Factors Associated With Caregiver Reporting of Developmental Concerns Among Children in Low-Income Communities

Abstract

Early detection and access to interventions for developmental delays in young children have been shown to improve health, social, and academic outcomes later in life. The purpose of this study is to examine the factors associated with caregivers' perception of child developmental concerns in low-income communities. A countywide survey was conducted in Los Angeles County (LAC), California, among 4,863 participating Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) families with children ages 1–4 years. Proportional odds ordinal logistic regression was used to evaluate the association between the severity of reported developmental concerns and respondent characteristics. Results indicate that demographic characteristics, support systems, health care visits during COVID-19, and maternal symptoms of depression are associated with higher odds of reporting more severe developmental concerns among the WIC population. Advancing policies, programs, and research that aim to improve early detection and access to childhood professionals for all families will be essential to allow all children in low-income households to optimize their development.

ACCESS TO DEVELOPMENTAL supports and services is critical to ensure children succeed in school and life. One in six children ages 3–17 years have one or more developmental delays or disabilities (DDs) (^{Zablotsky et al., 2019}). When a child does not meet age-based developmental—behavioral, language, learning, and physical—milestones, they are said to have a developmental delay (^{Bellman et al., 2013; Parma et al., 2019}). DDs can occur in only one or in several developmental domains including adaptive, cognitive, communication, physical, and social/emotional domains (^{Department of Developmental Services, 2015}). Although some DDs show obvious early signs, other children present more subtle signs that can be missed. Most DDs are present at birth, but can occur throughout childhood (^{Centers for Disease Control and Prevention, 2022a}), highlighting the need for early identification opportunities throughout childhood to detect DDs as they arise. Parental education, monitoring, and screening are therefore essential steps to ensuring children at risk of or with DDs access early intervention (EI) services (^{Mackrides & Ryherd, 2011}). When screening and services are available and accessed, many children show improvements in health outcomes, socioemotional skills, and academic performance, which can reduce costs of care (^{National Research Council and Institute of Medicine, 2000}).

EARLY IDENTIFICATION AND DISPARITIES

Early identification includes routine surveillance or monitoring and screening whether from parents or professionals (^{Parma et al., 2019}). The American Academy of Pediatrics recommends that pediatricians perform surveillance at every well-child visit and conduct a validated developmental screening at 9, 18, and 30 months (^{Hagan et al., 2017}). It is important to note that validated screening tools are not diagnostic but indicate if a child is likely to have delays. Children should be referred for formal assessment if screening indicates possible delays, and be referred to prevention and EI services based on formal assessment results (^{Centers for Disease Control and Prevention, 2022b}).

Unfortunately, evidence indicates there are significant disparities in screening and identification service rates. In an analysis of California Health Interview Survey (CHIS) data from parents of young children ages 1–5 years, several variables were related to screening completion rates. Children living in households with incomes above the 300% federal poverty line and children of parents with a greater than high school education level were more likely to report receiving a screening, whereas Hispanic children had lower rates of screening compared with White children (^{Lordi & Holtby, 2021}). Similar findings were replicated in the National Survey of Children's Health (NSCH) among parents of young children ages 9–35 months in the United States (^{Hirai et al., 2018}). These disparities highlight the importance of early childhood professionals to improve equity in access to services and also the role that many parents have to assume in tracking their child's development so they can communicate their concerns with professionals in order to get connected to services early.

With these demographic differences in early identification, it is unsurprising that disparities also exist in access to services. Hispanic and Black children are less likely to be diagnosed or are diagnosed at an older age with autism spectrum disorder and attention deficit hyperactivity disorder (ADHD) than their White peers; similar disparities were found with mental health diagnoses (^{Zuckerman et al., 2014}). In the Early Childhood Longitudinal Study-Birth Cohort data of 1,000 children eligible for EI services, at 24 months, only 12% of children were receiving services and Black children were significantly less likely to have received services according to parent self-report (^{Feinberg et al., 2011}).

