The disability and care squeeze: the effects of children's disability and special healthcare needs on parents' employment in Australia.

Insurance Matters: Adolescents with Special Healthcare Needs

Parental Joblessness, Financial Disadvantage and the Wellbeing of Parents and Children

This study examined parental employment and health insurance coverage among children with and without special health care needs. Special needs were defined as conditions likely to require a high amount of parental care, potentially affecting parental employment. Data from the 1994 National Health Interview Survey were analyzed for 21,415 children aged 5 to 17 years, including 1604 children with special needs. Logistic regression was used to estimate the effect of special needs on the odds of full-time parental employment and on the odds of a child's being uninsured, having Medicaid, or having employer-sponsored insurance. Parents of children with special needs had less full-time employment. Their children had lower odds of having employer-sponsored insurance (adjusted odds ratio [OR] = 0.7) than other children. Children with special needs had greater odds of Medicaid coverage (adjusted OR = 2.3-5.1, depending on family income). Children with and without special needs were equally likely to be uninsured. Lower full-time employment among parents of children with special needs contributes to the children's being less likely to have employer-sponsored health insurance. Medicaid covers many children with special needs, but many others remain uninsured.

Purpose: Neonatal morbidity is strongly related to birth weight, and low birth weight (LBW) is known to be associated with childhood and even adult outcomes. This study aimed to investigate the associations of parental socio-economic status (SES) on the risks of low birth weight in the Republic of Korea. Methods: Data on 450,574 singleton births were obtained from the National Birth Registration (NBR) database of 2008 and analyzed. Parental educational level and parental employment status were considered for the analysis. The place of birth, sex, marital status, parental age, and parity were included in the analysis of the unconditional multiple logistic regressions. LBW was defined as birth weight less than 2,500 g. Results: 15,782 (3.5% of total subjects) of LBW infants were identified. The group with the lowest educational level (below high school) had the highest odds ratio of LBW, in both the father and mother, in the multivariable analysis [odds ratio (OR) 1.38 and 1.35, respectively]. Regarding paternal employment status, unemployed group had statistically significantly higher OR compared to the non-manual group (OR 1.14). Maternal employment status was analyzed not to have significant effect on the risk of LBW. Conclusion: The study confirmed that low parental SES in educational level or employment status increased the likelihood of LBW.

Parental socioeconomic status and other sociodemographic determinants of health disparities among children and adolescents in Austria.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Describe and quantify coping skills and prevalence of depressive symptoms in parents of children with special health care needs (CSHCN). Describe the association of coping skills with parental depressive symptoms, severity of child's condition and family demographic characteristics. A baseline questionnaire was administered to parents of CSHCN 2-11 years old. Data were analyzed cross-sectionally. Coping skills were assessed using F-COPES, and depressive symptoms were measured using CESD 10, both previously tested tools. Multivariable regression models measured the association of coping skills with depressive symptoms, parents' rating of severity and demographic characteristics. Among 129 parents 54% had depressive symptoms above standard normal threshold. Parents with better coping skills had significantly fewer depressive symptoms. The severity of child's condition, parental marital status and employment status were significantly related to depressive symptoms; after accounting for these factors, better coping skills were still associated with fewer depressive symptoms (P-value < 0.05). Parents of CSHCN are at increased risk for depressive symptoms, especially if single and unemployed. In this study better parental coping skills were associated with fewer depressive symptoms, regardless of the severity of child's condition; and remained significant after accounting for demographic factors. Educational interventions to improve coping skills for parents of children who have a variety of diagnoses and severity levels may potentially mitigate the manifestation of depressive symptoms and in turn improve parenting.

