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1.
Acad Pediatr ; 24(2): 267-276, 2024 Mar.
Article in English | MEDLINE | ID: mdl-37981260

ABSTRACT

BACKGROUND: Parents of children with special health care needs (CSHCN) are at risk of poorer health outcomes. Material hardships also pose significant health risks to parents. Little is known about how protective factors may mitigate these risks and if effects are similar between mothers and fathers. METHODS: This was a cross-sectional survey study conducted using the US 2018/2019 National Survey of Children's Health, including parents of children 0 to 17 with income <200% of the federal poverty level. Separately, for parents of children with and without special health care needs (N-CSHCN), weighted logistic regression measured associations between material hardship, protective factors (family resilience, neighborhood cohesion, and receipt of family-centered care), and 2 outcomes: mental and physical health of mothers and fathers. Interactions were assessed between special health care needs status, material hardship, and protective factors. RESULTS: Sample consisted of parents of 16,777 children; 4440 were parents of CSHCN. Most outcomes showed similar associations for both mothers and fathers of CSHCN and N-CSHCN: material hardship was associated with poorer health outcomes, and family resilience and neighborhood cohesion associated with better parental health outcomes. Family-centered care was associated with better health of mothers but not fathers. Interaction testing showed that the protective effects of family resilience were lower among fathers of CSHCN experiencing material hardship. CONCLUSIONS: Family resilience and neighborhood cohesion are associated with better health outcomes for all parents, though these effects may vary by experience of special health care needs, parent gender, and material hardship.


Subject(s)
Disabled Children , Resilience, Psychological , Child , Female , Humans , Child Health , Cross-Sectional Studies , Family Health , Protective Factors , Health Services Accessibility , Health Services Needs and Demand
2.
Acad Pediatr ; 23(4): 773-781, 2023.
Article in English | MEDLINE | ID: mdl-36272724

ABSTRACT

OBJECTIVE: To examine the association of 1) extrinsic resilience factors and 2) adverse childhood experiences (ACEs) with a caregiver reported diagnosis of depression in a nationally representative sample of adolescents. METHODS: A cross sectional analysis of the 2016-2017 National Survey of Children's Health, restricted to adolescents 12 to 17 years old was conducted. The dependent variable was caregiver reported depression: no current diagnosis vs. current diagnosis of depression. Independent variables were reported ACEs dichotomized as lower (0-3) or higher (4 or more), and specific resilience factors: family resilience, neighborhood cohesion and caregiver emotional support. Resilience factors were analyzed as a composite score dichotomized as lower (0-3) or higher (4 or more) and individually. Purposeful selection multivariable logistic regression model building was used to estimate the associations between reported diagnosis of depression, ACEs and resilience factors adjusting for demographic covariates. RESULTS: Study sample consisted of 29,617 (weighted N = 24,834,232) adolescents, 6% with current reported diagnosis of depression, 8% with higher ACEs and 91% with higher resilience. Family resilience, neighborhood cohesion and caregiver emotional supports were each independently associated with lower odds of reported diagnosis of depression. However, with all resilience factors in the model, only family resilience and neighborhood cohesion (specifically school safety) remained significantly associated with lower odds of reported diagnosis of depression. CONCLUSION(S): In this nationally representative sample, family resilience and neighborhood cohesion were associated with lower odds of a reported diagnosis of depression even with confounding ACEs exposure. These factors may be important targets for future intervention.


Subject(s)
Adverse Childhood Experiences , Resilience, Psychological , Child , Humans , Adolescent , Depression/epidemiology , Cross-Sectional Studies , Family Health , Parents
6.
Infect Control Hosp Epidemiol ; 43(8): 1036-1042, 2022 08.
Article in English | MEDLINE | ID: mdl-34376267

ABSTRACT

BACKGROUND: Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes. METHODS: We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI. RESULTS: In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage. CONCLUSIONS: Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.


