The Commonwealth Fund Leadership Forum in Early Childhood Health and Development

Children require a health care system that promotes healthy development for all children while reaching out to the neediest. Barriers to care have been described as "voltage drops"—resistance points at which patients drop from the system like voltage from an electrical current. We examine the size and nature of these drops, ranging from insurance access to service quality, with respect to children. We find critical policy needs (such as expanded insurance opportunities, increased care coordination, and improved quality measurement) at all system levels. Comprehensive access to insurance and services does not guarantee that children will receive high-quality (safe and effective) care.

Chung PJ and Schuster MA. Access and Quality in Child Health Services: Voltage drops. Health Affairs. 2004; 23(5):77-87.

Data from a series of medical spending surveys over the past twenty-five years show that uninsurance rates for children have fallen to levels not seen since the late 1970s (about 8 percent). Rates of uninsurance have fallen in particular for poor children. Deteriorating family economic circumstances, along with a weakened safety net, contributed to the decrease of private insurance coverage and rising uninsurance rates between 1977 and 1987. Although family circumstances have stabilized since the late 1980s, high annual increases in health insurance costs have continued to erode private coverage. Public coverage expansions have reversed the surge in uninsurance rates during 1977-1987.

Cunningham and Kirby, Children's Health Coverage: A quarter-century of change. Health Affairs. 2004; 23(5)27-38.

Well-child care is a core service of pediatrics, but it receives little emphasis in pediatric training, reluctant consideration by insurers, and rare attention from researchers. Although it encompasses a variety of health-promoting and disease-preventing services, the desired outcomes of well-child care and quality standards for its provision have not been specified. It is not surprising, then, that preventive care services, as they are being provided currently, are not meeting the needs of many families, especially families with the most vulnerable children. The quality of child health supervision varies greatly among physician practices, and parents are signaling their dissatisfaction by failing to obtain approximately one-half of recommended preventive care services. In addition, evidence of effectiveness is lacking for much of the content of well-child care, which may jeopardize both its place as a covered insurance benefit and its reimbursement. It is time for major revision of well-child care, taking into account the varying needs of individual children and families, the operation of child health care practices, and the broad issues of access to primary care and payment for services within the US health care system. Because preventive health care for children, at least as it occurs within well-child visits, is authoritatively guided by the American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care,1 otherwise known as the periodicity schedule, review and revision of well-child care must begin with that document.

Schor EL. Rethinking Well-Child care. Pediatrics. 2004; 114:210-216.

Objectives. To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.

Methods. Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.

Results. Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.

Conclusions. While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Simpson L, Owens PL, Zodet MW, Chevarley FM, Dougherty D, Elixhauser A, and McCormick MC. Health Care for Children and Youth in the United States: Annual report on patterns of coverage, utilization, quality, and expenditures by income. Ambulatory Pediatrics. 2005; 5(1):45-46.

This paper addresses the state of health of U.S. children and finds it to be poorer in virtually every way than that of children in other countries. It explores several possible explanations, including population heterogeneity, social (including income) inequality, and inadequacy of the health services system. The latter explanation is found to relate to the underdevelopment of U.S. primary care. In light of the position taken by the World Health Organization regarding the importance of primary care, adopting the recommendations of a new National Research Council/Institute of Medicine report and some changes in health policy could help improve the health of American children.

Starfield B. U.S. Child Health: What's amiss, and what should be done about it? Health Affairs. 2004; 23(5)165-170.

Background. The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known.

Objective. To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services.

Study Design. The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health.

Outcome Measures. The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor.

Results. Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction.

Conclusions. Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care.

Zuckerman B, Stevens GD, Inkelas M, Halfon N. Prevalence and correlates of high-quality basic pediatric preventive care. Pediatrics. 2004; 114:1522-1599.

Context. Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health.

Objective. We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities.

Design. We analyzed data on 57553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0-3).

Results. A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in "good, fair, or poor health" (versus "excellent or very good") were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings.

Conclusions. The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities.

Bauman LJ, Silver EJ, Stein REK. Cumulative Social Disadvantage and Child Health. Pediatrics. April 2006; 117(4): 1321-1328.

CDC. “Unrealized prevention opportunities: reducing the health and economic burden of chronic diseases. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1997.

DeNavas-Walt C, Proctor BD, Smith J. “Income, Poverty, and Health Insurance Coverage in the United States: 2006.� U.S. Census Bureau, August 2007.

The life course health development (LCHD) framework organizes research from several fields into a conceptual approach explaining how individual and population health develops and how developmental trajectories are determined by interactions between biological and environmental factors during the lifetime. This approach thus provides a construct for interpreting how people's experiences in the early years of life influence later health conditions and functional status. By focusing on the relationship between experiences and the biology of development, the LCHD framework offers a better understanding of how diseases occur. By suggesting new strategies for health measurement, service delivery, and research, as well as for improving health outcomes, this framework also supports health care-purchasing strategies to develop health throughout life and to build human health capital.

Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. Millbank Quarterly. 2002; 80(3): 433-479.

This paper summarizes evidence on the effects of early environments on child, adolescent, and adult achievement. Life cycle skill formation is a dynamic process in which early inputs strongly affect the productivity of later inputs.

Heckman J. Skill Formation and the Economics of Investing in Disadvantaged Children. Science. 30 June 2006; 312(5782): 1900-2.

Objective. Social risk factors such as growing up in poverty, racial/ethnic minority status, and maternal depression have been associated with poorer health outcomes for children. This study examined the strength of association of 8 social risk factors, both individually and as part of a cumulative social risk index, on parent-reported child health status.

Methods. We performed an analysis of cross-sectional data from the 2003 National Survey of Children's Health, a telephone survey of 102353 parents of children aged 0 to 17 years. In bivariate and multivariate logistic regression models, 8 social risk factors were tested as independent predictors of 4 parent-reported child health outcomes: global health status, dental health, socioemotional health, and overweight. These risk factors were combined into a categorical "social risk index" ranging from low risk (0 risk factors) to very high risk ( 6 risk factors), and risk gradients were examined using linear polynomial testing and multivariate logistic regression.

Results. The percentage of children in poorer health increased with the number of social risk factors across all health outcomes. More than half of children had 2 risk factors, and 24% had 4. Low maternal mental health, black or Hispanic race/ethnicity, <200% of the federal poverty level, low household education, unsafe neighborhoods, and lack of health insurance increased the odds for less than very good child health in adjusted models. .

Conclusions. Multiple social risk factors have a cumulative effect on parent-reported child health status across physical and socioemotional domains, demonstrating a very strong risk gradient effect. These findings emphasize the importance of addressing multiple levels of social risk to achieve improvements in child health.

Larson K, Russ SA, Crall JJ, Halfon N. Influence of Multiple Social Risks on Children's Health. Pediatrics. February 2008; 121(2): 337-344.

Until recently, when anthrax triggered a concern about preparedness in the public health infrastructure, U.S. health policy and health spending had been dominated by a focus on payment for medical treatment. The fact that many of the conditions driving the need for treatment are preventable ought to draw attention to policy opportunities for promoting health. Following a brief review of the determinants of population health—genetic predispositions, social circumstances, environmental conditions, behavioral patterns, and medical care—this paper explores some of the factors inhibiting policy attention and resource commitment to the nonmedical determinants of population health and suggests approaches for sharpening the public policy focus to encourage disease prevention and health promotion.

McGinnis M, Williams-Russo P, Knickman J. The Case for More Active Policy Attention to Health Promotion. Health Affairs. March/April 2002; 21(2): 78-93.

Forecasts of life expectancy are an important component of public policy that influence age-based entitlement programs such as Social Security and Medicare. Although the Social Security Administration recently raised its estimates of how long Americans are going to live in the 21st century, current trends in obesity in the United States suggest that these estimates may not be accurate. From our analysis of the effect of obesity on longevity, we conclude that the steady rise in life expectancy during the past two centuries may soon come to an end.

Olshansky, S. Jay, et al. A Potential Decline in Life Expectancy in the U.S. in the 21st Century. New England Journal of Medicine. 17 March 2005; 352(11): 1138-1145.

Perrin, JM, Bloom SR, Gortmaker SL. Increase of Childhood Chronic Conditions in the United States. JAMA. 2007; 297: 2755-2759.

Objectives. In this study, we evaluated the relationship between household food security status and developmental risk in young children, after controlling for potential confounding variables.

Methods. The Children's Sentinel Nutritional Assessment Program interviewed (in English, Spanish, or Somali) 2010 caregivers from low-income households with children 4 to 36 months of age, at 5 pediatric clinic/emergency department sites (in Arkansas, Massachusetts, Maryland, Minnesota, and Pennsylvania). Interviews included demographic questions, the US Food Security Scale, and the Parents' Evaluations of Developmental Status. The target child from each household was weighed, and weight-for-age z score was calculated.

