Abstract: The relation between low socioeconomic status (SES) and depression has been well documented in adult populations. A number of studies suggest that family SES may be associated with depression among children and adolescents as well, although the evidence is mixed. We assessed the relation between family income and depressive symptoms among 457 children aged 11-13 years and examined pathways that may explain this relation. In-person interviews of children and their caregivers were conducted, including assessment of family income and administration of the Computer-based Diagnostic Interview Schedule for Children (C-DISC). Family income was significantly associated with depressive symptoms, with children in the lowest income group (<$35,000) reporting a mean of 8.12 symptoms compared to 6.27 symptoms in the middle income group ($35,000-$74,999) and 5.13 symptoms in the highest income group ($75,000; p<0.001). Controlling for the number of stressful life events experienced in the past 6 months attenuated the effect of low family income on depressive symptoms by 28%. Indicators of the family environment explained 45% and neighborhood median household income and aggravated assault rate explained 12% of the relation. The family environment, including parental divorce or separation and perceived parental support, appears to explain most of the relation between low family income and childhood depressive symptoms. Further exploration of the pathways between family SES and depression may suggest potential interventions to reduce the occurrence and persistence of depressive symptoms in children.

Abstract: BACKGROUND: Evidence suggests that over 90% of pediatric splenic injuries can be successfully managed nonoperatively. Although pediatric hospitals have rapidly adopted nonoperative management, variability exists among other types of hospitals. OBJECTIVES: We tested 2 a priori hypotheses: (1) spleen-injured children are more likely to receive splenectomy in for-profit hospitals than in not-for-profit hospitals; and (2) hospital charges for spleen cases are greater in for-profit hospital than in not-for-profit hospitals. RESEARCH DESIGN: Multivariable regression was performed with data from the Kid's Inpatient Database (KID) for years 2000 and 2003, controlling for patient and hospital characteristics. Children (0-18 years) hospitalized with a blunt traumatic (noniatrogenic) spleen injury in any of the states participating in KID (N = 5061), including adult and pediatric hospitals. Main outcome measures were splenectomy and hospital charges. RESULTS: A total of 756 children (14.9%) received splenectomies within 1 day of arrival. Splenectomy was found to be more likely among children treated at for-profit hospitals [odds ratio (OR), 1.75; 95% confidence interval (CI), 1.14-2.67] than among children treated in not-for-profit general hospitals. Splenectomies were much less common in children's hospitals (OR, 0.14; 95% CI, 0.05-0.41) than in not-for-profit general hospitals. Hospital charges for all spleen-injured children (regardless of treatment) were significantly greater in for-profit hospitals than in not-for-profit hospitals. CONCLUSIONS: For-profit hospitals seem to be trailing not-for-profit hospitals in the adoption of spleen-conserving management practices. The cost of caring for a child with a splenic injury also seems greater at for-profit hospitals, regardless of management path (ie, splenectomy vs. nonoperative management).

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Abstract: Objectives: We tested relations between aspects of maternal work and birth outcomes in a national sample and in subgroups known to experience disparities. Methods: Three indices of work attributes (Status and Recognition, Physical Demands, and Exposure to Conflict) were derived by factor analysis of variables extracted from the Department of Labor's O*Net database. The indices were linked to the National Longitudinal Survey of Youth using occupation codes for the primary jobs held by women who gave birth between 1979 and 2000 and worked during the quarter prior to birth (n = 3,386 births to n = 2,508 mothers). Multiple regression was used to model birth outcomes as functions of the work attribute indices, controlling for several measures of socioeconomic status and risk factors for adverse birth outcomes. Results: In the full sample, work-related Physical Demands were associated with lower average birthweight and increased odds of preterm birth while Status and Recognition was associated with higher average birthweight and lower odds of fetal growth restriction. In stratified models, Status and Recognition was associated with higher birth weight among women with low (versus high) income and with lower odds of preterm birth among women with low (versus high) education. Physical Demands were associated with higher rates of preterm birth among women with low (versus high) income and education and among African-American mothers (compared to Whites). Conclusions: The work environment is an important predictor of healthy births. Relations between maternal work attributes and birth outcomes differ by race/ethnicity and socioeconomic status and according to the outcome under investigation. Further research with measures of work attributes specific to maternal work experiences is recommended to confirm our findings.

Abstract: BACKGROUND: Although racial differences in hospital outcomes are well known for medical conditions (eg, cardiovascular disease), it is unknown whether differences exist for patients with traumatic brain injury (TBI). RESEARCH DESIGN: Using the National Trauma Data Bank, we examined racial and ethnic differences in hospital outcomes of 56,482 patients with moderate to severe TBI who were hospitalized in level I or II trauma-designated hospitals between 2000 and 2003. We examined racial and ethnic disparities in in-hospital mortality and the likelihood of survivors receiving postacute care at a rehabilitation center. RESULTS: After multivariable adjustment, compared with whites, we observed increased in-hospital mortality for blacks (odds ratio [OR] = 1.19, P = 0.026) and Asians (OR = 1.41, P = 0.005). We observed a trend toward significance for Hispanics (OR = 1.41, P = 0.077), but not for other races. For survivors, compared with whites, blacks and Hispanics were less likely to be discharged to a rehabilitation center (OR = 0.68, P < 0.001, and OR = 0.67, P = 0.002, respectively). CONCLUSIONS: Racial and ethnic disparities exist both in mortality and in discharge to postacute rehabilitation centers among persons with TBI.

