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Background and Objectives: The National Survey of Children's Health (NSCH) is the nation's primary source for data on children and youth with special health care needs (CYSHCN) and the only source for state-level estimates. We provide the latest estimates of CYSHCN in the United States, describe population characteristics, as well as the proportion that are served in a well-functioning system of care., Methods: Data from the 2016, 2017, 2018, and 2019 NSCH were appended, resulting in a final analytic sample of 30 301 CYSHCN. Bivariate associations between the covariates and SHCN status as well as the 6 core outcomes that comprise a well-functioning system of care were examined using χ2 tests. Multivariable logistic regression was used to identify factors independently associated with SHCN status and a well-functioning system of care., Results: The overall prevalence of CYSHCN was 18.8% and ranged from 13.6% in Hawaii to 24% of individuals included in the NSCH in West Virginia. The most reported type of SHCN was prescription medication use (29.3%), whereas 25.9% of CYSHCN had functional limitations. Over one-third reported no daily activity impacts, whereas 18.9% reported consistent or significant daily impacts. CYSHCN were more likely than non-CYSHCN to be male, older, non-Hispanic Black, live in poverty, and have public insurance but disparities by race and ethnicity and income were no longer significant after adjustment. Only 14.9% of CYSHCN were reported to receive care in a well-organized system. Rates were substantially lower among older and more heavily affected children with adjusted rate ratios for access to a well-functioning system of care, indicating a 72% reduction for adolescents (12-17), compared with young children (0-5) and a 24% to 53% reduction for those with more than a prescription medication qualifying need., Conclusions: CYSHCN remain a sizable and diverse population with distinct challenges in accessing well-functioning systems of care, particularly for those with the greatest needs. Our results provide a profile of the population designed to inform future surveillance, research, program, and policy priorities showcased in this Special Issue.

Background: Knowledge of adverse childhood events (ACEs), the associated access to healthcare and unmet needs among children and youth with special health care needs (CYSHCN) is limited., Objectives: Our objectives were to compare the likelihood of CYSHCN versus non-CYSHCN experiencing one or more ACEs and document differences in receipt of recommended and needed health care among CYSHCN with and without ACEs., Methods: We combined two years of data from the 2016 and 2017 National Survey of Children's Health (N = 71,181), providing a sample of 16,304 CYSHCN. Our primary outcome measures included eight adverse childhood events, compared to singular and aggregated ACEs among non-CYSHCN. We calculated associations between ACEs and secondary outcome measures for six components of well-functioning systems of care and unmet need for different types of health care using bivariate and multivariate analyses., Results: CYSHCN were more likely to have each of the ACEs measured and were likelier to experience aggregated levels of ACEs compared to non-CYSHCN. The likelihood of CYSHCN having a medical home with family-centered and coordinated care decreased with increased ACEs, while one or more ACES increased the likelihood of having unmet needs for mental health care., Conclusion: The findings of the current study extend our understanding of the additional adverse event burden associated with special health care needs status, the accompanying limitations in access to family-centered and coordinated care in a medical home and unmet need for mental health care, indicating that much work remains in establishing appropriate care systems for this very vulnerable population., (Published by Elsevier Inc.)

Objectives: The purpose of this study was to identify child, family/household, organization (provider), and neighborhood/community factors associated with parental concern about weight among children with overweight/obesity in order to inform effective interventions for improving health in this pediatric population., Methods: Prevalence of parental concern about child weight was estimated and factors identified within an adapted family ecological framework. Using cross-sectional data from the 2018 National Survey of Children's Health, we conducted bivariate and multivariable analyses of 10 to 17-year olds (N = 15,427) for whom height and weight information was reported by parents or primary caregivers., Results: There were 4287 children, aged 10 to 17 years, with overweight/obesity (31%). Approximately 34% of parents of children with overweight/obesity reported being concerned about their child's weight, with the remainder being not concerned. In adjusted analyses, 23% of children with overweight and 45% of children with obesity had parents who reported being concerned. Factors associated with parental concern among children with overweight/obesity included child weight status, female gender, peer social difficulties, the extent of the child's daily activities affected by health conditions, poorer parental coping, and having been told the child was overweight by a provider., Conclusions: Only one in three parents of children with overweight/obesity reported being concerned about their child's weight, although parental concern was more common among children affected by obesity more so than overweight. A combination of child, family, and organization (provider) factors were associated with parental concern. Provider feedback about child overweight may improve parental awareness of a weight-related health issue., (Published by Elsevier Inc.)

Background: Glaucoma drainage implants have been used with increasing frequency for the management of glaucoma. Patients who are candidates for glaucoma drainage devices often have more severe disease and are at risk of vision loss with post-operative elevations in intraocular pressure (IOP). One post-operative complication that can result in IOP elevation after glaucoma drainage device implantation is occlusion of the tube lumen., Case Presentation: Here, we present a novel case of tube occlusion by the anterior capsule in a patient who underwent combined phacoemulsification and Ahmed glaucoma valve implantation. The tube occlusion was successfully managed with Nd:YAG capsulotomy with immediate IOP lowering., Conclusions: While there have been previous reports of occlusion of the tube lumen by vitreous, iris, blood and fibrin, to our knowledge this is the first report of tube occlusion by the anterior lens capsule and the first report to describe its successful management.

