Household Language, Parent Developmental Concerns, and Child Risk for Developmental Disorder

doi:10.1016/j.acap.2008.12.006

Academic Pediatrics

Volume 9, Issue 2, March–April 2009, Pages 97-105

https://doi.org/10.1016/j.acap.2008.12.006 Get rights and content

Background

Provider elicitation of parent developmental and behavioral (DB) concerns is the foundation of DB surveillance. Language differences may affect whether providers assess parental DB concerns.

Objective

The aim of this study was to compare children in English versus Spanish primary language households by risk for DB disorder and provider elicitation of parental developmental and behavioral concerns.

Methods

The 2003 National Survey of Children's Health was used to compare 29 692 children, aged 0 to 71 months, who received preventive care in the previous 12 months and were in English versus Spanish primary language households. Using logistic regression, we tested the association of household primary language with child risk of developmental and behavioral disorder and parent-reported elicitation of developmental and behavioral concerns at health care visits.

Results

After adjusting for sociodemographic differences, children in Spanish primary language households were less likely than children in English primary language households to be at risk for DB disorder (40.5% vs 40.8%; AOR [adjusted odds ratio] 0.68, 95% confidence interval [CI], 0.55–0.85). Parents in Spanish primary language households reported less provider elicitation of developmental and behavioral concerns compared to all English primary language households (31.0% vs 43.7%; AOR 0.70, 95% CI, 0.57–0.85), but similar rates of elicitation compared to Hispanic English primary language households. Among households with children at moderate/high risk for DB disorder, parents in Spanish primary language households reported less elicitation of concerns than parents in English primary language households (AOR 0.63, 95% CI, 0.41–0.96).

Conclusion

Parents in Spanish primary language households reported lower child risk for developmental and behavioral disorder and less provider elicitation of developmental and behavioral concerns. These findings suggest that primary language may affect risk for developmental and behavioral disorder and likelihood of DB surveillance in children.

Section snippets

Methods

We used a nationally representative, cross-sectional survey to test the association of primary household language with 1) child risk of developmental and behavioral disorder (using a standardized screener), and 2) provider elicitation of developmental and behavioral concerns, among children who received preventive care in the previous 12 months, as reported by parents. This project was exempt from review by the Partners HealthCare Institutional Review Board.

Sample

Of the 102 535 households in the NSCH, 29 692 had parents reporting on children who were aged <6 years, received preventive care, and were English primary language or were Hispanic and had non-English primary language (Spanish primary language), and thus were included in our analysis (Figure). Of the households, 27 358 (92.2%) were English primary language and 2334 (7.7%) were Spanish primary language households. More English primary language households were excluded due to age criteria (68.5%

Discussion

Asking parents for concerns about their child's development and behavior is fundamental to developmental and behavioral surveillance. In this study, we found that pediatric providers ask parents about developmental concerns at low rates, and that language or ethnic differences may significantly impact whether providers ask parents about their concerns. Spanish primary language and Hispanic, English primary language parents were less likely to report that a provider asked about their

Acknowledgments

This work was supported in part by a National Research Service Award (T32 HP10018) from the Health Resources and Services Administration, Department of Health and Human Services, to the Harvard Pediatcic Health Services Research Fellowship. We thank Jonathan Winickoff, MD, for his comments and manuscript review and the Child and Adolescent Health Measurement Intiative Data Resource Center at Oregon Health & Science University for use of their dataset.

