Recent scholarship indicates that youth homelessness is a significant problem outside urban areas. However, previous studies have not examined how local contexts shape the experiences of youth who are homeless in rural areas and small towns with high rates of poverty and epidemic drug use. To address this gap, this analysis draws from two components of a large national study of homelessness among youth, using data collected in a small non-urban setting in the Northwest including (1) a subset of 41 (out of 215 nationally) in-depth interviews with youth and (2) a subset of 16 surveys (out of 523 nationally) with service providers. We explored availability of services and how youth navigate housing instability and the service landscape in small communities. We discovered that current or prior addictions sometimes posed risks to the safety of youth and compromised their ability to rely on family supports – a support proving critical in the absence of a formal service infrastructure. Our results suggest that youth experiencing housing instability in the context of high rates of drug use and limited formal services must often choose between meeting competing needs: a place to stay versus sobriety. We discuss the implications for policy, practice, and research.
Susanna R. Curry, Gina Miranda Samuels, Christine Cerven et al.
This article examines associations between child care subsidy use in early childhood and children’s middle school outcomes. Using a unique database linking administrative records of child care subsidy receipt with parental earnings, social assistance data, and students’ public school outcomes, we generate quasi-experimental estimates of subsidy effects on children’s reading and math test scores and school absences in third through eighth grades. Findings suggest that subsidies are associated with reduced absenteeism in seventh and eighth grades and with increased reading and math scores in third grade, but only for the subset of children whose subsidies were used to attend licensed center- or home-based care. Results provide initial evidence for longer term impacts of the child care subsidy program on children’s school performance.
BACKGROUND AND AIMS: While research has focused on outcomes of tobacco control policies, less is known about the mechanisms by which policies may affect tobacco use. We estimated the associations of changes in cigarette taxes and smoke-free legislation with (1) any household cigarette expenditure and (2) the level of household expenditure on cigarettes, as well as (3) tested interactions with socio-economic circumstances. DESIGN: Difference-in-differences regression models to estimate the associations between changes in US state cigarette taxes and smoke-free legislation with changes in household expenditure on cigarettes. SETTING: Forty US states and District of Columbia. PARTICIPANTS: From annual, cross-sectional surveys (with a longitudinal component) between 2000 and 2014, 128 138 households interviewed quarterly in the Consumer Expenditure Survey. MEASUREMENTS: Dependent measures included any household cigarette expenditure, expenditure in real dollars and budget share of cigarette expenditure. Policy measures included state cigarette taxes and 100% smoke-free legislation. Covariates included respondent age, race/ethnicity, sex; household education; poverty level; family structure; and number of children and adults. FINDINGS: Every $1.00 cigarette tax increase was associated with a 1.5 percentage point (-0.028, -0.002) reduction in any cigarette expenditure and an increase of 0.1% (0.1%, 0.1%) budget share and $10.11 ($8.38, $11.84) absolute expenditure. The association with absolute expenditure was stronger among smoking households above poverty level ($10.73; $8.94, $12.51) than below ($4.72; $2.37, $7.07). The enactment of smoke-free legislation was associated with $2.33 (-$4.56, -$0.10) less expenditure, but not with any expenditure (0.1%; -1.6%, 1.8%) or budget share (-0.1%; -0.1%, 0.1%). The association with absolute expenditure was stronger among households above poverty level (-$2.62; -$4.95, -$0.29) than below (-$0.34; -$4.27, $3.58) CONCLUSION: Cigarette tax increases in the United States between 2000 and 2014 may have reduced smoking prevalence due to an absolute and relative increase in household tobacco expenditure while smoke-free policies appear to have led to a reduction in expenditure. Although tax increases had a stronger impact on absolute expenditure among households above the poverty level, impact on relative expenditure was similar, and consequences for socio-economic inequalities in smoking will vary based on the broader financial situation of households.