ROLE OF EARLY CHILDHOOD PROFESSIONALS

Recognizing DDs as close to the onset as possible is critical to optimize child development because identification and intervention opportunities are proven to have greater impact when implemented at the first sign of delay (^{Mackrides & Ryherd, 2011}). Many professions support early identification and intervention, and health care providers have long been the primary developmental monitors and screeners given their frequent contact with young children (^{Lipkin & Macias, 2020}). There are several barriers, however, that can hinder health care providers accomplishing this role, including competing priorities and limited time with patients (^{Oberklaid & Efron, 2005}). Given capacity limitations among health care providers, regular screening conducted by other early childhood professionals has a role in extending services and reducing disparities. For instance, home visiting programs (HVPs) are a widely used prevention strategy where trained visitors provide family support and information to expectant and new parents in their own home or wherever they are most comfortable. HVPs are designed to enhance parent–child relationships, increase parenting knowledge and skills, and support children's early health and development. As such, many HVPs include developmental conversations, screening, and linkage to services as an integral part of the program (^{Supplee, 2016}). Similarly, childcare professionals can play a key role in identifying concerns as they spend substantial time with the child, can receive training to conduct developmental screenings, and have the time to better work with families to understand referral services available to families (^{Boh & Johnson, 2018}).

ROLE OF FAMILY

The identification and acknowledgment of developmental concerns by families is essential in order to advocate for their children's care. By being aware of developmental milestones, parents are better able to identify when their children are not meeting them. Although early identification of DDs often is noted by early childhood professionals, caregivers typically spend the most time with their children and are often the first to note a concern (^{Hirai et al., 2018}). There is scarce literature focused on how identification of DDs is affected by specific family dynamics such as household size and employment status of caregivers, but one can surmise that these family factors could impact early identification of areas of developmental concern by members of the household. More children in the household could serve as comparisons for development; more adults in the household could mean more opportunities for an adult to notice milestones going unmet (^{Bickel et al., 2015; Sapiets et al., 2021}). Parent employment status is an indicator for both socioeconomic status and availability to provide caregiving to a child in the home. Working families and households with higher incomes are more likely to utilize some form of childcare (^{Malik, 2019}), and the type of childcare utilized (e.g., licensed center-based care vs. unlicensed family care) may contribute to higher or lower prevalence of concerns identified.

THE CURRENT STUDY

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a nutrition assistance program of the United States Department of Agriculture) that serves pregnant and postpartum women, infants, and children younger than 5 years from low-income households. Due to its broad reach to low-income households, serving 6.2 million participants in 2020 (^{U.S. Department of Agriculture, 2022b}) and providing nutrition assistance and educational programming to 57% of program-eligible individuals (^{U.S. Department of Agriculture, 2022a}), WIC can support in educating parents and improving parents' early identification of DDs. Although DD screening is beyond the scope of nutrition assistance programs, WIC programs nationally are closely linked to health and social service providers, and frequently provide referrals and outreach to partners that support EI. The Los Angeles County (LAC) WIC Survey occurs every 3 years, providing an opportunity to assess developmental concerns among a large random sample of low-income families served by WIC. The current study focuses on developmental concerns reported by parents of young children who participated in the 2020 LAC WIC Survey. This research aims to identify factors associated with the detection of DDs in order to identify programs and other resources that serve young children, which could be leveraged, prioritizing historically underserved populations.

MATERIALS AND METHODS

Data sources and study sample

Data for this study were drawn from the 2020 LAC WIC Survey. The LAC WIC Survey is a computer-assisted telephone survey conducted triennially to assess WIC families' experiences with WIC services, health care, and public services as well as community and household characteristics. The survey was conducted with a random sample of certified WIC participants in LAC between July and December 2020. Eligibility requirements for participants included residing within LAC, being at least 17 years of age, and being able to complete the survey in English or Spanish. The sample included augments of randomly selected Asian families, Black families, and families residing in target communities within the county. The response rate was 53%, and 6,753 surveys were completed. Primary reasons for nonresponse included repeated failure to respond to calls, invalid phone numbers, ineligible respondents, and refusals. For the current analysis, the sample was restricted to respondents with a child 1–4 years old, with missing data for one or fewer developmental concerns (and without any developmental concern reported as “don't know”) resulting in a sample size of 4,863. The survey was reviewed and approved by the Committee for the Protection of Human Subjects for the California Health and Human Services Agency.