Abstract: OBJECTIVE: To determine the television-, DVD-, and video-viewing habits of children younger than 2 years. DESIGN: A telephone survey of 1009 parents of children aged 2 to 24 months. SETTING: Parents in Minnesota and Washington state were surveyed. PARTICIPANTS: A random sample of parents of children born in the previous 2 years was drawn from birth certificate records. Households in which English was not spoken were excluded, as were children with major disabilities. MAIN OUTCOME MEASURE: The amount of regular television and DVD/video viewing by content, reasons for viewing, and frequency of parent-child coviewing. RESULTS: By 3 months of age, about 40% of children regularly watched television, DVDs, or videos. By 24 months, this proportion rose to 90%. The median age at which regular media exposure was introduced was 9 months. Among those who watched, the average viewing time per day rose from 1 hour per day for children younger than 12 months to more than 1.5 hours per day by 24 months. Parents watched with their children more than half of the time. Parents gave education, entertainment, and babysitting as major reasons for media exposure in their children younger than 2 years. CONCLUSIONS: Parents should be urged to make educated choices about their children's media exposure. Parental hopes for the educational potential of television can be supported by encouraging those parents who are already allowing screen time to watch with their children.

Abstract: OBJECTIVE: To test the association of media exposure with language development in children under age 2 years. STUDY DESIGN: A total of 1008 parents of children age 2 to 24 months, identified by birth certificates, were surveyed by telephone in February 2006. Questions were asked about child and parent demographics, child-parent interactions, and child's viewing of several content types of television and DVDs/videos. Parents were also asked to complete the short form of the MacArthur-Bates Communicative Development Inventory (CDI). The associations between normed CDI scores and media exposure were evaluated using multivariate regression, controlling for parent and child demographics and parent-child interactions. RESULTS: Among infants (age 8 to 16 months), each hour per day of viewing baby DVDs/videos was associated with a 16.99-point decrement in CDI score in a fully adjusted model (95% confidence interval = -26.20 to -7.77). Among toddlers (age 17 to 24 months), there were no significant associations between any type of media exposure and CDI scores. Amount of parental viewing with the child was not significantly associated with CDI scores in either infants or toddlers. CONCLUSIONS: Further research is required to determine the reasons for an association between early viewing of baby DVDs/videos and poor language development.

Abstract: Approximately 10% of African-American women smoke during pregnancy compared to 16% of White women. While relatively low, the prevalence of smoking during pregnancy among African-American women exceeds the Healthy People 2010 goal of 1%. In the current study, we address gaps in extant research by focusing on associations between racial/ethnic residential segregation and smoking during pregnancy among urban African-American women. We linked measures of segregation to birth certificates and data from the 2000 census in a sample of US-born African-American women (n = 403,842) living in 216 large US Metropolitan Statistical Areas (MSAs). Logistic regression models with standard errors adjusted for multiple individual observations within MSAs were used to examine associations between segregation and smoking during pregnancy and to control for important socio-demographic confounders. In all models, a u-shaped relationship was observed. Both low segregation and high segregation were associated with higher odds of smoking during pregnancy when compared to moderate segregation. We speculate that low segregation reflects a contagion process, whereby salutary minority group norms are weakened by exposure to the more harmful behavioral norms of the majority population. High segregation may reflect structural attributes associated with smoking such as less stringent tobacco control policies, exposure to urban stressors, targeted marketing of tobacco products, or limited access to treatment for tobacco dependence. A better understanding of both deleterious and protective contextual influences on smoking during pregnancy could help to inform interventions designed to meet Healthy People 2010 target goals.

Abstract: OBJECTIVE: The effect of violent television programming on preschoolers' behaviors is poorly understood. The objective of this study was to test the hypothesis that exposure to violent television viewing when children are 2 to 5 years of age would be associated with antisocial behavior at ages 7 to 10. METHODS: Data were derived from the Panel Study of Income Dynamics. Our primary outcome was being in the 88th percentile of the Behavioral Problem Index antisocial subdomain. Our primary predictor was exposure to violent screen content. RESULTS: Data were available for 184 boys and 146 girls at both time periods. Adjusting for baseline Behavioral Problem Index scores and age, parental education, maternal depression, and cognitive and emotional support, violent television programming was associated with an increased risk for antisocial behavior for boys but not for girls. Neither educational nor nonviolent programming was associated with increased risk for boys or girls. CONCLUSIONS: Viewing of violent programming by preschool boys is associated with subsequent aggressive behavior. Modifying the content that is viewed by young children may be warranted.

Abstract: ABSTRACT: BACKGROUND: There is limited evidence in preschool children linking media use, such as television/video viewing and computer use, to obesity and adiposity. We tested three hypotheses in preschool children: 1) that watching > 2 hours of TV/videos daily is associated with obesity and adiposity, 2) that computer use is associated with obesity and adiposity, and 3) that > 2 hours of media use daily is associated with obesity and adiposity. METHODS: We conducted a cross-sectional study using nationally representative data on children, aged 2-5 years from the National Health and Nutrition Examination Survey, 1999-2002. Our main outcome measures were 1) weight status: normal versus overweight or at risk for overweight, and 2) adiposity: the sum of subscapular and triceps skinfolds (mm). Our main exposures were TV/video viewing (</= 2 or > 2 hours/day), computer use (users versus non-users), and media use (</= 2 or > 2 hours/day). We used multivariate Poisson and linear regression analyses, adjusting for demographic covariates, to test the independent association between TV/video viewing, computer use, or overall media use and a child's weight status or adiposity. RESULTS: Watching > 2 hours/day of TV/videos was associated with being overweight or at risk for overweight (Prevalence ratio = 1.34, 95% CI [1.07, 1.66]; n =1340) and with higher skinfold thicknesses (beta = 1.08, 95% CI [0.19, 1.96]; n = 1337). Computer use > 0 hours/day was associated with higher skinfold thicknesses (beta = 0.56, 95% CI [0.04, 1.07]; n = 1339). Media use had borderline significance with higher skinfold thicknesses (beta = 0.85, 95% CI [-0.04, 1.75], P=0.06; n = 1334) CONCLUSION: Watching > 2 hours/day of TV/videos in US preschool-age children was associated with a higher risk of being overweight or at risk for overweight and higher adiposity-findings in support of national guidelines to limit preschool children's media use. Computer use was also related to higher adiposity in preschool children, but not weight status. Intervention studies to limit preschool children's media use are warranted.

