"When You Look at This Chart, That Is Not My Whole Life": Caregiver Perspectives to Inform Improved Primary Care Practice and Outcomes.

OBJECTIVE: Worsening rates of infant and maternal mortality in the United States serve as an urgent call for multi-modal intervention. Infant Well Child Visits (WCVs) provide an opportunity for prevention, however not all infants receive the recommended schedule of visits, with infants of low-income and Black families missing a higher portion of WCVs. Due to diverse experiences and needs of under-resourced communities throughout the United States, caregiver voice is essential when designing improvement efforts. METHODS: Purposeful sampling and interviewing of 10 caregivers in Cincinnati, OH was performed by community peer researchers. Interview transcripts were evaluated by the research team, with identification of several important themes. RESULTS: Nine out of 10 caregivers self-identified as Black. All young children of the interviewed caregivers had Medicaid as their insurance provider. All interviews highlighted rich perspectives on caregiver hopes for their child, family, and selves. Establishing trust through empathy, shared decision making, and the nurturing of interpersonal patient-practitioner relationships is crucial for fostering a positive healthcare experience. Levels of mistrust was perceptibly high across several interviews, with lack of racial concordance between medical provider and family exacerbating the issue for some caregivers. Caregivers voiced a tendency to rely on family and community members for when to seek out health care for their children, and additionally cited racism and perceptions of being rushed or judged as barriers to seeking further care. CONCLUSION: This study emphasizes the importance of being community-informed when considering interventions. Prior research on the topic of missed WCV's often focused on material resource availability and limitations. While that was commented on by caregivers in this study as well, equal-if not more-attention was directed toward interpersonal relationship formation, the presence or absence of trust between practitioner and caregiver, and the importance of social-emotional support for caregivers. We highlight several opportunities for systemic improvements as well as future directions for research.

Reducing WIC Administrative Burdens to Promote Health Equity.

This Viewpoint discusses barriers to Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation for low-income and racial and ethnic minoritized families and outlines strategies that health care professionals and health systems can use to help families overcome these barriers.

Early Literacy Developmental Activities and Pre-Kindergarten Learning Skills in the Context of Childhood Adversity.

OBJECTIVE: School readiness (SR) encompasses a wide range of skills that affect children's ability to succeed in school and later in life. Shared reading is an important strategy that assists children in gaining SR skills, whereas adverse childhood experiences (ACEs) negatively affect a child's SR. This study assessed if early literacy developmental activities (shared reading, singing, or storytelling) were associated with improved SR among children with and without ACEs. METHODS: 2020-2021 National Survey of Children's Health data were used for analysis. We identified children aged 3-5 years to assess their exposure to ACEs, participation in reading/storytelling/singing, and overall SR. RESULTS: In a sample of 17,545 children, 29% of children were exposed to one or more ACEs. Seventy-seven percent of children with no ACEs received daily early literacy developmental activities compared to 23% of children who experienced any ACE. On ordinal logistic regression, daily early literacy developmental activities were associated with 56% greater odds of higher SR among children not exposed to ACEs (OR: 1.56; 95% CI: 1.29, 1.88; P < .01). Among children exposed to ACEs, daily early literacy developmental activities were also associated with higher SR (OR: 1.50; 95% CI: 1.06, 2.13; P = .02). CONCLUSIONS: Shared reading, storytelling, and singing are associated with improved SR in both children who have and have not been exposed to ACEs. However, children exposed to ACEs had fewer experiences with early literacy developmental activities. Future efforts should address the barriers that limit shared reading, singing, or storytelling for children exposed to ACEs.

Household Health-Related Social Needs in Newborns and Infant Behavioral Functioning at 6 Months.

