Form (TRF) (1(1/2)-5 years). RESULTS One hundred sixty-nine of 233 consenting families (73%) participated. Nonresponders did not differ from responders in their childs age or TRF scores. Fifty-five children (33%) had a deployed parent. Parents with children aged 3 years or older and a deployed spouse had significantly higher depression scores than those without a deployed spouse. There were no differences in the demographic characteristics between groups. After controlling for respondents age, stress and depressive symptoms, deployed service members rank, and total number of children in the home, we found an age by deployment interaction: children aged 3 years or older with a deployed parent had significantly higher CBCL externalizing and total scores (externalizing, 48.50 vs 43.31, P < .05; total, 47.71 vs 42.68, P < .05) and externalizing and total TRF scores (externalizing, 50.21 vs 45.62, P < .05; total, 48.54 vs 43.73, P < .05) compared with same-aged peers without a deployed parent. CONCLUSIONS This study is the first to show that children aged 3 years or older with a deployed parent exhibit increased behavioral symptoms compared with peers without a deployed parent after controlling for caregivers stress and depressive symptoms.

Volumetric MRI Study of Brain in Children With Intrauterine Exposure to Cocaine, Alcohol, Tobacco, and Marijuana

OBJECTIVE. The objective of this study was to use volumetric MRI to study brain volumes in 10- to 14-year-old children with and without intrauterine exposure to cocaine, alcohol, cigarettes, or marijuana. METHODS. Volumetric MRI was performed on 35 children (mean age: 12.3 years; 14 with intrauterine exposure to cocaine, 21 with no intrauterine exposure to cocaine) to determine the effect of prenatal drug exposure on volumes of cortical gray matter; white matter; subcortical gray matter; cerebrospinal fluid; and total parenchymal volume. Head circumference was also obtained. Analyses of each individual substance were adjusted for demographic characteristics and the remaining 3 prenatal substance exposures. RESULTS. Regression analyses adjusted for demographic characteristics showed that children with intrauterine exposure to cocaine had lower mean cortical gray matter and total parenchymal volumes and smaller mean head circumference than comparison children. After adjustment for other prenatal exposures, these volumes remained smaller but lost statistical significance. Similar analyses conducted for prenatal ethanol exposure adjusted for demographics showed significant reduction in mean cortical gray matter; total parenchymal volumes; and head circumference, which remained smaller but lost statistical significance after adjustment for the remaining 3 exposures. Notably, prenatal cigarette exposure was associated with significant reductions in cortical gray matter and total parenchymal volumes and head circumference after adjustment for demographics that retained marginal significance after adjustment for the other 3 exposures. Finally, as the number of exposures to prenatal substances grew, cortical gray matter and total parenchymal volumes and head circumference declined significantly with smallest measures found among children exposed to all 4. CONCLUSIONS. These data suggest that intrauterine exposures to cocaine, alcohol, and cigarettes are individually related to reduced head circumference; cortical gray matter; and total parenchymal volumes as measured by MRI at school age. Adjustment for other substance exposures precludes determination of statistically significant individual substance effect on brain volume in this small sample; however, these substances may act cumulatively during gestation to exert lasting effects on brain size and volume.

US Housing insecurity and the health of very young children.

OBJECTIVES We investigated the association between housing insecurity and the health of very young children. METHODS Between 1998 and 2007, we interviewed 22,069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each childs household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or>1 family/residence) and multiple moves (≥ 2 moves within the previous year). RESULTS After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI =1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (-0.082 vs -0.013; P= .02). CONCLUSIONS Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.

Risk of sudden infant death syndrome among infants with in utero exposure to cocaine

To determine whether the risk of sudden infant death syndrome (SIDS) among infants exposed to cocaine in utero may be elevated, we assessed the risk for SIDS in a large, well-described, prospective cohort of infants whose mothers had or had not used cocaine during pregnancy. Of 996 women consecutively enrolled while registering for prenatal care, 175 used cocaine during pregnancy. Only one infant of the mothers who used cocaine died of SIDS, a risk of 5.6 in 1000, compared with four infants among the 821 nonexposed infants, a risk of 4.9 in 1000. The relative risk for SIDS among infants whose mothers used cocaine during pregnancy compared with those whose mothers did not use cocaine was 1.17 (95% confidence interval 0.13, 10.43), suggesting that there is no increased risk of SIDS among infants exposed in utero to cocaine.

Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive care unit: a preliminary study.

Objectives: Traumatic stress symptoms from multiple causes are endemic among impoverished women who are also at high risk for delivering infants requiring neonatal intensive care unit (NICU) care, but whether this event itself constitutes a distinct traumatic stress trigger is unknown. Previous research does suggest having an infant in the NICU generates traumatic stress among white middle-class mothers, stress that can impact their infant’s behavior and development. This study evaluated the prevalence of acute posttraumatic stress symptoms among low-income mothers of infants admitted to the NICU compared with similar mothers with infants in the well baby nursery (WBN). Methods: A total of 59 NICU and 60 WBN mothers were recruited from the Boston Medical Center. Within the first week after birth, all participants were assessed for postpartum acute posttraumatic stress and depression symptoms and asked about lifetime traumatic events before the birth of their baby. The acute posttraumatic stress symptoms were analyzed as a continuous variable and whether they reached the categorical severity criteria for acute stress disorder. Results: NICU mothers show increased symptoms of acute posttraumatic stress and depression. Twenty-three percent of NICU and 3% of WBN reached severity criteria for acute stress disorder. When controlling for relevant covariates, having a newborn in the NICU had a significant association with the number of mothers’ acute posttraumatic stress symptoms not fully explained by their symptoms of depression or prior lifetime history of traumatic events. Conclusions: Addressing acute posttraumatic stress symptoms may enhance interventions to help urban families of NICU infants.

A Brief Indicator of Household Energy Security: Associations With Food Security, Child Health, and Child Development in US Infants and Toddlers

OBJECTIVE. Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children <36 months of age. METHODS. A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or ≥1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations. RESULTS. Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length. CONCLUSIONS. As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms

The purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on childrens growth and development from birth to adolescence. At the 12-month visit, childrens attachment status was scored from videotapes of infant-caregiver dyads in Ainsworths strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale-Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to childrens attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure-disorganized/insecure-other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in childrens later development of posttraumatic stress symptoms following a traumatic event.

Socioemotional Effects of Fathers' Incarceration on Low-Income, Urban, School-Aged Children

OBJECTIVE. The goal was to evaluate whether children of incarcerated fathers are more likely to report or exhibit behavioral symptoms than their equally disadvantaged peers without an incarcerated father. METHODS. During an ongoing longitudinal study of intrauterine cocaine exposure involving 102 children (50% male and 89% black) from urban, low-income homes, questions regarding incarceration of the childs father were asked of the childs primary caregiver at each visit during school age. Children were administered the Childrens Depression Inventory between the ages of 6 and 11 years, and their primary caregivers completed the Child Behavior Checklist. In addition, the childrens teachers completed the Teacher Report Form. Childrens Depression Inventory, Child Behavior Checklist, and Teacher Report Form data obtained at the oldest available age after the first report of paternal incarceration were analyzed. RESULTS. In bivariate analyses, children whose fathers were in jail had higher Childrens Depression Inventory total scores compared with children without incarcerated fathers, indicating more depressive symptoms. This finding was robust in multivariate analyses after adjustment for childrens age, gender, prenatal cocaine and alcohol exposure, and school-age violence exposure. Teachers reported higher Teacher Report Form externalizing scores for children whose fathers were in jail, after adjustment for age, gender, prenatal cocaine and marijuana exposure, and school-age violence exposure. CONCLUSIONS. Children of incarcerated fathers reported more depressive symptoms and their teachers noted more externalizing behaviors, after controlling for other biopsychosocial risks. Interventions targeted to ameliorate the distress of children with incarcerated fathers should be considered.

Maternal marijuana use and neonatal outcome: uncertainty posed by self-reports.

To assess the validity of self-reported marijuana use during pregnancy, this study randomly allocated pregnant women into a group who were told their urine would be tested for marijuana, alcohol, and other drugs and another group not so tested. Women told they would be tested reported more marijuana use during pregnancy than did untested women. Moreover, urine assays identified more women who used marijuana during pregnancy than were willing to admit it in the interview even after being told their urine would be tested. No differences in reported drinking or cigarette smoking during pregnancy were found between tested and untested women.