Abstract: OBJECTIVE: Television and video/DVD viewing among very young children has become both pervasive and heavy. Previous studies have reported an association between early media exposure and problems with attention regulation but did not have data on the content type that children watched. We tested the hypothesis that early television viewing of 3 content types is associated with subsequent attentional problems. The 3 different content types are educational, nonviolent entertainment, and violent entertainment. METHODS: Participants were children in a nationally representative sample collected in 1997 and reassessed in 2002. The analysis was a logistic regression of a high score on a validated parent-reported measure of attentional problems, regressed on early television exposure by content and several important sociodemographic control variables. RESULTS: Viewing of educational television before age 3 was not associated with attentional problems 5 years later. However, viewing of either violent or non-violent entertainment television before age 3 was significantly associated with subsequent attentional problems, and the magnitude of the association was large. Viewing of any content type at ages 4 to 5 was not associated with subsequent problems. CONCLUSIONS: The association between early television viewing and subsequent attentional problems is specific to noneducational viewing and to viewing before age 3.

Abstract: OBJECTIVE: To test the hypotheses that block play improves language acquisition and attention. DESIGN: Randomized controlled trial. SETTING: Pediatric clinic. PARTICIPANTS: Children aged 1(1/2) to 2(1/2) years. INTERVENTION: Distribution of 2 sets of building blocks. MAIN OUTCOME MEASURES: Scores on the MacArthur-Bates Communicative Development Inventories, television viewing based on diary data, and the hyperactivity domain of the Child Behavior Checklist. RESULTS: Of 220 families approached in the clinic waiting room, 175 (80%) agreed to participate in the study. At least 1 diary was returned from 92 of the 175 families (53%). A total of 140 families (80%) completed exit interviews. Of the children in the intervention group, 52 (59%) had block play reported in their diaries compared with 11 (13%) in the control group (P<.01). The linear regression results for language acquisition were as follows: entire sample--raw score, 7.52 (P=.07); percentile, 8.4 (P=.15); low-income sample--raw score, 12.40 (P=.01); percentile, 14.94 (P=.03). For attention the results were as follows: entire sample--odds ratio, 0.49 (P=.29); low-income sample--odds ratio, 0.48 (P=.26) There were no statistically significant differences with respect to hyperactivity scores. CONCLUSIONS: Distribution of blocks can lead to improved language development in middle- and low-income children. Further research is warranted.

Abstract: OBJECTIVES: To test associations between individual health outcomes and ecological variables proposed in causal models of relations between income inequality and health. DESIGN: Regression analysis of a large, nationally representative dataset, linked to US census and other county and state level sources of data on ecological covariates. The regressions control for individual economic and demographic covariates as well as relevant potential ecological confounders. SETTING: The US population in the year 2000. PARTICIPANTS: 4817 US adults about age 40, representative of the US population. MAIN OUTCOME MEASURES: Two outcomes were studied: self reported general health status, dichotomised as "fair" or "poor" compared with "excellent", "very good", or "good", and depression as measured by a score on the Center for Epidemiologic Studies depression instrument >16. RESULTS: State generosity was significantly associated with a reduced odds of reporting poor general health (OR 0.84, 95%CI: 0.71 to 0.99), and the county unemployment rate with reduced odds of reporting depression (OR 0.91, 95%CI: 0.84 to 0.97). The measure of income inequality is a significant risk factor for reporting poor general health (OR 1.98, CI: 1.08 to 3.62), controlling for all ecological and individual covariates. In stratified models, the index of social capital is associated with reduced odds of reporting poor general health among black people and Hispanics (OR 0.40, CI: 0.18 to 0.90), but not significant among white people. The inequality measure is significantly associated with reporting poor general health among white people (OR 2.60, CI: 1.22 to 5.56) but not black people and Hispanics. CONCLUSIONS: The effect of income inequality on health may work through the influence of invidious social comparisons (particularly among white subjects) and (among black subjects and Latinos) through a reduction in social capital. Researchers may find it fruitful to recognise the cultural specificity of any such effects.

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Abstract: BACKGROUND: The effects of early exposure to television remain poorly defined. Although some have speculated that television may be habit-forming, evidence is lacking especially in young children. OBJECTIVE: To test the hypothesis that television viewing in the first 4 years of life is associated with protesting having the television turned off at age 6. METHODS: We used data from the National Longitudinal Survey of Youth. Parents reported how much television their children watched before the age of 4. They also reported how often their children protested having the television turned off at age 6. Their responses to this question were dichotomized to almost never vs other. Multivariate logistic regression was used to test the independent association of early television watching with subsequent protest at turning off the television, controlling for externalizing behavior scores at age 6, parenting style, and other covariates. RESULTS: Data were available for 1331 children. Sixty-three percent of children protested having the television turned off at age 6. In a logistic regression model, hours of television viewed per day before age 4 was associated with increased odds of protesting at age 6 (1.08 [1.02-1.15]). CONCLUSION: Early television exposure is associated with resistance to turning off the television at school age.

Abstract: BACKGROUND: Innovations to improve the delivery of pediatric preventive care are needed. METHODS: We enrolled children, 0 to 11 years of age, into a factorial, randomized, controlled trial of a tailored, evidence-based, Web site (MyHealthyChild) that provided information on prevention topics before a scheduled well-child visit. There were 2 components of the intervention, namely, parental Web content and provider notification. Parental Web content provided information to parents about prevention topics; provider notification communicated to physicians topics that were of interest to parents. We assigned 887 children randomly to 4 groups (usual care, content only, content and notification, or notification only). Outcomes were determined with telephone follow-up surveys conducted 2 to 4 weeks after the visit. Poisson regression analysis was used to determine the independent effects of each intervention on the number of topics discussed and the number of preventive practices implemented. RESULTS: Parents in the notification/content group and in the notification-only group reported discussing more MyHealthyChild topics with their provider. Parents in the notification/content group and in the content-only group reported implementing more MyHealthyChild topic suggestions (such as use of a safety device). CONCLUSIONS: A Web-based intervention can activate parents to discuss prevention topics with their child's provider. Delivery of tailored content can promote preventive practices.

