Neal Halfon

Racial and ethnic disparities in birth outcomes: a life-course perspective.

Background: In the United States, Black infants have significantly worse birth outcomes than do White infants. The cause of these persisting racial disparities remains unexplained. Most extant studies focus on differential exposures to protective and risk factors during pregnancy, such as current socioeconomic status, maternal risky behaviors, prenatal care, psychosocial stress, or perinatal infections. These risk factors during pregnancy, however, do not adequately account for the disparities. Methods: We conducted a literature review for longitudinal models of health disparities, and presented a synthesis of two leading models, using a life-course perspective. Traditional risk factors during pregnancy are then reexamined within their life-course context. We conclude with a discussion of the limitations and implications of the life-course perspective for future research, practice, and policy development. Results: Two leading longitudinal models of health disparities were identified and discussed. The early programming model posits that exposures in early life could influence future reproductive potential. The cumulative pathways model conceptualizes decline in reproductive health resulting from cumulative wear and tear to the bodys allostatic systems. We propose a synthesis of these two models, using the life-course perspective. Disparities in birth outcomes are the consequences of differential developmental trajectories set forth by early life experiences and cumulative allostatic load over the life course. Conclusions: Future research on racial disparities in birth outcomes needs to examine differential exposures to risk and protective factors not only during pregnancy, but over the life course of women. Eliminating disparities requires interventions and policy development that are more longitudinally and contextually integrated than currently prevail.

Life course health development: an integrated framework for developing health, policy, and research.

The life course health development (LCHD) framework organizes research from several fields into a conceptual approach explaining how individual and population health develops and how developmental trajectories are determined by interactions between biological and environmental factors during the lifetime. This approach thus provides a construct for interpreting how peoples experiences in the early years of life influence later health conditions and functional status. By focusing on the relationship between experiences and the biology of development, the LCHD framework offers a better understanding of how diseases occur. By suggesting new strategies for health measurement, service delivery, and research, as well as for improving health outcomes, this framework also supports health care-purchasing strategies to develop health throughout life and to build human health capital.

Prevalence and impact of disabling chronic conditions in childhood.

OBJECTIVES This study provides a current national profile of the prevalence and impact of chronic conditions causing childhood disability. Disability is defined as a long-term reduction in ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition. METHODS A cross-sectional descriptive analysis was performed on data from 99513 children younger than 18 years who were included in the 1992-1994 National Health Interview Survey. The response rate exceeded 93% during each year. RESULTS A significant proportion of children, estimated at 6.5% of all US children, experienced some degree of disability. The most common causes of childhood disability were respiratory diseases and mental impairments. Prevalence of disability was higher for older children, boys, and children from low-income and single-parent families. Childhood disability is estimated to result in 66 million restricted activity days annually, including 24 million days lost from school. Furthermore, disability in childhood results in an added 26 million physician contacts and 5 million hospital days annually. CONCLUSIONS Childhood disability has profound impacts on children, the education system, and the health care system.

Access to health care for children with special health care needs.

Objective. To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. Methods. We analyzed data on 57 553 children younger than 18 years old included in the 1994–1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. Results. Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994–1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87.6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6.1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14.9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. Conclusions. This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.

Patterns of Comorbidity, Functioning, and Service Use for US Children With ADHD, 2007

