Children's behavioral and mental health in primary care settings: A survey of self-reported comfort levels and practice patterns among pediatricians.

INTRODUCTION: Despite the well-documented youth mental health crisis, there has been a lag in the development of a specialized workforce to meet needs of young people experiencing these challenges. Little is known about the comfort of primary care pediatricians when faced with children and adolescents with mental health care concerns. METHOD: A brief online survey was conducted to assess patterns of behavioral and mental health concerns in pediatric practices affiliated with a pediatric health system in Alabama. The survey asked about frequency of conditions that providers encountered, comfort treating these conditions, and frequency of external referrals. RESULTS: Pediatric providers reported high volumes of children with mental health concerns and varying levels of comfort treating independently. Providers frequently refer externally. CONCLUSIONS: High rates of referrals could further stress an already overloaded system of specialty care. Interventions must be implemented to ensure a workforce prepared to meet the growing needs of youth requiring support for mental and behavioral health conditions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Telehealth utilization barriers among Alabama parents of pediatric patients during COVID-19 outbreak.

BACKGROUND: Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs. METHODS: This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above. RESULTS: Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child. CONCLUSIONS: This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

Telehealth use among pediatric Alabama Medicaid enrollees, March-December 2020: Variations by race/ethnicity & place of residence.

During the early days and months of the COVID-19 pandemic, healthcare facilities experienced a slump in non-COVID-related visits, and there was an increasing interest in telehealth to deliver healthcare services for adult and pediatric patients. The study investigated telehealth use variation by race/ethnicity and place of residence for the pediatric enrollees of the Alabama Medicaid program. This retrospective observational study examined Alabama Medicaid claims data from March to December 2020 for enrollees less than 19 years. There were 637,792 pediatric enrollees in the Alabama Medicaid program during the study period, and 16.9% of them had used telehealth to meet healthcare needs. This study employed a multivariate Poisson mixed-effects model with robust error variance to obtain differences in telehealth utilization and found that Non-Hispanic Black children were 80% as likely, Hispanic children were 55% as likely, and Asian Children were 46% as likely to have used telehealth compared to Non-Hispanic White children. Pediatric enrollees in large rural areas and isolated areas were significantly less likely (IRR: 0.90 for both, p<0.05) to use telehealth than those in urban areas. This study's findings suggest that attention needs to be paid to addressing race/ethnicity disparities in accessing telehealth services.

Social determinants of health and emergency department utilization in Alabama Children's Health Insurance Program.

OBJECTIVES: Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race. STUDY DESIGN: This was a retrospective, pooled cross-sectional analysis. METHODS: We used ALL Kids data to identify ED visits (injury and all-cause) among children who were enrolled at any time from 2015 to 2017. Exploratory factor analysis was used to categorize SDOH from 18 selected Census tract-level variables. Multilevel Poisson regression models were used to evaluate the effects of community and individual factors and their interactions. RESULTS: Census tract-level SDOH were grouped as low socioeconomic status (SES), urbanicity, and immigrant-density factors. Low SES and urbanicity factors were associated with ED visits (injury and all-cause). The low SES and urbanicity factors also moderated the association between race and ED visits (injury and all-cause). CONCLUSIONS: The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.

Creating a Virtual Meeting Platform Via Online Survey Tool: Leveraging Community Engagement Technology in the Early Days of COVID-19.

At the outset of the COVID-19 pandemic, Alabama's Title V Children and Youth with Special Health Care Needs (CYSHCN) team was forced to innovate in order to gather community input and to prioritize the findings of the 2020 Title V Maternal and Child Health Five-Year Comprehensive Needs Assessment. On a shortened timeline, the team pivoted from a full-day, in-person meeting of professionals and family representatives to an asynchronous, online "meeting" that included all planned and necessary content, allowed for comment by community members, and resulted in a prioritized list of needs. This needs assessment process showed that by using a platform like the online survey tool, Qualtrics, in an innovative way, programs can capture broader, more diverse perspectives without sacrificing quality of communication, content, or feedback. It shows the possibility for strengthening maternal and child health (MCH) systems and other systems of care though rich engagement. This model can be easily replicated in other survey tools, benefiting other states that are faced with difficulties convening geographically dispersed professionals and communities.

Classifying children with ASD by service utilization and treatment type: A cluster analysis of a nationally representative United States survey.