Abstract: Residential segregation is a common aspect of the urban experiences of African-Americans in the United States (US), yet few studies have considered how segregation might influence perinatal health. Here, we develop a conceptual model of relationships between segregation and birth outcomes and test the implications of the model in a sample of 434,376 singleton births to African-American women living in 225 US Metropolitan Statistical Areas (MSAs). Data from the National Center for Health Statistics 2002 birth files were linked to data from the 2000 US Census and two distinct measures of segregation: an index of isolation (the probability that an African-American resident will encounter another African-American resident in any random neighborhood encounter) and an index of clustering (the extent to which African-Americans live in contiguous neighborhoods). Using multilevel regression models, controlling for individual- and MSA-level socioeconomic status and other covariates, we found higher isolation was associated with lower birthweight, higher rates of prematurity and higher rates of fetal growth restriction. In contrast, higher clustering was associated with more optimal outcomes. We propose that isolation reflects factors associated with segregation that are deleterious to health including poor neighborhood quality, persistent discrimination and the intra-group diffusion of harmful health behaviors. Associations with clustering may reflect factors associated with segregation that are health-promoting such as African-American political power empowerment, social support and cohesion. Declines in isolation could represent positive steps toward improving birth outcomes among African-American infants while aspects of racial contiguity appear to be mitigating or indeed beneficial. Segregation is a complex multidimensional construct with both deleterious and protective influences on birth outcomes, depending on the dimensions under consideration. Further research to understand racial/ethnic and economic health disparities could benefit from a focus on the contributory role of neighborhood attributes associated with the dimensions segregation and other social geographies.

Abstract: OBJECTIVES: We examined how race and ethnicity influence injury and illness risk and number of days of work missed as a result of injury or illness. METHODS: We fit logistic regression and negative binomial regression models using generalized estimating equations with data from 1988 to 2000 on currently employed African American, Hispanic, and non-Hispanic White participants in the National Longitudinal Survey of Youth. RESULTS: Occupational factors-having a blue-collar occupation, working full-time, having longer tenure, working 1 job versus 2, and working the late shift-were associated with increased odds of an occupational injury or illness. Although racial/ethnic minority workers were no more likely than Whites to report an occupational injury or illness, they reported missing more days of work. African American and Hispanic men missed significantly more days of work than non-Hispanic White men, and African American women missed significantly more days of work than non-Hispanic White women. CONCLUSIONS: Factors associated with occupational health are multifaceted and complex. Our findings suggest that race/ethnicity influences the duration of work absence owing to injury or illness both indirectly (by influencing workers' occupational characteristics) and directly (by acting independently of occupational factors).

Abstract: Prior studies have consistently found the incidence and persistence of depression to be higher among persons with low incomes, but causal mechanisms for this relationship are not well understood. This study uses the National Longitudinal Survey of Youth 1979 cohort to test several hypotheses about the robustness of the depression-income relationship among adults. In regressions of depression symptoms on income and sociodemographic variables, income is significantly associated with depression. However, when controls for other economic variables are included, the effect of income is considerably reduced, and generally not significant. Employment status and the ratio of debts-to-assets are both highly significant for men and for women both above and below the median income. Fixed-effects estimates suggest that employment status and financial strain are causally related to depression, but income is not. Instrumental variable estimates suggest that financial strain may not lead to depression.

Abstract: OBJECTIVE: To test the independent effects of television viewing in children before age 3 years and at ages 3 to 5 years on several measures of cognitive outcomes at ages 6 and 7 years. DESIGN: Using data from a nationally representative data set, we regressed 4 measures of cognitive development at ages 6 and 7 years on television viewing before age 3 years and at ages 3 to 5 years, controlling for parental cognitive stimulation throughout early childhood, maternal education, and IQ. RESULTS: Before age 3 years, the children in this study watched an average of 2.2 hours per day; at ages 3 to 5 years, the daily average was 3.3 hours. Adjusted for the covariates mentioned earlier, each hour of average daily television viewing before age 3 years was associated with deleterious effects on the Peabody Individual Achievement Test Reading Recognition Scale of 0.31 points (95% confidence interval [CI], -0.61 to -0.01 points), on the Peabody Individual Achievement Test Reading Comprehension Scale of 0.58 points (95% CI, -0.94 to -0.21 points), and on the Memory for Digit Span assessment from the Wechsler Intelligence Scales for Children of -0.10 points (95% CI, -0.20 to 0 points). For the Reading Recognition Scale score only, a beneficial effect of television at ages 3 to 5 years was identified, with each hour associated with a 0.51-point improvement in the score (95% CI, 0.17 to 0.85 points). CONCLUSIONS: There are modest adverse effects of television viewing before age 3 years on the subsequent cognitive development of children. These results suggest that greater adherence to the American Academy of Pediatrics guidelines that children younger than 2 years not watch television is warranted.

Abstract: BACKGROUND: Bullying is a major public health issue, the risk factors for which are poorly understood. OBJECTIVE: To determine whether cognitive stimulation, emotional support, and television viewing at age 4 years are independently associated with being a bully at ages 6 through 11 years. METHODS: We used multivariate logistic regression, using data from the National Longitudinal Survey of Youth, to adjust for multiple confounding factors. RESULTS: Parental cognitive stimulation and emotional support at age 4 years were each independently protective against bullying, with a significant odds ratio of 0.67 for both variables associated with a 1-SD increase (95% confidence interval, 0.54-0.82 for cognitive stimulation and 0.54-0.84 for emotional support). Each hour of television viewed per day at age 4 years was associated with a significant odds ratio of 1.06 (95% confidence interval, 1.02-1.11) for subsequent bullying. These findings persisted when we controlled for bullying behavior at age 4 years in a subsample of children for whom this measure was available. CONCLUSION: The early home environment, including cognitive stimulation, emotional support, and exposure to television, has a significant impact on bullying in grade school.

