AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE & DENTISTRY BY H. BARRY WALDMAN, DDS, MPH, PHD AND STEVEN P. PERLMAN, DDS, MSCD, DHL (HON)
THINGS YOU’VE HEARD
1. The prevalence of children with disabilities has continued to increase.
2.Male children have higher prevalence of disabilities than female children.
3. Children living in poverty experience the highest rates of disability.
4. Compared to children in households with advanced education, children in households with education less than
high school education have a greater prevalence of disability.
5. Hispanic children have a lower prevalence of disabilities than non-Hispanic white and black children.1
BUT THERE HAVE BEEN CHANGES
The recent 2014 publication in Pediatrics by Houtrow et al. repeats these prevalence reports in its analysis of the National Health Interview Survey (NHIS) data sets for the period between 2001 and 2011, but also highlights some of the dramatic changes that this information is undergoing. 1
1. The prevalence of disability among non institutionalized children < 18 years has continued to increase, growing by 15.6 percent between 2001-2002 and 2010-2011. Nearly 6 million children were considered to be disabled in 2010 to 2011 (an increase from 4,991,000 to 5,912,000 children, or 6.87 percent to 7.94 percent during the study period).
An increase was found for all child age groups, both genders and Hispanic and non-Hispanic whites. “Despite the statistically significant increase in disability rates among Hispanics, they repeatedly reported significantly
lower rates of disability, than non-Hispanic whites and blacks.” 1
2. Children living in poverty experienced the highest rates of disability, “… but unexpectedly, children living in households with incomes > 400 percent above the federal poverty level experienced the largest increase
(28.4 percent) (compared to 10.7 percent increase for children living in households with incomes below the federal poverty level) over the 10-year period.” 1 “For the first time since the NHIS began tracking childhood disability
in 1957, the rise in reported prevalence is disproportionally occurring among socially advantaged families.” 1
3. Significant increases in disability prevalence occurred for children of college-educated parents but not for children of parents with a high school education or less.
4. Significant increases in disability prevalence occurred for children in two-parent families. Although disability prevalence rates have been higher for children in single parent families, there were limited changes during
this same period.
5. The percentage of children with disabilities related to any physical health condition declined by 11.8 percent during the period of the study, while the cases related to any neurodevelopmental or mental health condition
increased by 20.9 percent. “Advances in medical technology, healthcare delivery, and public health intervention do not explain why more children are diagnosed with neurodevelopmental and behavioral conditions and the resulting rise in disability.” 2
6. There was a marked decrease (24.2 percent) in asthma as the cause of childhood disability. However, there was a marked increase (63.1 percent) in disability associated with speech problems and other mental, emotional or behavioral problems (64.7 percent). (see Tables 1 & 2)
WHAT MAY BE CAUSING THESE DEVELOPMENTS?
The researchers emphasize that these changes “…are most certainly multifactorial, including biological, familial, social and cultural factors.”1 For example, there have been changes in diagnostic labeling thresholds – a child formerly observed as unable to concentrate may now be seen as diagnosable by parents, teachers and
professionals.3 In addition, the “relationship between autism and higher parental education and older maternal age may also help explain why the most pronounced increases in disability are among the advantaged families.” 1,4
Expanded use of diagnostic and treatment services among children in more advantaged families may explain why more children are identified with disabilities. Essentially more advantaged families tend to have better access to healthcare.5 In addition, health providers may be influenced to provide more services by the higher income
parents who tend to be more involved in the education and health processes than other parents.6
The 2014 study also indicated that in the 2010 to 2011 period, 61.1 per 1,000 Hispanic children, compared to 86.7 per 1,000 non-Hispanic white and 93.5 per 1,000 non-Hispanic black children, were reported by parents to have disabilities.1 Is it possible that “such a small” percent of Hispanic children, (in particular those children in Spanish
speaking families) have special healthcare needs? The reality is that, “Parental report of health conditions is somewhat dependent on access to appropriate health or educational services for diagnosis, as well as communication of that diagnosis to the parent.”7 Hispanic children are more likely than non-Hispanic white children to: 1) lack
access to healthcare services and specialized health practitioners, 2) be uninsured and 3) lack a medical home. 8-10 Results from an earlier 2001 survey of children with special needs described comparable barriers faced by children in Spanish speaking households. In addition, there are the further findings of a lower prevalence of the need for, and use of, prescription medication for chronic conditions.7,8
As a result, developmental problems may be more likely to be undiagnosed among Hispanic children. This may explain why the prevalence of certain developmental conditions (autism, intellectual disabilities and cerebral palsy) is lower in Hispanic children.11 In the same way, “attention-deficit/hyperactivity disorder (ADHD) may be diagnosed less often (and under treated) in Hispanics than in Caucasian patients.”12
Similarly, Hispanic children may experience higher rates of unmet mental health service needs as a result of both language and cultural issues.13 The list of adverse health consequences for children because of language
communication issues (e.g. inadequate or incorrect medical and family histories, and the listing of medications that are being taken) continues with the outcomes of misdiagnoses, inappropriate medication and hospitalizations. 14
In addition, there is the fact that parents of Hispanic children (especially parents from Spanish speaking households) may be less likely to report health problems and needs for their children because of their reluctance to share such personal details in a telephone survey.11 The outcome of these and other related factors is that Hispanic
children “…experience marked disparities in obtaining timely medical care, only some of which is associated with language differences.”15 One cannot over-emphasize the need for healthcare providers to maintain an awareness of the diversity of the Hispanic population, which consists largely of persons of Mexican, Puerto Rican and Cuban descent. “In spite of the fact that Hispanics share a similar language, religion and belief system, there are other significant cultural differences among these subgroups.