Purpose: This study's purpose was to determine the prevalence of physical, mental, and developmental health conditions among US children and assess the association with urban versus rural residence., Methods: Bivariate/multivariable analyses were conducted with cross-sectional data for children aged 0-17 years (N = 71,811) from the 2016-2017 National Survey of Children's Health. Prevalence estimates of excellent/very good health were derived from parents' qualitative judgments. Parent-reported health conditions were aggregated by condition type (physical, mental, developmental). Prevalence was determined for condition type and severity. Adjusted risk ratios assessed the effect of residence on having physical, mental, or developmental conditions., Results: Among rural children in the general population, we found lower crude rates of excellent/very good overall health and higher rates of ≥1 physical condition(s) and ≥1 mental condition(s), as well as these 2 conditions in combination with ≥1 developmental condition(s). Rural children in the general population were also more likely to have physical and mental conditions that parents rated as moderate/severe in unadjusted analyses. To a lesser extent, these differences held true for the children with special health care needs. Risk ratios for rural residence were largely nonsignificant in adjusted analyses., Conclusions: While rural children had lower crude rates of parent-reported excellent/very good health and higher crude rates of parent-reported or doctor-diagnosed physical and mental health conditions compared to urban children, the same pattern of urban-rural differentials was not evident in the adjusted analyses. Compositional and contextual differences in the urban/rural populations suggest that social determinants of health may have accounted for rate disparities in child health conditions., (© 2020 National Rural Health Association.)

Background: Hearing difficulties (HD) affect a sizable minority of children in the United States and can have a significant impact on child development. Children with HD may face barriers around language development, communication abilities, learning, and social interactions, which in turn can affect multiple aspects of their lives., Objective/hypothesis: Little is known about the extent to which children with HD have access to a system of care and we hypothesize that this population may experience significant unmet needs., Methods: In this cross-sectional study, using bivariate and multivariable regression models, we analyzed data from the 2009/2010 National Survey of Children with Special Health Care Needs (NS-CSHCN). Selected survey items were used to assess health and healthcare characteristics of CSHCN with some level of HD (n = 2,315) compared to those without HD (n = 37,851). The study sample included 40,242 CSHCN aged 0-17 years, whose caregivers responded to the survey., Results: Approximately 694,000 CSHCN in the U.S. were reported to have any level of HD, representing 6.3% of the CSHCN population. Compared to CSHCN without HD, those with HD were less likely to have access to a medical home, community services, or have adequate health insurance., Conclusions: Significant deficits in medical home access, adequate insurance, and accessibility of community-based services are evident for CSHCN with HD. Families having knowledge of how and when to access community services and partner with providers in their child's health care is important for the overall health and wellbeing of this subpopulation of CSHCN., (Published by Elsevier Inc.)

Childhood mental, behavioral, and developmental disorders (MBDDs) are associated with adverse outcomes that can persist into adulthood (1,2). Pediatric clinical settings are important for identifying and treating MBDDs (3). Early identification and treatment of MBDDs can promote healthy development for all children (4), especially those living in poverty who are at increased risk for MBDDs (3,5) but might have reduced access to care (6). CDC analyzed data from the 2016 National Survey of Children's Health (NSCH) on MBDDs, risk factors, and use of federal assistance programs (e.g., Supplemental Nutrition Assistance Program [SNAP]) to identify points to reach children in poverty. In line with previous research (3,6), compared with children in higher-income households, those in lower-income households more often had ever received a diagnosis of an MBDD (22.1% versus 13.9%), and less often had seen a health care provider in the previous year (80.4% versus 93.8%). Among children living below 200% of the federal poverty level (FPL) who did not see a health care provider in the previous year, seven of 10 were in families receiving at least one public assistance benefit. Public assistance programs might offer collaboration opportunities to provide families living in poverty with information, co-located screening programs or services, or connection to care., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

We examined parent-reported adverse childhood experiences (ACEs) and associated outcomes among American Indian and Alaska Native (AI/AN) children aged 0-17 years from the 2011-2012 National Survey of Children's Health. Bivariate and multivariable analyses of cross-sectional data on 1,453 AI/AN children and 61,381 non-Hispanic White (NHW) children assessed race-based differences in ACEs prevalence and differences in provider-diagnosed chronic emotional and developmental conditions, health characteristics, reported child behaviors, and health services received as a function of having multiple ACEs. AI/AN children were more likely to have experienced 2+ ACEs (40.3% versus 21%), 3+ ACEs (26.8% versus 11.5%), 4+ ACEs (16.8% versus 6.2%), and 5+ ACEs (9.9% versus 3.3%) compared to NHW children. Prevalence rates for depression, anxiety, and ADHD were higher among AI/AN children with 3+ ACEs (14.4%, 7.7%, and 12.5%) compared to AI/ANs with fewer than 2 ACEs (0.4%, 1.8%, and 5.5%). School problems, grade failures, and need for medication and counseling were 2-3 times higher among AI/ANs with 3+ ACEs versus the same comparison group. Adjusted odds ratio for emotional, developmental, and behavioral difficulties among AI/AN children with 2+ ACEs was 10.3 (95% CI = 3.6-29.3). Race-based differences were largely accounted for by social and economic-related factors.