Parental and family inputs are particularly important for children with disabilities receiving benefits from the Supplemental Security Income (SSI) program. These children often need disability or health-related care, and nonfamily sources provide only limited access. This is the first study to analyze family and nonfamily caregiving for these children with disabilities based on nationally representative quantitative data from the National Survey of SSI Children and Families (NSCF), a survey focusing on SSI recipient children with disabilities. The data suggests substantial variability in the need for caregiving among children on SSI. We find that there is also substantial variation in family inputs related to parental education, living arrangements, the presence of other children of preschool age and other factors that affect the quality and quantity of caregiving. Our analysis confirms that family caregiving is much more substantial for these children than nonfamily caregiving, and that caregiving from both sources is associated with various indicators of the nature and extent of disabilities. We find some – but weaker – evidence of an association between the child's disabilities and parental employment. Overall, while there is some substitution between parental employment and caregiving there appears to be a substantial net burden on the family arising from the child's needs for caregiving. We also find that there are significant predictors of family caregiving and parental employment that are unrelated to the child's disabilities. Most of these show opposite relationships to caregiving and parental employment – negative for one, positive for the other or vice versa. However, better parental education substantially increases the odds of both caregiving and parental employment. Parental disability sharply reduces the odds of parental employment and somewhat increases the odds of reported family caregiving. Overall, the challenges are especially substantial for single mothers who cannot share the extra burden of raising a child with severe disabilities with a spouse.

This study examined the relationship between special health care needs and social-emotional and learning competence in the early years, reporting on two waves of data from the Kindergarten Cohort of Growing up in Australia: The Longitudinal Study of Australian Children (LSAC). Six hundred and fifty children were identified through the two-question Special Health Care Needs Screener as having special health care needs. Children with special health care needs were more likely to be male, to have been of low birth weight, to be taking prescription medications, to be diagnosed with a specific health condition and to be from families where the mother was less well educated. These children scored significantly lower on teacher-rated social-emotional and learning competencies prior to school compared to a control group of children without special health care needs. Multiple regression analyses indicated that being identified with a special health care need prior to school predicted lower social-emotional and learning competencies in the early years of school. Results are discussed in terms of the implications for policy and practice.

The passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996 represented one of the most profound developments in American social policy since the Great Society programs of the mid- 1960s and has the potential to affect the health of millions of American children. The overall purpose of the legislation, commonly referred to as welfare reform, was to decrease reliance on welfare and increase the economic independence of poor families. Its impact has been far-reaching, affecting many determinants of child health and well-being, such as family resources, reproductive choices, maternal employment, parental supervision, childcare, and access to health insurance.The implementation of PRWORA has been associated with unprecedented declines in the number of children receiving public benefits. In the first 2 years after welfare reform, the number of children receiving welfare benefits fell by 28%.1,2 In addition, the number of children enrolled in Medicaid, the principal public health insurance program for poor children in the United States, also fell, despite provisions in the legislation to extend Medicaid coverage to all children who lose welfare benefits.3 Similarly, the number of children receiving food stamps has dropped by 20% between 1996 and 1998.4–6 Although there is consensus that both growth in the economy and welfare policies themselves have contributed to these declines, the exact proportion attributable to each factor remains unclear.7–9This discussion considers how these major shifts in public support for poor children and their families are likely to affect patterns of child health and the provision of clinical services to children. It addresses these concerns by exploring 4 related issues: the elements of the welfare legislation most likely to affect child health, the impact of this legislation on enrollment in public programs for children, the potential health effects of welfare reform, and the role of pediatric and other child health practitioners in addressing these health effects through clinical practice and public advocacy.The PRWORA legislation ended the federal guarantee of income support to poor families by replacing the longstanding entitlement program Aid to Families With Dependent Children (AFDC) with limited block grants to the states under the new Temporary Assistance for Needy Families (TANF) program. Through these block grants, the states were given substantial power over many aspects of welfare policy and implementation, which has led to unprecedented variation in state welfare programs. Among the many changes in welfare that PRWORA imposed, there are 6 key elements of the new welfare law that have implications for child health: time limits, work requirements, family caps, the uncoupling of TANF and Medicaid, sanctions, and changes in related social programs.The federal law mandates a 5-year lifetime limit for cash benefits. Once families reach their time limit, benefits are terminated regardless of their social or economic situation. States can institute shorter limits and 23 states have done so; several states have time limits of 2 years or less (Table 1).10 Exemptions and extensions are permitted for factors such as domestic violence, parent disability, or caring for a young child; however, 18 states do not allow extensions in any circumstance.The federal law also mandates that single parents receiving TANF must seek work (Table 1).11 In many states, educational activities such as pursuing high school diploma equivalency, job training, or college, no longer fulfill work requirements. Although 28 states have adopted the federal guideline that exempts parents of children younger than 1 year of age from work, 12 states have set the age for exemption much lower at 3 months of age (Table 1). Although states can provide exemptions to women with chronically ill children, most states have adopted highly restrictive criteria. For example, in Massachusetts work exemptions are limited to only those women whose children meet SSI disability standards, a practice that has recently been challenged in court.12 Similarly, state exemptions for when a parent is disabled or a victim of domestic violence have been highly restrictive.13 Failure to comply with work requirements can result in reduction or termination of benefits (Table 1).Although there was no specific federal requirement to eliminate benefits for children born to women already on welfare, states were allowed to do so and 23 states have chosen to restrict cash assistance to such family cap children to provide a disincentive for childbearing while on welfare.10 Nineteen of these states provide no additional assistance, 2 provide partial increases in cash benefits, 1 provides additional assistance as vouchers rather than cash, and 1 provides additional assistance to a third party rather than to the parent (Table 1). For families who have an additional child while on welfare, the family cap restrictions do not reduce total benefits to the family, but effectively result in a decrease in household income per family member. In an additional effort to discourage childbearing while on welfare, 4 states have provisions that require mothers who have children while receiving TANF to work soon after birth.10,13Before 1996, welfare and Medicaid were administratively linked. The PRWORA legislation created different eligibility requirements and funding mechanisms for the 2 programs. Families found ineligible for TANF could still qualify for Medicaid, which remains an entitlement program. PRWORA maintained Medicaid eligibility guidelines similar to those of the former AFDC program and specified that Medicaid benefits could continue for a transitional year after families leave TANF for employment (Table 1). This provision was intended to address the likelihood that the jobs available to this population may not provide health insurance. The State Child Health Insurance Plan (SCHIP) was also established in 1997 to reduce the number of uninsured low-income children. By the beginning of fiscal year 1999, the majority of states had begun implementing their SCHIP enrollment plans, although the pace of enrollment has varied across states.14The welfare law mandated that cash benefits must be reduced if parents fail to comply with work requirements, a practice that many states had implemented even before this legislation.13States vary regarding the causes, severity, and duration of sanctions. For example, some states will impose sanctions if immunization or routine pediatric health care is not appropriately documented (Table 1).The welfare legislation also included changes in 2 other important programs that benefit low-income children—food stamps and the Supplemental Security Income (SSI) programs. New restrictions were imposed in the food stamps program, including a reduction of benefit levels and allowances for reductions in food stamp benefits if families were penalized under TANF rules.4,15 Welfare reform tightened SSI eligibility by eliminating the Individualized Functional Assessment as a basis for evaluating disability in children and by requiring eligibility redeterminations.16,17 These individualized assessments allowed children to be considered disabled if their conditions were of comparable severity to those of an adult or if they had a combination of impairments that did not individually meet disability criteria.18Since the enactment of PRWORA, there have been substantial declines in enrollment of children in important programs that serve as the safety net for poor children—TANF, Medicaid, food stamps, and SSI. The difference between states in the size of enrollment decreases is likely caused by differences in their specific welfare policies as well as their overall economic situation.7,8,19 There is evidence that there is persistent need for these programs despite a strong economy, which has implications for future periods of economic slowdown.20,21Since the enactment of welfare reform, the number of children receiving welfare benefits decreased by 28%, from 8.6 million in 1996 to 6.2 million in 1998 (Table 2).1,2 During this same period, the rate of child poverty decreased by 1.6%. However, this decrease reflected overall poverty trends and did not necessarily represent the experiences of children leaving welfare.22An even more striking decline occurred among adults, with the total number of people receiving TANF falling by 43% from 12.2 million in August 1996 to 6.9 million in June of 1999.23 Although the welfare caseload began to decline from its peak of 14.2 million in 1994, before passage of welfare reform, 61% of the decrease since 1994 occurred in the last 2 years. The