Ellen Johnson Silver

Cumulative Social Disadvantage and Child Health

CONTEXT. Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health. OBJECTIVE. We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities. DESIGN. We analyzed data on 57553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0–3). RESULTS. A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in “good, fair, or poor health” (versus “excellent or very good”) were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings. CONCLUSIONS. The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities.

School Recess and Group Classroom Behavior

OBJECTIVES. This study examines the amount of recess that children 8 to 9 years of age receive in the United States and compares the group classroom behavior of children receiving daily recess with that of children not receiving daily recess. METHODS. This is a secondary analysis of a public-use data set, the Early Childhood Longitudinal Study, Kindergarten Class of 1998–1999, third-grade data set. Children were categorized into 2 levels of recess exposure, that is, none/minimal break (<1 break of 15 minutes/day) or some recess. Some recess was further categorized into 5 levels on the basis of frequency and duration of recess. Child, parent, school, and classroom characteristics of those with and without recess were compared. The group classroom behavior was assessed by using the teachers rating of class behavior. RESULTS. Complete data were available for 10301 to 11624 children 8 to 9 years of age. There were equal numbers of boys and girls (boys: 50.3%). Children exposed to none/minimal break (30%) were much more likely to be black, to be from families with lower incomes and lower levels of education, to live in large cities, to be from the Northeast or South, and to attend public school, compared with those with recess. Teachers rating of classroom behavior scores were better for children with some recess than for those with none/minimal break. This finding was maintained in multivariate regression analysis. However, among children receiving daily recess, the teachers rating of class behavior scores did not differ significantly according to the level of exposure. CONCLUSIONS. These results indicated that, among 8- to 9-year-old children, having ≥1 daily recess period of >15 minutes in length was associated with better teachers rating of class behavior scores. This study suggests that schoolchildren in this age group should be provided with daily recess.

Content Validity of the Psychiatric Symptom Index, CES-Depression Scale, and State-Trait Anxiety Inventory from the Perspective of DSM-IV

We compared the item content of three commonly used scales of psychiatric symptoms [the broad-band Psychiatric Symptom Index (Ilfeld) and two narrow-band scales, the Center for Epidemiologic Studies-Depression Scale (Radloff) and the State-Trait Anxiety Inventory (Spielberger)], with diagnostic criteria and criterion-based symptoms for Major Depressive Episode and Generalized Anxiety Disorder as they appeared in DSM-IV. The Psychiatric Symptom Index and the Center for Epidemiologic Studies—Depression Scale each measured 7 of 9 criterion-based symptoms of Major Depressive Episode. The Psychiatric Symptom Index and State-Trait Anxiety Inventory each measured 5 of 8 domains for Generalized Anxiety Disorder. The Psychiatric Symptom Index had comparable content validity to the narrow-band measures. All met a majority of DSM-IV criteria for depression and anxiety, supporting their applicability for current research.

Relationships of Self-Esteem and Efficacy to Psychological Distress in Mothers of Children With Chronic Physical Illnesses

This study examined relationships of childrens illness-related functional limitations and 2 maternal psychological resources, self-esteem and efficacy, to symptoms of psychological distress in 365 urban mothers of 5- to 9-year-old children with diverse chronic illnesses. Multiple regression controlling for sociodemographic variables indicated that presence of functional limitations in the child and lower resources each were associated with higher maternal scores on a psychological symptom scale. Self-esteem had a main effect on maternal distress; however, a significant Efficacy x Functional Status interaction term suggested that mothers experienced greater distress when their children had illness-related functional limitations and maternal efficacy was low. Interventions aimed at enhancing maternal psychological resources may reduce the likelihood of distress in mothers of children with chronic illness.

Comparing Different Definitions of Chronic Conditions in a National Data Set

OBJECTIVES To compare the application of 4 different definitions of chronic conditions and disabilities in children using a large national database. METHODS The study used data on children 0-17 years of age from the 1994 and 1995 National Health Interview Survey (NHIS) Core Interview and Disability Supplement. We selected items to create algorithms that operationalized 4 extant definitions and compared the proportions of children identified by each. For each definition we conducted bivariate and logistic regression analyses of age and sociodemographic and health-related characteristics potentially related to presence of disability. We then compared the results across definitions to determine if they were equally likely to identify children across a full range of sociodemographic variables, ages, and health-related characteristics. We also examined the level of agreement among definitions and determined the degree to which they identified the same or different children. RESULTS Using a single data set, the 4 operational definitions identified somewhat different proportions of children as having chronic conditions or disability overall (the range was 13.7%-17%). However, the ways in which the definitions identified children along a spectrum of variables did not differ substantially across the definitions. The percent agreement in identification between any two individual definitions was > or = 95%. In general, a higher proportion of children were identified among males, whites, those in older age groups, and among those whose parents had lower levels of education and those who were living below the poverty level. Although the same set of variables identified children with conditions who fit all 4 definitions compared with children who met the criteria for 1 to 3 definitions, higher rather than lower parent education was associated with agreement across all definitions. CONCLUSIONS Little has been known about the comparability of different definitions for identifying children with chronic conditions, special health care needs, and disability. Our findings suggest substantial overlap in the numbers and characteristics of the children that several different conceptual definitions identify. It remains unclear whether subgroups with higher or lower proportions of children with chronic disorders represent a substantive finding or whether they result from methodological problems shared by the ways in which the definitions are operationalized.