Instruments

Respondents were asked a series of questions regarding their concerns about their child's development based on the screening questions drawn from the NSCH (^{Data Resource Center for Child and Adolescent Health, 2021}). There were nine developmental concerns questions and the distribution of the individual developmental concerns can be found in Table 1.

Table 1. - Distribution of Individual Developmental Concerns Reported for Children Ages 1–4 Years From the 2020 LA County WIC Survey

Developmental Concern	No Concern		Minor Concern		Major Concern		Don't Know		Total n
	n	%	n	%	n	%	n	%
(If less than 15 months) How [your child] makes speech sounds	408	94.3	22	5.1	2	0.6	–	–	432
(If 15 months or older) How [your child] talks and makes words	3,484	78.7	679	15.3	255	5.8	9	0.2	4,431
How well [your child] can see or hear	4,729	97.3	100	2.1	27	0.6	3	0.1	4,863
How [your child] gets along with others	4,258	87.6	509	10.5	75	1.5	17	0.3	4,863
[Your child]'s feelings and moods	4,060	83.6	676	13.9	112	2.3	11	0.2	4,863
How [your child] is learning to do things for (him/her)self	4,474	92.1	325	6.7	55	1.1	4	0.1	4,863
Whether [your child] can do what other children (his/her) age can do	4,402	90.6	333	6.9	93	1.9	28	0.6	4,863
(If 24 months or older) How well [your child] understands what you say	3,111	90.3	287	8.3	45	1.3	2	0.1	3,445
(If 24 months or older) How [your child] is learning preschool or school skills	2,825	82.2	444	12.9	113	3.3	56	1.6	3,438

Note. The responses answered the following survey question: “The next questions are about concerns you may have about [your child]. To what extent is this a problem for [your child]?”

Study variables

For the main developmental concern variable, the series was coded into a three-tiered variable to define the level of concern a respondent has for their child's overall development. A major concern was defined as any response of a “big problem” for any of the age-determined developmental concern questions. Any response of a major concern took precedence over minor or no concerns reported. A minor concern was defined as any response of “a small problem” if no major concern was reported in the series. No concerns was defined as all questions in the series having a response of “not a problem.”

Assessed household characteristics included participation in a HVP during the child's first year, current use of childcare services for the child, household size, the availability of practical and emotional support, and parental employment (either mother or father, both, or neither). Respondents were also asked questions regarding delays to their child's routine medical care visits due to the COVID-19 pandemic. The question assessed disruption of routine care during the pandemic due to a delay initiated either by the parent or by the health care provider. Additionally, sociodemographic characteristics were analyzed to describe the sample, including child's sex and age, mother's age, race, education, ethnicity, health insurance coverage, and symptoms of depression as assessed with the Patient Health Questionnaire-2 (PHQ-2). The PHQ-2 is a common depression screening that is comprised of two items that inquire about the degree an individual has experienced a depressed mood and anhedonia (i.e., reduced ability to experience pleasure) over a two-week period on a 4-point scale (0 = not at all to 3 = nearly every day). The PHQ-2 is a subset of the PHQ-9 depression module. It has been shown to be a valid depression screening tool with an 82% sensitivity and a 92% specificity for major depression (^{Kroenke et al., 2003}).

Statistical analysis

Poststratification weights were used to standardize survey respondents to the LAC WIC recipient population. Respondent characteristics assessed in this analysis were chosen based on the characteristics that may lead a respondent to have increased knowledge of child development milestones that would result in respondents reporting concerns. χ² and t tests were used to assess the unadjusted relationships between the developmental concerns and respondent characteristics. Proportional odds ordinal logistic regression was used to evaluate the association between respondent characteristics and developmental concerns. Interpretation of the cumulative proportional odds ratio (OR) and corresponding 95% confidence interval (CI) represents the relative odds of being above a specified category of developmental concern compared to being in or below the specified category (major vs. minor/none or minor vs. none). Higher odds of parental report of more severe developmental concerns may indicate a higher prevalence of DDs in specific groups, or greater parental awareness of deviation from developmental milestones in specific groups. Independent variables in the proportional odds ordinal logistic regression model include child sex, child age in years, household size, participation in a HVP in the child's first year, current use of childcare services, number of parents employed, delays in child's routine health care visits, availability of practical and emotional support, maternal race-ethnicity–language preference, maternal education, maternal health insurance coverage, and maternal screening for symptoms of depression. Data were analyzed using SAS Enterprise Guide 8.3 (SAS, Cary, North Carolina). p values < .05 were considered statistically significant. A sensitivity analysis in which families with multiple minor developmental concerns were categorized as having any major concern was conducted.