size of the drop varies from 12% in Rhode Island and Nebraska to over 80% in Idaho, Wisconsin, and Wyoming.23,24One problem with evaluating Medicaid enrollment trends is the significant time lag in reporting these data.25 Fiscal year 1998 data are only now becoming available and have yet to be verified. Medicaid enrollment data compiled from a recent survey of 21 states are available but do not include information for children.26 However, the data that are available for the period between 1996 and 1997 indicate that the number of children enrolled in Medicaid fell by 1 million, from 16.3 to 15.3 million, a 6% decrease (Table 2).3,27 This reduction occurred while the child uninsurance rate remained stable at 15%, translating to 11 million uninsured children.21 As with the TANF decline, the reason for the decreases in Medicaid enrollment are understood to be multifactorial but are likely to include practical administrative barriers resulting from the uncoupling of Medicaid and TANF, as well as improvements in local economic conditions.7,28 In addition, part of the decline in Medicaid enrollment is attributable to a decrease in the participation rate in the program among poor children from 63% in 1996 to 58% in 1998.29The effort to expand coverage to a larger proportion of poor children through SCHIP has only offset a portion of the Medicaid declines. A recent survey of the 12 states with the most uninsured children demonstrated that increases in SCHIP enrollment were overshadowed by even larger decreases in Medicaid enrollment, resulting in substantially fewer children enrolled in federally funded health insurance programs 3 years after welfare reform.30 Indeed, evidence indicates that there are at least 2.6 million uninsured children eligible for SCHIP and 4.7 million uninsured children eligible for Medicaid.31,32 SCHIP enrollment data suggest that although enrollment increased by over 50% from 833 000 to 1.3 million between December 1998 and June 1999 this only accounted for 50% of those predicted to be eligible.33 As SCHIP enrollment proceeds, information must be gathered on how many of these uninsured yet eligible children are captured.Food stamps are an important resource for low-income families regardless of whether they receive welfare benefits. Concurrent with the dramatic decrease in the total number of TANF recipients from 1996 to 1998, there has been a comparable 24% decrease in overall food stamp enrollment from 24.9 million to 18.9 million participants, the lowest number since 1979.4 In the face of this decline, the increased need for food assistance was documented in a 1999 survey of 26 major cities that found requests for food assistance by families with children increased by 15% in the previous year and that two thirds of those requesting food assistance were working.20This evidence suggests that food stamp enrollment cannot be explained only by a decreased need for food assistance. Rather, the overall decline is likely to be attributable to a combination of overall economic conditions, specific tightening of food stamp eligibility requirements under PRWORA and to spillover effects of other welfare reform policies geared to reducing caseloads.4Studies have indicated sharp declines in the use of food stamps by families who leave welfare. Former welfare recipients left the food stamp program at greater rates than other families, but those with the lowest incomes were especially likely to stop receiving food stamps.15 These declines are not caused by ineligibility because most families are still eligible because their incomes have remained low after leaving welfare.4,34–38Not surprisingly, the number of children receiving food stamps also decreased, falling 20% from 13.2 million in 1996 to 10.5 million in 1998 (Table 2).39 This drop accounts for nearly one half of the total decline in food stamp enrollment. In addition, the rate of participation of poor children decreased from 94% to 84% between 1995 and 1997, despite rising rates of demand for subsidized school lunches and emergency food assistance.4The SSI program is one of the most important programs providing supplemental income support for families with disabled children. After the stricter eligibility standards for SSI went into effect, eliminating the Individualized Assessment Plan and requiring eligibility redeterminations, the overall enrollment dropped by 11%, from 955 000 to 847 000 between December 1996 and December 1999.40 Children who lost their SSI benefits through redeterminations also lost their Medicaid coverage until this was reinstated by the 1997 Balanced Budget Act.18,40Although there are many potential ways welfare reform can influence the well-being of poor children and their families, we consider the principal pathways to be: changes in family resources, influences on parental supervision, and alterations in access to health care.Although PRWORA has many complex components, its primary impact will depend on whether it serves to increase or decrease resources for families who leave and those who remain on welfare. Despite the centrality of this issue, there are limited data on the long-term economic status of families after they leave the welfare rolls. Recent studies of different states have shown that one half to two thirds of people who left welfare were employed when surveyed 3 to 12 months later.34–38 However, all of these welfare leaver studies are limited by relatively short follow-up periods. These studies also indicate that although many former recipients are working, their earnings do not raise them above the poverty level, because most are employed in low-wage, entry-level work.34,41This concentration in low-wage work is consistent with the evidence that families who leave welfare for work face significant barriers to employment, including inadequate education, training, and previous work experience.42–44 Former recipients also tend to be young single parents with young children.34 Child health is often cited as a barrier to parental employment among welfare recipients.42–44 This is not surprising because recent studies indicate that children of welfare recipients have a higher burden of illness than do other poor children—20% to 40% of families receiving AFDC had children with chronic illnesses, compared with 10% of all poor families.45–47Because it may be difficult for women with chronically ill children to meet the new work requirements, they will be more vulnerable to sanctions or benefit terminations for noncompliance. Although states can provide exemptions to work requirements because of child illness, many base such exemptions on strict criteria such as SSI disability designation. Such exemptions, however, will not affect mothers of chronically ill children who have significant health needs and require parental participation in their medical care, but who may not meet SSI disability standards. For example, chronically ill children with respiratory diseases have 3 times the number of physician visits and 4 times the rate of hospitalizations of healthy children.47Although the dramatic declines in TANF rolls may well reflect improved social conditions for some families previously reliant on public assistance, a portion of poor families will likely experience significant hardship, particularly during difficult economic times. Taken together, the barriers to employment, sanctions, and the termination of benefits outlined above will cause some families to experience declines in available income. There is much evidence to indicate that decreases in family resources, including food stamps, resulting from welfare policies have the potential to cause predictable and substantial adverse child health effects.48–55The impact of the substantial declines in food stamp participation on the nutritional status of poor children must also be considered. Poor children are 5 times more likely to experience food insecurity and hunger, and they have significantly lower intake of calories, iron, folate, and other nutrients, compared with nonpoor children.56,57 Undernutrition is associated with numerous adverse health outcomes, including poor growth, iron deficiency, lead poisoning, and impaired cognitive development.53,55,57–59In contrast, food stamp use is associated with a lower risk of inadequate food intake and improved nutritional status.Parental work requirements included in welfare reform raise important questions regarding childcare arrangements while parents are working. Inadequate or substandard childcare poses a variety of risks, including injuries, communicable diseases, and noncompliance with prescribed medical regimens.60 In the case of chronically