Results. Overall, 21% of the children lived in food-insecure households and 14% were developmentally "at risk" in the Parents' Evaluations of Developmental Status assessment. In logistic analyses controlling for interview site, child variables (gender, age, low birth weight, weight-for-age z score, and history of previous hospitalizations), and caregiver variables (age, US birth, education, employment, and depressive symptoms), caregivers in food-insecure households were two thirds more likely than caregivers in food-secure households to report that their children were at developmental risk.

Conclusions. Controlling for established correlates of child development, 4- to 36-month-old children from low-income households with food insecurity are more likely than those from low-income households with food security to be at developmental risk. Public policies that ameliorate household food insecurity also may improve early child development and later school readiness.

Rose-Jacobs R, Black MM, Casey PH, Cook JT, Cutts DB, Chilton M, Heeren T, Levenson SM, Meyers AF, Frank DA. Household Food Insecurity: Associations with At-Risk Infant and Toddler Development. Pediatrics. January 2008; 121: 65-72.

Social trends and medical progress have fueled major changes in the epidemiology of child health in the United States. Injuries remain a major contributor to childhood illness and death. However, among noninjury causes, chronic illness now accounts for the majority of children's hospital days and deaths. Although mortality rates for all children have fallen dramatically, social disparities persist. Approximately half of all excess deaths among African American children occur during infancy, primarily from extremely premature births, and the remaining portion, primarily from homicide and serious chronic conditions. These challenges may require changes in today's child health practices and policies.

Wise PH. The Transformation of Child Health in the United States. Health Affairs. 2004; 23(5): 9-25.

Before the crucial upcoming debate over reauthorization of the State Children's Health Insurance Program (SCHIP) and all of the 10,000 general health reform questions that this discussion will engender, we should consider one fundamental moral question, for our answer will reveal the kinds of policies we actually want to pursue: Who should be allowed to sit at our health care table of plenty?

This essay sketches an answer to this question, drawing on the literature of various faith traditions as well as recent health services research. The short answer is: Everyone, but poor kids have a special place reserved for them.

Nichols, L.N. The Moral Case For Covering Children (And Everyone Else). Health Affairs. March/April 2007; 26(2): 405-407.

Many common chronic and mental disorders have modifiable precursors that arise during childhood. The life-course model of how health is produced provides a scientific basis for understanding the continuity between child and adult health. Life-course health policy seeks to promote the well-being of the young, both because of its intrinsic value and because doing so will improve the health of the population at all ages. It mandates increased attention to the promotion of biopsychosocial adaptability and other approaches to preventing the precursors to future disorders. Finally, it requires health policies to foster positive long-term outcomes focused on the individual, family, and community.

Forrest, C.B., Riley, A.W. Childhood Origins Of Adult Health: A Basis For Life-Course Health Policy. Health Affairs. September/October 2004; 23(5): 155-164.

Objective. Little is known about factors that influence whether children with chronic conditions die at home. We sought to test whether deaths attributable to underlying complex chronic conditions (CCCs) were increasingly occurring at home and to determine what features were associated with home deaths.

Design. A retrospective case series was conducted of all deaths that occurred to children age 0 to 18 years in Washington state from 1980 to 1998 using death certificate data, augmented with 1990 US Census data regarding median household income by zip code in 1989, to determine the site of death.

Results. Of the 31 455 deaths identified in infants, children, and adults younger than 25 years, 52% occurred in the hospital, 17.2% occurred at home, 8.5% occurred in the emergency department or during transportation, 0.4% occurred in nursing homes, and 21.7% occurred at other sites. Among children who died as a result of some form of CCC (excluding injury, sudden infant death syndrome, and non-CCC medical conditions), the percentage of cases younger than 1 year who died at home rose slightly from 7.8% in 1980 to 11.6% in 1998, whereas the percentage of older children and young adults who had a CCC and died at home rose substantially from 21% in 1980 to 43% in 1998. Children who had lived in more affluent neighborhoods were more likely to have died at home. Using leukemia-related deaths as a benchmark, deaths as a result of congenital, genetic, neuromuscular, and metabolic conditions and other forms of cancer all were more likely to have occurred at home. Significant variation in the likelihood of home death, not explained by the individual attributes of the cases, also existed across the 39 counties in Washington state.

Conclusions. Children who die with underlying CCCs increasingly do so at home. Age at death, specific condition, local area affluence, and the location of home all influence the likelihood of home death. These findings warrant additional study, as they have implications for how we envision pediatric palliative care, hospice, and other supportive services for the future.

Feudtner C, Silveira MJ, Christakis DA. Where Do Children With Complex Chronic Conditions Die? Patterns in Washington State, 1980-1998. Pediatrics. April 2002; 109(4): 656-660.

Objective. To determine the proportion of children aged 10 to 35 months who were reported ever to have received a developmental assessment (DA) and to examine characteristics of the child, family, and health care setting associated with the receipt of a DA.

Methods. The National Survey of Early Childhood Health, conducted in 2000, is a survey of 2068 parents of children 4 to 35 months of age. Children were classified as having received a DA in response to 2 questions: whether the child's pediatric provider ever told parents that he or she was doing a "developmental assessment" and/or parents recalled explicit components of a DA, such as stacking blocks or throwing a ball. Parent-reported receipt of a DA was assessed in relationship to child and family, health care access, other measures of health care content and process, and measures of quality and satisfaction.

Results. Approximately 57% of children 10 to 35 months of age ever received a DA. Forty-two percent of parents recalled ever being told by their child's pediatric provider that a DA was being done. Thirty-nine percent recalled their child's being asked to perform specific tasks routinely included in a DA. Bivariate analysis indicates that receipt of a DA is not associated with child or family sociodemographic characteristics such as maternal education and household income, with the exception of race/ethnicity. Less acculturated Hispanic parents reported a DA more frequently than parents in other racial/ethnic groups (66% vs 56%). A smaller proportion of parents whose children who used community health centers reported their child's ever having received a DA compared with children who use other settings (51% vs 60%). Compared with other children, parents whose child ever received a DA reported more frequently than other parents that the time spent with the child's provider during the last well-child visit was adequate (94% vs 80%). They also reported longer visits (19 minutes vs 16 minutes), higher family-centered care ratings (mean: 71 vs 59), and higher satisfaction with well-child care (8.9 vs 8.4). Receipt of a DA is also associated with the content of developmentally focused anticipatory guidance received. For each health supervision topic analyzed, frequency of discussion is higher for children who ever received a DA. In multivariate analysis, odds of receiving a DA are higher for children with longer visits with the provider (odds ratio: 1.03; 95% confidence interval: 1.01-1.05) and lower for children in community health clinics compared with a private office (odds ratio: 0.61; 95% confidence interval: 0.39-0.96), even accounting for total well-child visits to the pediatric provider.

Conclusion. Although guidelines endorse the routine provision of DAs, parents of many children do not report receiving DAs. Children who receive assessments are more likely to receive other developmental services, and their parents are more likely to report greater satisfaction with care and rate the interpersonal quality of well-child care more favorably. The substantial number of children who do not receive these routinely recommended services raises important questions about the quality of care received.

Halfon N, Regalado M, Sareen H, Inkelas M, Reuland CP, Glascoe FP, Olson LM. Assessing development in the pediatric office. Pediatrics. 2004; 113(6): 1926-33.

Objective. To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996.

Research Design. Comparison of clinician-identified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 (Monroe County Study) and 1996 (Child Behavior Study). Data were collected from clinician visit questionnaires developed originally for the 1979 study.

Setting. Private practice offices of 425 community-based pediatricians and family practitioners across both studies.

Patients. We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices. The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians.

Selection Procedure. Each clinician enrolled consecutive eligible patients for both studies.

Measurements and Results. From 1979 to 1996, clinician-identified psychosocial problems increased from 6.8% to 18.7% of all pediatric visits among 4- to 15-year-olds. We found increases in all categories of psychosocial problems, except for mental retardation. Attentional problems showed the greatest absolute increase (1.4%-9.2%) and emotional problems showed the greatest relative increase (.2%-3.6%). The use of psychotropic medications, counseling, and referral also increased substantially. In particular, the percentage of children with Attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increases in psychosocial problems were associated with increases in the proportions of single-parent families and Medicaid enrollment from 1979 to 1996. Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems.

Conclusions. Substantial increases in the identification of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population.

Kelleher KJ, McInerny TK, Gardner WP, Childs GE, Wasserman RC. Increasing Identification of Psychosocial Problems: 1979-1996. Pediatrics. 2000; 105: 1313-1321.

American Academy of Pediatrics (AAP). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition. (Hagan JF, Shaw JS, & Duncan PM, eds.), Elk Grove Village, IL: American Academy of Pediatrics. 2008.

