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. 2023 Dec 1;177(12):1306-1313.
doi: 10.1001/jamapediatrics.2023.4229.

Behavior Problems in Low-Income Young Children Screened in Pediatric Primary Care

Robert T Ammerman  1   2 , Constance A Mara  1   2 , Chidiogo Anyigbo  2   3 , Rachel B Herbst  1   2 , Allison Reyner  4 , Tiffany M Rybak  1   2 , Jessica M McClure  1 , Mary Carol Burkhardt  2   3 , Lori J Stark  1   2 , Robert S Kahn  2   5
Affiliations

Behavior Problems in Low-Income Young Children Screened in Pediatric Primary Care

Robert T Ammerman et al. JAMA Pediatr. .

Abstract

Importance: Screening of behavior problems in young children in pediatric primary care is essential to timely intervention and optimizing trajectories for social-emotional development. Identifying differential behavior problem trajectories provides guidance for tailoring prevention and treatment.

Objective: To identify trajectories of behavior problems in children 2 to 6 years of age screened in pediatric primary care.

Design, setting, and participants: This retrospective cohort study identified trajectories of behavior problems and demographic and clinical correlates. Data were collected as part of routine care in 3 pediatric primary care offices and 3 school-based health centers in Ohio serving a primarily low-income population. In total, 15 218 children aged 2 to 6 years with well-child visits between July 13, 2016, and January 31, 2022, were included.

Exposure: Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) at annual well-child visits.

Main outcomes and measures: Trajectory groups were identified using latent growth mixture modeling of SDQ total difficulties scores, and relative risk ratio (RRR) of various demographic (eg, race) and clinical (eg, depression in caregiver) variables were assessed by multinomial logistic regression analysis.

Results: Of 15 281 children (51.3% males), 10 410 (68.1%) were African American or Black, 299 (2.0%) were Asian, 13 (0.1%) were American Indian or Alaska Native, 876 (5.7%) were multiracial, 26 (0.2%) were Native Hawaiian and Other Pacific Islander, 2829 (18.5%) were White, and 39 (0.02%) were categorized as other. In addition, 944 (6.2%) identified as Hispanic and 14 246 (93.2%) as non-Hispanic. Four behavior problem trajectory groups reflecting severity were identified: low-stable (LS; 10 096 [66.1%]), moderate-decreasing (MD; 16.6%), low-increasing (LI; 13.1%), and high-increasing (HI; 4.3%). Relative to the LS group, patients in each elevated group were more likely to be male (HI RRR, 1.87 [95% CI, 1.55-2.26]; MD RRR, 1.55 [95% CI, 1.41-1.71]; and LI RRR, 1.94 [95% CI, 1.70-2.21]), White (HI RRR, 2.27 [95% CI, 1.83-2.81]; MD RRR, 1.28 [95% CI, 1.13-1.45]; and LI RRR, 1.54, [95% CI, 1.32-1.81]), publicly insured (HI RRR, 0.49 [95% CI, 0.28-0.84]; MD RRR, 0.56 [95% CI, 0.43-0.73]; and LI RRR, 0.50 [95% CI, 0.35-0.73]), have a social need (HI RRR, 3.07 [95% CI, 2.53-3.73]; MD RRR, 2.02 [95% CI, 1.82-2.25]; and LI RRR, 2.12 [95% CI, 1.84-2.44]), and have a caregiver with depression (HI RRR, 1.66 [95% CI, 1.38-2.00]; MD RRR, 1.44 [95% CI, 1.31-1.58]; and LI RRR, 1.39 [95% CI, 1.23-1.58]). Relative to the LI group, patients in the MD group were less likely to be male (RRR, 0.80; 95% CI, 0.68-0.93).

Conclusions: The substantial portion of young children with increased behavior problems observed in this cohort study underscores the need for screening in pediatric primary care. Caregivers with depression and family social needs warrant prioritization in early prevention and treatment to alter elevated trajectories.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Anyigbo reported receiving a grant from National Center for Advancing Translational Sciences during the conduct of the study. Dr Rybak reported receiving a grant from the National Institute of Diabetes and Digestive Kidney Diseases (NIDDK) from 2019 to 2021 outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Observed Mean Strengths and Difficulties Questionnaire (SDQ) Total Difficulties Scores in 4 Trajectory Groups Over Time
See this image and copyright information in PMC

References

    1. Perou R, Bitsko RH, Blumberg SJ, et al. Mental health surveillance among children—United States, 2005-2011. MMWR Suppl. 2013;62(2):1-35. - PubMed
    1. Shim R, Szilagyi M, Perrin JM. Epidemic rates of child and adolescent mental health disorders require an urgent response. Pediatrics. 2022;149(5):e2022056611. doi:10.1542/peds.2022-056611 - DOI - PubMed
    1. Meade J. Mental health effects of the COVID-19 pandemic on children and adolescents: a review of the current research. Pediatr Clin North Am. 2021;68(5):945-959. doi:10.1016/j.pcl.2021.05.003 - DOI - PMC - PubMed
    1. National Academies of Sciences Engineering and Medicine. The State of Mental, Emotional, and Behavioral Health of Children and Youth in the United States: Proceedings of a Workshop. National Academies Press; 2020.
    1. Costello EJ. Early detection and prevention of mental health problems: developmental epidemiology and systems of support. J Clin Child Adolesc Psychol. 2016;45(6):710-717. doi:10.1080/15374416.2016.1236728 - DOI - PubMed

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