OBJECTIVE: To determine patterns of comorbidity, functioning, and service use for US children with attention-deficit/hyperactivity disorder (ADHD). METHODS: Bivariate and multivariable cross-sectional analyses were conducted on data from the 2007 National Survey of Childrens Health on 61 779 children ages 6 to 17 years, including 5028 with ADHD. RESULTS: Parent-reported diagnosed prevalence of ADHD was 8.2%. Children with ADHD were more likely to have other mental health and neurodevelopmental conditions. Parents reported that 46% of children with ADHD had a learning disability versus 5% without ADHD, 27% vs 2% had a conduct disorder, 18% vs 2% anxiety, 14% vs 1% depression, and 12% vs 3% speech problems (all P < .05). Most children with ADHD had at least 1 comorbid disorder: 33% had 1, 16% had 2, and 18% had 3 or more. The risk for having 3 or more comorbidities was 3.8 times higher for poor versus affluent children (30% vs 8%). Children with ADHD had higher odds of activity restriction (odds ratio: 4.14 [95% confidence interval: 3.34–5.15]), school problems (odds ratio: 5.18 [95% confidence interval: 4.47–6.01]), grade repetition, and poor parent-child communication, whereas social competence scores were lower and parent aggravation higher. Functioning declined in a stepwise fashion with increasing numbers of comorbidities, and use of health and educational services and need for care coordination increased. CONCLUSIONS: Clinical management of ADHD must address multiple comorbid conditions and manage a range of adverse functional outcomes. Therapeutic approaches should be responsive to each childs neurodevelopmental profile, tailored to their unique social and family circumstances, and integrated with educational, mental health and social support services.

A National Profile of Childhood Epilepsy and Seizure Disorder

OBJECTIVE: To determine sociodemographics, patterns of comorbidity, and function of US children with reported epilepsy/seizure disorder. METHODS: Bivariate and multivariable cross-sectional analysis of data from the National Survey of Children’s Health (2007) on 91 605 children ages birth to 17 years, including 977 children reported by their parents to have been diagnosed with epilepsy/seizure disorder. RESULTS: Estimated lifetime prevalence of epilepsy/seizure disorder was 10.2/1000 (95% confidence interval [CI]: 8.7–11.8) or 1%, and of current reported epilepsy/seizure disorder was 6.3/1000 (95% CI: 4.9–7.8). Epilepsy/seizure disorder prevalence was higher in lower-income families and in older, male children. Children with current reported epilepsy/seizure disorder were significantly more likely than those never diagnosed to experience depression (8% vs 2%), anxiety (17% vs 3%), attention-deficit/hyperactivity disorder (23% vs 6%), conduct problems (16% vs 3%), developmental delay (51% vs 3%), autism/autism spectrum disorder (16% vs 1%), and headaches (14% vs 5%) (all P < .05). They had greater risk of limitation in ability to do things (relative risk: 9.22; 95% CI: 7.56–11.24), repeating a school grade (relative risk: 2.59; CI: 1.52–4.40), poorer social competence and greater parent aggravation, and were at increased risk of having unmet medical and mental health needs. Children with prior but not current seizures largely had intermediate risk. CONCLUSIONS: In a nationally representative sample, children with seizures were at increased risk for mental health, developmental, and physical comorbidities, increasing needs for care coordination and specialized services. Children with reported prior but not current seizures need further study to establish reasons for their higher than expected levels of reported functional limitations.

Foster care: an update.

OBJECTIVE To inform child and adolescent psychiatrists about the almost 500,000 children now residing in the American foster care system. This overview surveys the pediatric, developmental, and psychiatric needs of these children. METHOD Child and adolescent psychiatrists, pediatricians, a child welfare researcher, a social worker, and a psychologist developed a consensus paper from their experience with child welfare and a review of the literature in their respective fields. RESULTS Being in foster care is a defining experience in these childrens lives. They are at risk in myriad ways: for instance, being poor, having chronic health deficits, experiencing the trauma of abuse and neglect, and suffering from a gamut of emotional challenges. Evolutionary developments in foster care such as therapeutic foster homes, kinship care, and changes in Medicaid funding will continue to alter the system. CONCLUSIONS Foster children are a huge reservoir of unmet pediatric and psychiatric needs; research on them is spotty at best. It is hoped that child and adolescent psychiatrists will meet the challenges these youngsters present and will advocate for them.

Lifecourse health development: past, present and future.