The American Academy of Pediatrics proposed a definition of the medical home in a 1992 policy statement. Efforts to establish medical homes for all children have encountered many challenges, including the existence of multiple interpretations of the “medical home� concept and the lack of adequate reimbursement for services provided by physicians caring for children in a medical home. This new policy statement contains an expanded and more comprehensive interpretation of the concept and an operational definition of the medical home.

American Academy of Pediatrics (AAP), Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The Medical Home. Pediatrics. 2002; 110:184-186.

The optimal health of children can best be achieved by providing access to comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 21. These services encompass medical care, critical care, pediatric surgical care, behavioral health services, specialized services for children with special health care needs, and oral health. It replaces the 1997 statement, "Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years."

American Academy of Pediatrics. Scope of Benefits Statement, AAP Bright Futures II, AAP Medical Home Statement, (Scope of Benefits, 2006; Bright Futures; Recommendations for Preventive Pediatric Health Care; Medical Home statement).

Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. Care coordination often is complicated because there is no single entry point to multiple systems of care, and complex criteria determine the availability of funding and services among public and private payers. Economic and sociocultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care pediatricians have a vital role in the process of care coordination, in concert with the family.

According to the Maternal and Child Health Bureau (MCHB) definition, which was later adopted by the American Academy of Pediatrics (AAP), "children with special health care needs are those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who require health and related services of a type or amount beyond that required by children generally." Primary care pediatricians and other professionals caring for children with special health care needs generally acknowledge the importance of and the need for coordination of care. New initiatives from health care reform and managed care are reshaping the traditional direct clinical care role of the primary care pediatrician to include gatekeeper and coordination roles. This transition to managed systems of care from traditional fee-for-service care has important implications for aspects of care coordination. The primary care pediatrician may be required to assume even greater responsibility for providing care coordination for their patients under capitated arrangements. This policy statement reviews the importance of the primary care pediatrician's role in care coordination in the context of the medical home.

American Academy of Pediatrics (AAP), Committee on Children with Disabilities. Care Coordination: Integrating health and related systems of care for children with special health care needs. Pediatrics. 1999; 104(4):978-981.

Care coordination is a process that links children with special health care needs and their families to services and resources in a coordinated effort to maximize the potential of the children and provide them with optimal health care. Care coordination often is complicated because there is no single entry point to multiple systems of care, and complex criteria determine the availability of funding and services among public and private payers. Economic and sociocultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care pediatricians have a vital role in the process of care coordination, in concert with the family.

American Academy of Pediatrics (AAP), Care Coordination in the Medical Home: Integrating health and related systems of care for children with special health care needs. Pediatrics. 2005; 116(5):1238-1244.

Medicaid is a vital safety net for children that must be maintained. It is the largest single insurer of children, yet millions of children who are eligible remain unenrolled. Every effort should be made to implement expanded eligibility and streamlined enrollment procedures. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefits should be maintained for all eligible children. On average, Medicaid covers 30% of a pediatrician's patients, yet inadequate reimbursement affects children's access to care. States should increase reimbursement to at least parity with Medicare.

American Academy of Pediatrics, Committee on Child Health Financing. Medicaid Policy Statement. Pediatrics. 2005; 116:274-280.

Policymakers considering the 2009 reauthorization of the State Children's Health Insurance Program (SCHIP) have an opportunity to strengthen federal provisions to promote primary, preventive, and developmental child health care. Several pieces of legislation introduced in 2007 focused on aspects of child health quality, but none placed a specific emphasis on primary care. This issue brief describes three legislative proposals and additional quality provisions related specifically to primary care to consider for incorporation into federal law. These provisions include: 1) establishing a core set of primary child health service outcomes for tracking within Medicaid and SCHIP; 2) creating a structure within the Centers for Medicare and Medicaid Services that focuses on strengthening primary, preventive, and developmental child health services; 3) supporting additional research on child health quality and outcomes in primary care; and 4) providing incentives to states to promote evidence-based practices in children's primary health care.

Bruner C, Fitzgerald C, & Plaza C. Improving Child Health Care Through Federal Policy: An Emerging Opportunity. New York, NY: The Commonwealth Fund. 2008.

Bruner C, Floyd S, & Copeman A. (2003). State Early Childhood Policy Technical Assistance Network — Financing school readiness strategies: An annotated bibliography. Des Moines, IA: Child and Family Policy Center.

A growing body of evidence highlights the importance of early development and points to the need for actively promoting healthy development and systematically addressing developmental, behavioral, and psychosocial issues early in life. However, many children with developmental issues or those at risk are not identified early enough and not consistently linked to needed services and supports. Pediatric health care providers have an important role to play in providing developmental care and linking children to services and resources within the broader community. While multiple strategies are being tested by pediatricians and others working in child health, to date no study has primarily focused on how pediatric practices link young children and families to developmental care. This report provides a first step in reviewing the current state of pediatric primary care linkage to developmental services, identifying key strategies, developing a linkage typology, and providing recommendations to improve linkage for developmental care.

Fine A & Mayer R. Beyond Referral: Pediatric Care Linkages to Improve Developmental Health. New York, NY: The Commonwealth Fund. 2006.

Kaye N, May J, and Abrams M. State Policy Options to Improve Delivery of Child Development Services: Strategies from the Eight ABCD States. New York: Commonwealth Fund. 2006.

Objective. To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in 1 community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants.

Design. Observational intervention study in 1 North Carolina county (population 182 000) involving low- income pregnant mothers and their infants, primary care practices, and departments of health and mental health. An interrupted time-series design was used to assess rates of preventive services in office practices before and after the intervention, and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program's initiation. Outcomes were assessed when the infants reached 12 months of age.

Interventions. Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families. We selected interventions that were directed toward major risk factors (eg, poverty, ineffective care systems for preventive care in office practices) and for which there was existing evidence of efficacy. The interventions involved community-, practice-, and family-level strategies to improve processes of care delivery to families and children. The objectives of the community-level intervention were: 1) to achieve policy level changes that would result in changes in resources available at the level of clinical care, 2) to engage multiple practice organizations in the intervention to achieve an effect on most, if not all, families in the community, and 3) to enhance communication between, among, and within public and private practice organizations to improve coordination and avoid duplication of services. The objective of the practice-level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered. To assist the health department in implementing the family-level intervention, we provided assistance in hiring and training staff and ongoing consultation on staff supervision, including the use of structured protocols for care delivery, and regular feedback data about implementation of the program. Interventions with primary care practices focused on the design of the delivery system within the office and the use of teamwork and data in an "office systems" approach to improving clinical preventive care. All practices (N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems (eg, preventive services flow sheets) for preventive services delivery. Family-level interventions addressed the process of care delivery to high-risk pregnant women (100% poverty) and their infants. Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center, the county's largest provider of prenatal care to underserved women. The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant's first year of life to provide parental education on fetal and infant health and development, enhance parents' informal support systems, and link parents with needed health and human services. We included training in injury prevention and discipline, and home visitors assisted mothers in obtaining care from one of the primary care offices.

Results. There were high levels of participation, changes in the organization of the delivery system, and improvements in preventive health outcomes. Agencies cooperated in joint contracting, staff training, and defining program eligibility. All 8 eligible practices agreed to participate and 7/8 implemented at least 1 new office system element. Of eligible women, 89% agreed to participate, and outcome data were available on 80% (180/225). After adjusting for differences in baseline characteristics, intervention group women were significantly more likely than comparison group women to use contraceptives (69% vs 47%), not smoke tobacco (27% vs 54%) and have a safe and stimulating home environment for their children. Intervention group children were more likely to have had an appropriate number of well-child care visits (57% vs 37%) and less likely to be injured (2% vs 7%). Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child (7.7 months vs 11.3 months).

Conclusions. We observed a number of positive effects at all 3 levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

Margolis PA, Stevens R, Bordley WC, Stuart J, Harlan C, Keyes-Elstein L, Wisseh S. From Concept to Application: The impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics. 2001; 108(3):e42-63.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) seeks to achieve greater efficiency and effectiveness in the health care system by requiring payers and providers to use standardized procedure codes for payment claims. HIPAA has a significant impact on the translation of benefit designs into medical claims payment standards. This presents challenges for children with Medicaid coverage, since the Medicaid program employs a unique definition of medical necessity that ties coverage to childhood growth and development. To comply with HIPAA, state Medicaid agencies must eliminate local payment codes, a process that may result in reduced levels of coverage for children, particularly for primary health and support services such as mental health services, early intervention, physical and speech therapy, home care, case management, and transportation. To avoid unintentional reduction of child development services, the authors suggest revising HIPAA to allow states to customize payment coding to their unique coverage standards.

Markus AR, Rosenbaum S, Stewart A. (2005) How Medical claims simplification can impede delivery of child developmental services. New York, NY: The Commonwealth Fund.