In addition, English-language proficiency and socioeconomic variables, factors that are known to influence healthcare outcomes, may also differ markedly among Hispanic subgroups.”12 (See a previous review in EP magazine for a more extensive presentation of this topic.16) The fact that the percent increase between 2001 to 2011
(22.9 percent) in the proportion of Hispanic children with disabilities (highest among all other groups) to some degree, may represent a changing willingness to report personal family details.
WHY IS IT IMPORTANT TO NOTE THESE DEVELOPMENTS?
It seems sacrilegious even to consider the possibly that concerns for the health, living, social and economic status of the exploding numbers of elderly are receiving too much emphasis. The daily assault of news articles, conferences, television presentations, political speeches and a seemingly infinite number of other documentations surely have
convinced the general population that the needs of the aged surpass our understanding – even our imagination. This is not to say that the increasing population of the elderly, in particular, the very older women (mostly) does not need a host of necessary support functions. Rather it is to raise the question of whether the needs of other segments of the
population (in particular, children) are being overshadowed as the government and the general population increasingly turn their attention to the elderly.
Given these realities it is essential to document and publicize the increasing numbers of children with disabilities and the specifics of these changes, if we are to provide for their current and future needs. Unfortunately children can’t vote and seniors do vote. In fact 61 percent of citizens age 65 and older voted in the November 2010 election, the best turnout of any age group. “Retirees have valuable government benefits to protect.”17•
ABOUT THE AUTHORS:
H. Barry Waldman, DDS, MPH, PhD – Distinguished Teaching Professor, Department of General Dentistry at Stony Brook University, NY; E-mail:firstname.lastname@example.org Steven P. Perlman, DDS, MScD, DHL (Hon) – Global
Clinical Director, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine, Private pediatric dentistry practice – Lynn MA.
1. Houtrow AJ, Larson K, Olson LM, Newacheck PW, Halfon N. Changing trends of childhood disiablt9y, 2001-2011. Pediatrics published online August 18, 2004 DOI: 10.1542peds.2014-0594
2. Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental diseases in US children, 1987-2008. Pediatrics 2011;187(6):1034-1042.
3. Robinson LM, Skaer TL, Sciar DA, Galin RS. Is attention deficit hyperactivity disorder increasing among girls in the US? Trends in diagnosis and the prescribing of stimulants. CNS Drugs 002;16(2)129-137.
4. Windham GC, Anderson MC, Croen LA, et al. Birth prevalence of autism spectrum disorder in the San Francisco Bay area by demographic and ascertainment source characteristics. Journal Autism Developmental Disorder 2011;41(10)1362-1372.
5. Larson K, Halfon N. Family income gradients in the health and healthcare access of US children. Maternal Child Health Journal 2010;14(3)332-342.
6. Wagner M, Newman L, et al. A national picture of parent and youth participation in IEP and transition planning meetings. Journal Disability Policy Studies 2012;23:140-155.
7. Avila RM, Blumberg SA. Centers for Disease Control and Prevention. Chronic developmental conditions among Hispanic children in the United States, 2003 and 2005-2006. Web site: http://www.cdc Accessed April 30, 2009.
8. Kuhlthau K, Nyman RM, Ferris TG, Beal AC, Perrin JM. Correlates of use of specialty care. Pediatrics 2004;113(3Pt 1):e249-55.
9. Flores G, Olson L, Tomany-Korman SC. Racial and ethnic disparities in early childhood health and healthcare. Pediatrics 2005;115(2):e183-93.
10. Yu SM, Nyman RM, Kogan MD, Huang ZJ, Schwalberg RH. Parent’s language of interview and access to care for children with special healthcare needs. Ambulatory Pediatrics 2004;4(2):181-7.
11. Read D, Bethell, C, Blumberg SJ, Abreau M, Molina C. An evaluation and cultural validity of the Spanish language version of the children with special healthcare needs screener. Maternal Child Health Journal 2007;11:568-85.
12. Rothe EM. Considering cultural diversity in the management of ADHD in Hispanic patients. Journal National Medical Association 2005;97(10 Suppl):17S-23S.
13. Lopez C, Bergren MD, Painter SG. Latino disparities in child mental health services. Journal Child Adolescent Psychiatric Nursing 2008;21(3):137-45.
14. Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to healthcare for Latino children. Archives Pediatric Adolescent Medicine 1998;152:1119-25.
15. Brousseau DC, Hoffmann RG, Yauck J, Nattinger AB, Flores G. Disparities for Latino children in the timely receipt of medical care. Ambulatory Pediatric 2005;5:319-25.
16. Waldman HB, Perlman SP. Is it possible that a smaller percent of Hispanic children have special healthcare needs? EP magazine 2011;41(June):48-49.
17. Brandon E. U.S. News. Why older citizens are more likely to vote. Web site: http://money.usnews.com/money/retirement/articles/2012/03/19/why-older-citizens-are-more-likely-to-vote Accessed August 21, 2014.