Importance: Dysfunctional patterns of behavior during infancy can predict the emergence of mental health disorders later in childhood. The Baby Pediatric Symptom Checklist (BPSC) can identify indicators of behavioral disorders among children aged 0 to 18 months. Understanding the association of early health-related social needs (HRSNs) with poor infant behavioral functioning can inform interventions to promote early childhood mental well-being. Objective: To examine the association between household HRSNs in the first 4 months of life and BPSC results at 6 months. Design, Setting, and Participants: This was a retrospective cohort analysis of longitudinal electronic health record data. Covariates were selected based on the biopsychosocial ecological model. Logistic regression analyses examined the association of HRSN domains and the number of HRSNs with the 6-month BPSC outcomes. Participants were recruited from 6 primary care clinics within 1 health system. Children aged 5 to 8 months who were evaluated for 6-month well-child visits between March 30, 2021, and June 30, 2022, were included in the study. Exposure: Responses to the first HRSN screening tool that a caregiver completed for infants between 0 and 4 months of age. HRSN domains were examined individually and as the number of positive HRSNs. Main Outcome and Measures: BPSC screen identified for clinical review due to 1 or more elevated subscales (inflexibility, irritability, and difficulty with routines) at 6 months. Results: A total of 1541 children (mean [SD] age, 6.1 [0.5] months; 775 female [50.3%]) were included in the study. A total of 405 children (26.3%) had a BPSC screen identified for clinical review, and 328 caregivers (21.3%) reported at least 1 HRSN. Food insecurity (174 [11.3%]) and benefits issues (169 [11.0%]) were the most frequently reported HRSN. Children in households with food insecurity had statistically significant higher odds of inflexibility (adjusted odds ratio [aOR], 1.73; 95% CI, 1.14-2.63), difficulty with routines (aOR, 1.64; 95% CI, 1.05-2.57), and irritability (aOR, 1.86; 95% CI, 1.13-3.08) than children in households without food insecurity. Children in households with benefits issues had statistically significant higher odds of difficulty with routines (aOR, 1.70; 95% CI, 1.10-2.65) and irritability (aOR, 1.70; 95% CI, 1.03-2.82). Children in households with 2 or more HRSNs had consistently higher odds of having a BPSC screen identified for clinical review (aOR, 2.16; 95% CI, 1.38-3.39) compared with children with no HRSNs. Conclusions and Relevance: Results of this cohort study suggest that household food insecurity, benefits issues, and the number of HRSNs were significantly associated with a BPSC screen identified for clinical review at 6 months of age. These findings highlight the urgency of intervening on HRSNs in the newborn period to prevent adverse infant behavioral outcomes.

Behavior Problems in Low-Income Young Children Screened in Pediatric Primary Care.