Ramler M, Nakatsukasa-Ono W, Loe C, Harris K. The Influence of Child Care Health Consultants in Promoting Children's Health and Well-Being: A Report on Selected Resources. Newton, MA: Healthy Child Care Consultant Network Support Center. 2006.

Objective. To examine the evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years. Data Sources: Peer-reviewed publications addressing clinical evaluations of primary care services from the MEDLINE and PsychINFO databases.

Study Selection. Criteria for selection were as follows: (1) publication between 1979 and 1999; (2) evaluation of efficacy or effectiveness of education, intervention, and care coordination services or validation of assessment approaches; (3) services applicable to an office practice setting; (4) target population including children aged birth to 3 years; and (5) publication in English.

Data Extraction. A total of 312 publications were abstracted and reviewed by both of us; 47 were selected for inclusion.

Data Synthesis. Assessments of parental concerns and psychosocial risk factors using validated approaches seem to be more accurate in identifying developmental problems than clinicians' appraisals. In general, study results support the efficacy of (1) primary care educational efforts toward promoting optimal parent-child interaction, parents' understanding of child temperament, book-sharing activities, and approaches to healthy sleep habits and (2) office interventions such as counseling for the management of excessive infant crying and sleep problems.

Conclusions. The literature suggests that many primary care activities promoting the optimal development of children are efficacious. Evaluations of developmental assessment and services in primary care should be expanded in depth and breadth. The implications for clinical practice, training, and health care policy are discussed.

Regaldo M, Halfon N. Primary Care Services Promoting Optimal Child Developent from Birth to Age 3 Years: Review of the literature. Archives of Pediatric Adolescent Medicine. 2001; 155: 1311-1322.

Rosenbaum S. Strategies for Improving Early Childhood Development Services within the Health Care System. New York: Commonwealth Fund, January 2002.

Scientists have had a long-standing fascination with the complexities of the process of human development. Parents have always been captivated by the rapid growth and development that characterize the earliest years of their children's lives. Professional service providers continue to search for new knowledge to inform their work. Consequently, one of the distinctive features of the science of early childhood development is the extent to which it evolves under the anxious and eager eyes of millions of families, policy makers, and service providers who seek authoritative guidance as they address the challenges of promoting the health and well-being of young children.

Shonkoff JP, Phillips DA. Eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington DC: National Research Council and Institute of Medicine, 2000.

VanLandeghem K., Curtis D, & Abrams M. (2002). Reasons and strategies for strengthening childhood development services in the healthcare system. Portland, ME: National Academy for State Health Policy.

A study of pediatric and family practices in Vermont and North Carolina found that a collaborative quality improvement program helped practices implement systems to provide parents with child-rearing guidance and information on healthy development. It also increased parents' satisfaction with their children's care.

Margolis P.A., McLearn K.T., Earls F. et al. Assisting Primary Care Practices in Using Office Systems to Promote Early Childhood Development. Ambulatory Pediatrics. November/December 2008; 8(6): 383-87.

The Iowa Department of Public Health's 1st Five Healthy Mental Development Initiative is bridging public and private health care systems to improve early detection of social-emotional delays and prevention of mental health problems among young children and their families. Key features of the 1st Five model include: user-friendly mental and developmental health screening and referral forms; ongoing education and support for medical office staff on healthy development and use of screening and referral tools; specially trained care coordinators to identify and address a wide range of children's and families' needs; relationships with community resources that provide early intervention; and timely notification of outcomes to the referring physician offices. With an evaluation under way, early 1st Five experience indicates that families identified through the program have a range of unmet needs: each physician referral results in an average of three to five follow-up referrals for services.

Silow-Carroll, S. Iowa's 1st Five Initiative: Improving Early Childhood Developmental Services Through Public-Private Partnerships, The Commonwealth Fund, September 2008.

http://www.aapd.org/upload/news/2007/1537.pdf

http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/03_StateAgencyResponsibilities.asp

http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/

Cohen-Ross D, Cox L. In a time of growing need: State choices influence health coverage access for children and families: A 50-State update on eligibility rules, enrollment, and renewal procedures, and cost-sharing practices in Medicaid and SCHIP for children and families. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2005.

To increase the participation of Medicaid children in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and to improve their health, Congress included several provisions in the Omnibus Budget Reconciliation Act of 1989 (OBRA'89) that addressed problematic program features. The impact of these provisions on children's health service use was investigated in a study funded by the Health Care Financing Administration. After conducting site visits to four states, the authors analyzed claims data for the children residing there and found evidence that, in 1992, these states placed a higher priority on improving the effectiveness of EPSDT than they did before 1989. The states' efforts to expand the EPSDT provider base and to enhance outreach and service provision were either directly or indirectly inspired by OBRA'89. The authors also found evidence of a significant impact on provider participation and caseloads and on children's use of both preventive care and diagnostic and treatment services. However, the effects were modest in comparison to the size of the progress that is required.

Gavin NI, Adams EK, Herz EJ, Chawla AJ, Ellwood MR, Hill IT, Zimmerman BL, Wasserman J. The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89. Milbank Quarterly. 1998; 76(2): 207-50.

Johnson K. Maximizing the Use of EPSDT to Improve the Health and Development of Young Children. Project THRIVE SHORT TAKE (No. 2). New York: National Center for Children in Poverty, 2006.

Kaiser Commission on the Future of Medicaid.

http://www.kaiseredu.org/topics_reflib.asp?id=128&rID=3&parentid=65#Children

The majority of states have implemented separate SCHIP (S-SCHIP) programs that significantly depart from Medicaid and resemble less comprehensive commercial products. This difference in program design may result in S-SCHIP potentially being less responsive to children with special needs (CSHCNs). This study explores how responsive insurers are to these higher than average needs. We found that, with one exception, insurers did not agree on the coverage of any specific service, but overall they provided coverage beyond state limits and exclusions. Second, the less acute the childhood condition, the more frequently insurers imposed exclusions. Finally, in the majority of states, some insurers excluded services that arguably should have been covered according to the plan/contract language. We conclude that SCHIP coverage at current levels may not be sufficient to care for CSHCNs, making external reviews of insurers' coverage decisions and coordination with other sources of care important components of SCHIP program design.

Markus A, Rosenbaum S, Stein RE, Joseph J. From SCHIP Benefit Design to Individual Coverage Decisions. Washington, DC: George Washington University. January, 2006.

The goal of equitable access to health care continues to be elusive for poor children. Medicaid, the major source of financing such care, has been eroded by a series of actions by the administration and the Congress. A survey of the Medicaid-based EPSDT (Early and Periodic Screening, Diagnosis, and Treatment) programs in the fifty states pinpoints shortcomings in adequate financing and sound standards of practice. Reconciling child health goals with program realities will require new federal and state initiatives.

Rosenbaum S, Johnson K. Providing Health Care for Low-income Children: Reconciling Child Health Goals with Child Health Financing Realities. Milbank Quarterly. 1986; 64: 422-478.

Rosenbaum S, Johnson K. Making Medicaid and SCHIP work for families and children (Starting Points Issue Brief). Washington, DC: George Washington University School of Public Health and Health Services and Carnegie Corporation of New York, 2001.

http://www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/mil_prep042605.pdf

Rosenbaum S, Maurey DR, Shin P, Hidalgo J. National Security and U.S. Child Health Policy: The origins and continuing role of Medicaid and EPSDT. Washington, DC: George Washington University. 2005.

This report analyzes the provisions of the Deficit Reduction Act of 2005 (DRA) and assesses their implications for the provision of early childhood preventive and developmental services in Medicaid. The DRA may have significant effects, given the high proportion of young children enrolled in Medicaid—28 percent of all children under age 6 in 2001—and the broad range of services covered. The law imposes citizenship documentation requirements on applicants and recipients, including children. It gives states broad powers to restructure coverage through the use of a "benchmark" option but also retains Early and Periodic Screening, Diagnostic, and Treatment services as the coverage standard for children under age 19. The law gives states greater authority to impose cost-sharing for Medicaid-covered benefits and services. Finally, it redefines the federal role in financing targeted case management services, which have assumed a central role in child development programs for vulnerable children and families.

Rosenbaum S, Markus AR. The Deficit Reduction Act of 2005: An overview of key Medicaid provisions and their implications for early childhood development services. George Washington University and The Commonwealth Fund, October 2006.

Contained in the Deficit Reduction Act of 2005 is a provision that could greatly affect Medicaid's signature child health coverage standard, embodied since 1967 in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. Whether the core child health and developmental principles that have been EPSDT's touchstone for four decades will continue to guide Medicaid depends on whether and how these principles will be incorporated into states' coverage reforms.

Rosenbaum S, Wise P. Crossing the Medicaid-Private Insurance Divide: The case of EPSDT. Health Affairs. 2007; 26(2):382-392.