BACKGROUND: If there are patterns of the distribution of services and treatments across the population of people with ASD, these patterns should be based along clinical characteristics or other service needs and not sociodemographic characteristics unrelated to evidence-based care. We examined how individuals in a broad, nationally representative sample "grouped together" based on service utilization and services needed but not covered by insurance. By understanding various treatment patterns, clinicians, researchers, policymakers, and self-advocates and their families can better advocate for high-quality, evidence-based services to be provided equitably. METHODS: Using the 2011 Survey of Pathways to Diagnosis and Services, a cluster analysis was performed to explore patterns in this population based on medication use, private services use, school-based service use, and services not covered by insurance. Differences in clusters were then explored through multinomial logistic regression. RESULTS: Six clusters emerged, showing differences in the level of service/medication usage and insurance coverage. Differences across clusters were associated with the level of functional limitation and age at ASD diagnosis. Disparities by insurance type, functional limitation, and age at diagnosis exist among patterns of ASD service provision. CONCLUSIONS: Our analysis showed that intervention for children with ASD can be across several scales - high and low users of services (both private and school-based), high and low users of medications, and high and low levels of reported non-covered services. The differences were clustered in multiple ways. Further research should incorporate longitudinal and nationally representative data to explore these relationships further.

Disparities in Telehealth Utilization in a Population of Publicly Insured Children During the COVID-19 Pandemic.

Telehealth became a crucial vehicle for health care delivery in the United States during the COVID-19 pandemic. However, little research exists on inequities in telehealth utilization among the pediatric population. This study examines disparities in telehealth utilization in a population of publicly insured children. This observational, retrospective study used administrative data from Alabama's stand-alone Children's Health Insurance Program, ALL Kids. Rates of any telehealth use for March to December 2020 were examined. In addition-to capture lack of health care utilization-rates of having no medical claims were examined and compared with March to December 2019 and 2018. Multinomial logit models were estimated to investigate how telehealth use and having no medical claims (reference category: having medical claims but no telehealth) were associated with race/ethnicity, rural-urban residence, and family income. Of the 106,478 enrollees over March to December 2020, 13.4% had any telehealth use and 24.7% had no medical claims. The latter was greater than no medical claims in 2019 (19.5%) and 2018 (20.7%). Black and Hispanic children had lower odds of any telehealth use (odds ratio [OR]: 0.81, P < 0.01; OR: 0.68, P < 0.01) and higher odds of no medical claims (OR: 1.11, P < 0.05; OR: 1.73, P < 0.05) than non-Hispanic White children. Rural residents had lower odds of telehealth use than urban residents. Those in the highest family income-based fee group had higher odds of telehealth use than the lowest family income-based fee group. As telehealth will likely continue to play an important role in health care delivery, additional efforts/investments are required to ensure telehealth does not further exacerbate inequities in pediatric health care access.

Community-Level Social Determinants of Health and Well-Child Visits Among Alabama Medicaid Enrollees.

Well-child visits focus on health promotion and disease detection and are critical to the appropriate provision of care. Evidence has shown that participation in well-child visits is associated with various patient-level factors; however, there has been an increasing focus on the influence of community-level social determinants of health (SDoH). This study explored associations between well-child visits and community-level SDoH at the census tract level among children enrolled in Alabama Medicaid. Through this analysis, it is possible to understand the distribution of care among this underserved population in different geographic settings, thus identifying potential disparities and areas for targeted intervention. Using administrative data from 2015 to 2017 enrollees in Alabama Medicaid that have been geographically linked to information on urbanicity and poverty, logistic regressions (both in total and stratified by age group) were estimated with separate community-level urbanicity, poverty variables, and individual characteristics. The regressions were repeated using a combined urbanicity/poverty variable. Looking at urbanicity and poverty together, with the exception of the least urban areas, it was those living in census tracts where there was discordance in urbanicity and poverty that had the highest likelihood of receiving well-child visits compared with those in census tracts classified as medium poverty (all urbanicity levels). There is a positive effect for Medicaid enrollees in the middle tertile of urbanicity in areas of low and high poverty and in wealthier more urban areas. If poverty and urbanicity were explored separately, some of the nuances would not have been apparent.

Disruption of Pediatric Emergency Department Use during the COVID-19 Pandemic.