Importance: Screening of behavior problems in young children in pediatric primary care is essential to timely intervention and optimizing trajectories for social-emotional development. Identifying differential behavior problem trajectories provides guidance for tailoring prevention and treatment. Objective: To identify trajectories of behavior problems in children 2 to 6 years of age screened in pediatric primary care. Design, Setting, and Participants: This retrospective cohort study identified trajectories of behavior problems and demographic and clinical correlates. Data were collected as part of routine care in 3 pediatric primary care offices and 3 school-based health centers in Ohio serving a primarily low-income population. In total, 15 218 children aged 2 to 6 years with well-child visits between July 13, 2016, and January 31, 2022, were included. Exposure: Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) at annual well-child visits. Main Outcomes and Measures: Trajectory groups were identified using latent growth mixture modeling of SDQ total difficulties scores, and relative risk ratio (RRR) of various demographic (eg, race) and clinical (eg, depression in caregiver) variables were assessed by multinomial logistic regression analysis. Results: Of 15 281 children (51.3% males), 10 410 (68.1%) were African American or Black, 299 (2.0%) were Asian, 13 (0.1%) were American Indian or Alaska Native, 876 (5.7%) were multiracial, 26 (0.2%) were Native Hawaiian and Other Pacific Islander, 2829 (18.5%) were White, and 39 (0.02%) were categorized as other. In addition, 944 (6.2%) identified as Hispanic and 14 246 (93.2%) as non-Hispanic. Four behavior problem trajectory groups reflecting severity were identified: low-stable (LS; 10 096 [66.1%]), moderate-decreasing (MD; 16.6%), low-increasing (LI; 13.1%), and high-increasing (HI; 4.3%). Relative to the LS group, patients in each elevated group were more likely to be male (HI RRR, 1.87 [95% CI, 1.55-2.26]; MD RRR, 1.55 [95% CI, 1.41-1.71]; and LI RRR, 1.94 [95% CI, 1.70-2.21]), White (HI RRR, 2.27 [95% CI, 1.83-2.81]; MD RRR, 1.28 [95% CI, 1.13-1.45]; and LI RRR, 1.54, [95% CI, 1.32-1.81]), publicly insured (HI RRR, 0.49 [95% CI, 0.28-0.84]; MD RRR, 0.56 [95% CI, 0.43-0.73]; and LI RRR, 0.50 [95% CI, 0.35-0.73]), have a social need (HI RRR, 3.07 [95% CI, 2.53-3.73]; MD RRR, 2.02 [95% CI, 1.82-2.25]; and LI RRR, 2.12 [95% CI, 1.84-2.44]), and have a caregiver with depression (HI RRR, 1.66 [95% CI, 1.38-2.00]; MD RRR, 1.44 [95% CI, 1.31-1.58]; and LI RRR, 1.39 [95% CI, 1.23-1.58]). Relative to the LI group, patients in the MD group were less likely to be male (RRR, 0.80; 95% CI, 0.68-0.93). Conclusions: The substantial portion of young children with increased behavior problems observed in this cohort study underscores the need for screening in pediatric primary care. Caregivers with depression and family social needs warrant prioritization in early prevention and treatment to alter elevated trajectories.

Health Insurance Coverage Gaps Among Children With a History of Adversity.

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

Racial Inequities in Breastfeeding Counseling Among Pregnant People Who Use Cannabis.

We examined how breastfeeding advice in the context of cannabis use differed by race and ethnicity. Data from the 2017-2018 PRAMS (Pregnancy Risk Assessment Monitoring System) survey were used to assess differences in breastfeeding guidance related to cannabis use among 1,213 individuals who self-reported cannabis use 3 months before or during pregnancy. A multivariable logistic regression model was specified to examine the extent to which the odds of receiving prenatal advice against breastfeeding if using cannabis differed by self-reported race and ethnicity. We found that non-Hispanic Black people were four times more likely than non-Hispanic White people to be advised against breastfeeding if using cannabis (adjusted odds ratio 4.1, 95% CI 2.1-8.2). Pregnant non-Hispanic Black people were disproportionately advised not to breastfeed if using cannabis.

Association Between Adverse Childhood Experiences at Age 5 Years and Healthcare Utilization at Age 9 Years.

OBJECTIVE: To determine associations between adverse childhood experiences (ACEs) at age 5 years and healthcare utilization patterns at age 9 years. STUDY DESIGN: We conducted a secondary analysis using longitudinal data from the Fragile Families and Child Wellbeing Study. Caregivers (n = 2521) provided data on their child's ACEs at age 5 years and on 4 types of healthcare utilization at age 9 years: past-year well visits, dental visits, primary care sick visits for injury or illness, and emergency room (ER) visits. Logistic regression analysis was used to examine the association between ACEs at age 5 and each type of healthcare utilization, adjusting for relevant sociodemographic covariates. RESULTS: Among the 2521 children (51% male, 48% Non-Hispanic Black), 77% had ≥1 ACE at age 5. Children with ≥4 ACEs had lower odds of a dental visit (aOR, 0.51; 95% CI, 0.29-0.91) and higher odds of a primary care sick visit (aOR, 1.77; 95% CI, 1.20-2.64) and an ER visit (aOR, 1.70; 95% CI, 1.11-2.59) compared with children with no reported ACEs. CONCLUSION: Our findings demonstrate suboptimal healthcare utilization patterns among families with ACEs and indicate a need for targeted interventions that support appropriate healthcare utilization for children who endure adversity.