Subject(s)
Ambulatory Surgical Procedures , Surgical Wound Infection , Ambulatory Surgical Procedures/adverse effects , Child , Humans , Incidence , Retrospective Studies , Risk Factors , Surgical Wound Infection/epidemiology , Surgical Wound Infection/etiology
7.
Acad Pediatr ; 22(3): 422-430, 2022 04.
Article in English | MEDLINE | ID: mdl-34389516

ABSTRACT

OBJECTIVE: Adolescents and young adults (AYA) with sickle cell disease (SCD) experience high rates of acute care utilization and increased morbidity. At this high-risk time, they also face the need to transition from pediatric to adult services, which, if poorly coordinated, adds to heightened morbidity and acute care utilization. The study objective was to characterize the feasibility, acceptability, and short-term efficacy of a protocolized transition navigator (TN) intervention in AYA with SCD. METHODS: We developed a protocolized TN intervention that used ecological assessment and motivational interviewing to assess transition readiness, identify goals, and remove barriers to transition, and to provide disease and pain management education and skills to AYAs with SCD. RESULTS: Ninety-three percent (56/60) of enrolled individuals completed the intervention. Participation in the TN program was associated with significant improvement in mean transition readiness scores (3.58-4.15, P < .0001), disease knowledge scale (8.91-10.13, P < .0001), Adolescent Medication Barriers Scale (40.05-35.39, P = .003) and confidence in both disease (22.5-23.96, P = .048) and pain management (25.07-26.61, P = .003) for youth with SCD. CONCLUSION: The TN intervention was acceptable to youth with SCD, feasible to implement at an urban academic medical center, and addressed barriers to transition identified by the youth. Longer-term assessment is needed to determine if the TN intervention improved successful transfer to and retention in adult care.


Subject(s)
Anemia, Sickle Cell , Transition to Adult Care , Academic Medical Centers , Adolescent , Anemia, Sickle Cell/therapy , Child , Humans , Young Adult
8.
Pediatrics ; 148(6)2021 12 01.
Article in English | MEDLINE | ID: mdl-34814175

ABSTRACT

BACKGROUND: Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS: This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS: A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS: CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.


Subject(s)
Bacteremia/therapy , Catheter-Related Infections/therapy , Catheterization, Central Venous , Central Venous Catheters , Salvage Therapy/methods , Adolescent , Ambulatory Care , Bacteremia/microbiology , Candidemia/epidemiology , Catheter-Related Infections/microbiology , Catheterization, Central Venous/adverse effects , Central Venous Catheters/adverse effects , Child , Child, Preschool , Device Removal , Female , Hospitals, Pediatric , Humans , Infant , Infant, Newborn , Male , Regression Analysis , Retrospective Studies , Salvage Therapy/statistics & numerical data , Time Factors , Treatment Failure , Treatment Outcome , Young Adult
9.
Pediatrics ; 147(1)2021 01.
Article in English | MEDLINE | ID: mdl-33386333

ABSTRACT

BACKGROUND: Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. METHODS: Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. RESULTS: Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). CONCLUSIONS: Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.


Subject(s)
Ambulatory Care , Catheter-Related Infections/epidemiology , Catheterization, Central Venous/adverse effects , Central Venous Catheters/adverse effects , Sepsis/epidemiology , Academic Medical Centers , Antibiotic Prophylaxis/adverse effects , Case-Control Studies , Child , Cohort Studies , Hospitalization/statistics & numerical data , Humans , Incidence , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Risk Factors , Serum Albumin/analysis , United States/epidemiology , Urban Population
11.
Infect Control Hosp Epidemiol ; 41(11): 1292-1297, 2020 11.
Article in English | MEDLINE | ID: mdl-32880250

ABSTRACT

OBJECTIVE: Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN: Retrospective case-control study. SETTING: Four academic medical centers. PATIENTS: Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS: Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS: Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS: Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.


Subject(s)
Catheter-Related Infections , Cross Infection , Pneumonia, Ventilator-Associated , Sepsis , Surgical Wound Infection , Urinary Tract Infections , Case-Control Studies , Catheter-Related Infections/economics , Catheters , Child , Delivery of Health Care , Health Care Costs , Humans , Retrospective Studies , Surgical Wound Infection/economics , Urinary Tract Infections/economics
12.
Public Health Rep ; 135(4): 442-451, 2020.
Article in English | MEDLINE | ID: mdl-32639897

ABSTRACT

OBJECTIVES: Coordinated measurement strategies are needed to inform collaborative approaches to improve access to and quality of care for persons with sickle cell disease (SCD). The objective of our study was to develop a multilevel measurement strategy to assess improvements in access to and quality of care for persons with SCD in 4 US regions. METHODS: From 2014 through 2017, regional grantees in the Sickle Cell Disease Treatment Demonstration Program collected administrative and patient-level electronic health record (EHR) data to assess quality improvement initiatives. Four grantees-covering 29 US states and territories and an SCD population of 56 720-used a collective impact model to organize their work. The grantees collected administrative data from state Medicaid and Medicaid managed care organizations (MCOs) at multiple points during 2014-2017 to assess improvements at the population level, and local patient-level data were abstracted from site-level EHRs at regular intervals to track improvements over time. RESULTS: Administrative data were an important source of understanding population-level improvements but were delayed, whereas patient-level data were more sensitive to small-scale quality improvements. CONCLUSIONS: We established a shared measurement approach in partnership with Medicaid and Medicaid MCO stakeholders that can be leveraged to effectively support quality improvement initiatives for persons with SCD in the United States.