Summer Sherburne Hawkins, Melissa A. Kull, Christopher F. Baum
The etiology of child maltreatment is profoundly influenced by families’ well-being and by a complex network of social, community, and societal supports and policies. Racism embedded in these systems has led to large inequities in wealth and advantage, which in turn are widely believed to drive racial and ethnic disproportionalities in the child welfare system (ie, 1 group’s representation in child welfare being out of proportion with their representation in the general population). It has been recognized that a public health, multisectoral, and multifaceted approach is needed to substantially reduce child maltreatment in the United States.1 Yet, we too often look to the child welfare system to respond to these problems when it is neither positioned nor adequately funded to comprehensively address root causes of maltreatment and inequities.The policy focus for child maltreatment in the United States has historically been more reactive than proactive or prevention-based. In 1971, the Comprehensive Child Development Act was passed by Congress but vetoed by the President. This bipartisan legislation would have created a multibillion-dollar national child care system with the intent of supporting early child development and parental workforce participation. Three years later, in 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was first passed, setting standards for receiving and responding to allegations of child abuse and neglect. CAPTA was and remains important and necessary policy. However, the early 1970s could be understood as a decision point when the collective emphasis for the approach to child maltreatment in the United States was set as investigative and surveillance-based, rather than prevention-focused.State and federal funding for child care and early education in the United States have failed to meet the societal need. In 2017, the United States ranked 35th among 37 countries tracked by the Organization for Economic Cooperation and Development in government spending on early childhood education and care.2 Because of low levels of funding, only 15% of 12.8 million eligible children in 2018 received child care subsidies through the state-federal Child Care and Development Fund block grant, the largest federal program subsidizing child care for low-income families.3 Families living in poverty spend on average 30% of their income on child care, and inequities in the geographic availability of quality child care options correlate with socioeconomic status and race.4 Limited supply and access, lack of affordability, and low levels of governmental funding leave child care unattainable for far too many Americans.The Build Back Better (BBB) plan offers an opportunity to invest in the upstream primary prevention of child maltreatment. Many of the policies contained in the BBB framework have an evidence base to support their capacity to prevent child maltreatment, including child care subsidies,5 tax credits,5,6 housing assistance,5,7 and expansions in affordable health care.5,8 Even modest improvements in families’ economic well-being, whether it be through economic and concrete supports or reductions in out-of-pocket expenses, have been shown to decrease rates of child maltreatment and have the endorsement of the Centers for Disease Control and Prevention as a prevention strategy for child maltreatment.9–11 There are numerous reasons why the aforementioned policies are good for the well-being of children and families, and evidence suggests that the prevention of child maltreatment should be among them. However, with the lapse of the Child Tax Credit and the fate of BBB being in doubt (as of Spring 2022), advocates must look for progress where it might be most attainable.The BBB plan proposes to make the largest investment in child care in US history, something that we as a nation failed to do in 1971. The BBB plan would invest $273 billion in child care for children up to 5 years of age and $109 billion to fund free universal preschool for children 3 and 4 years of age, both over the next 6 years.12 This would be a seismic change for the landscape of child care and early education in the United States, offering numerous benefits for families’ economic stability, parental workforce participation,13 children’s developmental and educational outcomes,14 and would constitute a promising step toward addressing inequities.4Universal child care and early education could also have considerable implications for the prevention of child maltreatment by decreasing families’ out-of-pocket expenses and increasing income through higher workforce participation, particularly among mothers.13 Better access to quality child care might also reduce family stress, supervisory neglect, and families’ need to use inappropriate alternative caregivers, who may perpetrate physical or sexual abuse. Greater spending on child care for lower-income families has been associated with lower rates of maltreatment, foster care placements, and maltreatment-related fatalities.5 And policies making child care subsidies more available to families already involved with the child welfare system have been associated with less need for foster care.15Using estimates from Puls et al for the associations between spending on public benefit programs, including child care, Medicaid, and cash, housing, and in-kind assistance,5 and data from the Children’s Bureau’s annual Maltreatment Reports,16 we estimate here that the investments in the BBB plan for child care alone might reduce investigations for suspected maltreatment by 6.4%, victimization by 6.0%, foster care by 3.1%, and