Does a Medical Home Buffer the Association between Child Poverty and Poor Health?

OBJECTIVE: To evaluate effects of the medical home on health status and health care use among children living in poverty compared with children not living in poverty. METHODS: Data from the 2016-2017 National Survey of Children's Health were used to examine the associations of having a medical home with health outcomes of interest, among children living in poverty and among children not living in poverty. RESULTS: Among 69,039 children ages 0-17 years, children living in poverty had lower medical home access (31%) compared with those not living in poverty (50%). Medical home access was favorably associated with health outcomes, but the strength of these association did not vary according to poverty status. CONCLUSIONS: Notwithstanding the efficacy of the medical home at promoting child health, children living in poverty did not have greater health benefits associated with medical home access compared with children not living in poverty.

Clusters of adverse childhood experiences and unmet need for care coordination.

BACKGROUND: The lack of consensus on how to measure ACEs limits our estimation of their impact on health outcomes and understanding of which ACE clusters drive unmet care coordination (CC) needs. OBJECTIVES: 1) Identify latent classes of ACEs among a representative group of U.S. children; 2) Examine the association between these classes and unmet needs for CC. PARTICIPANT AND SETTING: Using the 2016-2017 National Survey of Children's Health, we sampled children ages 0-17 the who had seen >1 healthcare provider within 12 months (n = 38,758). METHODS: We conducted latent class analyses and weighted logistic regression analyses to examine associations between latent classes and unmet need for CC. RESULTS: We identified seven distinct classes: household poverty and parental divorce, household poverty and parental death, household poverty only, household substance abuse and witnessing violence, multiple ACEs, household poverty and child discrimination, and household poverty and household mental illness. Children in the following classes had the greatest odds of unmet need for CC: household poverty only (AOR 2.0; 95% CI, 1.42-2.84), household poverty and household mental illness (AOR 1.67; 95% CI, 1.15-2.44), multiple ACEs (AOR 2.31; 95% CI, 1.53-3.50), and household poverty and child discrimination (AOR 3.55; 95% CI, 1.71-7.37). CONCLUSIONS: Children who experienced specific combinations of ACEs, have an increased risk of unmet need for CC, with those experiencing both poverty and discrimination having the highest odds of unmet need for CC. Discrimination widens the gap of unmet CC need for poor children.

Associations between Adverse Childhood Experiences and Need and Unmet Need for Care Coordination.

Introduction: Children exposed to adverse childhood experiences (ACEs) may access multiple systems of care to address medical and social complexities. Care coordination (CC) optimizes health outcomes for children with special health care needs who often use multiple systems of care. Little is known about whether ACEs are associated with need and unmet need for CC. Methods: Use of the 2016-2017 National Survey of Children's Health to identify children who saw ≥1 health care provider in the last 12 months. The study team used weighted logistic regression analyses to examine associations between 9 ACE types, ACE score and need and unmet need for CC. Results: In the sample (N=39,219, representing 38,316,004 US children), material hardship (aOR, 1.50; 95% CI, 1.29-1.75), parental mental illness (aOR, 1.31; 95% CI, 1.07-1.60), and neighborhood violence (aOR, 1.33; 95% CI, 1.01-1.74) were significantly associated with an increased need for CC. Material hardship was also associated with unmet need for CC (aOR, 2.37; 95% CI, 1.80 - 3.11). Children with ACE scores of 1, 2, 3, and ≥4 had higher odds of need and unmet need for CC than children with 0 ACEs. Discussion: Specific ACE types and higher ACE scores were associated with need and unmet need for CC. Evaluating the unique needs of children who endured ACEs should be considered in the design and implementation of CC processes in the pediatric healthcare system.