Subject(s)
Anemia, Sickle Cell/therapy , Delivery of Health Care/statistics & numerical data , Delivery of Health Care/standards , Practice Guidelines as Topic , Quality Improvement/statistics & numerical data , Quality Improvement/standards , Humans , United States/epidemiology
14.
Infect Control Hosp Epidemiol ; 41(8): 891-899, 2020 08.
Article in English | MEDLINE | ID: mdl-32498724

ABSTRACT

OBJECTIVE: Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI. DESIGN: Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors. SETTING: Five urban, academic medical centers, part of the New York City Clinical Data Research Network. PATIENTS: Potential patients were age <22 years who were seen between October 2010 and September 2015. RESULTS: In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1-6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics. CONCLUSIONS: Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.


Subject(s)
Catheter-Related Infections , Cross Infection , Urinary Tract Infections , Adult , Case-Control Studies , Catheter-Related Infections/epidemiology , Catheters, Indwelling/adverse effects , Child , Humans , Incidence , Retrospective Studies , Risk Factors , Urinary Catheterization , Urinary Tract Infections/epidemiology , Urinary Tract Infections/etiology , Young Adult
16.
Pediatrics ; 145(2)2020 02.
Article in English | MEDLINE | ID: mdl-31949000

ABSTRACT

BACKGROUND: Material hardship has been associated with adverse health care use patterns for children with special health care needs (CSHCN). In this study, we assessed if resilience factors were associated with lower emergency department (ED) visits and unmet health care needs and if they buffered associations between material hardship and health care use for CSHCN and children without special health care needs. METHODS: A cross-sectional study using the 2016 National Survey of Children's Health, restricted to low-income participants (<200% federal poverty level). Separately, for CSHCN and children without special health care needs, weighted logistic regression was used to measure associations between material hardship, 2 resilience factors (family resilience and neighborhood cohesion), and 2 measures of use. Moderation was assessed using interaction terms. Mediation was assessed using structural equation models. RESULTS: The sample consisted of 11 543 children (weighted: n = 28 465 581); 26% were CSHCN. Material hardship was associated with higher odds of ED visits and unmet health care needs for all children. Resilience factors were associated with lower odds of unmet health care needs for CSHCN (family resilience adjusted odds ratio: 0.58; 95% confidence interval: 0.36-0.94; neighborhood cohesion adjusted odds ratio: 0.53; 95% confidence interval: 0.32-0.88). For CSHCN, lower material hardship mediated associations between resilience factors and unmet health care needs. Neighborhood cohesion moderated the association between material hardship and ED visits (interaction term: P = .02). CONCLUSIONS: Among low-income CSHCN, resilience factors may buffer the effects of material hardship on health care use. Future research should evaluate how resilience factors can be incorporated into programs to support CSHCN.


Subject(s)
Disabled Children , Emergency Service, Hospital/statistics & numerical data , Health Services Needs and Demand/statistics & numerical data , Poverty/psychology , Resilience, Psychological , Adolescent , Child , Child, Preschool , Confidence Intervals , Cross-Sectional Studies , Disabled Children/statistics & numerical data , Family/psychology , Female , Humans , Male , Needs Assessment , Odds Ratio , Residence Characteristics , Risk Factors
17.
Acad Pediatr ; 19(7): 733-739, 2019.
Article in English | MEDLINE | ID: mdl-30853575