Abstract: BACKGROUND: A digital divide with respect to computer and Internet access has been noted in numerous studies and reports. Equally important to ownership is comfort with computers and Internet technology, and concerns about privacy of personal data. OBJECTIVE: To measure how households in a pediatric clinic vary in their attitudes toward computers, concerns about Internet confidentiality, and comfort using the Internet and whether these views are associated with household income or education. DESIGN/METHODS: A phone survey was administered to a population-based sample of parents with children aged 0 to 11 years. All children received medical care from a community-based clinic network serving patients in King County, Wash. RESULTS: Eighty-eight percent of respondents used a computer once a week or more, and 83% of respondents reported favorable feelings toward computers. Although 97% of respondents were willing to share personal information over the Internet, many respondents considered data security important. While household income and parental education were associated with comfort and familiarity with computers, the effect is small. Respondents who already owned a computer and had Internet access did not differ in their perceptions according to socioeconomic or educational attainment. CONCLUSIONS: Most families like using computers and feel comfortable using the Internet regardless of socioeconomic status. Fears about the digital divide's impact on the attitudes of parents toward computers or their comfort using the Internet should not be seen as a barrier to developing Internet-based health interventions for a pediatric clinic population.

Abstract: OBJECTIVE: To test the role of social determinants-including race, education, income, and demographic factors-of child mental health services use, defined as having had a visit to a mental health professional for depression, attention-deficit, or for any reason. DATA SOURCES/STUDY SETTING: National Longitudinal Survey of Youth and the Child/Young Adult supplement, a nationally representative sample of 7-14-year-old children born to women who were 14-22 years old at the start of data collection, in 1979. African Americans and Latinos were over-sampled, and population weights are available to make nationally representative inferences. STUDY DESIGN: Indicators of mental health service use were regressed on social and economic determinants, family structure variables, and insurance variables, controlling for need as captured by several different symptom scales. PRINCIPAL FINDINGS: Girls are much less likely to obtain needed treatment for externalizing behavior disorders than are boys, and are somewhat less likely to obtain needed treatment for depression than boys. Middle children are less likely to obtain needed treatment for any mental health problem than are oldest, youngest, or only children. The presence of the father inhibits the likelihood that the child will receive treatment, particularly for depression. African Americans and Latinos are less likely than white children to receive treatment. In contrast to these rich results for the social and demographic determinants of children's specialty mental health utilization, the economic and insurance variables (including maternal education and income) seem to hold little predictive power. CONCLUSIONS: These results argue for interventions to sensitize parents-especially fathers-to the need to pay attention to the mental health needs of their children, in particular girls and middle children. The analysis also suggests that the literature on intrahousehold decision making and on the gender dimensions of investment in children is worth extending to mental health treatment decisions.

Abstract: This study examined the association between early emotional support provided by parents and child internalizing and externalizing problems, using a nationally representative, longitudinal sample of 1361 children. Parental emotional support was assessed using the Home Observation for the Measurement of the Environment, incorporating both parent report and interviewer observation. We found that, controlling for child externalizing problems at age 6 years, parental emotional support at age 6 years was negatively related to child externalizing problems at age 8 years. A developmental model that assessed the timing of the emergence of this relationship was then analyzed by including parental emotional support at ages 2, 4, and 6 years as predictors of child externalizing problems at age 8 years. The developmental model suggested that less parental emotional support as early as age 2 years is associated with later externalizing problems in children. This study discusses the importance of very early parental emotional support in promoting positive child development.

Abstract: CONTEXT: Despite evidence that more than 90% of children with traumatic injuries to the spleen can be successfully managed nonoperatively, there is significant variation in the use of splenectomy. As asplenic children are at increased risk of overwhelming postsplenectomy infection, nonoperative management may be considered a quality of care indicator. OBJECTIVE: To test the hypothesis that children are more likely to undergo splenectomy in general hospitals than in children's hospitals. DESIGN: Retrospective cohort study using data from the Kid's Inpatient Database (KID) for the year 2000. Multivariable regression was used to control for patient and hospital characteristics. SETTING AND PARTICIPANTS: All children aged 0 to 16 years who were hospitalized with a traumatic (noniatrogenic) spleen injury in nonfederal short-stay hospitals in any of the 27 states participating in KID (N = 2851). MAIN OUTCOME MEASURE: Splenectomy performed within 1 day of arrival. RESULTS: A total of 11 children (3%) with splenic injuries receiving care at children's hospitals underwent splenectomy compared with 383 children (15.4%) cared for at general hospitals (P<.001). After adjusting for patient characteristics, injury severity, and hospital characteristics, splenectomy was more likely among children treated at general hospitals (odds ratio, 5.01; 95% confidence interval, 2.21-11.36) than among children treated at children's hospitals. CONCLUSIONS: There is considerable variation in the management of pediatric splenic injuries, with significantly lower rates of splenectomy at designated children's hospitals. Quality improvement interventions, including increased education and training for physicians in general hospitals, may be needed to increase the use of spleen-conserving management practices.

Abstract: Past studies have noted a digital divide, or inequality in computer and Internet access related to socio-economic class. This study sought to measure how many households in a pediatric primary care outpatient clinic had household access to computers and the Internet, and whether this access differed by socio-economic status or other demographic information. We conducted a phone survey of a population-based sample of parents with children ages 0 to 11 years old. Analyses assessed predictors of having home access to a computer, the Internet, and high-speed Internet service. Overall, 88.9% of all households owned a personal computer, and 81.4% of all households had Internet access. Among households with Internet access, 48.3% had high speed Internet at home. There were significant associations between home computer ownership or Internet access and parental income or education. There was no relationship these factors and high speed Internet access. Over 60% of families with annual household income of $10,000-$25,000, and nearly 70% of families with only a high-school education had Internet access at home. While income and education remain significant predictors of household computer and internet access, many patients and families at all economic levels have access, and might benefit from health promotion interventions using these modalities.