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, which was designed to ensure that Medicaid-eligible children receive comprehensive health services, is the only national attempt to provide a right to these services. The political factors that have shaped national EPSDT policy during the past decade are described, based on a conceptual framework developed by John W. Kingdon. The analysis focuses on the roles of two distinct sets of policy entrepreneurs: child health advocates and fiscally conservative governors. Their activities are described in relation to the larger political environment, or "political stream," from the period of the expansion of Medicaid eligibility for pregnant women and children in the late 1980s to the enactment of a new State Children's Health Insurance Program (SCHIP) in 1997. The relative saliency of eligibility and benefit issues in children's health policies had a major influence on the politics and outcomes.

Sardell A, Johnson K. The Politics of EPSDT Policy in the 1990s: Policy Entrepreneurs, political streams, and children's health benefits. Milbank Quarterly. 1998; 76:175-206.

Schor EL, Abrams MK, Shea K. Medicaid: Health Promotion and Disease Prevention for School Readiness. Health Affairs. 2007; 26(2): 420-429.

Smith V. Opportunities to Use Medicaid in Support of Maternal and Child Health Services. Rockville, MD: HRSA. December 2000.

www.gao.gov/new.items/d03222.pdf

U.S. Government Accountability Office (GAO), Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's Access to Care. GAO-03-222, January 2003.

Van Dyck P, Johnson K. EPSDT Services for Children. Maternal and Child Health Practices, (4th edition). Editors: Wallace, Nelson, and Sweeney PJ. Oakland, CA, Third Party Publishing Co., 1994.

http://www.cbo.gov/ftpdocs/78xx/doc7861/m_m_schip.pdf

http://www.chcs.org/usr_doc/EPSDT_at_40.pdf

Rosenbaum S, Wilensky S, Allen K. EPSDT at 40: Modernizing a Pediatric Health Policy to Reflect a Changing Health Care System. 2008.

http://www.cbpp.org/schip-chartbook.htm

Ku L, Lin M., Broaddus M. Improving Children's Health: A Chartbook about the Roles of Medicaid and SCHIP, Washington, DC: Center on Budget and Policy Priorities, 2007.

Objectives. We describe instability of health insurance coverage for children aged 2 to 17 years and relate insurance instability to access, utilization and satisfaction.

Methods. Three 2-year panels of the Medical Expenditure Panel Survey were used to measure insurance instability and its relationship to access, utilization, and problems with medical care.

Results. Over a 2-year period, 53% of children were continuously insured with private coverage, 19% had continuous public insurance, 20% had a single gap in coverage, 2% had multiple gaps, and 6% were continuously uninsured. Compared with children continuously insured through private coverage, children with single or multiple gaps or who were continuously uninsured were significantly more likely to lack a usual source of care (adjusted odds ratios [AORs] = 2.3, 3.5, and 4.5, respectively), to have no well-child visits (AORs = 1.2, 2.2 and 2.4, respectively), and to have unmet medical or prescription drug needs (AORs = 4.5, 4.2 and 3.4, respectively). There were no significant differences between children continuously insured through private coverage and children with single or multiple gaps or continuously uninsured and having at least 1 problem with medical care (AORs = 0.8, 1.3, and 1.4, respectively). While there were no differences between children continuously insured through private coverage and children with multiple gaps or continuously uninsured, children with single gap in coverage were significantly more likely to report having at least one problem with medical care (AOR = 1.5).

Conclusions. Compared with those with continuous coverage, children with gaps in coverage--especially those with multiple gaps--are less likely to have a usual source of care and receive well-child care. The national debate should incorporate discussions of policies to promote not only expansions of coverage, but also initiatives to eliminate gaps in coverage.

Cassedy A, Fairbrother G, Newacheck, P. The Impact of Insurance Instability on Children's Access, Utilization, and Satisfaction with Health Care. Ambulatory Pediatrics. 2008; 8(5): 321-328.

http://www.futureofchildren.org/pubs-info2825/pubs-info_show.htm?doc_id=161387

The David and Lucille Packard Foundation. The Future of Children: Health Insurance for Children. 2003; 13(1).

Compelling evidence from neuroscience about how early relationships and experience influence the architecture of the brain, and in turn early school success, has led to increasing policy and practice attention to implementing child development and family support programs like Early Head Start for infants and toddlers.

But, there is also a group of babies, toddlers, and parents who face so many risks that programs like these alone may not be enough. This issue brief focuses on the special challenges of helping babies and toddlers whose earliest experiences, environments, and especially relationships create not a warm and nurturing atmosphere, but what scientists have called “toxic stressâ€�—exposing them to such high and consistent levels of stress that their growing brains cannot integrate their experiences in ways that promote growth and learning. It describes 10 strategies that programs and communities can implement to ensure these babies, toddlers, and families are connected to sufficiently intensive supports that can get them on a path to early school success.

Knitzer J, Lefkowitz J. Pathways to early school success: Helping the most vulnerable infants, toddlers, and families. New York, NY: National Center for Children in Poverty, Columbia University Mailman School of Public Health. 2005.

Johnson K, Knitzer J. Spending smarter: A funding guide for policymakers to promote social and emotional health and school readiness. New York, NY: National Center for Children in Poverty, Columbia University Mailman School of Public Health . 2005.

Johnson K, Kaye N. Using Medicaid to support young children's healthy mental development. Portland, ME: National Academy for State Health Policy. 2004.

Rosenthal J, Kaye N. State Approaches to Promoting Young Children's Healthy Mental Development. Portland, ME: National Academy for State Health Policy. 2005.

Rosenthal J, et al. The Role of State Health Policy in Multi-Sector System and Service Linkages for Young Children. Portland, ME: National Academy for State Health Policy. 2008.

Kaye N, Rosenthal J. Improving the Delivery of Health Care that Supports Children's Healthy Mental Development: Update on Accomplishments and Lessons from a Five-State Consortium. New York, NY: The Commonwealth Fund. 2008.

Objective. Policy discussions regarding the mental health needs of children and adolescents emphasize a lack of use of mental health services among youth, but few national estimates are available. The authors use three national data sets and examine ethnic disparities in unmet need (defined as having a need for mental health evaluation but not using any services in a 1-year period) to provide such estimates.

Method. The authors conducted secondary data analyses in three nationally representative household surveys fielded in 1996-1998: the National Health Interview Survey, the National Survey of American Families, and the Community Tracking Survey. They determined rates of mental health service use by children and adolescents 3-17 years of age and differences by ethnicity and insurance status. Among the children defined as in need of mental health services, defined by an estimator of mental health problems (selected items from the Child Behavior Checklist), they examined the association of unmet need with ethnicity and insurance status.

Results. In a 12-month period, 2%-3% of children 3-5 years old and 6%-9% of children and adolescents 6-17 years old used mental health services. Of children and adolescents 6-17 years old who were defined as needing mental health services, nearly 80% did not receive mental health care. Controlling for other factors, the authors determined that the rate of unmet need was greater among Latino than white children and among uninsured than publicly insured children.

Conclusions. These findings reveal that most children who need a mental health evaluation do not receive services and that Latinos and the uninsured have especially high rates of unmet need relative to other children. Rates of use of mental health services are extremely low among preschool children. Research clarifying the reasons for high rates of unmet need in specific groups can help inform policy and clinical programs.

Kataoka SH, Zhang L, Wells KB. Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. American Journal of Psychiatry. 2002; 159: 1548-1555.

Child and Adolescent Health Measurement Initiative. National Survey of Children' with Special Health Care Needs, 2005. Retrieved August 9, 2007 from www.cshcndata.org & http://mchb.hrsa.gov/chscn/pages/coordination.htm.

Fox HB, McManus MA, Almeida RA, Lesser C. Medicaid managed care policies affecting children with disabilities: 1995 and 1996. Health Care Financing Review. 1997; 18(4):23-36.

Objective. To analyze medical necessity standards used by state Medicaid agencies and the largest commercial insurers in the United States on the basis of criteria related to scope of health problems covered and requirements for effectiveness and cost.

Methods. Information was obtained from managed care contract documents used by the 45 state Medicaid agencies enrolling children into managed care organizations and from certificates of coverage used by the largest health maintenance and preferred provider organization insurers in each state.

Results. Commercial insurers are more likely than Medicaid agencies to articulate medical necessity standards that limit coverage to treatment for illnesses and injuries and to include stringent requirements for cost and evidence of effectiveness.

ConclusionTo reduce the discretion retained by insurers in determining medical necessity, particularly around the scope of health problems covered, much greater clarity and uniformity in medical necessity language will be required in the future.

Fox HB, McManus MA. A national study of commercial health insurance and Medicaid definitions of medical necessity: What do they mean for children? Ambulatory Pediatrics. 2001; 1: 16-22.

McPhearson M. A new definition of children with special health care needs. Pediatrics. 1998; 102:137-140.