RESULTS

The final weighted sample consisted of 4,863 respondents. Approximately 40% of the sample reported any type of concern in their child's developmental skills based on response to the questions from the NSCH (Table 1). In more detail, 31.6% reported at least one minor concern whereas 8.9% of the sample reported at least one major concern for their child. Results of the sensitivity analysis in which families with multiple minor concerns were categorized as having any major concern did not differ from the main analysis (data not shown). Demographically, the sample is made up of 50.4% male children. Respondents were primarily Hispanic of English (44.7%) or Spanish (27.2%) language preference, and had one (59.2%) or both (15.3%) parents currently employed (Table 2). A minority participated in a HVP during the child's first year (20.3%), and were currently using childcare services (26.9%). A majority of mothers reported availability of practical (77.4%) and emotional (89.8%) support and reported current health insurance coverage (85.2%), whereas few mothers screened positive for symptoms of depression (7.3%). The average child age was 2.4 years (SD = 1.1) and households contained an average of 4.6 people (SD = 1.6). The proportion of respondents reporting developmental concerns varied by race-ethnicity, with Asian, Black, English-speaking Hispanic, Spanish-speaking Hispanic, White, and other groups reporting no concerns (57%, 60%, 60%, 59%, 56%, and 59%, respectively), only minor concerns (33%, 31%, 31%, 33%, 33%, and 32%, respectively) and any major concern (10%, 9%, 9%, 8%, 11%, and 9%, respectively) at similar rates.

Table 2. - Distribution of Demographic Characteristics by Developmental Concerns Reported for Children Ages 1–4 Years From the 2020 LA County WIC Survey

Variable Name, N (%)	Full Sample Weighted N = 4,863		No Concern n = 2,893 (59.5)		Minor Concern n = 1,536 (31.6)		Major Concern n = 434 (8.9)		p
	n	%	n	%	n	%	n	%
Child sex									<.0001
Male	2,450	50.4	1,354	46.8	824	53.6	272	62.7
Female	2,413	49.6	1,539	53.2	712	46.4	162	37.3
Maternal race/ethnicity–language									.354
Asian	113	2.3	65	2.2	37	2.4	11	2.5
Black	500	10.3	301	10.4	153	9.9	46	10.5
Hispanic, EN	2,174	44.7	1,315	45.4	666	43.3	194	44.7
Hispanic, SP	1,322	27.2	786	27.1	436	28.4	101	23.2
White	637	13.1	358	12.4	207	13.5	72	16.7
Other	117	2.4	69	2.4	37	2.4	10	2.4
Maternal education									.020
Did not graduate HS	1,212	24.9	730	25.3	385	25.1	96	22.2
HS graduate	1,485	30.5	927	32.1	438	28.6	120	27.6
Some college or higher education	2,166	44.5	1,235	42.7	713	46.4	218	50.2
Participation in home visiting during child's first year	988	20.3	533	18.4	358	23.3	97	22.4	.002
Currently using childcare services	1,308	26.9	429	26.3	118	28.0	760	27.3	.568
Practical support available	3,765	77.4	2,280	78.8	1,181	76.9	304	70.0	.001
Emotional support available	4,367	89.8	2,611	90.3	1,373	89.4	383	88.3	.384
Employment									.643
Both parents employed	744	15.3	454	15.7	232	15.1	58	13.4
Only one parent employed	2,880	59.2	1,692	58.5	927	60.4	260	59.9
Neither parent employed	1,240	25.5	747	25.8	377	24.5	116	26.7
Delays in child's routine medical care visits									<.0001
Yes, parent delayed the visit	573	11.8	296	10.2	221	14.4	56	12.8
Yes, health care provider delayed visit	793	16.3	424	14.6	275	17.9	95	21.8
Did not delay visits	3,497	71.9	2,174	75.1	1,040	67.7	284	65.4
Mother has health insurance	4,139	85.1	2,482	85.8	1,286	83.7	371	85.5	.221
Mother screened positive for symptoms of depression (PHQ-2)	355	7.3	147	5.1	139	9.1	69	15.8	<.0001
	M	SD	M	SD	M	SD	M	SD
Child age	2.4	1.1	2.3	1.1	2.5	1.0	2.6	1.0	<.0001
Household size	4.6	1.6	4.7	1.6	4.6	1.5	4.5	1.6	.0549