OBJECTIVES: There is evidence of substantial declines in pediatric emergency department (ED) utilization in the United States in the first several months of the coronavirus disease 2019 (COVID-19) pandemic. Less is known about whether utilization changed differentially for socioeconomically disadvantaged children. This study examined how changes in pediatric ED visits during the initial months of the COVID-19 pandemic differed by two markers of socioeconomic disadvantage: minoritized race (MR) (compared with non-Hispanic White [NHW]), and publicly insured (compared with privately insured). METHODS: This study used electronic medical records from a large pediatric ED for the period January to June 2020. Three time periods in 2020 were compared with corresponding time periods in 2019. Changes in overall visits, visits for MR versus NHW children, and Medicaid-enrolled versus privately insured children were considered, and changes in the acuity mix of ED visits and share of visits resulting in inpatient admits were inspected. RESULTS: Compared with 2019, total ED visits declined in time period (TP) 1 and TP2 of 2020 (54.3%, 48.9%). Declines were larger for MR children (57.3%, 57.8%) compared with NHW children (50.5%, 39.3%), and Medicaid enrollees (56.5%, 52.0%) compared with privately insured (48.3%, 39.0%). The MR children group experienced steeper percentage declines in high-acuity visits and visits, resulting in inpatient admissions compared with NHW children. In contrast, there was little evidence of difference between TP0s of 2019 and 2020. CONCLUSIONS: The role of socioeconomic disadvantage and the potential effects on pediatric ED visits during COVID-19 is understudied. Because disadvantaged children sometimes lack access to a usual source of health care, this raises concerns about unmet health needs and worsening health disparities.

Disparities by race and insurance-status in declines in pediatric ED utilization during the COVID19 pandemic.

Pediatric Emergency Department (ED) utilization in the U.S. saw large declines during the COVID19 pandemic. What is relatively unexplored is whether the extent of declines differed by race and insurance status. An observational study was conducted using electronic medical record (EMR) data from the largest pediatric ED in Alabama for 2020 and 2019. The four subgroups of interest were African-American (AA), Non-Hispanic White (NHW), privately insured (PRIVATE), and publicly insured or self-insured (PUBLIC-SELF). Percentage changes in the 7-day moving average between dates in 2020 and 2019 were computed for total and high-severity ED visits by subgroup. Trends in percentage changes were plotted. T-tests were used to compare mean changes between subgroups. Large percentage declines in total ED visits and somewhat smaller percentage declines in high-severity visits were observed from March 2020. Declines were consistently larger for AA than NHW and for PUBLIC-SELF than PRIVATE. T-test results indicated mean date-specific percentage declines were significantly larger for AA than NHW for total visits (-38.92% [95% CI: -41.1, -36.8] versus -29.11% [95% CI: -30.8, -27.4]; p<0.001) and high-severity visits (-24.31% [95% CI: -26.2, -22.4] versus -19.49% [95% CI:-21.2, -17.8]; p<0.001), and larger for PUBLIC-SELF than PRIVATE for total visits (-36.32% [95% CI:-38.4, -34.3] versus 27.63% [95% CI:-29.2, -26.0]; p<0.001) and high-severity visits (-21.72% [95% CI: -23.5, -19.9] versus -20.01% [95% CI: -21.7, -18.3]; p = 0.04). In conclusion, significant differences by race and insurance status were observed in the decline in ED visits during the COVID19 pandemic, including high-severity visits. Minority-race and publicly insured or self-insured children often depend on the ED for health needs, lacking a usual source of care. Thus, these findings have worrisome implications regarding unmet healthcare needs and future exacerbations in health disparities.

Infant Mortality among Adolescent Mothers in the United States: A 5-Year Analysis of Racial and Ethnic Disparities.