ill children, flexibility in parental employment as well as appropriate child care are essential to maintaining reasonable health. For example, children with asthma who adhere to their medical regimens are more likely to have their disease well-controlled.61–63Depending on the age of the child, parental time and supervision are needed for the recognition of symptoms, administration of appropriate treatments, and attendance at medical visits.64–67Former welfare recipients are unlikely to find jobs that provide the flexibility needed to care for a chronically ill child, because most find low-wage work in industries characterized by limited parental benefits or leave policies.41,68 National data suggest that employed poor mothers and mothers of chronically ill children have less sick leave than do other mothers.60 In particular, a substantial proportion of former welfare recipients lacked sick leave or vacation leave or a flexible schedule that might allow them to care for a sick child.41,46 This disparity between the amount of illness poor families experience and the degree of work flexibility available to them suggests that these parents will be faced with the difficult decision of what to do when their child is sick or needs to go to the doctor and they are unable to take time off from work.The problem of inadequate day care for current and former TANF recipients was underscored by recent data suggesting a shortage of affordable day care, especially for infants and toddlers.69,70 The gap in available care is particularly striking for poor families who work nonday schedules because most child care providers are unavailable during these off hours.69–71 For many families, this means that they will have to rely on unregulated day care, which is more available during nonstandard hours. This contributes to the use of lower quality day care by poor families, a factor that increases the risk of deleterious child health and developmental outcomes.71–73 PRWORA provided additional funding for child care subsidies, which are critical in assisting former recipients to obtain affordable quality day care.69 However, most states are unable to provide child care subsidies to all families who meet the eligibility criteria, resulting in waiting lists and copayments to restrict access to limited child care funds.69,74The primary means of providing health insurance to children on welfare has been the Medicaid program. The reduction in Medicaid enrollment since the passage of PRWORA raises concerns about uninsured children in families leaving welfare. Despite provisions for continued coverage, several studies provide consistent evidence that up to one half of children in the examined states were not enrolled in Medicaid 6 months after leaving welfare and that there was limited use of available transitional Medicaid coverage.34,36,75,76Medicaid dropout of eligible children is at least partly caused by administrative barriers and the lack of coordination between Medicaid and welfare agencies.19,25,28 Overall, 40% of former recipients and 25% of their children were uninsured.75Recipients uninsured by Medicaid are unlikely to have employer-based private insurance because the proportion who found jobs providing such insurance varies considerably, from 10% to 60% and even those who have access to employer insurance may not be able to afford the cost of the premiums.27,28,36 The fact that a substantial proportion of children who leave welfare become uninsured is of concern because research has repeatedly shown that poor children without health insurance experience impaired access to health care. They are less likely to have a regular source of care and are more likely to have difficulty obtaining prescription medications and to delay seeking care because of cost concerns.77,78 Moreover, uninsured children with a chronic illness are more likely to have had no physician visit in the previous 12 months.79,80 Thus, welfare policies that unintentionally result in higher rates of uninsured children can be expected to result in a variety of adverse health outcomes and a growing burden on the financial well-being of clinical practices and institutions that care for poor children in the United States.The nature and scale of welfare reform will create new challenges and opportunities for clinicians who care for poor children in the United States. The persistence of continued high rates of uninsurance in the face of a decline in Medicaid enrollment represents a serious barrier to improved child health and will generate new financial burdens for clinical practices and institutions serving poor families. The extent to which uninsurance remains a problem depends on how successful individual states are in enrolling eligible children in their Medicaid and SCHIP programs. Early evidence suggests that there is considerable variation in how effective states have been in their outreach efforts and in overcoming important administrative barriers to enrollment, such as frequent eligibility redeterminations and complicated applications.25,28,81 In addition, hospitals and clinics that are confronted with higher rates of uncompensated care because of uninsured children will have a strong financial incentive to address this problem.From a policy perspective, there is an urgent need to understand what portion of the declines noted in Medicaid, food stamps, and SSI is attributable to economic growth or welfare policies. This will be key in determining whether more attention should be focused on program policies or on policies in for an economic The pediatric could to raise public of these trends and to seek including those by the American of Although the data on enrollment trends in these programs are from a relatively short time these are the only data and more information on child health and well-being to a more regarding PRWORA as it its in must consider the that if some families are unable to leave welfare and poverty during the current economy, it is likely that the potential for adverse will increase during an economic enrollment efforts greater attention should be to population that are such is children of who for Medicaid because of that Medicaid will be as evidence of a public and will affect their for will need to a of the problem of uninsured children and institute outreach such as those by the American of the by the and the by the of Health and and the National caring for low-income families may need to patterns of practice and new to meet the different welfare reform may generate for their limits will new economic burdens on families. work requirements may require greater by with day care providers to health care regimens and practice to parents with limited work will also need to serve as of information and assistance for families who may be eligible for Medicaid, food stamps, and transitional child care subsidies even after welfare benefits should be that in many states, medical may to be a critical for TANF time limits, maternal work requirements, and maintaining health insurance for children with health care provide assistance for their clinicians caring for poor children should have a of local welfare policies and should with social and For example, one pediatric has a of routine regarding health food and welfare by a and follow-up to families in obtaining needed clinical could also serve as an essential source of data on the impact of welfare reform on children. particularly those focused on children with chronic illness, could provide information on the health of children who changes in their welfare Health care providers could also an important role in families who more into poverty under welfare reform provisions even if the overall experience of the population Such can use the power of to set research and policy can to welfare reform policy by providing regarding to effectively or and Although we data from such as the National of American Families as well as the of the of data on child health in these studies will be are in a to significant to the health and well-being of children during the implementation of welfare reform by the experience of clinical practice and research to the of child health over welfare has to the states, health care providers are in a to influence local policy through their Through the pediatric can that the health of children is included in the of the effects of social welfare Through clinical we can that the discussion of welfare reform is by a of the experience that the research was in part by funding from the the the National of National of and the Health and the and the for the Children of the who previous of this and and who in the of the