Note. p values for associations between categorized family duration on WIC and covariates were calculated with χ² and F tests (ANOVA) for categorical and continuous variables, respectively. EN = English-speaking; HS = high school; NH = non-Hispanic; PHQ-2 = Patient Health Questionnaire-2; SP = Spanish-speaking; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

Higher odds of reporting a more severe developmental concern was associated with: male sex (OR [95% CI] = 1.455 [1.298, 1.632]) versus female, a 1-year increase in child age (OR [95% CI] = 1.26 [1.196, 1.329]), maternal education level greater than a high school (OR [95% CI] = 1.227 [1.035, 1.455]) versus less than a high school education, participation in a HVP during the child's first year (OR [95% CI] = 1.355 [1.178, 1.558]) versus no participation during the first year, delays in routine child health care visits by either the provider (OR [95% CI] = 1.444 [1.238, 1.683]) or the parent (OR [95%CI] = 1.492 [1.251, 1.779]) versus no delays in care, and maternal positive screening for symptoms of depression (OR [95% CI] = 2.166 [1.757, 2.671]) versus a negative screening; lower odds of reporting a higher severity developmental concern for Spanish-speaking Hispanic families (OR [95% CI] = 0.812 [0.662, 0.997]) versus White families and families having practical support available (OR [95% CI] = 0.819 [0.704, 0.955]) versus no practical support available (Table 3). Due to the high significance of maternal positive screening for symptoms of depression, a secondary cross-tabulation was conducted (results not included) and results showed that mothers who screened positive for depression were more likely to have a male child and delay medical care for their child.

Table 3. - Proportional Odds Ratios for Association of Child, Maternal, and Household Sociodemographic Factors and Reported Developmental Concerns^a Among the 2020 Los Angeles County WIC Survey Participants

Effect	Proportional OR [95% CI]
Child sex, male	1.455 [1.297, 1.632]b
Maternal race/ethnicity–language
NH-Asian	0.952 [0.638, 1.426]
NH-Black	0.841 [0.662, 1.068]
Hispanic, EN	0.863 [0.723, 1.030]
Hispanic, SP	0.812 [0.662, 0.997]
NH-otherc	0.895 [0.601, 1.334]
NH-White	1.00 (reference)
Child age (years)	1.261 [1.196, 1.329]
Number of people in the household	0.965 [0.930, 1.001]
Maternal education
Greater than high school education	1.225 [1.034, 1.455]
High school graduate	1.002 [0.846, 1.185]
Less than high school education	1.00 (reference)
Participation in home visiting during child's first year	1.351 [1.175, 1.558]
Currently using childcare services	1.006 [0.878, 1.153]
Practical support available	0.819 [0.704, 0.955]
Emotional support available	1.076 [0.873, 1.326]
Employment
Both parents employed	0.936 [0.766, 1.129]
Only one parent employed	1.076 [0.937, 1.236]
Neither parent employed	1.00 (reference)
Delays in child's routine medical care visits
Yes, parent delayed the visit	1.445 [1.238, 1.683]
Yes, health care provider delayed visit	1.492 [1.251, 1.779]
Did not delay visits	1.00
Mother has health insurance	0.880 [0.746, 1.039]
Mother screened positive for symptoms of depression (PHQ-2)	2.167 [1.757, 2.671]

Note. CI = confidence interval; EN = English-speaking; NH = non-Hispanic; OR = odds ratio; SP = Spanish-speaking; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

^aOdds ratios were determined from the multinomial logistic regression model for respondents with children 1–4 years old in a weighted sample (n = 4,859). Developmental concerns was a three-category variable (no concern, minor concern, and major concern). The odds ratios should be interpreted as the odds of reporting one-category more severe outcome (major vs. minor or minor vs. none) independent of all other covariates.