Neuroimaging and behavioral studies have indicated that expertise in dance is associated with differences in the visual processing of dance movements. This study sought to determine if dance expertise was also associated with the ability to recognize visual differences between dance movements. Participants (20 dancers and 20 non-dancers) watched pairs of video clips showing dance phrases. Within each pair of phrases a manipulation was made to a single movement in the categories of shape (25%), time (25%), or space (25%), or there was no manipulation made between the two videos (25%). After viewing each pair, participants used pencil and paper to indicate if they observed a difference between the phrases and, if so, in which category. Group differences were compared for each category with four separate t-tests. Results showed that dancers were better at recognizing manipulations of space, time, and trials with no change but did not differ from non-dancers at recognizing manipulations of shape. Results are discussed in reference to the tested hypothesis that the ability and experience to produce an action is associated with enhanced perception of similar actions.

Purpose: Elevated risk for obesity is found in rural environments and in some minority populations. It is unclear whether living in rural or nonmetropolitan areas and being a minority compound the risk of obesity beyond that of either factor acting alone. Our purpose was to examine adolescent obesity in light of the potential concomitant influences of race/ethnicity, residency, and obesity-related lifestyle behaviors., Methods: We assessed obesity prevalence, physical activity, consumption of fatty snack foods, and screen time in 8,363 US adolescents based on variation in race/ethnicity and residency. Descriptive, bivariate, and multivariate statistics were used to: (1) calculate race- and residency-based rates of obesity and obesity-related lifestyle behaviors and (2) generate race- and residency-based obesity odds ratios as a function of those same behaviors., Findings: The results indicated that nonmetropolitan black youth had the highest risk of obesity (26%), rate of consuming fatty snack foods on more than 2 days/week (86%), and rate of spending more than 2 hours/day in screen time (91%) compared to white metropolitan youth. Compared to their metropolitan counterparts, black nonmetropolitan youth had greater odds of being obese if they exercised less than daily (1.71 times), ate fatty snack foods on more than 2 days/week (1.65 times), or spent more than 2 hours/day in screen time (1.64 times)., Conclusions: Race/ethnicity and residency may have a compounding effect on the risk of obesity. Prevention and intervention must be viewed in a socioecological framework that recognizes the importance of culture and community on obesity-related behaviors., (Published 2013. This article is a U.S. Government work and is in the public domain in the USA.)

The purpose of this study was to determine the prevalence of chronic conditions and functional difficulties of American Indian/Alaska Native (AIAN) children with special health care needs (CSHCN). We conducted bivariate and multivariable analysis of cross-sectional data on 40,202 children from the 2009-2010 National Survey of Children with Special Health Care Needs aged birth through 17 years, including 1,051 AIAN CSHCN. The prevalence of AIAN CSHCN was 15.7 %, not significantly different from the prevalence of US white CSHCN (16.3 %). As qualifiers for special needs status among AIAN children the use of or need for prescription medication was the most frequent (70 %), compared to the lower rates of need for elevated service use (44 %) and emotional, mental, or behavioral treatment/counseling (36 %). Asthma (45 %), conduct disorder (18 %), developmental delay (27 %), and migraine headaches (16 %) were significantly more common chronic conditions among AIAN CSHCN compared to white CSHCN, as were functional difficulties with respiration (52 %), communication (42 %), anxiety/depression (57 %), and behavior (54 %). AIAN CSHCN were also more likely to have 3 or more chronic conditions (39 vs. 28 %, respectively) and 3 or more functional difficulties (70 vs. 55 %, respectively) than white CSHCN. Results indicated a greater impact on the daily activities of AIAN CSHCN compared to white CSHCN (74 vs. 63 %). Significantly greater disease burden among AIAN CSHCN suggests that care must be taken to ensure an appropriate level of coordinated care in a medical home to ameliorate the severity and complexity of their conditions.