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According to US census data, of families who spoke a language other than English at home, 75% were Latino.6 Latino families face difficulties accessing services for their children, eliciting developmental concerns to their medical providers, and obtaining autism diagnoses.20,21 Still, there is a beneficial effect of bilingualism in areas of cognition, regardless of socioeconomic status.10
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Bilingualism does not seem to confer an extra vulnerability on children with autism spectrum disorder; however, differences in qualitative use of language were observed.
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Using nationally representative data from the 2011 Survey of Pathways to Diagnosis and Treatment, we compared child age at parent's first developmental concern with age at first discussion of concerns with a provider, and categorized provider response as proactive or reassuring/passive, among 1420 children with ASD and 2098 children with ID/DD. In the children with ASD, we tested the association between provider response type and years of diagnostic delay.
Compared with children with ID/DD, children with ASD were younger when parents first had concerns and first discussed those concerns with a provider. Compared with parents of children with ID/DD, parents of children with ASD were less likely to receive proactive responses to their concerns and more likely to receive reassuring/passive responses. Among children with ASD, those with more proactive provider responses to concerns had shorter delays in ASD diagnosis compared with those with passive/reassuring provider responses.
Although parents of children with ASD have early concerns, delays in diagnosis are common, particularly when providers' responses are reassuring or passive, highlighting the need for targeted improvements in primary care.
Developmental and autism screening through 2-1-1: Reaching underserved families
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Efforts are underway to improve the delivery of these screenings within primary care settings,17–19 but reaching the goal of universal developmental and autism screening will be challenging if primary care is the sole delivery mechanism. There are at least four major barriers to implementing universal developmental and autism screening in medical settings: inconsistent access to preventive care and a medical home20,21; low prevalence of developmental and autism screening by healthcare providers (especially for non–English speaking families)22–25; frequent use of nonstandardized screening procedures26,27; and inconsistent referrals for further evaluation when screening indicates potential problems.20,28–30 Given the magnitude of these barriers, a broader menu of strategies is needed for reaching underserved children.
Developmental disorders, including autism spectrum disorders (ASDs), are increasing in prevalence. Early identification is necessary for early intervention, which is critical for reducing challenges and lifetime costs, especially for ASDs. Because not all children have equal access to developmental and autism screening through primary care settings, nontraditional methods are needed to reach underserved populations.
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In adjusted analyses, we included covariates, on the basis of previous studies that may confound the relationship between our quality measures and DD risk. These included child race/ethnicity (Hispanic/Latino and non-Latino Black/African-American, non-Latino white, non-Latino multiracial, and non-Latino other race/ethnicity), child gender and age (categorized as 10–23, 24–47, and 48–71 months), household income as a percent of the federal poverty level (FPL; 0%–99%, 100%–199%, 200%–399%, and ≥400%), parental education for the parent in the household with the highest educational attainment (<high school, high school completion, and some college/college degree), primary language spoken at home (English or another language), child health insurance status (uninsured, privately insured, or publicly insured), and special health care need as determined by the Children with Special Health Care Needs (CSHCN) Screener.6–8,26–28 We used the NSCH single imputation data file for income data; there is an 8.5% missing rate for this variable without imputation.
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Disparities: Mental Health Care Use, Risk of Developmental DisordersHousehold Language, Parent Developmental Concerns, and Child Risk for Developmental Disorder

Background

Objective

Methods

Results

Conclusion

Section snippets

Methods

Sample

Discussion

Acknowledgments

J Pediatr

Ambul Pediatr

Limited English proficiency, primary language at home, and disparities in children's health care: how language barriers are measured matters

Public Health Rep

The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children

Pediatrics

Low income parents' reports of communication problems with health care providers: effects of language and insurance

Public Health Rep

Measuring the quality of preventive and developmental services for young children: national estimates and patterns of clinicians' performance

Pediatrics

Parents' perceptions of pediatric primary care quality: effects of race/ethnicity, language, and access

Health Serv Res

Parents' concerns about children's development: prescreening technique or screening test?

Pediatrics

Parental concerns about their child's emotions and behaviour and referral to specialist services: general population survey

BMJ

Pediatrics

Developmental surveillance and screening of infants and young children

Pediatrics

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Bright Futures Steering Committee. Recommendations for preventive pediatric health care

Pediatrics

How do primary care physicians identify young children with developmental delays? A national survey

J Dev Behav Pediatr

Pediatricians' reported practices regarding developmental screening: do guidelines work? Do they help?

Pediatrics

Assessing development in the pediatric office

Pediatrics

Disparities: Mental Health Care Use, Risk of Developmental Disorders
Household Language, Parent Developmental Concerns, and Child Risk for Developmental Disorder