^bIndicates a statistically significant association (p < .05).

^cNH-other includes all responses for race–ethnicity that are not categorizable as NH-White only, NH-Black only, or Hispanic only. This includes Asian, Pacific Islander, Native American, and multiple race responses.

DISCUSSION

This study analyzed factors that might be associated with higher odds of reporting developmental concerns in a low-income population of parents of young children. The factors studied are grouped into four domains: demographic characteristics, support systems, health care visits during COVID-19, and maternal symptoms of depression. Although demographic factors are generally static and cannot be intervened upon, the other domains of characteristics evaluated in this study may be modifiable through interventions. It is important to understand how demographic factors play a role in which children get identified for EI in order to inform policies and systems of the gaps in providing adequate resources and referrals. It is equally important to understand how support systems, the health care system, and caregiver mental health may contribute to parents' understanding of child development and access to resources, as results showed higher odds of reporting developmental concerns when participating in HVPs. These parent characteristics and systems may contribute to parental willingness and ability to identify developmental concerns, and understanding facilitators and barriers to parents being able to fulfill this role is critical to improving early detection and referral.

Demographic differences

Male children being more likely to be the subject of developmental concern than female children is consistent with prior results reported by ^{Zablotsky et al. (2019)} that found that males were more likely to be diagnosed in general with any DD. Indeed, they found that the prevalence of having any DD increased for males between 2009 and 2017. However, it is important to note that diagnosis prevalence rates do not necessarily equate to DD prevalence rates. Males and females can exhibit developmental concerns differently. For instance, males with ADHD are more likely to exhibit externalizing behaviors related to hyperactivity and impulsivity whereas females with ADHD are more likely to exhibit socioemotional behaviors like depression and anxiety (^{Little & McLennan, 2010; Rucklidge, 2008}). Differences like this can lead to a referral bias as externalizing behaviors, which are more likely to be exhibited by males, are more likely to be referred for screening and services (^{Little & McLennan, 2010}). These sex-based differences in referral for developmental concerns are important considerations for those who provide education on early childhood development to take into account when talking with parents and providers, to ensure female children with DD are not disproportionately left out of referral for services.

The prevalence of developmental concerns increased with higher child age, possibly because there are more opportunities for a delay to present and more interactions pre-pandemic with similarly aged children in which to observe delays relative to peers. Given the benefits of EI, this raises concerns as only 3.5% of infants and toddlers receive public EI services (U.S. Department of Education, 2021), which is much lower than the prevalence (15%–17%) of children estimated to have a DD during early childhood (^{Rice et al., 2014; Zablotsky et al., 2019}).

Mothers with an education level greater than high school were more likely to report having a stronger developmental concern compared with children of mothers with less than a high school education. Other studies found parents with higher levels of education were more likely to report their child received screening at their medical home (^{Hirai et al., 2018; Lordi & Holtby, 2021}). Whether the present study's result of higher developmental concerns among mothers with greater education is due to greater understanding of child development and/or them being more comfortable talking to their child's doctor about developmental concerns and advocating for their child, prompting a screening, could not be determined.