The Maternal and Child Health Bureau recently revised its measure of family-provider shared decision-making (SDM) to better align with parents' views and the intent of SDM. We sought to assess achievements in meeting the revised measure; examine socio-demographic/health correlates; and determine the relationships between SDM and access to quality health care. We analyzed data for 40,242 children with special health care needs (CSHCN) from the 2009-2010 National Survey of CSHCN and assessed the prevalence of SDM and association with other US CSHCN socio-demographic/health characteristics using bivariate and multivariate methods. Logistic regression was used to determine associations between SDM and having a medical home and preventive medical/dental visits. Approximately 70% of families of CSHCN perceived themselves as shared decision-makers in their child's care. Families of CSHCN with greater functional limitations had twice the odds of lacking SDM than those never affected. Disparities in attainment rates were noted for families with low versus high income (61 vs. 77%), less versus more than high school education (59 vs. 73%), privately insured versus uninsured (76 vs. 57%), and minority versus white race (63 vs. 74%). CSHCN with medical homes had 6 times greater odds of perceived SDM and as much as one and a half times the odds of receiving preventive care than CSHCN without a medical home. Major differences in family SDM perceptions are associated with having a medical home, particularly when characterized by family-centered care. Populations of concern are those with more functionally limited children and increased socio-economic challenges.

Purpose: Treatment of inherited metabolic disorders is accomplished by use of specialized diets employing medical foods and medically necessary supplements. Families seeking insurance coverage for these products express concern that coverage is often limited; the extent of this challenge is not well defined., Methods: To learn about limitations in insurance coverage, parents of 305 children with inherited metabolic disorders completed a paper survey providing information about their use of medical foods, modified low-protein foods, prescribed dietary supplements, and medical feeding equipment and supplies for treatment of their child's disorder as well as details about payment sources for these products., Results: Although nearly all children with inherited metabolic disorders had medical coverage of some type, families paid "out of pocket" for all types of products. Uncovered spending was reported for 11% of families purchasing medical foods, 26% purchasing supplements, 33% of those needing medical feeding supplies, and 59% of families requiring modified low-protein foods. Forty-two percent of families using modified low-protein foods and 21% of families using medical foods reported additional treatment-related expenses of $100 or more per month for these products., Conclusion: Costs of medical foods used to treat inherited metabolic disorders are not completely covered by insurance or other resources.

Objective: To determine characteristics of children with special health care needs (CSHCN) with hearing difficulties including patterns of hearing aid use, comorbidity, and social and communication function., Methods: Bivariate and multivariable analysis of cross-sectional data on 40,723 children aged from birth to 17 years from the 2005-2006 National Survey of Children with Special Health Care Needs, including 1,982 (5%) with parent-reported hearing difficulties., Results: Among CSHCN, 383 (1%) used hearing aids, representing 20% of those with reported hearing difficulties. Odds of hearing aid use increased with age, primary language other than English, and lower income. More than half (58%) of the aided children reported hearing difficulties even with their aid. Among CSHCN with cerebral palsy, 13% had reported hearing difficulties and 3% used hearing aids. Equivalent figures for children with Down syndrome were 24% and 4%, mental retardation/developmental delay 12% and 5%, and autism spectrum disorder 9% and 2%. Overall, two-thirds of CSHCN with hearing difficulties had one or more sensory/developmental comorbidities; CSHCN with both hearing difficulties and a sensory/developmental comorbidity had highest odds of learning difficulties, speaking/communication difficulties, feeling anxious/depressed, acting out/bullying, and difficulty making friends. CSHCN with hearing difficulties alone, or sensory/developmental conditions alone had intermediate odds, after socio-demographic adjustment., Conclusions: Sensory/developmental comorbidities are common among CSHCN with hearing difficulties, and they are associated with higher odds of poorer social, communication, and educational function. Services for CSHCN must be equipped to address a range of hearing difficulties as well as sensory/developmental comorbidities and to improve social/emotional functioning as well as learning and communication.

We examined trends and neighborhood and sociobehavioral determinants of sleep problems in US children aged 6-17 between 2003 and 2012. The 2003, 2007, and 2011-2012 rounds of the National Survey of Children's Health were used to estimate trends and differentials in sleep problems using logistic regression. Prevalence of sleep problems increased significantly over time. The proportion of children with <7 days/week of adequate sleep increased from 31.2% in 2003 to 41.9% in 2011-2012, whereas the prevalence of adequate sleep <5 days/week rose from 12.6% in 2003 to 13.6% in 2011-2012. Prevalence of sleep problems varied in relation to neighborhood socioeconomic and built-environmental characteristics (e.g., safety concerns, poor housing, garbage/litter, vandalism, sidewalks, and parks/playgrounds). Approximately 10% of children in neighborhoods with the most-favorable social environment had serious sleep problems, compared with 16.2% of children in neighborhoods with the least-favorable social environment. Children in neighborhoods with the fewest health-promoting amenities or the greatest social disadvantage had 37%-43% higher adjusted odds of serious sleep problems than children in the most-favorable neighborhoods. Higher levels of screen time, physical inactivity, and secondhand smoke exposure were associated with 20%-47% higher adjusted odds of sleep problems. Neighborhood conditions and behavioral factors are important determinants of sleep problems in children.