The Relationship of Depressive Symptoms to Parenting Competence and Social Support in Inner-City Mothers of Young Children

Objective: Despite the high prevalence of maternal depression and its negative consequences for children, many pediatricians fail to identify this problem. Our goal was to determine whether simple questions about parenting competence and the adequacy of maternal social support might be useful to providers in determining which inner-city mothers are likely to be depressed. Methods: We surveyed a convenience sample of 279 English-speaking mothers of children 6 months to 3 years old prior to a routine visit at an urban, hospital-based general pediatrics clinic. The mothers self-completed the Psychiatric Symptom Index (PSI) and the Parenting Stress Index Sense of Competence subscale, and rated the adequacy of their social support, and provided health and sociodemographic data by face-to-face interview. Results: 41% of mothers had “high” PSI symptom levels and 22% had scores above a criterion that suggests major depressive disorder. In addition, 15% experienced high parenting stress (low competence) and 42% reported little or no social support. High distress was unrelated to a variety of sociodemographic risk factors, but significantly associated with a poor sense of parenting competence (Adj. OR = 3.3, 95% CI = 1.5, 7.0) and inadequate perceived social support (Adj. OR = 2.3, 95% CI = 1.2, 4.4), as well as with having health-related activity limitations (Adj. OR = 3.2, 95% CI = 1.1, 9.0). Conclusions: Negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children. These factors are often assessed during routine pediatric visits and may be helpful to pediatricians in identifying mothers needing further evaluation or treatment by mental health specialists.

Behavioral Problems in School-Aged Children of Mothers with HIV/AIDS

This study examined the relationships between selected risk and resistance factors and maternal reports of child behavior problems on the Child Behavior Checklist (CBCL) in families affected by maternal HIV/AIDS. Data were obtained from 193 mothers with late-stage HIV/AIDS who were included in a sample consecutively recruited from the New York City Division of AIDS Services Income Support to participate in Project Care, a randomized trial of a permanency planning intervention. Each mother reported on one HIV negative index child 5–12 years of age. Child behavior problems were related significantly to the mother’s psychological distress and marginally to her having illness-related activity restrictions, but not to other measures of maternal physical health, stigma or disclosure of her HIV to the child. Two child dispositional factors, productivity and independence, and two family factors, adaptability and a good parent–child relationship, were related to better child functioning, but family cohesion was a risk factor for poorer adjustment in this sample. These are likely to be key target variables useful to policy makers in planning programs to assist these children in coping successfully with their mother’s illness.

Factors associated with psychological distress in urban mothers with late-stage HIV/AIDS.

Factors associated with psychological distress were examined in 220 low-income, mostly minority mothers with late-stage HIV/AIDS. Mothers lived with at least one HIV-negative child of age 2–12 years and participated in a study of the effectiveness of a custody planning intervention provided by The Family Center. The mothers exhibited extraordinarily high levels of psychological disturbance on the Psychiatric Symptom Index (PSI). Multiple regression showed that higher PSI Total scores were significantly related to the mothers reports of having non-HIV-related medical conditions, spending time in bed in the past 2 weeks, having more activity restrictions, and having a lot of difficulty caring for her child due to ill health. Higher scores also were associated with lower education, experiencing more negative life events, and greater receipt and lower adequacy of social support. Thus, higher distress was associated with inability to perform usual activities and mobilization of support. However, other HIV-related health factors, traditional background characteristics, and psychosocial measures (e.g., HIV stigma, parenting stress, family environment) failed to indicate who was most vulnerable. Researchers need to identify the mechanisms of risk and develop appropriate mental health interventions.

Psychological outcomes of a support intervention in mothers of children with ongoing health conditions: The parent-to-parent network

We compared depression, anxiety, anger, cognitive disturbance, and total scores on the Psychiatric Symptom Index (Ilfeld, 1976) for 365 mothers of 5-to-8 year-olds with diverse health conditions who were randomized either to an experimental (EG) or control (CG) group. EG mothers were offered a 12-month community-based support intervention; CG mothers received standard care. Posttest scores of EG and CG mothers did not differ significantly. Although intervention effects were not related to participation level or illness-related and sociodemographic factors, a significant interaction with stressful life events (SLE) was found. Among mothers reporting more than five SLE in the past year, posttest anxiety was lower in the EG than in the CG, but no difference was found between EG and CG mothers having less than five SLE. The intervention also acted as a moderator variable, with correlations of SLE and posttest depression, anxiety, and total symptoms significantly lower in the EG than CG. Possible explanations for these findings are discussed.

Social-Emotional Screening for Infants and Toddlers in Primary Care

BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk. We aim to describe a program designed to identify the social-emotional status of young children in the pediatric setting by using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) as a universal screening tool, and to assess the effect of interventions by a colocated psychologist on changes in ASQ:SE scores over time. METHODS: In a prospective cohort design we analyzed scores on ASQ:SE surveys completed on children 6 to 36 months of age, to determine if children were at risk for problems in social-emotional development. The probability of remaining at risk over time was then compared between subjects receiving intervention by the psychologist, and those who declined intervention. Logit specifications were used in multivariate comparisons to control for a set of covariates. RESULTS: Three thousand one hundred and sixty-nine children were screened; 711 (22.4%) scored at or above the risk cutoff. Among the 711 at-risk children, 170 were rescreened. At the time of rescreening, those children who received intervention from the psychologist showed significant improvement on ASQ:SE scores compared with those who declined intervention (P = .01). CONCLUSIONS: Universal social-emotional screening in a busy pediatric practice is challenging. Significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of a psychologist promotes the ability to effectively address young children’s social-emotional development within their medical home.