Harsh Parenting and High Socioeconomic Stress May Be Associated with Higher Internalizing Problems Like Anxiety in Children, ECHO Study Finds

Authors: Lue Williams, Veronica Oro, Leslie Leve, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Internalizing problems in childhood such as chronic internal distress may be early indicators of problems associated with disorders such as depression and anxiety. Internalizing by children can be influenced by biological and environmental factors, including parent-child relationships and socioeconomic status.

This study examined the relationship between two early childhood stress factors, harsh parenting and socioeconomic stress, and children’s development from childhood through adolescence. For this study, the researchers characterized harsh parenting, or “parental hostility” as non-supportive and controlling parenting practices, displays of anger and disappointment in children, and discipline through punishment. Socioeconomic stress reflects disadvantages associated with factors like household income. Few studies have examined early childhood predictors of internalizing behavior development, so this research fills an important gap by examining the role of diverse risk factors in early life, between the ages of 18 months and 5 years, on patterns of internalizing symptoms later in childhood. The study design, which used data collected from participants over a long period, also allowed the research team to explore the long-range impact of early life influences across critical stages of children’s physical, social, and psychological development.

What were the study results?

Researchers observed that, within the study sample, children fell into three main groups based on the severity of their internalizing behaviors and how those behaviors progressed with age: low, moderate-increasing, and higher-increasing. Some of the internalizing behaviors reported include feeling anxious or depressed, being withdrawn, and complaining of aches and sickness. Parents who reported more negative interactions with children in early childhood had children who were more likely to be in the group with the highest internalizing behaviors. Children with more socioeconomic stress in their households were also most likely to be in the highest internalizing behaviors group, as compared with both the low- and moderate-internalizing symptoms groups.

Researchers also observed that household socioeconomic stress directly predicted children’s mental health. Study investigators did not find any significant relationship between child sex assigned at birth and how likely they would be to show internalizing behaviors.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was this study's impact?

The findings from this study suggest that in addition to focusing on children’s symptoms when treating internalizing problems, health service providers may also wish to consider the broader context of caregiver behavior and access to resources for care.

Who was involved?

The study included two samples—a nationwide sample of 481 children who were adopted at birth and a sample of 1,053 children from six predominantly low-wealth, rural communities in eastern North Carolina and central Pennsylvania. Adopted children from the Early Growth and Development Study (EGDS) have lived in their adoptive homes since birth and were recruited into the study between 2003 and 2009. Children from the Family Life Project (FLP) were raised by their biological parents and were recruited into the study at birth, between September 2003 and 2004. Results may not be representative of the general population.

What happened during the study?

The researchers analyzed data collected from children and families that participated in the EGDS and FLP. EGDS children and families completed assessments approximately every nine months when adoptees were under the age of 3, and every one to two years after that. FLP participant families completed an initial home visit assessment when children were 2 months old and participated in annual assessments thereafter.

What happens next?

Future studies are needed to further support programming and research efforts by exploring mechanisms that underlie the relationship between socioeconomic stress, parenting styles, and children’s internalizing behaviors identified in the current study.

Where can I learn more?

Access the full journal article, titled “Influence of Early Childhood Parental Hostility and Socioeconomic Stress on Children’s Internalizing Symptom Trajectories from Childhood to Adolescence,” in Frontiers in Psychiatry.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published April 16, 2024

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Harsh Parenting and High Socioeconomic Stress May Be Associated with Higher Internalizing Problems Like Anxiety in Children, ECHO Study Finds

ECHO Study Suggests Living Near Green Space Is Associated with Lower Anxiety and Depression in Preschool-Age Kids

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ECHO Study Suggests Living Near Green Space Is Associated with Lower Anxiety and Depression in Preschool-Age Kids

Authors: Nissa Towe-Goodman

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

While previous research has suggested that access to nature is important for mental health, there are a limited number of studies that have examined these effects on young children. ECHO investigators addressed this research gap by looking at whether exposure to green space was associated with internalizing symptoms (e.g., anxiety, depression) and externalizing symptoms (e.g., aggression, rule-breaking) among children.

What were the study results?

The ECHO researchers found that higher levels of green spaces, up to three-fourths of a mile from a child’s home, were linked with lower symptoms of anxiety and depression from ages 2 to 5. Although green space was also linked with symptoms of aggression and rule-breaking in early childhood, this association was reduced after accounting for factors such as poverty levels, unemployment, and housing costs. Researchers found no significant association between residential green space and internalizing or externalizing symptoms in middle childhood, ages 6 to 11.