We examined the effects of prematurity (<37 weeks of gestation) and low birthweight (<2500 g) on mental health outcomes among US children aged 2-17 years. The 2011-2012 National Survey of Children's Health (N = 95,677) was used to estimate prevalence of parent-reported mental health problems in children. Prevalence of mental disorders was 22.9% among children born prematurely, 28.7% among very-low-birth-weight (<1500 g) children, and 18.9% among moderately low-birth-weight (1500-2499 g) children, compared with 15.5% in the general child population. Compared to those born full term, children born prematurely had 61% higher adjusted odds of serious emotional/behavioral problems, 33% higher odds of depression, and 58% higher odds of anxiety. Children born prematurely had 2.3 times higher odds of autism/ASD, 2.9 times higher odds of development delay, and 2.7 times higher odds of intellectual disability than term children. Very-low-birth-weight children had 3.2 times higher odds of autism/ASD, 1.7 times higher odds of ADD/ADHD, 5.4 times higher odds of development delay, and 4.4 times higher odds of intellectual disability than normal-birth-weight children. Social factors were significant predictors of mental disorders in both premature/low-birth-weight and term/normal-birth-weight children. Neurodevelopmental conditions accounted for the relationship between prematurity and depression/anxiety/conduct problems. Prematurity and low birthweight are significant risk factors for mental health problems among children.

Background. The proportion of US children with special health care needs (CSHCN) with epilepsy/seizure disorder who receive care in high-quality health service systems was examined. Methodology. We analyzed data for 40,242 CSHCN from the 2009-2010 National Survey of CSHCN and compared CSHCN with epilepsy/seizure disorder to CSHCN without epilepsy/seizure disorder. Measures included attainment rates for 6 federal quality indicators with comparisons conducted using chi square and logistic regression methods. In addition, CSHCN with epilepsy/seizure disorder were compared to CSHCN without epilepsy/seizure disorder on the basis of 14 unmet health care needs. Results. Lower attainment rates for receiving comprehensive care in a medical home and easily accessible community-based services were found for CSHCN with epilepsy/seizure disorder versus CSHCN without epilepsy/seizure disorder (medical home: 32% versus 43%; accessible community-based services: 50% versus 66%, resp.) in unadjusted analyses. Lower adjusted odds for these indicators as well as greater unmet need for specialists, dentistry, prescriptions, therapies, and mental health care were also found for CSHCN with epilepsy/seizure disorder. Conclusions. Further efforts are needed to improve attainment of high-quality health care services for CSHCN with epilepsy/seizure disorders.

To examine national patterns of peer and parent interactive play opportunities that enhance early learning/socialization. Bivariate and multivariable analyses of cross-sectional data on 22,797 children aged 1-5 years from the National Survey of Children's Health 2007 were performed to determine the child, family, and neighborhood factors associated with four parent-initiated activities. Outcomes measures included time (days/week) children spent: participating in peer play; being read to; sung to/told stories; and taken on family outings. Covariates included race/ethnicity, poverty, TV watching, childcare, child and maternal physical and mental health, family factors (structure, size, language, stress, education), and neighborhood factors (amenities, support, physical condition, safety). According to adjusted regression models, minority children from lower income, non-English-speaking households with limited education, poorer maternal health and greater parenting stress were read to/told stories less than children without these characteristics, while neighborhood factors exerted less influence. In contrast, significant reductions in days/week of peer play were associated with unsupportive neighborhoods and those with the poorest physical conditions and limited amenities. Likewise, reductions in outings were associated with fewer neighborhood amenities. The findings of this study indicate that a variety of child, family, and neighborhood factors are associated with parent-initiated behaviors such as reading, storytelling, peer interactive play, and family outings. Appropriate evidence-based home visiting interventions targeting child health, parenting skills, early childhood education, and social services in at-risk communities would appear to be appropriate vehicles for addressing such parent-initiated play activities that have the potential to enhance development.

The goals of this study are to estimate federal maternal and child health (MCH) expenditures and identify their sources. This analysis is intended to provide a broad view of MCH funding appropriations and a basis for discussion of whether funds could be better utilized for the benefit of the population served. Data on federal maternal and child health expenditures for fiscal year (FY) 2006 were derived from examining federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. Based on selected criteria, we identified programs targeting children under 21 or pregnant/parenting women within the United States. The funding levels of agency programs for maternal and child health activities were determined and the programs briefly summarized. The identifiable funding for maternal and child health programs in FY 2006 approached $57.5 billion dollars. Funding sources for maternal and child health were concentrated within the U.S. Department of Health and Human Services, but spread across several different agencies within the department and in the Departments of Defense, Education, Agriculture, Housing and Urban Development, and the Environmental Protection Agency. Multiple agencies and offices often funded related activities, without evidence of a common underlying strategy. Federal maternal and child health funding mechanisms may lead to a fragmentation in maternal and child health activities. The funding and service delivery apparatus would benefit from an integrative MCH infrastructure approach to pediatric research, service delivery, and data collection/access that incorporates life-course and social/environmental determinants perspectives.

