Poverty and Mental, Behavioral and Developmental Disorders in Young Children, 2016

Mental, behavioral and developmental disorders (MBDDs) in childhood are linked to problems that can last into adulthood, and children living in poverty are at higher risk while often having less access to care. Pediatric clinics are important places to find and treat these disorders, and early identification and treatment can help every child develop well. A CDC analysis of the 2016 National Survey of Children's Health looked at how MBDDs, their risk factors and families' use of federal assistance programs differ by income — to find new ways of reaching children in poverty.

The survey

The National Survey of Children's Health, run by the Health Resources and Services Administration's Maternal and Child Health Bureau and conducted by the U.S. Census Bureau, represents noninstitutionalized U.S. children aged 0–17. Parents of 50,212 children took part (an interview completion rate of 69.7% and a weighted response rate of 40.7%); this analysis covered 16,912 children aged 2 to 8.

A child counted as having an MBDD if a parent said a doctor or other health care provider had ever diagnosed one of the following: anxiety problems, depression, attention-deficit/hyperactivity disorder, behavioral or conduct problems, Tourette syndrome, autism spectrum disorder, learning disability, intellectual disability, developmental delay or language problems. Parents also answered questions about income, insurance, their child's medical care, financial strain, emotional support, their neighborhood and their own health, and whether they received public assistance such as SNAP, WIC or free or reduced-price school meals.

Findings

• 17.4% of children aged 2 to 8 had at least one MBDD.
• Income mattered. Prevalence rose at each step down the income ladder, from 13.9% in households at 400% or more of the federal poverty level to 22.1% in households below 100%.
• Access to care fell with income. 80.4% of children in lower-income households had seen a health care provider in the past year, compared with 93.8% in the highest-income households; 5% did not get care they needed, compared with 0.8%.
• Other risk factors followed income — child care problems and lack of neighborhood support, for example — with one exception: inadequate insurance was reported less often in lower-income households than in the highest-income ones.

Reaching children through public assistance

Among children in households below 200% of the poverty level, 82.6% had seen a health care provider in the past year, and 73.4% were in families receiving public assistance.

• Of those who had not seen a provider in the past year, 69.0% — about seven in ten — received public assistance, and 19.2% had a diagnosed MBDD.
• Among children who had not seen a provider and did have an MBDD, 81.7% received public assistance.

That roughly one in five of these children had a diagnosed disorder without a recent provider visit, while lower-income families reported more difficulty getting needed care, raises concern that MBDDs may be undertreated among children in poverty.

What could help

Since most children see a health care provider each year regardless of income, the American Academy of Pediatrics' recommendation to screen for MBDDs and for family and social risk factors at primary care visits should in principle be feasible — though screening is hard in practice, and MBDDs may be underdiagnosed even among children seen recently.

Public assistance programs offer another way in. CDC's Learn the Signs. Act Early. program, for example, gives WIC staff resources to share with parents about spotting developmental delays and helps with referrals to primary care. Similar efforts could be built into other assistance programs, if designed carefully to avoid stigma. Expanding developmental and behavioral health services co-located in assistance programs, schools and early-learning settings, and federally qualified health centers might also remove barriers to care for families living in poverty.

Limitations

• The data are cross-sectional, so cause and effect cannot be established.
• Survey weights may not fully correct for nonresponse.
• All measures rely on parents' reports, which can be affected by recall and by wanting to give socially acceptable answers.

Sources

• Robyn A. Cree, Rebecca H. Bitsko, Lara R. Robinson, Joseph R. Holbrook, Melissa L. Danielson, Camille Smith, Jennifer W. Kaminski, Mary Kay Kenney and Georgina Peacock, "Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders and Poverty Among Children Aged 2–8 Years — United States, 2016," Morbidity and Mortality Weekly Report, CDC: https://www.cdc.gov/mmwr/volumes/67/wr/mm6750a1.htm