Note: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was this study's impact?

Most research evaluating the effect of green space on health so far has been limited in children and studied one or a few cities at a time. ECHO Program researchers were able to examine data from children in 199 counties across 41 U.S. states, exploring the connection between exposure to green spaces from birth and anxiety, depression, aggression, and other symptoms during early or middle childhood. These findings suggest that green initiatives such as parks, urban forest programs, or protected natural areas may influence early emerging anxiety and depression symptoms.

Who was involved?

The 2,103 children included in the study were born between 2007 and 2013 and ranged in age from 2 to 11, spanning early and middle childhood.

What happened during the study?

Researchers analyzed information from parents who completed the Child Behavior Checklist for their children from ages 2 to 11 and combined this data with the family’s residential address since the child was born and satellite-based imagery of vegetation density around their homes. Green space exposure was measured using the Normalized Difference Vegetation Index (NDVI), a widely used metric for quantifying vegetation density using sensor data. NDVI values range from -1 to 1. High NDVI values (approximately 0.6 to 0.9) represent dense vegetation, such as forests; values approaching 0 represent areas without live vegetation.

What happens next?

Future studies can explore the types of natural areas linked with early mental health and examine the role of green space around schools. Investigating how early exposure to nature influences mental health into adolescence and adulthood could also be an important area to study.

Where can I learn more?

Access the full journal article, titled “Green space and internalizing or externalizing symptoms among children,” in JAMA Network Open.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published April 10, 2024

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ECHO Study Suggests Living Near Green Space Is Associated with Lower Anxiety and Depression in Preschool-Age Kids

New ECHO Research Highlights Gaps in Literature Studying Role of Fathers in Child Development

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New ECHO Research Highlights Gaps in Literature Studying Role of Fathers in Child Development

Authors: Elena Jansen, Kristine Marceau, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

While few studies on parental health and child development include fathers in any substantial way, a growing body of literature emphasizes their vital role—even in the period before birth. This study reviewed existing literature on what is known about the father’s role in child development. It highlights how a father’s history and personal characteristics before the baby is born, during pregnancy, and after birth can influence their child directly via their parenting behaviors and indirectly by influencing the child’s mother. The study also discusses how the ECHO Program can address key gaps in the literature by designing studies that address unanswered questions.

What were the study results?

The researchers reviewed the existing literature to find out which characteristics or behaviors of fathers have been connected to children’s development, especially their physical and mental health. While many studies give some information about the role of fathers, often fathers do not provide this information themselves, or existing data do not allow researchers to compare the role of fathers to that of mothers. Compared to the pregnancy and pre-pregnancy stages, this study allows researchers to better understand a father’s role once a baby is born. The study team created a model to guide future inquiry and suggest methods researchers can use to help fill in some knowledge gaps in the future. One unique aspect of this work is describing how fathers can impact the child by first influencing the mother, for example, by helping her follow healthy behaviors, such as cooking or helping to cook healthy meals and eating healthy food himself.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should always consult with a qualified healthcare provider for diagnosis and for answers to your personal questions.

What was this study's impact?

This review of other publications reveals gaps in the research community’s understanding of the father’s role in child development. First, very little is known about the father’s role in child development before birth. The study authors noted that more studies are needed to research mothers and fathers before they have children, focusing on including fathers in a substantial way. Some of the father data collected in the existing literature was reported by the mother. This highlights a gap in the literature and the need to incorporate maternal and paternal reported data on father characteristics. Second, this review demonstrates how studying the effect of fathers on child development has revealed additional insights into children’s health outcomes, including reasons for declines in physical or mental health.

This study also introduces a model designed to guide other researchers in focusing on pieces of the puzzle that are currently less understood. The model may help explain how each parent interacts with their child and which influence has a stronger impact or is more prevalent for which parent.

Who was involved?

This literature review involved an in-depth look into existing research on the role of fathers in child development and evaluated its quality. The study focuses on three specific child outcome areas of the ECHO program: obesity, neurodevelopment, and positive health.

What happened during the study?