maltreatment-related fatalities by 11.6%. Application of these estimates to 2014 to 2019, mirroring the 6-year funding period proposed in BBB, yields a striking number of potentially safer children: 1.3 million fewer children investigated, 244 000 fewer children substantiated as victims, 39 000 fewer children entering foster care, and 1198 fewer deaths. Given that 1 year’s incidence of investigated child maltreatment costs the United States economy an estimated $2 trillion,17 investments in child care and early education must be weighed against the maltreatment that they may prevent.We must broaden our discourse on economic and concrete supports for families, and child care subsidies and universal early education specifically. Universal child care and early education have the potential to provide economic support for families, increase parental workforce participation, create living-wage jobs, improve children’s development and kindergarten readiness, begin to address some dimensions of inequities, and lastly prevent child maltreatment. Substantively increasing funding for child care and early education would provide a down-payment on the long-term health and development of our next generation of Americans.Pediatricians are in a unique position to facilitate change in these areas and should: Recognize the growing body of evidence indicating that programs providing economic and concrete supports to families, including child care and early education, have the capacity to reduce child maltreatment, and treat them accordingly in both clinical and policy contexts.Become familiar with existing child care and early education resources in their area, paying particular attention to geographic inequities in access, availability, and quality (https://www.childcareaware.org/resources/map/).Ask families about their resource needs, including child care needs, perceived options, and arrangements, and connect them to resources. (Child Care Aware, local referral agencies dedicated to connecting families to quality, affordable child care [https://www.childcareaware.org/resources/ccrr-search/]).Advocate with policy-makers at the local and state levels on the importance of accessible, affordable, and quality child care and early education for child and family well-being, either directly or through their local AAP Chapter (https://www.aap.org/en/community/chapter-websites/).Familiarize themselves with how their state invests in the Child Care and Development Fund relative to their eligible population (Fig 1), how their state may limit access through restrictive policies,18 and advocate for further investments (https://ccdf.urban.org/search-database).Advocate with federal decision-makers for passage of BBB or its elements, particularly child care subsidies and universal early education (AAP Committee on Federal Government Affairs; https://www.aap.org/en/community/aap-committees/ committee-on-federal- government-affairs/).We thank both Gretchen Cusick, PhD, and Zach Laris, MPH, for their review of this article.
Abstract Childhood and adolescent and young adult (AYA) cancer survivors experience poor health outcomes in adulthood. Adverse childhood experiences (ACEs) also portend poor health outcomes for the general population. Resilience can mitigate effects of ACEs. We examined the feasibility of assessing ACEs and resilience in childhood and AYA cancer patients. We also described occurrences of ACEs, resilience, and poor health outcomes. Of 52 participants, most rated their study experience favorably, with privacy in answering sensitive questions. Half reported ACEs, and those with ACEs had lower resilience; X2(3, N = 52) = 9.4, p = .02. Further investigations of ACEs and resilience in larger cohorts are warranted to delineate associations with long‐term health outcomes.
Lindsay F. Schwartz, Marcia M. Tan, Julie S. McCrae et al.
Few sexual health studies have examined subgroup differences in youth risk behaviors that sufficiently account for sexual orientation and gender identity. This study used 2017 New York City Youth Risk Behavior Survey data (N = 10,191), a stratified cluster-sampled survey, to examine descriptive differences in the prevalence of risky sexual behaviors, such as failing to use contraception and engaging in sexual activity while intoxicated, among others. Weighted logistic regression analyses revealed that LGBTQ youth were more likely to engage in risky sexual behaviors than non-LGBTQ youth, placing them at increased risk of pregnancy, sexually transmitted infections (STIs), and human immunodeficiency virus (HIV). Results suggest the need for prevention and intervention programs, and more fundamentally, basic health education and care for these adolescents whose risk for sexual and reproductive health concerns outweighs their non-LGBTQ peers.
Madeline Travers, Lauren E. Murray, Melissa A. Kull
We analyze Illinois families facing multiple barriers and their interactions with public-sector services. Using administrative data from five state agencies to identify families' receipt of child welfare, mental health, and substance abuse services as well as adult and juvenile incarcerations, we identify individuals across systems using probabilistic record-linkage techniques, defining family clusters based on networks of individuals who share child welfare and food stamp cases. We show that 23 percent receive services in two or more of these areas. This concentration accounts for 86 percent of the funding for these services used by the entire sample. They experience more and more severe problems. This population is otherwise heterogeneous, engaging with different types of services and clustered in certain parts of the state.