Nageswaran S, Roth MS, Kluttz-Hile CE, Farel A. Medical Homes for Children with Special Healthcare Needs in North Carolina. North Carolina Medical Journal. 2006; 67(2):103-109.

Objectives. To provide the first nationally representative data on total health care expenses, out-of-pocket health care expenses, and information on the extent to which out-of-pocket expenses are financially burdensome for families of children with special health care needs (CSHCN). To also compare utilization and expenditure patterns for children with and without special health care needs.

Design. We used data from the 2000 Medical Expenditure Panel Survey (MEPS). We present univariate, bivariate, and multivariate statistics on utilization and expenditures adjusted for the complex sample design.

Participants. The 2000 MEPS data set contains 6965 children younger than 18 years. Using the CSHCN definition adopted by the federal Maternal and Child Health Bureau and operationalized using the CSHCN Screener, 949 children (15.6%) were identified as children with special health care needs.

Main Outcome Measures. Compared with other children, CSHCN had 3 times higher health care expenditures ($2099 vs $628; P.01). The 15.6% of CSHCN accounted for 42.1% of total medical care costs (excluding dental costs) and 33.6% of total health care costs (including dental costs) attributed to children in 2000. Families of CSHCN were best protected against inpatient hospital care expenses and most exposed to dental care expenses. Families of CSHCN experiencing high out-of-pocket expenses (exceeding 5% of family income) were approximately 11 times more likely to be from households with incomes below 200% of the federal poverty level (odds ratio, 10.9; 95% confidence interval, 3.55-33.76) than to be from families with incomes at or above 400% of the federal poverty level.

Conclusions. Families with CSHCN experience much higher expenditures, including out-of-pocket expenditures, than other children. Insurance plays an important protective role for families of CSHCN, but it still provides incomplete protection. Health policy changes that would extend the breadth and depth of insurance coverage are needed to ensure that all families of CSHCN are protected against burdensome expenses.

Newacheck P, Kim A. National Profile of Health Care Utilization and Expenditures for Children with Special Health Care Needs. Archives of Pediatrics and Adolescent Medicine. 2005; 159: 10-17.

Objective. The purpose of this article is to report the findings of the National Survey of Children With Special Health Care Needs regarding parent perceptions of the extent to which children with special health care needs (CSHCN) have access to a medical home.

Methods. Five criteria, selected to reflect the characteristics of a medical home as defined by the American Academy of Pediatrics (AAP) policy statement on the medical home, were analyzed to describe the extent to which CSHCN receive care characteristic of the medical home concept. These criteria included having 1) a usual place for sick/well care, 2) a personal doctor or nurse, 3) no difficulty in obtaining needed referrals, 4) needed care coordination, and 5) family-centered care received. Items from the Survey were selected and clustered to characterize each of the 5 components. Criteria for each item were established with the requirement that the criteria must be met for all items in a component to receive credit for the component.

Results. Results of the survey indicate that 1) approximately half of CSHCN receive care that meets all 5 components established for medical home; 2) most CSHCN have a usual source of care and a personal doctor or nurse, but other components of the medical home, especially elements of care coordination and family-centered care, are lacking; 3) access to a medical home is significantly affected by race/ethnicity, poverty, and the limitations imposed on daily activity by the child's special health care need; and 4) parents of children who do have a medical home report significantly less delayed or forgone care, significantly fewer unmet health care needs, and significantly fewer unmet needs for family support services. The 5 components described represent major characteristics of the comprehensive care model recommended for all children by the AAP.

Conclusions. The findings suggest that although some components of the medical home concept have been achieved for most CSHCN, the comprehensive care model described by the AAP policy statement on the medical home is not yet in place for a significant number of CSHCN and their families.

Strickland B, McPherson M, Weissman G, van Dyck P, Juang ZJ, Newacheck P. Access to the Medical Home: Results of the National Survey of Children with Special Health Care Needs. Pediatrics. 2004; 113(5 suppl): s1485-1492.

Background. Children with special health care needs (SHCNs) are an important population from health care services, economic, and policy perspectives. However, until recently, no national data on their prevalence and health care service needs that use a commonly accepted definition have existed.

Objective. To provide national estimates of the number of children with SHCNs and their characteristics, including an assessment of how well their needs are being met.

Setting. The United States.

Participants. Interviews were conducted by telephone with the families of 38 866 children with SHCNs younger than 18 years using the State and Local Area Integrated Telephone Survey platform developed by the Centers for Disease Control and Prevention, Atlanta, Ga.

Main Outcome Measures. Prevalence of SHCNs, demographic and socioeconomic correlates of SHCNs, access to care, satisfaction with care, and impact on the family.

Results An estimated 12.8% of US children experienced an SHCN in 2001. Prevalence was highest among boys, school-age children, and children in lower-income families. A substantial minority of these children experienced unmet health needs (17.7%) or lacked critical elements of family-centered health care (33.5%). The impact on families was pronounced, as 20.9% reported their child's health care caused financial problems, and 29.9% reported cutting back or quitting work because of their child's condition. These adverse child- and family-level impacts were concentrated among low-income and uninsured children with SHCNs.

Conclusions. Children with SHCNs and their families represent an important underserved population. In addition, substantial disparities are present in access, satisfaction, and family impact.

Van Dyck P, Kogan MD, McPherson MG, et al. Prevalence and Characteristics of Children with Special Health Care Needs. Archives of Pediatrics and Adolescent Medicine. 2004; 158:884-890.

Wise PH, Huffman LC, Brat G. A Critical Analysis of Care Coordination Strategies for Children with Special Health Care Needs. Technical Review, No. 14. (AHRQ Pub. No. 07-0054) June 2007.

Objective. To present an epidemiologic profile of children with special health care needs using a new definition of the population developed by the federal Maternal and Child Health Bureau.

Methods. We operationalized the new definition using the recently released 1994 National Health Interview Survey on Disability. Estimates are based on 30 032 completed interviews for children <18 years old. The overall response rate was 87%.

Results. Eighteen percent of US children <18 years old in 1994, or 12.6 million children nationally, had a chronic physical, developmental, behavioral, or emotional condition and required health and related services of a type or amount beyond that required by children generally. This estimate includes children with existing special health care needs but excludes the at-risk population. Prevalence was higher for older children, boys, African-Americans, and children from low-income and single-parent households. Children with existing special health care needs had three times as many bed days and school absence days as other children. An estimated 11% of children with existing special health care needs were uninsured, 6% were without a usual source of health care, 18% were reported as dissatisfied with one or more aspects of care received at their usual source of care, and 13% had one or more unmet health needs in the past year.

Conclusions. A substantial minority of US children were identified as having an existing special health care need using national survey data. Children with existing special health care needs are disproportionately poor and socially disadvantaged. Moreover, many of these children face significant barriers to health care.

Newacheck PW, et. al. An Epidemiologic Profile of Children With Special Health Care Needs. Pediatrics. 1998; 102: 117-123.

Agency for Health care Research and Quality, Alliance for Pediatric Quality Mission, available at http://www.kidsquality.org/content.aspx?c=5

Background. Little is known about the magnitude of deficits in the quality of care delivered to children, since comprehensive studies have been lacking.

Methods. We assessed the extent to which care processes recommended for pediatric outpatients are delivered. Quality indicators were developed with the use of the RAND-UCLA modified Delphi method. Parents of 1536 children who were randomly selected from 12 metropolitan areas provided written informed consent to obtain medical records from all providers who had seen the children during the 2-year period before the date of study recruitment. Trained nurses abstracted these medical records. Composite quality scores were calculated by dividing the number of times indicated care was documented as having been ordered or delivered by the number of times a care process was indicated.

Results. On average, according to data in the medical records, children in the study received 46.5% (95% confidence interval [CI], 44.5 to 48.4) of the indicated care. They received 67.6% (95% CI, 63.9 to 71.3) of the indicated care for acute medical problems, 53.4% (95% CI, 50.0 to 56.8) of the indicated care for chronic medical conditions, and 40.7% (95% CI, 38.1 to 43.4) of the indicated preventive care. Quality varied according to the clinical area, with the rate of adherence to indicated care ranging from 92.0% (95% CI, 89.9 to 94.1) for upper respiratory tract infections to 34.5% (95% CI, 31.0 to 37.9) for preventive services for adolescents.

Conclusions. Deficits in the quality of care provided to children appear to be similar in magnitude to those previously reported for adults. Strategies to reduce these apparent deficits are needed.

Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine. 2007; 357(15): 1515-23.