Ninety-seven percent of children who have special health care needs are cared for by their mothers. These mothers cite that their informal care work can be intrinsically rewarding, however, the role is not without substantial difficulties and consequences. We investigated differences in the health and well-being of mothers whose young children do and do not have special health care needs. Quantitative data are drawn from Growing Up in Australia: The Longitudinal Study of Australian Children. This study employs a matched-case control methodology to compare the experiences of a group of 292 mothers whose children are identified as having long term special health care needs to those mothers whose children are typically developing at two time points; Wave 1 (2004) and Wave 3 (2008). The findings support previous research that mothers of children with special health care needs have poorer general health and mental health than mothers whose children do not have special needs. Mothers of children with special health care needs also perceived life as more difficult. Longitudinally, this study also shows that maternal well-being remains relatively stable during the years when children are transitioning to formal schooling. Implications for policy makers, practitioners and early childhood professionals are discussed.

To describe the meal patterns of Jena schoolchildren and their associations with children's weight status and parental characteristics. Cross-sectional study. Twenty schools in Jena (100,000 inhabitants), south-east Germany. A total of 2054 schoolchildren aged 7-14 years with information on BMI standard deviation score (BMI-SDS) and weight status (based on German reference values), of whom 1571 had additional information about their parents (parental education and employment status, weight status according to WHO guidelines) and meal patterns (school lunch participation rate, meal frequencies, breakfast consumption and frequency of family meals). Weight status of the children was associated with weight status, education and employment status of the parents. Meal patterns were strongly dependent on children's age and parental employment. As age increased, the frequency of meal consumption, participation rate in school lunches and the number of family meals decreased. Using linear regression analysis, a high inverse association between BMI-SDS and meal frequency was observed, in addition to relationships with parental weight status and paternal education. Age-specific prevention programmes should encourage greater meal frequency. The close involvement of parents is essential in any strategy for improving children's (families') diets.