OBJECTIVES: To examine the birth prevalence of congenital macroglossia and identify demographic variables and comorbidities that may influence length of stay and cost of care. STUDY DESIGN: Retrospective cross-sectional study using the Kids' Inpatient Database 2003, 2006, 2009, and 2012. METHODS: Demographics were analyzed. Linear regression modeling and multivariate analyses were performed. RESULTS: The birth prevalence of congenital macroglossia was 4.63/100 000 births. Patients were classified as isolated (n = 349, 48.1%) or syndromic (n = 377, 51.9%). A higher incidence of isolated macroglossia was seen in females (odds ratio, OR [95% confidence interval, 95% CI]: 1.93 [1.45-2.56] and African Americans (2.02 [1.41-2.88]). Length of stay was higher for syndromic patients than for nonsyndromic patients (22.6 days [18.6-26.6] vs 7.93 days [5.95-9.90], as were inpatient costs ($3619USD [$27 628-$44 754] vs $10 168USD [$6272-$14 064]. After accounting for gender, race, location, and socioeconomic status, the presence of macroglossia alone increased length of stay by 4.07 days (0.42-7.72 days) in nonsyndromic patients and 12.02 days (3.63-20.4 days) in syndromic patients. The cost of care increased by $6207USD ($576-$11 838) among nonsyndromic newborns and $17 205USD ($374-34 035) among syndromic patients. CONCLUSION: The birth prevalence of congenital isolated macroglossia appears to vary by sex and race. Prolonged length of stay and increased costs are associated with both isolated macroglossia and syndromic macroglossia, even after controlling for other syndromic comorbidities.
Jonathan C. Simmonds, Anju K. Patel, Nicholas R. Mildenhall et al.
Adverse childhood experiences (ACEs) contribute to public health concerns, as they have been linked to chronic diseases in adulthood. From the seminal ACEs study in the mid-1990s (Felitti et al., 1998) to today, the Centers for Disease Control (2016) reports well over 50 studies that link ACEs to adult health conditions such as cancer, heart disease, lung disease, and mental illness. This preponderance of evidence has prompted widespread attention to the possibility that preventing and successfully treating ACE-associated traumatic stress would greatly reduce our country’s incidence of chronic disease and the associated public health burden and cost (Danese et al., 2009). To illustrate, one study suggests that child abuse and neglect alone costs the United States $124 billion annually, with individual lifetime costs that are higher than or equal to the economic burden of diabetes and stroke (Fang, Brown, Florence, & Mercy, 2012). That child maltreatment is just one category of 10 total ACEs suggests that the total financial impact of ACEs in the United States is likely much greater and that some populations, such as children involved in child welfare, may be disproportionately affected by the negative effects of adverse childhood experiences.
Julie S. McCrae, Kimberly Bender, Samantha M. Brown et al.
This study uses data from the National Child Abuse and Neglect Data System (NCANDS) and the Adoption and Foster Care Analysis and Reporting System (AFCARS) to examine the incidence of maltreatment among children in out-of-home care (OOHC), the nature of that maltreatment (neglect, physical abuse, sexual abuse, or emotional maltreatment), the source of maltreatment reports, and the relationship between maltreatment in OOHC and child characteristics (i.e., age, gender, race, ethnicity, and disability). We found that 6.5% of children in OOHC in a given reporting year were the subject of a child maltreatment report and 0.9% were substantiated maltreatment victims. Children with disabilities were more likely to experience maltreatment in OOHC than children without disabilities. Children who were maltreated while in OOHC were less likely to experience neglect and emotional maltreatment and more likely to experience physical or sexual abuse than other children who were maltreated. Reports involving maltreatment of children in OOHC were less likely to be substantiated than reports involving other children regardless of the report source, maltreatment type, or child characteristics. The relevance of these findings for preventing further harm to children who have already been neglected or abused are discussed.