This literature review begins by describing data collected by the ECHO Cohort and identifying critical gaps in the research related to the role of fathers in ECHO’s five key health outcome areas. After understanding the program’s data collection methods, the research team analyzed multiple research papers categorized into three broad stages of child development—preconception, prenatal, and postnatal. The review concludes with the presentation of a new proposed conceptual model to guide future studies considering paternal influences in ECHO and beyond.

What happens next?

With more data becoming available from the ECHO Program, information on fathers' characteristics can be connected to the rich data on family characteristics, mothers' influences, and child development. Additional data will be gathered to provide further insights and answer remaining questions.

Where can I learn more?

Access the full journal article, titled “The Role of Fathers in Child Development from Preconception to Postnatal Influences: Opportunities for the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) Program” in Developmental Psychobiology.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published December 27, 2023

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New ECHO Research Highlights Gaps in Literature Studying Role of Fathers in Child Development

ECHO Researchers Measure Pandemic-Related Traumatic Stress in Families

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ECHO Researchers Measure Pandemic-Related Traumatic Stress in Families

Authors: Courtney K. Blackwell, et al.

Who sponsored this study?

This research was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of The Director, National Institutes of Health with co-funding from the Office of Behavioral and Social Sciences Research.

Why was this study needed?

The COVID-19 pandemic and subsequent social distancing strategies may have ongoing negative effects on mental health. To measure this, ECHO researchers developed the Pandemic-related Traumatic Stress Scale (PTSS) based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Acute Stress Disorder criteria. This study describes the development and validation of this new measurement tool and reports differences in pandemic-related traumatic stress in a large sample of children and adults.

What were the study results?

On average, caregivers had the highest levels of pandemic-related traumatic stress, followed by adolescents, pregnant/postpartum individuals, and children. Within these groups, the researchers found additional differences related to age and gender. Adolescents, females, and caregivers of children under 5 had higher PTSS scores on average than younger children, males, and caregivers of children 5 and older, respectively.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

The researchers found that PTSS is a reliable way to measure pandemic-related traumatic stress in the context of the COVID-19 pandemic. Higher levels of pandemic-related traumatic stress were associated with greater symptoms of distress and lower life satisfaction. Unlike previous measures that capture traumatic stress reactions to a single event, the PTSS was developed to evaluate potential traumatic stress reactions to ongoing large-scale threats without defined time limits. Researchers and doctors can use this scale to distinguish general stress, depression, and anxiety from traumatic stress, helping them to identify people with higher levels of traumatic stress who may need mental health support.

Who was involved?

This study included 17,830 children and adults from 47 ECHO Cohort study sites representing all 50 states, Washington, DC, and Puerto Rico. Researchers split the sample into four groups including 1,656 pregnant or postpartum individuals; 11,483 adult caregivers; 1,795 adolescents aged 13 to 21; and caregivers who reported on 2,896 children aged 3 to 12.

What happened during the study?

Between April 2020 and August 2021, caregivers reported on behaviors observed in children aged 3 to 12, and adolescents and adults completed self-reported surveys on pandemic-related traumatic stress, depressive symptoms, anxiety, general stress, and life satisfaction.

What happens next?

The PTSS can be used beyond the immediate COVID-19 pandemic context. The PTSS could be adapted to evaluate reactions to other severe stressors that last a long time.

Where can I learn more?

Access the full journal article, titled “Development and Psychometric Validation of the Pandemic-related Traumatic Stress Scale for Children and Adults,” in Psychological Assessment.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Published November 3, 2023

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ECHO Researchers Measure Pandemic-Related Traumatic Stress in Families

New ECHO Cohort Research Finds Adolescents with Disabilities May Have Been More Vulnerable to Social Disruptions During COVID-19 Pandemic

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New ECHO Cohort Research Finds Adolescents with Disabilities May Have Been More Vulnerable to Social Disruptions During COVID-19 Pandemic

Authors: Phillip Sherlock, Maxwell Mansolf, Courtney Blackwell, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Although researchers have looked at how the COVID-19 pandemic affected the mental health of children of all ages, few studies have examined the pandemic’s impact on children and teens with pre-existing mental, emotional, behavioral, and developmental (MEBD) disabilities like depression, anxiety, attention-deficit hyperactivity disorder (ADHD), and Autism Spectrum Disorder (ASD).