BackgroundMuch research has been conducted into the determinants of physical activity (PA) participation among adolescent girls. However, the more specific question of what are the determinants of particular forms of PA participation, such as the link between participation through a sports club, has not been investigated. Accordingly, the aim of this study was to investigate the relationships between participation in a sports club and socio-economic status (SES), access to facilities, and family and peer support, for female adolescents.MethodsA survey of 732 female adolescent school students (521 metropolitan, 211 non-metropolitan; 489 Year 7, 243 Year 11) was conducted. The survey included demographic information (living arrangements, ethnicity indicators, and indicators of SES such as parental education and employment status and locality); access to facilities; and family and peer support (travel, encouragement, watching, praise, joint participation). For each characteristic, sports club participants and non-participants were compared using chi-square tests. Multiple mediation analyses were used to investigate the role of access, family and peer support in the link between SES and sport participation.ResultsThere were significant associations (p<0.05) between sports club participation and: all demographic characteristics; all measures of family and peer support; and access to sport-related facilities. Highest levels of participation were associated with monolingual Australian-born families, with two parents, at least one of whom was well-educated, with both parents employed, and high levels of parental assistance, engagement and support. Participation in club sport among both younger and older adolescent girls was significantly positively associated with the SES of both their neighbourhoods and their households, particularly in metropolitan areas. These associations were most strongly mediated by family support and by access to facilities.ConclusionsTo facilitate and promote greater participation in club sport among adolescent girls from low SES neighbourhoods and households, strategies should target modifiable determinants such as facility access and parental support. This will involve improving access to sports facilities and promoting, encouraging and assisting parents to provide support for their daughters’ participation in sport clubs.

We used the 2005-2006 National Survey of Children with Special Health Care Needs to compare 3 types of outcomes between children with and those without parental reported muscular dystrophy: (1) functional limitations; (2) health care experiences in terms of the 5 components of a medical home; and (3) family impacts, including financial or out-of-pocket costs and parental employment and time use. We used weighted logistic regression to examine their associations with muscular dystrophy after adjustment for socio-demographic characteristics. Among children with special health care needs, children with reported muscular dystrophy were much more likely to have difficulties with ambulation and self-care. They were more likely to have family members who reported financial problems, reduced or stopped employment, and spent more than 10 hours weekly providing or coordinating care. Muscular dystrophy was not associated with the likelihood of having a medical home after adjustment for socioeconomic status and other socio-demographic characteristics.

Parental employment and work-family stress: Associations with family food environments