Objectives: Family-provider partnerships and satisfaction with services together are one of the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau's (MCHB) 6 core outcomes for children with special health care needs (CSHCN) and are tracked using the 2005-2006 National Survey of Children with Special Health Care Needs. Our objectives were to examine demographic, health, and other correlates/associations, with the perception of family-provider partnership and satisfaction with care; determine the associations between these perceptions and other child/family outcomes; and evaluate differences in the perception of partnership and satisfaction between the families of CSHCN and other children., Methods: We analyzed data for 40,723 CSHCN from the 2005-2006 National Survey of CSHCN and assessed the prevalence of family-provider partnerships and satisfaction with care and their association with other family-child outcomes. The partnership/satisfaction core outcome results were compared with a referent group of children without special needs included in the 2005-2006 survey., Results: The proportion of CSHCN attaining the core outcome was 57.4% and was lower for households with no health insurance, minority ethnic status, non-English speakers, nontraditional family structure, lower income, and lower functioning CSHCN. Lower rates of satisfaction and partnership were associated with poorer child and family outcomes. Disparities in attainment rates were noted for CSHCN versus other children., Conclusions: Although parent perceptions of family-provider partnership were relatively high, satisfaction with care contributed to an overall lower attainment rate for the partnership/satisfaction core outcome. Providers, families, government, and advocates need to work together to increase attainment of family-provider partnerships and satisfactory care experiences., (Published by Elsevier Inc.)

Objective: The purpose of this study was to establish prevalences and sociodemographic characteristics associated with parent-reported speech and hearing difficulties among children with special health care needs (CSHCN); determine unmet needs for therapy, hearing aids, and communication devices; and examine the association between unmet needs and resources such as health insurance, early intervention/special education, and a medical home., Methods: Data were analyzed for 300,910 children without special health care needs and 40,723 CSHCN from the 2005-2006 National Survey of Children with Special Health Care Needs. Prevalence, sociodemographic characteristics, and unmet needs for 7132 CSHCN with speech difficulties and 1982 CSHCN with hearing difficulties were assessed. Logistic regression was used to determine the associations between unmet needs for therapy or hearing/communication devices and resources for addressing needs for therapy, hearing, and communication aids., Results: The parent-reported prevalence of speech difficulty among CSHCN in the general population was 2.9% and approximately 20% among all CSHCN, in contrast to the lower prevalence of hearing difficulty (0.7% and 5%, respectively). Relative unmet need was greatest for communication devices and least for hearing aids. The strongest association with reducing unmet needs was having a medical home, and the most significant aspect of medical home was having effective care coordination., Conclusions: Having a medical home is significantly associated with fewer unmet needs for therapy and hearing/communication devices among CSHCN with speech and hearing difficulties. Care coordination may constitute an important factor that allows the primary care provider to link with services that CSHCN with communication problems require., (Published by Elsevier Inc.)

Objective: Low dental care service utilization among Medicaid-enrolled children has often been attributed to low Medicaid reimbursement levels. The purpose of this study was to provide estimates of preventive dental care utilization by Medicaid-enrolled children with special health care needs (CSHCN) and investigate the association of Medicaid preventive dental care reimbursement levels with the receipt of preventive dental care., Methods: We analyzed data for 40256 CSHCN (1-17 years of age). Unadjusted estimates of not needing, needing and receiving, and needing but not receiving preventive dental care are presented. Multilevel logistic regression models were fitted to examine associations between state Medicaid dental-procedure reimbursement and receipt of preventive dental care., Results: Some significant associations were found between state-level Medicaid dental-procedure reimbursements and receipt of preventive dental care. The strongest individual-level factor associated with not receiving needed preventive dental care was not receiving needed preventive medical care. Parents of Medicaid-enrolled CSHCN were less likely to report receiving needed preventive dental care and more likely to report not needing or not receiving preventive dental care than non-Medicaid-enrolled CSHCN., Conclusions: Medicaid-enrolled CSHCN received less needed preventive dental care than non-Medicaid-enrolled CSHCN. An important link to receiving appropriate dental care may be the primary care provider. Raising the level of preventive dental care reimbursement along with other policy changes should increase the frequency of CSHCN receiving preventive dental services. State Medicaid agencies must develop models of medical-dental care management for CSHCN in their programs to ensure the most appropriate care.

The issue of whether speech is supported by the same neural substrates as non-speech vocal tract gestures has been contentious. In this fMRI study we tested whether producing non-speech vocal tract gestures in humans shares the same functional neuroanatomy as non-sense speech syllables. Production of non-speech vocal tract gestures, devoid of phonological content but similar to speech in that they had familiar acoustic and somatosensory targets, was compared to the production of speech syllables without meaning. Brain activation related to overt production was captured with BOLD fMRI using a sparse sampling design for both conditions. Speech and non-speech were compared using voxel-wise whole brain analyses, and ROI analyses focused on frontal and temporoparietal structures previously reported to support speech production. Results showed substantial activation overlap between speech and non-speech function in regions. Although non-speech gesture production showed greater extent and amplitude of activation in the regions examined, both speech and non-speech showed comparable left laterality in activation for both target perception and production. These findings posit a more general role of the previously proposed "auditory dorsal stream" in the left hemisphere--to support the production of vocal tract gestures that are not limited to speech processing.

