The Whole Child: A Synthesis Across Topics
Protective factors such as good access to care, smoke-free homes, and strong family connections have been shown to correlate with fewer risks and better health outcomes among CSHCN and children generally. However, such health-promoting factors, or lack of them, rarely exist in isolation. In fact, the major factors promoting children’s health may not be the existence of individual assets, but rather the combined influence of multiple factors.1,2 Additionally, the timing of protective or risk factors in childhood may correlate with their long-term health risks and the development of health across the life span. This section explores how protective and risk factors combine through the use of summary indicators in each of three areas: (1) health care quality; (2) the home environment and (3) the neighborhood and school environment. Each summary measure represents a minimum standard for children. In many cases, the minimum standard for achieving these summary measures is far less than is recommended by organizations such as the American Academy of Pediatrics, and children who meet criteria for these indicators may still be at risk for poor outcomes. However, these standards represent basic health care, family, environmental, and community factors that all children should receive in order to promote positive health, development and well being.
Health Care Quality Summary Measure
All children should have access to basic health services that allow them to get better, stay healthy, and develop to their full potential. Minimum features of this kind of care include access to a medical home, adequate health insurance, and preventive care. Children who have access to these types of services are more likely to be up-to-date on their immunizations, avoid preventable hospitalizations, and have families that are more satisfied with their child’s medical care.3,4 Access to basic care is particularly important for CSHCN, whose medical needs are greater than children in the general population. The health care system performance summary measure describes a basic level of health care services provided to children. To meet measure criteria for the health care system performance summary measure, children must:
- Have access to a medical home (defined as care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective),
- Have health insurance that is adequate to meet their medical needs,
- Have had at least one preventive visit in the previous 12 months. This measure represents a low-level standard that is far more basic than other standards, such as the proportion of CSHCN who meet each of HRSA’s Maternal and Child Health Bureau Core Outcomes for children with special health care needs.5 Overall, 41.3 percent of children meet criteria for this minimum level of care (data not shown). States range substantially in the percent of children meeting this measure, with the lowest-performing State having only 30.3 percent of children meeting measure criteria and the highest-performing State having 55.5 percent of children meeting measure criteria. This still means that, even in the best performing State, more than 2 in 5 children do not meet measure criteria.
Despite that fact that CSHCN have greater need for health services than non-CSHCN, CSHCN are less likely to meet criteria for the health care system performance summary measure than non-CSHCN (35.9 percent versus 42.6 percent). CSHCN with more complex service needs are less likely to meet this standard of care than CSHCN with less complex service needs (30.3 percent versus 44.5 percent). In addition, children with emotional, behavioral, or developmental problems are less likely to meet measure criteria than CSHCN with other types of health problems. There are no differences in percent of CSHCN meeting the health care system performance summary measure according to insurance type, gender, or age. However, CSHCN with lower household incomes are less likely to meet measure criteria than are CSHCN with higher household incomes.
Home Environment Summary Measure
The Home Environment Summary Measure describes the environmental elements that a family can provide to promote optimal health in their child, and that are not highly dependent on household income or other resources. The components of the Home Environment Summary Measure depend on a child’s age. Children age 0-5 meet all criteria for the Home Environment Summary Measure if they:
- Have 4 or more family meals per week,
- Are read or sung to every day,
- Were ever breastfed,
- Watch 2 hours of television per day or less (for children 1 year or older),
- Experience no household tobacco smoke exposure.
Children age 6-17 meet all criteria for the Home Environment Summary Measure if they:
- Have 4 or more family meals per week,
- Have no television in their bedroom AND watch 2 hours of television per day or less,
- Parents have met all or most of their friends,
- Usually or always do all required homework,
- Experience no household tobacco smoke exposure.