OBJECTIVE: This study was aimed to examine differences in infant mortality outcomes across maternal age subgroups less than 20 years in the United States with a specific focus on racial and ethnic disparities. STUDY DESIGN: Using National Center for Health Statistics cohort-linked live birth-infant death files (2009-2013) in this cross-sectional study, we calculated descriptive statistics by age (<15, 15-17, and 18-19 years) and racial/ethnic subgroups (non-Hispanic white [NHW], non-Hispanic black [NHB], and Hispanic) for infant, neonatal, and postneonatal mortality. Adjusted odds ratios (aOR) were calculated by race/ethnicity and age. Preterm birth and other maternal characteristics were included as covariates. RESULTS: Disparities were greatest for mothers <15 and NHB mothers. The risk of infant mortality among mothers <15 years compared to 18 to 19 years was higher regardless of race/ethnicity (NHW: aOR = 1.40, 95% confidence interval [CI]: 1.06-1.85; NHB: aOR = 1.28, 95% CI: 1.04-1.56; Hispanic: aOR = 1.36, 95%CI: 1.07-1.74). Compared to NHW mothers, NHB mothers had a consistently higher risk of infant mortality (15-17 years: aOR = 1.12, 95% CI: 1.03-1.21; 18-19 years: aOR = 1.21, 95% CI: 1.15-1.27), while Hispanic mothers had a consistently lower risk (15-17 years: aOR = 0.72, 95% CI: 0.66-0.78; 18-19 years: aOR = 0.74, 95% CI: 0.70-0.78). Adjusting for preterm birth had a greater influence than maternal characteristics on observed group differences in mortality. For neonatal and postneonatal mortality, patterns of disparities based on age and race/ethnicity differed from those of overall infant mortality. CONCLUSION: Although infants born to younger mothers were at increased risk of mortality, variations by race/ethnicity and timing of death existed. When adjusted for preterm birth, differences in risk across age subgroups declined and, for some racial/ethnic groups, disappeared. KEY POINTS: · Infant mortality risk was highest for adolescents <15 years old across racial/ethnic groups.. · Racial/ethnic disparities in timing of death were present even among the youngest adolescents.. · Infants of NHB adolescents had greatest risk of mortality, especially as age increased.. · Preterm birth influenced infant mortality risk, especially among NHB adolescents..

Testing a Tailored Social-Ecological Model for Autism Spectrum Disorders.

OBJECTIVE: To propose a tailored social ecological model for Autism Spectrum Disorders and explore relationships between variables in a large nationally-representative dataset. METHODS: A tailored social-ecological model was developed and examined across variables in the 2016/2017 National Survey of Children's Health. A series of iterative multivariable logistic regressions were performed including individual, family, and community/neighborhood variables. A multivariable logistic regression using state-level fixed effects was performed to understand dynamics related to macro-level policies. RESULTS: In the full model, gender, disability severity, certain types of insurance coverage and household income were significantly related to ASD diagnosis. Females had lower odds of a diagnosis compared to males (aOR: 0.27; CI:0.18-0.41). Children with at least one other moderate/severe disability had odds 7.61 higher (CI:5.36-10.82) of a diagnosis than children without moderate/severe disabilities. Children with public insurance only (aOR:1.66; CI:1.14-2.41) or both private and public insurance coverage (aOR: 2.62; CI:1.6-4.16) had higher odds of a diagnosis compared to children with private insurance only. For those who reported it was "somewhat" or "very often" hard to cover basics with their income, odds of a diagnosis were higher compared to those who reported it was "never" or "hardly ever" hard to cover basics (aOR: 1.676; CI:0.21-2.56). CONCLUSIONS FOR PRACTICE: Patterns of ASD diagnosis are related to individual and family characteristics. There is some evidence that a child's environment has some relationship to reported ASD diagnosis. Professionals should be aware of an individual's environmental factors or context when assessing for ASD.

Evaluation of the Feasibility and Perceived Value of Integrating Learn the Signs. Act Early. Developmental Monitoring Resources in Early Head Start.

Many children with developmental disabilities are not identified before age 3 years old preventing them from being able to fully benefit from early intervention services. Early childhood educators, particularly those in Early Head Start (EHS) programs, are important partners in the early identification of children with developmental delays. Learn the Signs. Act Early. (LTSAE) is a program of the U.S. Centers for Disease Control and Prevention that provides free developmental monitoring resources to increase the early identification of children with developmental delays and disabilities. This paper presents findings from the first evaluation of the use of LTSAE resources in EHS, which was conducted across four states and 11 EHS programs from fall 2018 through spring 2019. Surveys (n=448) and interviews (n=39) with EHS management, staff, and parents indicated that LTSAE resources were valued and accepted, and their use in EHS considered feasible. Importantly, families and staff reported the LTSAE materials provided shared language to help them more effectively discuss development. These findings inform EHS and other early education programs that wish to enhance developmental monitoring, screening, and referral.

The weathering hypothesis and stillbirth: racial disparities across the life span.