Health policies that were put in place to prevent the spread of COVID-19 caused disruption of normal activities for children and families. Schools paused in-person learning, extracurricular activities were cancelled, and stay-at-home orders meant children spent more time quarantined with family members instead of engaging with friends and peers.

This study was needed to understand how the stresses of the COVID-19 pandemic impacted life satisfaction for adolescents with disabilities, as adolescence is a critical period of social development. Researchers aimed to learn which groups of adolescents were most affected by the pandemic, so that mental health practitioners, pediatricians, and family physicians might be better informed of potential intervention and prevention practices that could be implemented to help particularly vulnerable adolescents through difficult times in the future.

What were the study results?

When exposed to certain stresses during the COVID-19 pandemic, adolescents with a history of depression, anxiety, ASD, or ADHD had lower life satisfaction compared to their peers. These stresses included decreased social connectedness, decreased family engagement, stress related to medical care access, pandemic-related traumatic stress, and living in a single-caregiver household.

This study also found that 80% of adolescents, regardless of pre-existing conditions, reported decreases in social connectedness during the COVID-19 pandemic. Although the detrimental effect of decreased social connectedness was amplified among individuals with certain pre-existing MEBD conditions, this risk factor was widespread among the majority of adolescents.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

This study found that adolescents with decreased social connectedness typically had lower life satisfaction across several groups with different life circumstances. However, decreased social connectedness was more harmful for individuals with disabilities. This study allowed researchers to identify the groups of adolescents with disabilities who are most vulnerable and may need additional support during future emergencies. Findings from this study also highlight the importance of interventions aimed specifically at increasing social connectedness, family engagement, and access to medical support for all adolescents, and especially for those with disabilities.

Who was involved?

This study included COVID-19 survey data collected from April 2020 to August 2021 from a sample of 1,084 adolescents ages 11–21 years old, and their caregivers. The sample included individuals with and without disabilities from seven ECHO observational research sites in the U.S.

What happened during the study?

In addition to using pre-existing ECHO Cohort data about adolescents and their families, researchers administered a COVID-19-specfic survey to better understand the physical, mental, and social impact of the pandemic on young people and their families. Data were analyzed using a machine-learning process.

What happens next?

Findings from this study showed evidence of potential differences between adolescents with disabilities and their peers in terms of life satisfaction. Future research is needed to design studies that focus on the vulnerable subgroups identified in this study. Additionally, future studies may look into the long-term effects of decreased social connections and other risks resulting from the COVID-19 pandemic during developmentally critical time periods.

Where can I learn more?

Access the full journal article, titled “Life Satisfaction for Adolescents with Developmental and Behavioral Disabilities during the COVID-19 Pandemic,” in Pediatric Research.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Published October 24, 2023

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New ECHO Cohort Research Finds Adolescents with Disabilities May Have Been More Vulnerable to Social Disruptions During COVID-19 Pandemic

Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

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Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

Authors: Shuting Zheng, Maxwell Mansolf, Somer Bishop, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Behavior problems observed in a young child can provide information on that child’s risk for certain developmental conditions and later mental health issues. A valid and unbiased measure of childhood behavior is critical for helping researchers and clinicians answer questions about the development of behavior problems in children from different backgrounds.

What were the study results?

Scores from the Child Behavior Checklist (CBCL) 1.5–5—a commonly used, caregiver-reported measure of internalizing (e.g., anxious) and externalizing (e.g., aggressive) behavior problems in children ages 1.5 to 5 years—may be biased by demographic factors such as the child’s age or the caregiver’s sex, education level, and primary language. Researchers found that caregiver responses for a number of questions on the CBCL were affected by caregiver or child demographic factors. The language (English vs. Spanish) the caregiver used to complete the survey contributed most to measurement bias, followed by their education level and sex. The child’s age and race also influenced CBCL scores.

By determining the factors contributing to measurement bias, ECHO researchers identified a subset of questions on the CBCL that were less impacted by bias but still reliably captured childhood behavior problems.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

The results of this study highlight the need to carefully consider possible sources of bias when using caregiver-reported measures. This study was the first to use a large, diverse sample of families to examine how demographic factors influence the answers given for individual survey questions in the widely used CBCL. Developing surveys with less bias can help researchers and clinicians better measure and compare behavior problems across groups of children who differ in age and family background.

Who was involved?

The study included caregivers of 9,087 young children (ages 18 to 71 months) from 26 ECHO research sites across the United States.