During the latter half of the twentieth century, an explosion of research elucidated a growing number of causes of disease and contributors to health. Biopsychosocial models that accounted for the wide range of factors influencing health began to replace outmoded and overly simplified biomedical models of disease causation. More recently, models of lifecourse health development (LCHD) have synthesized research from biological, behavioral and social science disciplines, defined health development as a dynamic process that begins before conception and continues throughout the lifespan, and paved the way for the creation of novel strategies aimed at optimization of individual and population health trajectories. As rapid advances in epigenetics and biological systems research continue to inform and refine LCHD models, our healthcare delivery system has struggled to keep pace, and the gulf between knowledge and practice has widened. This paper attempts to chart the evolution of the LCHD framework, and illustrate its potential to transform how the MCH system addresses social, psychological, biological, and genetic influences on health, eliminates health disparities, reduces chronic illness, and contains healthcare costs. The LCHD approach can serve to highlight the foundational importance of MCH, moving it from the margins of national debate to the forefront of healthcare reform efforts. The paper concludes with suggestions for innovations that could accelerate the translation of health development principles into MCH practice.

Influence of Multiple Social Risks on Children's Health

OBJECTIVE. Social risk factors such as growing up in poverty, racial/ethnic minority status, and maternal depression have been associated with poorer health outcomes for children. This study examined the strength of association of 8 social risk factors, both individually and as part of a cumulative social risk index, on parent-reported child health status. METHODS. We performed an analysis of cross-sectional data from the 2003 National Survey of Childrens Health, a telephone survey of 102353 parents of children aged 0 to 17 years. In bivariate and multivariate logistic regression models, 8 social risk factors were tested as independent predictors of 4 parent-reported child health outcomes: global health status, dental health, socioemotional health, and overweight. These risk factors were combined into a categorical “social risk index” ranging from low risk (0 risk factors) to very high risk (≥6 risk factors), and risk gradients were examined using linear polynomial testing and multivariate logistic regression. RESULTS. The percentage of children in poorer health increased with the number of social risk factors across all health outcomes. More than half of children had ≥2 risk factors, and 24% had ≥4. Low maternal mental health, black or Hispanic race/ethnicity, <200% of the federal poverty level, low household education, unsafe neighborhoods, and lack of health insurance increased the odds for less than very good child health in adjusted models. CONCLUSIONS. Multiple social risk factors have a cumulative effect on parent-reported child health status across physical and socioemotional domains, demonstrating a very strong risk gradient effect. These findings emphasize the importance of addressing multiple levels of social risk to achieve improvements in child health.

Preventing low birth weight: is prenatal care the answer?

Objectives: To review the evidence of effectiveness of prenatal care for preventing low birth weight (LBW). Methods: We reviewed original research, systematic reviews, meta-analyses and commentaries for evidence of effectiveness of the three core components of prenatal care - risk assessment, health promotion and medical and psychosocial interventions - for preventing the two constituents of LBW: preterm birth and intrauterine growth restriction (IUGR). Results: Clinical risk assessment will fail to identify the majority of pregnancies at risk for preterm delivery or IUGR. While biophysical and biochemical modalities appear promising, their cost-effectiveness has not been demonstrated, nor can their routine use be recommended in the absence of effective interventions. Smoking cessation programs appear to be modestly effective. There is insufficient evidence to conclude a benefit for nutrition interventions, work counseling or preterm birth education. Only antenatal corticosteroid therapy has demonstrated a clear benefit in the tertiary prevention of preterm delivery. Interventions for which there is insufficient evidence to conclude a benefit include bed rest, hydration, sedation, cerclage, progesterone supplementation, antibiotic treatment, tocolysis without concomitant use of corticosteroids, thyrotropin-releasing hormone, psychosocial support and home visitation. Additionally, there is a paucity of evidence supporting the effectiveness of prenatal interventions, such as low-dose aspirin, bed rest, maternal hyperoxygenation, plasma volume expansion and antenatal fetal assessment, in preventing IUGR or its associated morbidity and mortality. Conclusions: Neither preterm birth nor IUGR can be effectively prevented by prenatal care in its present form. Preventing LBW will require reconceptualization of prenatal care as part of a longitudinally and contextually integrated strategy to promote optimal development of womens reproductive health not only during pregnancy, but over the life course.