Although stuttering is regarded as a speech-specific disorder, there is a growing body of evidence suggesting that subtle abnormalities in the motor planning and execution of non-speech gestures exist in stuttering individuals. We hypothesized that people who stutter (PWS) would differ from fluent controls in their neural responses during motor planning and execution of both speech and non-speech gestures that had auditory targets. Using fMRI with sparse sampling, separate BOLD responses were measured for perception, planning, and fluent production of speech and non-speech vocal tract gestures. During both speech and non-speech perception and planning, PWS had less activation in the frontal and temporoparietal regions relative to controls. During speech and non-speech production, PWS had less activation than the controls in the left superior temporal gyrus (STG) and the left pre-motor areas (BA 6) but greater activation in the right STG, bilateral Heschl's gyrus (HG), insula, putamen, and precentral motor regions (BA 4). Differences in brain activation patterns between PWS and controls were greatest in females and less apparent in males. In conclusion, similar differences in PWS from the controls were found during speech and non-speech; during perception and planning they had reduced activation while during production they had increased activity in the auditory area on the right and decreased activation in the left sensorimotor regions. These results demonstrated that neural activation differences in PWS are not speech-specific.

Objectives: The aims of this study were to determine the prevalence of parent-reported preventive dental care and better dental health in children with special health care needs (CSHCN) and to identify parent-reported dental problems, reasons for lack of preventive dental care, and factors associated with receiving preventive care and having better perceived dental health in CSHCN. A comparison group of children without special needs (CWOSN) was included., Methods: We analyzed the 2003 National Survey of Children's Health by using a sample of 17,001 CSHCN and a comparison group of CWOSN. Descriptive and between-group chi-square statistics were used to analyze child characteristics, parent-perceived dental problems, and reasons for lack of preventive dental care. Factors associated with receipt of preventive dental care and better reported dental health were examined using logistic regression., Results: Approximately 80% of CSHCN and 72% of CWOSN received preventive dental care. CSHCN parents reported more dental problems and fewer described their children as having good to excellent dental health compared to CWOSN, despite greater odds of having dental coverage and receiving preventive dental care. Disparities were evident in preventive dental care and dental health based on income, education, and insurance coverage., Conclusions: Most parents of CSHCN and CWOSN report that their children receive preventive dental care and have good to excellent dental health; however, disparities in dental health and receipt of preventive dental care exist. Accessing care coordination by using the medical/dental home model, particularly for CSHCN, may alleviate the situation in which some of the most vulnerable children are experiencing the worst dental health.

Background: During the past 2 decades, family-centered care has evolved as the standard of care for children with special health care needs. A major principle of family-centered care is a strong partnership between the family and provider, working together to address issues and barriers to accessing comprehensive care and related services. The federal Maternal and Child Health Bureau defines a positive family-provider partnership as a core program outcome. Our objective was to assess the extent to which families of children with special health care needs feel as though they are treated as partners in decision-making by their doctors., Methods: We analyzed the 2001 National Survey of Children With Special Health Care Needs, a nationally representative telephone survey of caretakers for 38,866 children with special health care needs. Bivariate and multivariate statistical methods were used to assess the frequency of meeting the partnership core outcome, as well as the demographic and socioeconomic predictors of meeting core outcome. We also examined the effect of partnership on indicators of access and well-being for children with special health care needs., Results: Among children with special health care needs, 85.8% of families reported usually or always feeling like a partner in their child's care. However, living in poverty, minority racial and ethnic status, absence of health insurance, and depressed functional ability placed children with special health care needs and their families at elevated risk of being without a sense of partnership. We found that sense of partnership was associated with improved outcomes across a number of important health care measures, including missed school days, access to specialty care, satisfaction with care, and unmet needs for child and family services., Conclusions: Results of the survey demonstrated that whereas most families of children with special health care needs feel they are partners in the care of their child, further work is needed, particularly for poor, uninsured, and minority children, as well as those with functional limitations. The survey results also demonstrate the importance of partnership; children whose care met the partnership core outcome experienced improved access to care and well-being.

Children with developmental speech disorders may have additional deficits in speech perception and/or short-term memory. To determine whether these are only transient developmental delays that can accompany the disorder in childhood or persist as part of the speech disorder, adults with a persistent familial speech disorder were tested on speech perception and short-term memory. Nine adults with a persistent familial developmental speech disorder without language impairment were compared with 20 controls on tasks requiring the discrimination of fine acoustic cues for word identification and on measures of verbal and nonverbal short-term memory. Significant group differences were found in the slopes of the discrimination curves for first formant transitions for word identification with stop gaps of 40 and 20 ms with effect sizes of 1.60 and 1.56. Significant group differences also occurred on tests of nonverbal rhythm and tonal memory, and verbal short-term memory with effect sizes of 2.38, 1.56, and 1.73. No group differences occurred in the use of stop gap durations for word identification. Because frequency-based speech perception and short-term verbal and nonverbal memory deficits both persisted into adulthood in the speech-impaired adults, these deficits may be involved in the persistence of speech disorders without language impairment.