What happened during the study?

The researchers used data from 26 ECHO research sites to evaluate how caregiver responses to the CBCL varied based on the characteristics (age, sex, race, bilingual status, and neurodevelopmental disorders) of the child and the characteristics (sex, education level, household income level, and depression diagnosis) of the caregiver. Researchers then selected the CBCL questions that showed the least amount of bias and compared how well this subset of questions worked for evaluating childhood behavior problems when compared to the full CBCL survey. Additionally, the researchers mapped the scores from the less biased question sets to the scores provided by the full item sets, allowing them to derive comparable scores to the original CBCL scale.

What happens next?

ECHO researchers plan to apply the newly identified subset of less biased CBCL survey questions, evaluating its reliability in identifying children with clinically significant behavior problems. The identification of question sets with little bias offers researchers and clinicians better alternatives for measuring and comparing behavior problems across groups of children who differ in age and family background.

Where can I learn more?

Access the full journal article, titled “Measurement Bias in Caregiver-Report of Early Childhood Behavior Problems across Demographic Factors in an ECHO-wide Diverse Sample,” in the Journal of Child Psychology & Psychiatry Advances.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published September 29, 2023

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Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

Educational Background and Child Age Influenced Experiences of Caregivers During COVID 19 Pandemic

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Educational Background and Child Age Influenced Experiences of Caregivers During COVID‑19 Pandemic

Authors: Kaja Z. LeWinn, Lisa Jacobson, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of The Director, National Institutes of Health supported this research.

Why was this study needed?

The COVID-19 pandemic and resulting public health measures presented unique challenges for families, frequently influenced by factors such as income and educational background. Yet while research has highlighted the sociodemographic factors that influenced adults’ experience, the COVID-19 pandemic generally interfered with population-based studies of children and families. However, in April 2020, the ECHO Program introduced a COVID‑19‑specific questionnaire that allowed researchers to gather information on how the pandemic and its effects on daily life were influencing the health of children. This study used ECHO data collected from April 2020 to March 2022 to examine sociodemographic differences in pandemic-related experiences.

What were the study results?

The study suggested that caregivers with less than a high school education were more likely to report challenges accessing COVID-19 testing for their children, were less likely to work remotely, and reported financial concerns and access to necessities such as food as top sources of stress. Caregivers with a master’s degree or higher, on the other hand, were more likely to name social distancing as the top source of their pandemic stress. The study also noted that caregivers with higher education had a significantly greater likelihood of having the option to work remotely. Caregivers with children between the ages of 1 and 5 reported the least support from school systems, the most difficulty finding childcare, and fewer remote learning options; were more likely to have healthcare appointments canceled due to COVID‑19 concerns, and were most concerned about how the pandemic would affect their ability to work.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

This study underscores the importance of understanding how children and caregivers from various backgrounds experienced the COVID-19 pandemic. This understanding can help uncover social inequities that could worsen conditions for some populations during future public health crises. These findings suggest that families with young children may be in particular need of more support related to childcare and work flexibility during future public health crises that involve school disruption.

Who was involved?

The study analyzed data from 14,646 ECHO children and 13,644 ECHO caregivers between April 2020 and March 2022.

What happened during the study?

Researchers measured COVID‑19 pandemic‑related experiences using three characteristics—caregiver education, child life stage, and urban or rural residence. Caregivers completed ECHO COVID‑19 surveys about their experiences during the pandemic for their children and themselves. Among children, researchers examined items related to COVID‑19 infection, access to COVID‑19 testing, changes to healthcare, and disruptions to school, preschool, or daycare. For caregivers, researchers examined remote work, childcare challenges, and their subjective ranking of pandemic‑related stressors.

What happens next?

Future research could explore the complex connections between the outcomes examined as well as the long-term impacts of COVID‑19 infection and pandemic‑related adversities for children in the ECHO Cohort over time.

Where can I learn more?

Access the full journal article, titled “Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States,” in JAMA Network Open.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Published August 23, 2023

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Educational Background and Child Age Influenced Experiences of Caregivers During COVID‑19 Pandemic

ECHO Study Suggests Caregiver Stress May Be Linked to Child Sleep Issues

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ECHO Study Suggests Caregiver Stress May Be Linked to Child Sleep Issues

Authors: Maxwell Mansolf, Courtney K. Blackwell, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Up to 50% of children and adolescents in the United States might experience sleep problems. Poor sleep can negatively affect brain development, learning, and physical and emotional well-being. Existing studies suggest there could be a link between poor sleep outcomes in children and teens and stress experienced by their caregivers, but these studies have primarily been limited to infants and young children. In this study, researchers used ECHO’s diverse data to study this association in school-age children and teens.