Overall, 28.7 percent of children meet the basic criteria for this summary measure. The most common reason for not meeting the measure criteria is watching 2 or more hours of television per day. There are significant State-level differences in the number of children who meet criteria for the Home Environment Summary Measure: the poorest-performing State had only 16.3 percent of children meeting the measure criteria, whereas the best-performing State had 46.9 percent of children meeting measure criteria—still fewer than half of all the children.
Fewer CSHCN meet measure criteria than non-CSHCN (22.7 percent versus 30.1 percent), even after statistical adjustment for differences between CSHCN and non-CSHCN (such as differences in income and race).
Among CSHCN, those children with more complex service needs, as well as those children with emotional, behavioral, or developmental problems, are less likely than other CSHCN to meet all criteria for the Home Environment Summary Measure.
Neighborhood and School Environment Summary Measure
A child’s health is influenced by the physical and social resources in his or her neighborhood and community. Having a safe and supportive community is positively associated with many child health outcomes, from lower rates of obesity and asthma to lower rates of unintentional injury and homicide.6 Since questions about school environment are only asked for school-age children, the Neighborhood and School Environment Summary Measure is only calculated among children aged 6-17 years. Children meet all criteria for this Summary Measure if they:
- Are usually or always safe in their community or neighborhood
- Live in a supportive neighborhood, defined as responding “usually/always” to all of the following:
- “People in my neighborhood help each other out.”
- “We watch out for each other’s children in this neighborhood.”
- “There are people I can count on in this neighborhood.”
- “If my child were outside playing and got hurt or scared, there are adults nearby who I trust to help my child.”
- Parent feels child is usually/always safe at school.
Overall, 51.1 percent of children meet criteria for the Neighborhood and School Environment Summary Measure. There was substantial variation across States, from a low of 32.6 percent to a high of 75.3 percent. CSHCN are only slightly less likely to meet measure criteria than non-CSHCN (48.6 percent versus 51.8 percent).
Among CSHCN, children with lower household incomes are less likely to meet measure criteria for neighborhood safety and support. For instance, only 28.8 percent of children with household incomes below 100 percent of the Federal poverty level live in a safe and supportive neighborhood, whereas 64.1 percent of children living above 400 percent of the Federal poverty level live in a safe and supportive neighborhood. These differences persist even after adjusting for other differences in poor versus non-poor CSHCN, such as differences in race and family structure.
Race, ethnicity, and language also are related to whether CSHCN meet criteria for the Neighborhood and School Environment Summary Measure: Hispanic and Black children are less likely to meet measure criteria than are White and Other/Multiracial children. However, after statistical adjustment for other differences between racial groups, only Black children are less likely than White children to meet criteria for Neighborhood Safety and Support.
The Whole Child Perspective: Meeting Multiple Summary Measures
All children need quality health care, a protective home environment, and safe schools and neighborhoods. Seventy percent of CSHCN meet at least one of the summary indices described above. Roughly one third of children (31.5 percent of CSHCN and 37.7 percent of non-CSHCN) meet two or more of the three summary indices. Of CSHCN, 13.5 percent met the standards for both the home environment and the neighborhood and school environment measures. Among children without special health care needs, this percentage was 17.3.
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2 Stevens GD. Gradients in the health status and developmental risks of young children: the combined influences of multiple social risk factors. Matern Child Health J 2006;10:187-99.
3 Van Cleave J, Davis MM. Preventive care utilization among children with and without special health care needs: associations with unmet need. Ambulatory Pediatrics. 2008;8(5):305-311.
4 Homer CJ et al. A Review of the Evidence for the Medical Home for Children With Special Health Care Needs. Pediatrics. Vol. 122 No. 4 October 2008, pp. e922-e937.
5 HRSA’s Maternal Child Health Bureau Core Outcomes for children with special health care needs: http://mchb.hrsa.gov/cshcn05/MCO/intro.htm
6 Cummins, S K. Jackson, R J. The built environment and children's health. [Review] Pediatr Clin North Am. 2001;48(5):1241- 52, x.