Abstract: BACKGROUND: Providers' interest in satisfying parents may provide an impetus for unnecessary antibiotic use in children. OBJECTIVES: To determine (1) whether receipt of antibiotics at a visit for cough and cold symptoms was associated with increased satisfaction and (2) whether nonreceipt of antibiotics at an initial visit but subsequent receipt of antibiotics in the course of the same illness episode was associated with decreased satisfaction. METHODS: Prospective cohort study of patients 2-10 years of age presenting to a university-affiliated pediatric clinic with cough and cold symptoms. Parents were enrolled at the index visit and then followed up by phone at least 7 days later (mean time to follow-up, 14.9 days). Satisfaction with the index visit on a 10 point scale was the primary outcome. The primary predictors were whether antibiotics were prescribed at the index visit and, if not, whether they were prescribed since that visit. Linear and median regression were used to adjust for income, child age, parental race and individual provider. RESULTS: A total of 539 parents were enrolled in the study, and 378 (70%) completed follow-up interviews. The mean age of participating children was 4.67 years (SD 2.16). Overall 47% of patients received antibiotics at the index visit, and 8% of those that did not reported receiving them between the index visit and the follow-up assessment. In the regression model, receiving antibiotics at the index visit trended toward being associated with higher satisfactions scores (0.28; P = 0.08). Among those who did not receive antibiotics initially, receiving them subsequently was associated with significantly lower median satisfaction score for the index visit (-3.0; P < 0.01). CONCLUSIONS: Receiving antibiotics after an initial visit for cough and cold symptoms at which antibiotics were not prescribed is associated with decreased satisfaction. Use of contingency prescriptions may be an important intervention.

Abstract: Prior studies have consistently found the occurrence of depression to be higher among persons with lower socio-economic status (SES), but causal mechanisms for this relationship are often not well understood. For example, while depression has been shown to increase during spells of unemployment, little work has been done on job attributes that may be related to depression among employed people early in their careers. This study links the 1992 wave of the National Longitudinal Survey of Youth 1979 cohort-which included Depression symptom scores on the Center for Epidemiologic Studies Depression (CES-D) instrument-to the US Department of Labor's new occupational characteristics O*Net dataset. The resulting dataset includes information regarding depression, SES, and specific attributes of jobs held by the young adult respondents. Job attributes included measures of social status, interpersonal stressors, and physical conditions. Multivariate analysis revealed that for young men, higher job status is associated with lower CES-D scores. Higher scores on the opposition scale, which measures the extent to which employees are obliged to take a position opposed to others, is associated with higher CES-D scores. For young women, physically uncomfortable or dangerous jobs are associated with more depressive symptoms. Results are stratified by race/ethnicity. For Black men, unlike for White men or Latinos, job security is associated with fewer depressive symptoms; and for Latino men, but not for Black or White men, physically uncomfortable or dangerous jobs are associated with more depressive symptoms. For Black women, job status is associated with fewer depressive symptoms. We conclude that part of the SES-depression relationship may arise from the psychosocial aspects of jobs, which we have found to be significantly and meaningfully associated with depressive symptoms among employed young adults.

Abstract: BACKGROUND AND OBJECTIVES: Although continuity of care has been found to be associated with improved health outcomes in children, little is known about what factors predict having consistent contact with a pediatric provider. This study explored what patient, family, provider, and system factors are associated with high continuity of both total and well-child care. METHODS: This cross-sectional study involved 759 patients presenting to a primary care pediatric clinic. Patients completed surveys about demographic variables, attitudes about continuity of care, and family functioning, as well as provider-level information. Outcomes were measured with a continuity of care index that quantified the degree to which a patient experienced continuous care with a provider. RESULTS: In Tobit regression models, the variables associated with increased total continuity of care were continuity belief, higher family control, increased provider availability, and better provider rating. Associated with decreased total continuity of care were: number of visits, patient age, and time at clinic. For well-child care, the variables associated with increased continuity of care were continuity belief, increased provider availability, better provider rating, and greater reported household income. Provider availability was the strongest predictor of total continuity of care, and continuity belief was the strongest predictor of well-child continuity of care. CONCLUSIONS: Increased provider availability may improve overall continuity of care for pediatric patients.

Abstract: CONTEXT: Induced abortion is one of the most common procedures performed among women in the United States. However, 87% of all counties had no abortion provider in 2000, and little is known about the attitudes and intentions of future health care providers, including advanced clinical practitioners, regarding abortion provision. METHODS: During March 2002, first- and second-year students in health sciences programs (i.e., medicine, physician assistant and nursing) at the University of Washington were anonymously surveyed. Univariate, bivariate and multivariate analyses were used to determine students' attitudes and intentions regarding provision of abortion services. RESULTS: Of the 312 students who completed the survey, 70% supported the availability of legal abortion under any circumstances. Thirty-one percent intended to provide medical abortion in their practice, and 18% planned to offer surgical abortion. Fifty-two percent of all respondents agreed that advanced clinical practitioners should be able to provide medical abortion, and 37% agreed that they should be able to provide surgical abortion services; however, greater proportions of advanced clinical practitioners (45-83%) than of medical students (21-43%) expressed such support. Sixty-four percent of all respondents were willing to attend a program whose curriculum requires abortion training. CONCLUSIONS: Although it may not be possible to require abortion training for every future health care provider, making abortion a standard part of clinical training would provide opportunities for future physicians and advanced clinical practitioners, and would likely ameliorate the abortion provider shortage.