Previous findings have shown that subjects respond to an alteration, or shift, of auditory feedback pitch with a change in voice fundamental frequency (F0). When pitch shifts exceeding 500 ms in duration were presented, subjects' averaged responses appeared to consist of both an early and a late component. The latency of the second response was long enough to be produced voluntarily. To test the hypothesis that there are two responses to pitch-shift stimuli and to clarify the role of intention, subjects were instructed to change their voice F0 in the opposite direction of the pitch-shift stimulus, in the same direction, or not to respond at all. In a second group, subjects were tested under the above conditions as well as under instructions to raise voice F0 or to lower F0 as rapidly as possible upon hearing a pitch shift. Results showed that, when given instructions to produce a voluntary response, subjects made both an early vocal response (VR1) and a later vocal response (VR2). The second response, VR2, was almost always made in the instructed direction, whereas VR1 was often made incorrectly. The latency of VR1 was reduced under instructions to respond to feedback pitch shifts by changing voice F0 in the opposite direction, compared with that when told to ignore the pitch shifts. Latency and amplitude measures of VR2 differed under the various experimental conditions. These results demonstrate that there are two responses to pitch-shift stimuli. The first is relatively automatic but may be modulated by instructions to the participant. The second response is probably a voluntary one.

A general conclusion that has emerged from the collective results of a number of studies regarding acoustic characteristics of children's speech production development is that both the duration and temporal variability of segments, words, and phrases tend to decrease as one considers increasingly older groups of children. While this conclusion is largely appropriate when considering averages for groups of children studied across intervals of several years, the limited amount of longitudinal data that exists suggests that similar patterns may not routinely be observed in the development of individual children, especially when shorter time periods are involved. Cross-sectional, acoustic studies have provided important general descriptions of speech production development, but additional longitudinal investigations are also needed to address issues that cannot be effectively evaluated utilizing cross-sectional data. For example, it was hypothesized in the present study that decreases in duration and variability would be greater when children were younger and that progressively smaller decreases would occur as they became older. Despite general tendencies for decreases in duration and variability to occur with increased age, it was also hypothesized that not all segments and words would be affected to the same extent in this regard. To consider these and related questions, the speech of 4 children was recorded approximately every 7-10 months for periods ranging from 4 to 6 years. There was some support for the notion that duration/variability decreases were greater when children were younger, but often this was not observed. It was also found that whereas some sounds/words decreased in duration across time, others remained relatively constant. Also, within the same word, certain segments became shorter across time, while others remained unchanged. These observations provide a perspective concerning speech production development that represents an important supplement to more general conclusions that have been obtained from group-oriented studies.

A number of cross-sectional, acoustic studies have found that young children's speech segments tend to be longer and more variable than those of older children and adults. However, very little longitudinal information of this nature is available that considers changes across time for individual children. The present investigation is a longitudinal analysis of several temporal characteristics of the speech of 12 children of various ages who were each seen twice, approximately 1 1/2 years apart. For the group, durations decreased on average from the initial to the follow-up recordings by approximately 10%, and temporal variability decreased by about 40%. For the individual children, however, it was found that some of them showed few, if any, changes in some of the temporal measurements made at the two different times, whereas others showed substantial differences. Younger children also did not necessarily show longer durations or greater variability than older children, nor did younger children always show greater changes across time than older children. Thus, although cross-sectional studies indicate that there is a general tendency when comparing groups for increased age to be associated with shorter durations and reduced variability, individual children may not evidence such patterns or changes across time.

Eighteen adults and 12 children, ranging from 7 to 11 years of age, participated in a study that investigated their abilities to control the temporal variability of their speech. For both the adults and the children, few substantive differences in performance were observed when considering control data versus findings from an experimental task in which they were specifically instructed to be as consistent as possible in producing various stimuli. Although some subjects did show reduced variability in the experimental condition, there was little evidence that such decreases typically represented more than random effects. In general, the results suggest that when producing multiple repetitions of words and short phrases, adults and 7-11-year-old children are essentially as consistent as they can be, whether specifically attempting to minimize variability or not. The basis for this could be that even in control conditions, subjects may perform at or near optimal levels of consistency across productions.

Electroglottographic (EGG) and acoustic waveforms of the first few glottal pulses of voicing were monitored and voice onset time (VOT) measured during an adaptation task performed by stutterers and controls. The fluent utterances of stutterers resembled those of control subjects. After dysfluencies, however, the EGG signal increased gradually, lending physiological support to the technique of "easy onset" of voicing. EGG waveforms also served to help differentiate mild from severe stutterers. Idiosyncratic ritualized laryngeal behavior, sometimes including physiological tremor, was evident in the EGG record.