What were the study results?

Children of caregivers who reported feeling stress from their life circumstances were more likely to experience sleep disturbances. This association was consistent across different groups of child and caregiver pairs studied, even after accounting for mental and physical health conditions.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should always consult with a qualified healthcare provider for diagnosis and for answers to your personal questions.

What was the study's impact?

This research suggests that children whose caregivers report increased perceived stress may be at higher risk for sleep issues. Screening for caregiver stress may help healthcare providers identify and plan interventions for children who may be at risk for sleep issues.

Who was involved?

The study included data from 2,641 children between ages 6 and 18 and their caregivers from 12 ECHO research sites. Most caregivers (78.6%) had at least some college education. About a third of the children (34.7%) had at least one mental health condition, and a quarter of the children (25%) had at least one physical health condition.

What happened during the study?

Researchers analyzed data provided by caregivers who completed the Perceived Stress Scale (PSS) about their own stress as well as the Child Behavior Checklist (CBCL), a common parent-reported child behavior survey, about their children’s emotional and behavioral well-being, including their sleep habits. The PSS is a widely used self-report survey that measures how much a person perceives their life as unpredictable, uncontrollable, and overloading over the previous month. To evaluate how caregiver stress affected child sleep patterns, researchers looked at responses to questions from the CBCL that addressed children’s experience with nightmares, insomnia, excessive sleep, troubled sleep, and ongoing tiredness.

What happens next?

Future sleep interventions may consider a more global approach to improving child and adolescent sleep health. Continued research on the factors that influence family health and well-being may guide interventions that address the entire family and the dynamics of the family relationship.

Where can I learn more?

Access the full journal article, titled “Caregiver Perceived Stress and Child Sleep Health: An Item-Level Individual Participant Data Meta-Analysis,” in the Journal of Child and Family Studies.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published July 15, 2023

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ECHO Study Suggests Caregiver Stress May Be Linked to Child Sleep Issues

Children and Adolescents Born Preterm Were More Likely to Use Healthcare Services Related to COVID-19 Symptoms

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Children and Adolescents Born Preterm Were More Likely to Use Healthcare Services Related to COVID-19 Symptoms

Authors: Elisabeth C. McGowan, Monica McGrath, Andrew Law, Barry Lester, et al

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

This is one of the first studies to look at healthcare use during the COVID-19 pandemic by a high-risk population—children and adolescents who were born preterm (37 or fewer weeks after gestation). By looking for possible patterns of healthcare utilization, this study can help healthcare providers to improve care for patients in future pandemics or other public health care crises.

What were the study results?

In this study, the researchers found that individuals born at 37 or fewer weeks after gestation were more likely to use healthcare services related to COVID-19 symptoms; those born extremely preterm (28 or fewer weeks) were even more likely to do so. For example, children and adolescents born extremely preterm were twice as likely to ask for an in-person appointment or a telehealth evaluation compared to individuals who were born after 37 weeks. Researchers saw that these differences were probably not caused by known risks for breathing problems such as asthma or chronic lung disease. Additionally, preterm children were no more likely to miss healthcare appointments overall than were individuals born at term.

What was the study's impact?

This study suggests that children and adolescents who were born preterm may be more likely to use healthcare during the COVID-19 pandemic than are children and adolescents who were born at full-term. Understanding the factors associated with both overall healthcare use and symptom-specific use may help healthcare providers identify the best strategies to provide targeted care. Understanding the different needs and patterns of healthcare use among children born preterm and their families during the first year of the pandemic, and why those patterns exist, are important first steps on the path to make healthcare more effective and efficient.

Who was involved?

This study included data from 42 ECHO research sites that together included 1,691 individuals ages 1–18 years. Of these individuals, 270 were born at less than 37 weeks of gestation. The study collected data from participants who were on average between 8 and 9 years of age. Approximately 40% of participants born preterm had reports of asthma-like symptoms within 1 year of healthcare use, compared to 20% of those born at term.