ABSTRACT

OBJECTIVE: Material hardships, defined as difficulty meeting basic needs, are associated with adverse child health outcomes, including suboptimal health care utilization. Children with special health care needs (CSHCN) may be more vulnerable to the effects of hardships. Our objective was to determine associations between material hardships and health care utilization among CSHCN. METHODS: We conducted a cross-sectional study surveying caregivers of 2- to 12-year-old CSHCN in a low-income, urban area. Independent variables were parent-reported material hardships: difficulty paying bills, food insecurity, housing insecurity, and health care hardship. Dependent variables were parent-reported number of emergency department (ED) visits, any hospital admission, and any unmet health care need. We used negative binomial and logistic regression to assess for associations between each hardship and each outcome. RESULTS: We surveyed 205 caregivers between July 2017 and May 2018 and analyzed the data in 2018. After adjustment, difficulty paying bills (incidence rate ratio [IRR], 1.51; 95% confidence interval [CI], 1.08-2.12) and health care hardship (IRR, 1.72; 95% CI, 1.08-2.75) were associated with higher rates of ED visits. There were no associations between hardships and hospital admission. Difficulty paying bills (adjusted odds ratio [AOR], 2.13; 95% CI, 1.14-3.98), food insecurity (AOR, 1.95; 95% CI, 1.02-3.71), and housing insecurity (AOR, 2.71; 95% CI, 1.36-5.40) were associated with higher odds of unmet health care need. CONCLUSIONS: Material hardships were associated with higher rates of ED visits and greater unmet health care need among low-income CSHCN. Future examination of the mechanisms of these associations is needed to enhance support for families of CSHCN.


Subject(s)
Emergency Service, Hospital/statistics & numerical data , Health Services Accessibility/statistics & numerical data , Hospitalization/statistics & numerical data , Patient Acceptance of Health Care/statistics & numerical data , Poverty/statistics & numerical data , Adult , Child , Child, Preschool , Cross-Sectional Studies , Facilities and Services Utilization , Female , Humans , Male
18.
J Pediatr Hematol Oncol ; 41(1): 56-63, 2019 01.
Article in English | MEDLINE | ID: mdl-30044352

ABSTRACT

National evidence-based guidelines recommend offering hydroxyurea to patients with sickle cell anemia 9 months of age and older using shared decision making, but offer no strategies to aid implementation. We developed a hydroxyurea multicomponent decision aid via a needs assessment, clinic observations, and iterative feedback to address parent decision needs and promote a discussion between clinicians and parents. A total of 75 parents and 28 clinicians participated across all phases. The decision aid was rated as useful. Hydroxyurea knowledge improved and decisional conflict decreased supporting the potential for use to facilitate shared decision making in pediatric sickle cell anemia.


Subject(s)
Anemia, Sickle Cell/drug therapy , Decision Making , Hydroxyurea/administration & dosage , Patient Education as Topic , Adolescent , Adult , Child , Child, Preschool , Female , Humans , Infant , Male , Middle Aged , Parents
19.
20.
Acad Pediatr ; 18(8): 897-904, 2018.
Article in English | MEDLINE | ID: mdl-29729425

ABSTRACT

OBJECTIVE: Prenatal maternal stresses have been associated with infant temperament patterns linked to later behavioral difficulties. Material hardships, defined as inability to meet basic needs, are important prenatal stressors. Our objective was to determine the associations between prenatal material hardships and infant temperament at 10 months. METHODS: This was a longitudinal study of mother-infant pairs in a randomized controlled trial of a primary care-based early obesity prevention program (Starting Early). Independent variables representing material hardship were: housing disrepair, food insecurity, difficulty paying bills, and neighborhood stress (neighborhood safety). Dependent variables representing infant temperament were assessed using questions from 3 subscales of the Infant Behavior Questionnaire: orienting/regulatory capacity, negative affect, and surgency/extraversion. We used linear regression to investigate associations between individual and cumulative hardships and each temperament domain, adjusting for confounders, and testing for depression as a moderator. RESULTS: Four hundred twelve mother-infant pairs completed 10-month assessments. Thirty-two percent reported food insecurity, 26% difficulty paying bills, 35% housing disrepair, and 9% neighborhood stress. In adjusted analyses, food insecurity was associated with lower orienting/regulatory capacity scores (ß = -0.25; 95% confidence interval [CI], -0.47 to -0.04), as were neighborhood stress (ß = -0.50; 95% CI, -0.83 to -0.16) and experiencing 3 to 4 hardships (compared with none; ß = -0.54; 95% CI, -0.83 to -0.21). For neighborhood stress, the association was stronger among infants of mothers with prenatal depressive symptoms (interaction term P = .06). CONCLUSION: Prenatal material hardships were associated with lower orienting/regulatory capacity. These findings support the need for further research exploring how temperament relates to child behavior, and for policies to reduce prenatal material hardships.


Subject(s)
Economic Status , Food Supply , Orientation , Prenatal Exposure Delayed Effects , Self-Control , Stress, Psychological , Temperament , Adult , Depression , Female , Hispanic or Latino , Housing , Humans , Infant , Linear Models , Longitudinal Studies , Male , Mothers , Patient Health Questionnaire , Poverty , Pregnancy , Residence Characteristics , Safety , Young Adult
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