CDC: Be vigilant in screening for psychological risk factors

May 3, 2016

The CDC is calling on pediatricians to increase surveillance of mental, behavioral, and development problems that could continue into adulthood if left unnoticed.

One in 7 school-aged children suffer from mental, behavioral, or developmental problems, according to a new federal report, and the Centers for Disease Control and Prevention (CDC) is urging pediatricians to take note of the risk factors of these issues in order to offer early interventions.

Georgina Peacock, MD, MPH, FAAP, director of CDC’s Division of Human Development and Disability, says pediatricians play a key role in collaborating with public health officials and other agencies serving the health needs of children who have or are at-risk for mental health disorders.

“By becoming more aware of the factors identified in this report, pediatricians will be better equipped to identify potential risk factors for mental, behavioral and developmental disorders (MBDDs) in early childhood, and factors that may impact the health of children with these disorders,” says Peacock. “The factors most strongly associated with these disorders were fair or poor parental mental health, lacking a medical home, difficulty getting by on the family’s income, and child care problems.”

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In its new report, CDC outlines the risk factors associated with childhood MBDDs based on parent-reported data from the National Survey of Children’s Health. Some of the top risk factors include inadequate health insurance, lacking a medical home, parental mental health problems, low income, parental employment problems due to lack of childcare, and a lack of community support resources and amenities.

Overall, CDC found that 15.4% of US children aged 2 to 8 years had at least 1 diagnosed MBDD, and the highest contributing sociodemographic factors included male gender, older age ranges of 4 to 8 years, non-Hispanic white ethnicity, and living in households with high poverty levels.

Prevalence of MBDD varied by state from 10.6% in California to 21.5% in Arkansas and Kentucky, according to CDC. In comparing risk factors by state, 26.5% of parents reported inadequate medical insurance as a top problem in South Carolina; 52.2% of parents in Arizona listed lacking a medical home as a top concern. Income and childcare problems were cited most in Arizona. Comparatively, Vermont parents reported the fewest problems with insurance and medical home access; parents in North Dakota reported the fewest income problems; and parents in Nevada had the last amount of problems related to childcare. Parental mental health issues affecting childhood MBDD were greatest in Washington DC and lowest in Kansas, according to CDC, and Washington DC, Maryland, and Mississippi parents reported the worst community conditions and amenities.

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Although 90% of the children studied in the report received preventive care at least once over the previous 12 months, MBDDs present in childhood are likely to persist into adulthood and increase risks of school and employment problems, says CDC. Children may outgrow certain MBDDs-particularly speech and language problems-but interventions are key. Children with MBDDs require more health and therapy services, and their families face additional stresses in dealing with the disorder and paying for therapies, CDC notes.

Peacock adds that the American Academy of Pediatrics (AAP) also released a new policy March 9, 2016 as part of its strategic priority on poverty and child health addressing how pediatricians can assess for socioeconomic needs, help families find resources, and collaborate care in the community.

In that report, AAP revealed that 1 in 5 US children live in poverty, and another 40% live in low-income households. The AAP urged pediatricians to create and keep on hand a resource guide for low-income families, citing the devastating effects poverty can have on childhood development.

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The AAP reported that childhood poverty can lead to life-long negative physical, psychosocial, and developmental effects.

“Children who experience poverty, particularly during early life or for an extended period, are at risk of a host of adverse health and developmental outcomes through their life course,” says AAP. “Poverty has a profound effect on specific circumstances, such as birth weight, infant mortality, language development, chronic illness, environmental exposure, nutrition, and injury. Child poverty also influences genomic function and brain development by exposure to toxic stress, a condition characterized by excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships.”

Lifelong hardships are common in children who have lived in poverty, which puts them at risk for problems with self-regulation and executive function, AAP adds. Parenting is more difficult in poverty, too, with parents continually struggling to secure food, housing, transportation, energy, and more.

Childhood poverty also carries the risk of increased negative effects for society. Children who grow up in poverty and don’t complete high school are more at risk of becoming teenage parents, being unemployed, or becoming incarcerated, resulting in a heavy social and economic burden.

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“A growing body of research shows that child poverty is associated with neuroendocrine dysregulation that may alter brain function and may contribute to the development of chronic cardiovascular, immune, and psychiatric disorders,” AAP notes in its report. “The economic cost of child poverty to society can be estimated by anticipating future lost productivity and increased social expenditure. A study compiled before 2008 projected a total cost of approximately $500 billion each year through decreased productivity and increased costs of crime and health care, nearly 4% of the gross domestic product.”

The AAP’s report highlights the need for greater surveillance and education on resources for families in needs, Peacock says.

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“Previous policy statements have been issued by AAP on the importance of screening for maternal depression, and on practicing within a medical home-parental mental health and lacking a medical home were 2 of the factors most strongly associated with early childhood MBDDs,” Peacock says.

The CDC report also acknowledges the impact factors like socioeconomic and family structure have on MBDD prevalence.

“Each significant factor might reflect the effect of insufficient parental and community resources to support optimal child development and might contribute to chronic stress. Chronic stress in early childhood can impact lifelong health,” CDC notes in its report. “A chronically activated physiologic stress response impacts the sympathetic nervous

system, metabolism, and the brain, resulting in increased risk for high blood pressure, obesity, inflammatory diseases, and mental and behavioral disorders.

“The prevalences of both poverty and MBDDs have been increasing among US children, underscoring the need for public health strategies to prevent and treat MBDDs,” reveals CDC. “Strategies that address socioeconomic (eg, poverty) and community (eg, neighborhood condition) factors form the foundation of the health impact pyramid framework where interventions have the greatest public health impact, including demonstrated impacts into adulthood, and are likely to be cost-effective.”

The CDC says more research is needed to determine which factors benefit most from interventions, but that it’s clear pediatricians are the front line in beginning that fact-finding mission.

“Because a large percentage of children were reported to receive preventive care, pediatric clinical settings might be one venue for identifying and possibly delivering services to children and families in need,” CDC states.