What happened during the study?

In this study, the researchers investigated whether children born preterm used healthcare during the COVID-19 pandemic differently than those born at term. Between April 2020 and August 2021, children’s caregivers and adolescents answered questionnaires regarding COVID-19 and healthcare use. The researchers studied healthcare use related to concerns about COVID-19 symptoms (like trouble breathing, fever, headache, muscle pain, fatigue, itchy eyes, nausea, diarrhea, vomiting, and loss of smell or taste) that resulted in overnight stays in hospitals, visits to urgent care centers or primary care offices, or virtual visits such as telehealth. They also explored changes in overall healthcare use during the pandemic, including missed healthcare appointments caused by parental concerns about going into a medical office or cancellation of an appointment by the provider.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What happens next?

Further studies may evaluate the role socioeconomic factors may play in healthcare utilization.

Where can I learn more?

Access the full journal article, titled “Healthcare Utilization During the COVID-19 Pandemic Among Individuals Born Preterm,” in JAMA Network Open.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published April 28, 2023

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Children and Adolescents Born Preterm Were More Likely to Use Healthcare Services Related to COVID-19 Symptoms

ECHO Study Suggests Childhood Maltreatment of Mothers Linked to Asthma, ADHD, and Autism Spectrum Disorder in Their Children

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ECHO Study Suggests Childhood Maltreatment of Mothers Linked to Asthma, ADHD, and Autism Spectrum Disorder in Their Children

Authors: Claudia Buss, Nora K. Moog

Who sponsored this study?

This research was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of The Director, National Institutes of Health.

What were the study results?

Results from this study suggest that mothers’ maltreatment experience as children may influence their own children’s future health. Children of mothers who were neglected or abused during childhood were more likely to have diagnoses of asthma, ADHD, and ASD. These children were also more likely to demonstrate symptoms and behaviors linked to depression (i.e., internalizing behaviors). Additionally, girls whose mothers experienced maltreatment during childhood were more likely to have obesity. Children with mothers who experienced childhood maltreatment were also more likely to develop several of these health outcomes at once. Furthermore, exposure to several different forms of maternal childhood maltreatment was associated with highest risk increases for most offspring health outcomes suggesting the more severe the maternal childhood experiences were, the higher the risk for adverse health outcomes in her child.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

This study highlights the impact of maternal childhood maltreatment experiences as a major determinant of health across generations. While not all children of mothers who experienced abuse or neglect during childhood develop health problems, those who do are at higher risk for developing more than one condition. Results from this study suggest that screening and identifying these children early on, can allow the opportunity to direct targeted interventions to interrupt the intergenerational impact of adversity.

Why was the study needed?

Childhood maltreatment increases the risk for adverse health outcomes, and this risk can be transmitted from one generation to the next. Previous studies have investigated single health outcomes in children of mothers that were exposed to childhood abuse or neglect. However, health outcomes can often be connected to one another and affected by the same factors. This study investigated six health outcomes simultaneously and investigated whether a mother’s own exposure to maltreatment affects a child’s risk for experiencing more than one of these health outcomes.

Who was involved?

This study included over 4,000 mothers and their children from 21 ECHO cohorts. About 44% of mothers who participated in the study reported experiencing some form of abuse or neglect during their own childhood.

What happened during the study?

Mothers self-reported on their childhood experiences, and researchers used this information to assign mothers to one of two groups: 1) exposed to childhood maltreatment and 2) not exposed to childhood maltreatment. The researchers compared the risk for physical and mental conditions, including asthma, internalizing behaviors (e.g., social withdrawal, trouble sleeping, symptoms of anxiety or depression), autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and obesity, between the children in the two groups. They also examined whether multiple health outcomes co-occur in the same child.

What happens next?

Follow-up studies will investigate the pathways between maternal childhood maltreatment experiences and child health outcomes. Other studies may also investigate if other forms of negative childhood experiences are linked to different consequences of childhood maltreatment in the next generation.

Where can I learn more?

Access the full journal article, titled “Intergenerational transmission of the consequences of maternal exposure to childhood maltreatment – a United States nationwide study of multiple cohorts in the ECHO program” in The Lancet Public Health.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published February 23, 2023

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ECHO Study Suggests Childhood Maltreatment of Mothers Linked to Asthma, ADHD, and Autism Spectrum Disorder in Their Children