Abstract: OBJECTIVE: Cross-sectional research has suggested that television viewing may be associated with decreased attention spans in children. However, longitudinal data of early television exposure and subsequent attentional problems have been lacking. The objective of this study was to test the hypothesis that early television exposure (at ages 1 and 3) is associated with attentional problems at age 7. METHODS: We used the National Longitudinal Survey of Youth, a representative longitudinal data set. Our main outcome was the hyperactivity subscale of the Behavioral Problems Index determined on all participants at age 7. Children who were > or = 1.2 standard deviations above the mean were classified as having attentional problems. Our main predictor was hours of television watched daily at ages 1 and 3 years. RESULTS: Data were available for 1278 children at age 1 and 1345 children at age 3. Ten percent of children had attentional problems at age 7. In a logistic regression model, hours of television viewed per day at both ages 1 and 3 was associated with attentional problems at age 7 (1.09 [1.03-1.15] and 1.09 [1.02-1.16]), respectively. CONCLUSIONS: Early television exposure is associated with attentional problems at age 7. Efforts to limit television viewing in early childhood may be warranted, and additional research is needed.

Abstract: OBJECTIVE: To conduct a population-based survey of television and other media usage in young children to determine (1) total media usage; (2) the proportion of children who have televisions in their bedrooms and who eat breakfast or dinner in front of the television; and (3) predictors of parental concern about the amount of television their child watches. STUDY DESIGN: Telephone survey administered to 1454 parents of children <11 years old derived from a diverse clinic population. RESULTS: The mean age of the index child was 5.05 years. Mean daily reported child media use was as follows: television (1.45 hours; SD, 1.5); videos (1.1 hours; SD, 1.30); and computer games (0.54 hours; SD, 0.96). Thirty percent of parents reported that their child ate breakfast or dinner in front of the television in the past week, and 22% were concerned about the amount of television that their child watched. In multivariate linear regression, eating breakfast or dinner in front of the television in the past week was associated with increased hours of television viewing (0.38 hours [0.21, 0.54]) and video (0.19 hours [0.04, 0.34]). Having a television in a child's bedroom was associated with increased hours of television (0.25 hours [0.07, 0.43]), video viewing (0.31 hours [0.16, 0.47]), and computer games (0.21 hours [0.10, 0.32]). In general, higher parental education was associated with decreased hours of television and video but not computer games. Older children were 2 to 3 times more likely than younger children to have a television in their bedroom and to have eaten a meal in front of it in the past week. More educated parents were less likely to report that their child had a television in their bedroom and more likely to be concerned about the amount of television their child viewed. CONCLUSIONS: Combined video and computer game usage exceeded television usage. Both children of low- and high-income parents are at risk for certain behaviors associated with television usage. Parents whose children watched more television were more likely to be concerned about the amount of television their child viewed.

Abstract: This study examined the relationships between jail incarceration during pregnancy and infant birth weight, preterm birth, and fetal growth restriction. We used multivariate regression analyses to compare outcomes for 496 births to women who were in jail for part of pregnancy with 4,960 Medicaid-funded births as matched community controls. After adjusting for potential confounding variables, the relationship between jail incarceration and birth outcomes was modified by maternal age. Relative to controls, women incarcerated during pregnancy had progressively higher odds of low birth weight and preterm birth through age 39 years; conversely, jail detainees older than 39 years were less likely than controls to experience low birth weight or preterm birth. For women in jail at all ages, postrelease maternity case management was associated with decreased odds of low birth weight, whereas prenatal care was associated with decreased odds of preterm birth. Local jails are important sites for public health intervention. Efforts to ensure that all pregnant women released from jail have access to enhanced prenatal health services may improve perinatal outcomes for this group of particularly vulnerable women and infants.

Abstract: Few studies have examined health care access for the growing population of pregnant women who cycle in and out of urban jails. The present study compared use of Medicaid-funded perinatal services for births to women who were in jail during pregnancy and births to women who had been in jail, but not while pregnant. Jail contact during pregnancy increased the likelihood women would receive prenatal care (odds ratio [OR] = 5.95; 95% confidence interval [CI] 2.18-16.23) and maternity support services (OR = 1.80; 95% CI 1.12-2.88), but was associated with fewer total prenatal and support visits. Jail contact during a previous pregnancy was associated with fewer prenatal care visits, more support service visits, and longer time receiving case management. Jail settings can become a place of coordination between public health and criminal justice professionals to ensure that pregnant women receive essential services following release. Service coordination may increase women's engagement in health services during future pregnancies, with or without subsequent incarceration.

Abstract:

Abstract: CONTEXT: The importance of continuity of care as a means to promote care coordination remains controversial. OBJECTIVE: To determine if there is an association between having an objective measure of continuity of care and parental perception that care is well coordinated. DESIGN: Cross-sectional study. SETTING AND POPULATION: Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys that included 5 items from the Components of Primary Care Index (CPCI) that relate to care coordination. MAIN PREDICTOR VARIABLE: A continuity of care index (COC) that quantifies the degree of dispersion of care among providers. MAIN OUTCOME MEASURES: Likelihood of parents reporting high scores on the care coordination domain as well as each of the 5 individual CPCI items related to care coordination. RESULTS: Greater continuity of care was associated with higher scores on the CPCI care-coordination domain (P <.001). Continuity of care was also specifically associated with increased odds of agreeing with all 5 individual CPCI items, including reporting that their child's provider "always knows about care my child received in other places" (OR 3.97 [2.11-7.49]), "communicates with the other health care providers my child sees" (OR 2.98 [1.63-5.44]), "knows the results of my child's visits to other doctors" (OR 2.02 [1.08-3.80]), and "always follows up on a problem my child has had, either at the next visit or by phone" (OR 6.20 [2.88-13.35]) and wanting one provider to coordinate all of the health care that the child receives (OR 3.28 [1.48-7.27]). CONCLUSIONS: Greater continuity of primary care is associated with better care coordination as perceived by parents. Efforts to improve and maintain continuity may be justified.

