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Poverty and Trends in 3 Common Chronic Disorders 3 139 Pediatrics 2017 ROUGH GALLEY PROOF – PovertyChristian D. Pulcini, MD, MEd,and MPH, a Bonnie Trends T. Zima, MD, MPH, b inKelly J. Kelleher,3 MD, c Amy J. Houtrow, MD, PhD, MPHa, d OBJECTIVES: Common Chronic Disorders abstract For asthma, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorder (ASD), the objectives were to: (1) describe percent increases in parent-reported lifetime prevalence and comorbidity over time and how these vary by socioeconomic status and (2) examine the extent poverty status is a predictor of higher- METHODS: than-average comorbidities. ’ – Secondary analyses of the National Survey of Children s Health for years 2003, 2007, and 2011 2012 were conducted to identify trends in parent-reported prevalence and comorbid chronic health conditions from a list provided in the survey among children with – asthma, ADHD, and ASD, and we examined variation by sociodemographic characteristics and insurance coverage. By using 2011 2012 data, multivariable regression was used to examine whether poverty status predicted higher-than-average comorbid conditions after RESULTS: adjusting for other sociodemographic characteristics. – Parent-reported lifetime prevalence of asthma and ADHD between 2003 and 2011 – 2012 rose 21% and 43%, respectively, whereas the parent-reported prevalence of ASD rose 32% between 2007 and 2011 2012. The percent increase in asthma was higher among girls and uninsured children. For ADHD, the rise in parent-reported prevalence only varied by age. Being poor was associated with nearly twice the adjusted odds (adjusted odds ratio = 1.72) of having at least 1 comorbidity among children with asthma and more than twice the adjusted odds (adjusted odds ratio = 2.60) of having at least 2 comorbidities among children CONCLUSIONS: with ADHD. Poverty status differentially influenced parent-reported lifetime prevalence of comorbidities for these target disorders. Future research is needed to examine how poverty influences lack of access and chronic stress and exposure on children to induce comorbidities, especially mental disorders. aDepartment of Pediatrics, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, WHAT’S KNowN ON THIS SUBJECT: Children in Pittsburgh, Pennsylvania; bSemel Institute for Neuroscience and Human Behavior, University of California, Los poverty with chronic conditions are more likely to Angeles, Los Angeles, California; cDepartment of Pediatrics, Nationwide Children’s Hospital, The Ohio State have higher rates of comorbid disorders and worse d University, Columbus, Ohio; and Department of Physical Medicine and Rehabilitation, University of Pittsburgh, outcomes than those not in poverty. Pittsburgh, Pennsylvania WHAT THIS STUDY AddS: The relationship between Dr Pulcini aided in the conceptualization of the study, drafted the initial manuscript, and reviewed poverty and comorbid health conditions differs for and revised the manuscript; Drs Zima and Kelleher aided in conceptualization of the study and critically reviewed and revised the manuscript; Dr Houtrow conceptualized and designed the children with asthma, attention-deficit/hyperactivity study and critically reviewed and revised the manuscript; and all authors approved the final disorder, and autism. manuscript as submitted. DOI: https:// doi. org/ 10. 1542/ peds. 2016- 2539 This article was retracted and replaced on October 17, 2017. Address correspondence to Amy J. Houtrow, MD, PhD, MPH, Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Pulcini CD, Zima BT, Kelleher KJ, et al. Poverty Copyright © 2017 by the American Academy of Pediatrics and Trends in 3 Common Chronic Disorders. Pediatrics. 2017;139(3):e20162539R Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 139, number 3, March 2017:e20162539 ARTICLE Pulcini et al https://doi.org/10.1542/peds.2016-2539R March 2017 Poverty and Trends in 3 Common Chronic Disorders 3 139 Pediatrics 2017 ROUGH GALLEY PROOF – 32 34 Poverty negatively affects the Children with chronic diseases, such Survey Program. Additionally, – development and well-being of as these target conditions, are also cell phone sampling methods were children and adolescents in a variety at higher risk for comorbid physical newly employed in 2011 2012. The of ways. Poor children are often and mental health conditions that– completion rate was 65.8% in 2003, exposed to inadequate nutrition, are chronic in nature and add to the 66.0% in 2007, and 54.1% for the 4, 12 14 – violence, and environmental toxins disease burden for the child, landline sample and 41.2% for the 1 3 among other risk factors. Children in which are often associated with cell phone sample in 2011 2012. Of – – poverty with chronic conditions also the substantial rise in their medical the 95677 completed interviews in 15 23 ’ are more likely– to have higher rates costs. Additionally, the well- 2011 2012, 31972 were conducted of comorbid2 4 disorders and worse established relationship between with respondents cell phones, with no outcomes. Nevertheless, it is less childhood poverty and greater risk expected nonresponse32,35 bias from cell clear whether the rate of chronic for chronic conditions including versus landline. – Study Variable Construction comorbidities among children living developmental2, 24 28 and behavioral in poverty is rising and whether disorders may place children the trends in chronic conditions are living in low-income families in differentially influenced by poverty double jeopardy of greater need29, for 30 Children were identified as having status. care and poorer access to care. asthma, ADHD, or ASD if their This rise in disease risk is coupled primary caregiver reported that These questions are of significance with an overall increase in childhood their child had ever been diagnosed because the overall expenditure in 31 poverty within this time period. with the condition. In addition, the Supplemental Security Income children were classified as having (SSI) program for children in 2015 Although of high public health 5 at least 1 comorbid condition if was $10.5 billion. Established in the significance, there is a paucity of their primary caregiver reported an 1970s, the SSI program for children information regarding the prevalence additional chronic condition. The with disabilities was created to trends of comorbid disorders such list of comorbid conditions a parent provide income support to families as depression and anxiety among could identify used in this analysis living under or near the federal US children with asthma, ADHD, included: bone, joint, and/or muscle poverty level (FPL). The program and ASD and the extent poverty problems; vision and/or hearing recently experienced controversy influences their rates of comorbid problems; depression and/or anxiety; because of its large growth, especially chronic conditions. To address this learning disability; diabetes; asthma among children with mental health knowledge gap, we conducted a data ’ (for ADHD and ASD); and ADHD (for disorders. This controversy resulted analysis by using the 3 waves of the – asthma and ASD). There were some in a Government Accountability National Survey of Children s Health 6 important methodological differences Office report and a National (NSCH) from 2003 through 2011 for several of the condition questions Academies of Sciences, Engineering, 2012. For these 3 target conditions, – 7 between the 2003 to the 2007 and and Medicine report that recognized the study objectives were to: (1) 2011 2012 surveys leading to the the challenges in identifying describe the percent increases in exclusion of a number of chronic comorbidities among children prevalence and comorbidity and how 8 conditions listed in the survey. In receiving SSI benefits. However, no these vary by poverty status and (2) addition, in the 2003 survey, the data to our knowledge have been examine the extent to which poverty indicator on ASD only asked if the published utilizing national data status is a predictor of higher-than- – child had ever received a diagnosis of sets to estimate the prevalence of average comorbid conditions. autism, whereas in 2007 and 2011 common chronic health conditions METHODS 2012, the question was expanded to and comorbidities among those in Data Source include Asperger disorder, pervasive poverty utilizing income data as developmental disorder, or other a potential proxy for SSI recipient ASD. As a result, analyses in which status. The data source is the NSCH and the ASD indicator were used were – In addition, the prevalence rates includes data from the survey limited to comparisons between – – of asthma, attention-deficit/ administration for the years32 34 2003, 2007 and 2011 2012. Another hyperactivity disorder (ADHD), and 2007, and 2011 2012. The methodological change was that the autism spectrum disorder (ASD) NSCH was designed to provide cross- vision and/or hearing problems and have significantly increased for more sectional national prevalence estimates depression and/or anxiety questions than a decade, mirroring trends in of a large number of health indicators from 2003 were split into separate – – overall chronic health conditions6, in 9 11 for children and uses the State and condition questions for 2007 and children and in the SSI program. Local Area Integrated Telephone 2011 2012. For our analyses, Downloaded from www.aappublications.org/news
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