State Medicaid/Children's Health Insurance Program (SCHIP) agencies play pivotal roles in ensuring that participating health plans provide quality care. In 2003, researchers interviewed SCHIP officials with oversight responsibilities in nine states and found that all agencies had formal monitoring procedures and that all of them regularly collected data that measured health plans' compliance with quantifiable standards. Several states designed a graduated incentive and penalty system, which they believed favored compliance. Many agencies also stressed the need for collaboration with participating plans, because of underlying systemic barriers. None of the surveyed states considered their contractual agreements with health plans as all-encompassing on quality improvement, which underscores the importance of additional, noncontractual strategies to improve the quality of care. The survey found a disparity between state expectations for health plan performance and the realities of the delivery system, including the priorities of health plans and providers. The sample states were good monitors who enforced general contractual standards of pediatric quality of care; however, one shortcoming was found. Few of the surveyed states focused on oral disease or lead poisoning as part of their overall quality improvement efforts.

Markus A, Rosenbaum S, Sonosky C, Repasch L, Mauery DR. State purchasing and enforcement quality care for children in Medicaid and SCHIP managed care. Managed Care Interface. 2006; 18(6):24-30.

Objective. Although clinical trials demonstrate the efficacy of quality improvement outreach in improving service delivery, evidence for broad community effectiveness has been lacking. The objective of this study was to test the effectiveness of a statewide pediatric quality improvement outreach program in improving preventive services for children who are younger than 5 years.

Methods. All pediatric practices in Vermont (n = 35) were invited to participate in a preventive services quality improvement initiative. Ninety-one percent agreed. Participating practices serve >80% of all Vermont children who are younger than 5 years. The main outcome measured was change in 9 preventive services areas: (1) immunizations up to date; (2) anemia screening; (3) tuberculosis risk assessment and indicated screening; (4) lead screening; (5) infant sleep position counseling; (6) environmental tobacco smoke-exposure risk assessment; (7) blood pressure screening; (8) vision screening; and (9) dental risk assessment.

Results. All practices demonstrated improvement in 1 or more preventive services areas. The mean number of areas chosen was 5 (range: 1-9). Practices that selected a specific preventive service area as a quality improvement goal were more likely to demonstrate improvement in that area than practices that did not choose to focus on that preventive services area.

Conclusions. The work in this project has provided the evidence for an effective statewide pediatric quality improvement outreach program to improve preventive services for children who are younger than 5 years. Practices' decision to focus on a specific preventive service area as a quality improvement goal seems necessary for improvement in that area. This approach may be effective in other states or regions.

Shaw JS, Wasserman RC, Barry S, Delaney T, Duncan P, Davis W, Berry P. Statewide quality improvement outreach improves preventive services for young children. Pediatrics. 2006;118(4):e1039-47. Epub 2006 Aug 28.

Simpson L. Lost in Translation? Reflection on the Role of Research in Children's Health Care Improvement. Health Affairs 2004; 23(5): 125-30.

In this article we describe and evaluate quality monitoring and improvement activities conducted by Massachusetts Medicaid for its primary care case management program, the primary care clinician plan (PCC). Emulating managed care organization (MCO) practices, the State uses claims to analyze and report service delivery rates on the practice level and then works directly with individual medical practices on quality improvement (QI) activities. We discuss the value and limitations of claims-based data for profiling, report provider perspectives, and identify challenges in evaluating the impact of these activities. We also provide lessons learned that may be useful to other States considering implementing similar activities.

Walsh EG, Osber DS, Nason CA, Porell MA, Asciutto AJ. Quality Improvement in a Primary Care Case Management Program. Health Care Finance Review. 2002; 23: 71-84.

A growing body of research links early childhood experiences with later cognitive, social, emotional, and physical health and development. By intervening early, providers and parents can influence children's health and development, including not only their readiness to learn at school but also the risk of many adult diseases. Increasingly, policymakers understand the importance of these early years for not only promoting learning but also for identifying and mediating risk that can compromise later functioning. Existing research suggests only a small proportion of children are born with neurodevelopmental problems, yet behavioral, mental health, and learning difficulties drive an ever-increasing number of school-age children into special education services. Many developmental concerns can be addressed with targeted counseling and information provided by pediatricians or by more in-depth interventions. However, it has been estimated that while approximately 12 percent to 16 percent of children experience developmental problems, only one-third of those children—usually those with the most obvious conditions—are identified in pediatric practices prior to school entry. These missed opportunities are of critical policy relevance because failure to identify problems until children enter school can compromise future educational success. To examine where these gaps in services are occurring, this report compares data from the 2000 National Survey of Early Childhood Health (NSECH), which contains information regarding parents' and guardians' concerns about their children's development, and the American Academy of Pediatrics (AAP) Periodic Survey of Fellows #46. This survey, developed to complement the NSECH, collected information from pediatricians regarding the kind of services they provide to children from birth to 35 months. The two data sets give a broad picture of the provision of early childhood developmental services. Improving and expanding such services can help to close the gaps identified in the surveys, but doing so will require action from a variety of players in the public and private sectors. Targeted policy steps to create a comprehensive system, including the creation of national standards and tools, improved pediatric training, an enhanced reimbursement system, quality improvement initiatives, and heightened parental involvement and awareness, will be necessary to meet the needs of young children and their families.

Halfon N, Inkelas M, Abrams M, Stevens G. Quality of Preventive Health Care for Young Children: Strategies for Improvement. The Commonwealth Fund, May 2005.

http://www.commonwealthfund.org/usr_doc/leatherman_pedchartbook_700.pdf?section=4039

Leatherman S, McCarthy D. Quality of Care for Children and Adolescents: A Chartbook. The Commonwealth Fund, April 2004.

Connecting the Dots: Creating a Holistic Picture of Children's Health. Washington, DC: Grantmakers in Health. 2008.

Kagan SL & Neville P. Integrating Services for Children and Families: Understanding the Past to Shape the Future. New Haven, CT: Yale University Press. 1993.

This paper presents a vision and rationale for reform of the U.S. child health system based on paradigmatic changes in the conceptualization of child health development. Reviewing well-known and well-documented accounts of how this system is under-performing, we suggest that a bold, well-defined, transformative, and long-term reform strategy is needed to address intractable problems in the underlying operating logic, organization, and financing of the current child health system. We conclude by considering an optimistic, long-term policy transformation agenda, building up emerging opportunities and changing realities in the United States and abroad.

Halfon N, DuPlessis H, Inkelas M. Transforming the U.S. Child Health System. Health Affairs. 2007; 26(2):315-330.

Johnson K, Theberge S. State of the States' ECCS Initiatives: Short Take No. 5. New York, NY: National Center for Children in Poverty, Project Thrive. 2007.

Perry A, Ettinger de Cuba S, Cook J, Frank DA. Food Stamps as Medicine: A New Perspective on Children's Health. Boston, MA: Children's Sentinel Nutrition Assessment Program. 2007.

The origin of the federal-state partnership in Maternal and Child Health (MCH) can be traced from the Children's Bureau grants of 1912, through the Sheppard-Towner Act, to the creation of Title V and other programs of today that mandate planning, accountability, and systems development. In the past decade with the transformation of the health care system and the emergence of managed care, there has been a resurgence of interest in public, professional, and governmental interest in quality measurement and accountability. Regional perinatal systems have been implemented in all states with varying levels of involvement by state health agencies and the public sector. This historical framework discusses two primary themes: the decades of evolution in the federal-state partnership, and the emergence in the last three decades of perinatal regional system policy, and suggests that the structure of the federal-state partnership has encouraged state variation. A survey of state MCH programs was undertaken to clarify their operational and perceived role in promoting quality improvement in perinatal care. Data and information from the survey, along with five illustrative state case studies, demonstrate great variation in how individual state agencies function. State efforts in quality improvement, a process to make things better, have four arenas of activity: policy development and implementation, definition and measurement of quality, data collection and analysis, and communication to affect change. Few state health agencies (through their MCH programs and perinatal staff) are taking action in all four arenas. This analysis concludes that there are improvements MCH programs could implement without significant expansion in their authority or resources and points out that there is an opportunity for states to be more proactive as they have the legal authority and responsibility for assuring MCH outcomes.

Johnson KA, Little GA. State Health Agencies and Quality Improvement in Perinatal Care. Pediatrics. 1999; 103;e233-247.

Improving Children's Healthy Development through Federal Policy Change.

http://www.commonwealthfund.org/topics/topics_show.htm?doc_id=729036

U.S. Department of Health and Human Services. 2008. State MCH-Medicaid Coordination: A Review of Title V and Title XIX Interagency Agreements (2nd Ed).

Rubin D, Halfon N, Raghavan R, Rosenbaum S, Johnson K. Protecting Children in Foster Care. Casey Family Programs, 2005.

Ruptier NM. Ensuring health care for foster children through Medicaid's EPSDT program. American Journal of Public Health. 1997; 7(2):290-291.

Objective. National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma.

Patients and Methods. Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed.

Results. Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes.

Conclusions. Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of Asthma Education on Children's Use of Acute Care Services: A Meta-analysis. Pediatrics. March 2008; 121: 575-586.

Context. The prevalence of overweight in children and adolescents and obesity in adults in the United States has increased over several decades.