Abstract: OBJECTIVE: This study examines whether four types of selection bias in estimates of the effectiveness of prenatal care utilization for improving birthweight occur in a population of economically disadvantaged women. METHODS: We categorized adequacy of prenatal care use using the Adequacy of Prenatal Care Utilization Index (APNCU) and the Revised-GINDEX for 142,381 Medicaid recipients who gave birth to a live, singleton infant in Washington State (1994-1998). Multinomial logistic regression was used to model categories of adequacy of prenatal care use as functions of variables chosen to indicate high- or low-risk status. A series of linear regression models were estimated to quantify the magnitude and direction of any bias in the effects of prenatal care on birthweight that could be attributed to accounting for each risk covariate. Results were examined for patterns of risk, prenatal care use, and estimation bias equated with the four selection processes. RESULTS: We found modest evidence of adverse, favorable, confidence, and estrangement selection biases. The overriding effect, relative to low prenatal care use, was overestimation of the adequate care coefficient by 8.68 g with the APNCU, and underestimation by 3.36 g with the R-GINDEX because of competing confidence and estrangement selection biases. Relative to intensive use, the effect of adequate care on birthweight was underestimated (17.58 g with the APNCU; 13.34 g with the R-GINDEX) because of adverse selection bias and a small countervailing favorable selection process. CONCLUSIONS: The underestimation of birthweight associated with prenatal care noted in prior studies appears to result from multiple selection processes working in different directions. Understanding selection processes can help the assessment of the contribution of prenatal care to birth outcomes and development of appropriate programs and policies.

Abstract: CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and improved quality of care by parental report. DESIGN: Cross-sectional study. SETTING AND POPULATION: Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys, which included validated measures of provider and clinic quality of care from the Consumer Assessment of Health Plan Survey. MAIN EXPOSURE VARIABLE: A continuity of care index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: The likelihood of parents reporting quality of care as high in several provider- specific items including reporting that providers respected what they had to say, treated them with courtesy and respect, listened to them carefully, explained things in a way they could understand, and spent enough time with their children. In addition, participants were asked to rate the overall quality of the clinic and their child's provider on a 10-point scale. RESULTS: In ordered logistic regression models, continuity of care was associated with statistically significantly higher Consumer Assessment of Health Plan Survey scores for 5 of the 6 items, including feeling that providers respected what parents had to say; listened carefully to them; explained things in a way that they could understand; asked about how their child was feeling, growing, and behaving; and spent enough time with their child. In addition, greater continuity of care was associated with a higher clinic rating, as well as a higher provider rating. CONCLUSIONS: Greater continuity of primary care is associated with higher quality of care as reported by parents. Efforts to improve and maintain continuity may be warranted.

Abstract: CONTEXT: End-of-life care is an important yet underdeveloped component of pediatric hospital services. OBJECTIVES: We sought 1) to describe the demographics of children who die in children's hospitals, 2) to describe the prevalence of complex chronic conditions (CCCs) among these cases, and 3) to test the hypotheses that cases with a greater number of CCC diagnoses experience longer periods both of mechanical ventilation and of hospitalization before death. Design and Methods. We identified all deaths of patients 0 to 24 years old that occurred in the 60 hospitals contributing discharge data to the National Association of Children's Hospitals and Related Institutions data consortium for the years 1991, 1994, and 1997. We classified discharge diagnoses into 9 major categories of CCCs (cardiovascular, neuromuscular, malignancy, respiratory, renal, metabolic, gastrointestinal, hematologic/immunologic, and other congenital/genetic). RESULTS: Of the 13 761 deaths identified, 42% had been admitted between 0 and 28 days of life, 18% between 1 and 12 months, 25% between 1 and 9 years, and 15% between 10 and 24 years. Fifty-three percent were white, 20% were black, and 9% were Hispanic. The principal payer was listed as a governmental source for 42% and a private insurance company for 35%. Based on all the discharge diagnoses recorded for each case, 40% had no CCC diagnosis, 44% had diagnoses representing 1 major CCC category, 13% had diagnoses representing 2 CCC categories, and 4% had diagnoses representing 3 or more CCC categories. Among cases that had no CCC diagnoses, the principal diagnoses were related to prematurity and newborn disorders for 32% of these cases, injuries and poisoning for 26%, and an assortment of acute and infectious processes for the remaining 42%. Mechanical ventilation was provided to 66% of neonates, 40% of infants, 36% of children, and 36% of adolescents. Cases with CCCs were more likely than non-CCC cases to have been mechanically ventilated (52% vs 46%), and to have been ventilated longer (mean: 11.7 days for CCC cases vs 4.8 days for non-CCC cases). The median duration of hospitalization was 4 days, while the mean was 16.4 days. After adjustment for age, sex, year, and principal payer, compared with patients with no CCC diagnoses, those with 1 major CCC category had a significantly lower hazard of dying soon after admission (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.57-0.62), those with 2 CCC categories even lower (HR: 0.53; 95% CI: 0.50-0.57), and those with 3 or more CCC categories the lowest hazard of rapid death (HR: 0.51; 95% CI: 0.46-0.57). This trend of diminishing hazard of rapid death was significant across the 3 groups of children with 1 or more CCCs. CONCLUSIONS: Children's hospitals care for a substantial number of dying patients, who differ widely by age and medical conditions. Children who die in the hospital with CCCs are more likely to experience longer periods of mechanical ventilation and hospitalization before death.

Abstract: CONTEXT: Prescribing practices for otitis media are not consistent with current evidence-based recommendations. OBJECTIVE: To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written. DESIGN: Randomized, controlled trial. SETTING: Primary care pediatric clinic affiliated with university training program. Intervention. A point-of-care evidence-based message system presenting real time evidence to providers based on their prescribing practice for otitis media. MAIN OUTCOME MEASURES: Proportion of prescriptions for otitis media that were for <10 days and frequency with which antibiotics were prescribed. RESULTS: Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers. CONCLUSIONS: A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition.

Abstract: CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. DESIGN: Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: ED utilization and hospitalization. RESULTS: Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma. CONCLUSIONS: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.