Objective: Given that studies have consistently demonstrated increased risk of stillbirth with increasing maternal age as well as race-ethnic disparities in stillbirth, the primary research question is how stillbirth risks within and between race-ethnic groups change with age.Design: Using fetal death (stillbirth) and live birth data from the National Center for Health Statistics 2007-2014. We calculated crude stillbirth rates (per 1,000 deliveries). Using multivariable logistic regression, we calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for stillbirth across age groups to examine disparities in stillbirth among non-Hispanic blacks (blacks) and non-Hispanic whites (whites).Results: Rates and risks of stillbirth increased as maternal age increased; however, the magnitude of risk varies by race-ethnicity. Compared to women less than 20, black women age 40+ had a risk of almost 3.5 times (aOR = 3.47, 95% CI = 3.24-3.70) whereas among white women age 40+, the risk was more than 2.5 times (aOR = 2.68, 95% CI = 2.55-2.82). The risk of stillbirth among blacks compared to whites increased, peaking at ages 30-34 (aOR = 2.64, 95% CI = 2.56-2.73). At age 35 and beyond, the disparity in risks declined.Conclusion: As age increased, the risk of stillbirth increased for both blacks and whites. Because the disparity in risk between blacks and whites did not continue to increase with age, stillbirth does not seem to reflect the weathering hypothesis as other perinatal outcomes do.

Why Is the U.S. Preterm Birth Rate So Much Higher Than the Rates in Canada, Great Britain, and Western Europe?

The portion of newborns delivered before term is considerably higher in the United States than in other developed countries. We compare the array of risk exposures and protective factors common to women across national settings, using national, regional, and international databases, review articles, and research reports. We find that U.S. women have higher rates of obesity, heart disease, and poor health status than women in other countries. This is in part because more U.S. women are exposed to the stresses of racism and income disparity than women in other national settings, and stress loads are known to disrupt physiological functions. Pregnant women in the United States are not at higher risk for preterm birth because of older maternal age or engagement in high-risk behaviors. However, to a greater extent than in other national settings, they are younger and their pregnancies are unintended. Higher rates of multiple gestation pregnancies, possibly related to assisted reproduction, are also a factor in higher preterm birth rates. Reproductive policies that support intentional childbearing and social welfare policies that reduce the stress of income insecurity can be modeled from those in place in other national settings to address at least some of the elevated U.S. preterm birth rate.

Disparities in Infant Mortality by Race Among Hispanic and Non-Hispanic Infants.

OBJECTIVES: U.S.-born Hispanic infants have a well-documented health advantage relative to other minority groups. However, little published research has examined racial heterogeneity within the Hispanic population, in relation to health outcomes. The current study aims to explore possible implications of racial identification for the health of U.S. born Hispanic compared to non-Hispanic infants. Methods Data were drawn from 2007 to 2008 NCHS Cohort Linked Live Birth-Infant Death Files, restricted to deliveries of Hispanic black, Hispanic white, non-Hispanic black (NHB) and non-Hispanic white mothers (NHW) (n = 7,901,858). Adjusted odds ratios for first week mortality, neonatal, postneonatal, and overall infant mortality were calculated for each group, using NHW as the reference group. RESULTS: A distinct health gradient was observed in which NHB infants (n = 1,250,222) had the highest risk of first week (aOR 2.29, CI 2.21-2.37), neonatal (aOR 2.23, CI 2.17-2.30), postneonatal (aOR 1.74, CI 1.68-1.81), and infant mortality (aOR 2.05, CI 2.00-2.10) compared to NHW infants (n = 4,578,150). Hispanic black infants (n = 84,377) also experienced higher risk of first-week (aOR 1.28 (1.12-1.47), neonatal (aOR .27, CI 1.13-1.44), postneonatal (aOR 1.34, CI 1.15-1.56), and infant mortality (aOR 1.30, CI 1.18-1.43) compared to both NHW and Hispanic white infants (n = 1,989,109). Conclusions for Practice: Risk of infant mortality varies among Hispanic infants by race, with poorer outcomes experienced by Hispanic black infants. Compared to non-Hispanic infants of the same race, Hispanic black infants experience a smaller health disadvantage and Hispanic white infants have better or similar infant health outcomes. Our findings suggest implications of racial heterogeneity on infant health outcomes, and provide insight into the role of race as a social construct.