Objective. To provide current estimates of the prevalence and trends of overweight in children and adolescents and obesity in adults.

Design, Setting, and Participants. Analysis of height and weight measurements from 3958 children and adolescents aged 2 to 19 years and 4431 adults aged 20 years or older obtained in 2003-2004 as part of the National Health and Nutrition Examination Survey (NHANES), a nationally representative sample of the US population. Data from the NHANES obtained in 1999-2000 and in 2001-2002 were compared with data from 2003-2004.

Main Outcome Measures. Estimates of the prevalence of overweight in children and adolescents and obesity in adults. Overweight among children and adolescents was defined as at or above the 95th percentile of the sex-specific body mass index (BMI) for age growth charts. Obesity among adults was defined as a BMI of 30 or higher; extreme obesity was defined as a BMI of 40 or higher.

Results. In 2003-2004, 17.1% of US children and adolescents were overweight and 32.2% of adults were obese. Tests for trend were significant for male and female children and adolescents, indicating an increase in the prevalence of overweight in female children and adolescents from 13.8% in 1999-2000 to 16.0% in 2003-2004 and an increase in the prevalence of overweight in male children and adolescents from 14.0% to 18.2%. Among men, the prevalence of obesity increased significantly between 1999-2000 (27.5%) and 2003-2004 (31.1%). Among women, no significant increase in obesity was observed between 1999-2000 (33.4%) and 2003-2004 (33.2%). The prevalence of extreme obesity (body mass index 40) in 2003-2004 was 2.8% in men and 6.9% in women. In 2003-2004, significant differences in obesity prevalence remained by race/ethnicity and by age. Approximately 30% of non-Hispanic white adults were obese as were 45.0% of non-Hispanic black adults and 36.8% of Mexican Americans. Among adults aged 20 to 39 years, 28.5% were obese while 36.8% of adults aged 40 to 59 years and 31.0% of those aged 60 years or older were obese in 2003-2004.

Conclusions The prevalence of overweight among children and adolescents and obesity among men increased significantly during the 6-year period from 1999 to 2004; among women, no overall increases in the prevalence of obesity were observed. These estimates were based on a 6-year period and suggest that the increases in body weight are continuing in men and in children and adolescents while they may be leveling off in women.

Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006; 295(13): 1549-1555.

Background. The prevalence and seriousness of childhood obesity has prompted calls for broad public health solutions that reach beyond clinic settings. Schools are ideal settings for population-based interventions to address obesity.

Objective. The purpose of this work was to examine the effects of a multicomponent, School Nutrition Policy Initiative on the prevention of overweight (85.0th to 94.9th percentile) and obesity (>95.0th percentile) among children in grades 4 through 6 over a 2-year period.

Methods. Participants were 1349 students in grades 4 through 6 from 10 schools in a US city in the Mid-Atlantic region with 50% of students eligible for free or reduced-price meals. Schools were matched on school size and type of food service and randomly assigned to intervention or control. Students were assessed at baseline and again after 2 years. The School Nutrition Policy Initiative included the following components: school self-assessment, nutrition education, nutrition policy, social marketing, and parent outreach.

Results. The incidences of overweight and obesity after 2 years were primary outcomes. The prevalence and remission of overweight and obesity, BMI z score, total energy and fat intake, fruit and vegetable consumption, body dissatisfaction, and hours of activity and inactivity were secondary outcomes. The intervention resulted in a 50% reduction in the incidence of overweight. Significantly fewer children in the intervention schools (7.5%) than in the control schools (14.9%) became overweight after 2 years. The prevalence of overweight was lower in the intervention schools. No differences were observed in the incidence or prevalence of obesity or in the remission of overweight or obesity at 2 years.

Conclusion. A multicomponent school-based intervention can be effective in preventing the development of overweight among children in grades 4 through 6 in urban public schools with a high proportion of children eligible for free and reduced-priced school meals.

Foster GD, Sherman S, Borradaile KE, Grundy KM, Vander Veur SS, Nachmani J, Karpyn A, Kumanyika S, Shults J. A Policy-Based School Intervention to Prevent Overweight and Obesity. Pediatrics. April 2008; 121: e794-e802.

Roberts DF, Foehr UG, Rideout, VJ, Brodie M. Kids and Media at the New Millennium: A Comprehensive National Analysis of Children's Media Use. Menlo Park, CA: The Henry J Kaiser Family Foundation, 1999.

National Research Council and Institute of Medicine. Children's Health, the Nation's Wealth: Assessing and Improving Child Health. Committee on Evaluation of Children's Health. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2004.

Scientists have had a long-standing fascination with the complexities of the process of human development. Parents have always been captivated by the rapid growth and development that characterize the earliest years of their children's lives. Professional service providers continue to search for new knowledge to inform their work. Consequently, one of the distinctive features of the science of early childhood development is the extent to which it evolves under the anxious and eager eyes of millions of families, policy makers, and service providers who seek authoritative guidance as they address the challenges of promoting the health and well-being of young children.

Shonkoff JP, Phillips DA. Eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington DC: National Research Council and Institute of Medicine, 2000.

Low-income children are in worse health than other children are. This paper explores the extent to which insults to health and activity limitations are responsible. In the most recent National Health Interview Survey (NHIS) data, low-income children are more likely than other children to have virtually every measured chronic or acute condition and are more likely to be limited by these conditions. Mental health conditions are particularly common and limiting. But the higher incidence of measured conditions and limits does not explain all of the relationships between income and overall health status, which suggests that unmeasured illnesses and injuries are also involved.

Currie J, Lin W. Chipping Away At Health: More On The Relationship Between Income and Child Health. Health Affairs. March/April 2007; 26(2): 331-344.

UNICEF, Report Card 7. Child Poverty in Perspective: An overview of child well-being in rich countries. United Nation's Children's Fund 2007.

http://www.unicef-irc.org/publications/pdf/rc7_eng.pdf

Background. In 2001, the American Academy of Pediatrics (AAP) adopted a policy that all infants and young children should be screened for developmental delays at regular intervals. The policy statement promoted the use of valid reliable instruments. It is unknown, however, what proportion of pediatricians follow this recommendation and whether such a practice is associated with improved identification of children with developmental difficulties.

Objectives. To describe the use of developmental screening tests among board-certified pediatricians practicing general pediatrics and to determine the association between standardized screening and the self-reported identification of children with developmental difficulties.

Methods. We mailed a survey to a random sample of AAP members. We used multivariate logistic/linear regression analyses to determine the association between standardized screening and the self-reported identification of children with developmental disabilities.

Results. Of the 1617 surveys mailed, 894 were returned, for a response rate of 55%. Of the respondents, 646 practiced general pediatrics and were included in the analysis. Seventy-one percent of those pediatricians indicated that they almost always used clinical assessment without an accompanying screening instrument to identify children with developmental delays. Only 23% indicated that they used a standardized screening instrument. The most commonly used instrument was the Denver II. Logistic regression modeling demonstrated odds ratios between 1.71 and 1.90 for a >10% rate of identification of developmental problems among patients of pediatricians reporting standardized screening. Each adjusted odds ratio bordered on statistical significance. Linear-regression models estimating the difference in mean proportions of children identified with developmental problems across screening groups failed to show a statistically or clinically significant difference in physician-reported identification rates.

Conclusions. Our findings indicate that, despite the AAP policy and national efforts to improve developmental screening in the primary care setting, few pediatricians use effective means to screen their patients for developmental problems. It is uncertain whether standardized screening, as it is practiced currently, is associated with an increase in the self-reported identification of children with developmental disabilities.

Sand N, Silverstein M, Glascoe FP, Gupta VB, Tonniges TP, O'Connor KG. Pediatricians' Reported Practices Regarding Developmental Screening: Do Guidelines Work? Do They Help? Pediatrics. 2005; 116: 174 - 179.

World Health Organization. World Report on Child Injury Prevention. 2008.

http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf

US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Using Managed Care Contracts to Promote Child Health. 2004.

ftp://ftp.hrsa.gov/mchb/ChildHealthMCContracts.pdf

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2006. Rockville, MD: U.S. DHHS, 2006.

U.S. Department of Health and Human Services. National Survey of Children's Health.

http://www.mchb.hrsa.gov/thechild/1child/1status/01status.htm

Children's Defense Fund. State of America's Children 2008 Report. 2008.

http://www.childrensdefense.org/site/PageServer?pagename=policyareas_stateamericaschildren_2008

Commission to Build a Healthier America. America's Health Starts with Healthy Children: How do States Compare? 2008.

http://www.commissiononhealth.org/PDF/819a3435-8bbb-4549-94db-7758248075cf/ChildrensHealth_Chartbook.pdf

World Health Organization. The World Health Report 2000 Health Systems: Improving Performance.

http://www.who.int/whr/2000/en/whr00_en.pdf