Differences in rate of concerns were identified by race-ethnicity only for Spanish-speaking Hispanics when compared with their White counterparts. White participants had the lowest percentage of reporting no developmental concerns, meaning they reported concerns of any severity more often than the other racial ethnic groups in our sample, which is consistent with other studies looking at screening and identification (^{Feinberg et al., 2011}). There are considerable disparities reported previously in screening and EI rates by race and ethnicity where minorities have lower rates of screening and EI (^{Hirai et al., 2018; Lordi & Holtby, 2021; Zuckerman et al., 2014}); however, these studies were made up of a predominantly non-Hispanic White study population. The finding that Spanish-speaking Hispanic families were less likely to report more severe developmental concerns in this study is consistent with ethnic minorities being less likely to identify DDs (^{Sapiets et al., 2021}). Similarly, research conducted among Hispanic caregivers found that non-English speakers were less likely to be asked by providers about developmental concerns than White caregivers (^{Guerrero et al., 2011}). Findings from CHIS (2005–2018) shows that Hispanic families had screened their children almost 20% less than White families (^{Lordi & Holtby, 2021}). Studies have shown that screening tools may not always be validated when translated and cultural differences exist when attempting to educate about DDs, potentially hindering screening and identification in non-English-speaking populations (^{Bevan et al., 2020}). It has been established that early childhood providers are the primary source for screening and identification, so it is critical to ensure these providers have the tools and training to conduct age-appropriate screening for non-English-speaking families. In the absence of disparities in parents identifying and reporting developmental concerns for the rest of the race-ethnicity groups, questions persist as to the underlying reasons children of color are less likely to be screened and served in general. One potential explanation is that the predominantly Hispanic population, with oversampled Black and Asian participants, could be contributing to the nonsignificance in the findings because these groups historically have lower rates of screening and identification of DDs in studies conducted with predominantly White study populations (^{Hirai et al., 2018; Lordi & Holtby, 2021; Zuckerman et al., 2014}).

Support systems

The demographic findings suggest the need for improved outreach and education about developmental milestones and the importance of EI so parents and providers are better able to identify DDs so children can be connected to needed services. As shown, this is particularly needed for families with infants and toddlers and with lower formal maternal education. Many states and counties across the United States are implementing early identification and EI models that could be leveraged to reduce disparities. One such model is Help Me Grow, which works to promote local cross-sector collaboration and seeks to coordinate existing resources and systems to promote early identification and connect young children at risk for or with DDs to EI services through: building a centralized access point to help families and providers access needed resources and services; family and community outreach to support families; child provider outreach to better identify developmental concerns and connect families to resources; and data collection and analysis to measure impact and support quality improvement (^{Harrington et al., 2017}; Help Me Grow National Center, 2022). In recent years, Help Me Grow has embraced the need to address social and environmental factors, with targeted strategies for underserved groups, to ensure all children involved are connected to services (Dworkin, 2020).

Families participating in HVPs were more likely to report minor and major developmental concerns, indicating a connection between the HVP and increased parental awareness of and ability to identify DDs in their child. HVPs have an established record of improving children's development (^{Peacock et al., 2013}) and this study adds to that literature. As such, HVPs could play an essential role in supporting early screening and identification, both by connecting families to services and supporting parents in advocating for their child. Home visitors often are a trusted resource, who parents can turn to with questions and who provide practical support such as education on developmental milestones, conducting developmental screenings, and helping link parents to services. The direction of the relationship between HVP use and developmental concerns cannot be determined by this cross-sectional study, however, as it is possible that families with developmental concerns were more likely to be linked to HVP.

In contrast to HVPs, participation in childcare was not related to reporting developmental concerns. Childcare is a broad term that includes more formal and informal programs such as federally funded Head Start and Early Head Start, preschool programs, childcare centers, and family, friend and neighbor care. Quality varies greatly across childcare settings, which may have affected this finding, as this study did not have data on type of childcare nor objective measures or parental perception of childcare quality, as it was beyond the scope of this study to assess childcare quality. Further research is needed on the relationships between childcare, program quality, and parental knowledge of child development.

Having practical support (defined as having someone you can turn to if you needed practical help, like getting a ride somewhere, or help with shopping or cooking a meal) was associated with lower odds of reporting a developmental concern. The same was not found for those reporting having emotional support (defined as having someone you can turn to if you needed someone to comfort or listen to you). Further exploration of the mechanisms underlying the lower rate of reported developmental concerns among mothers who reported having practical support, but not among those who reported having emotional support, is needed.

Health care visits during COVID-19

Significantly higher odds of reporting a developmental concern were also found if the parent or health care provider delayed routine child health care visits. It is important to note that data collection for this study took place from July to December 2020, in the midst of the COVID-19 pandemic. LAC took strong preventative measures during that time, with many routine health care appointments delayed or deferred by both health care providers and patients. The overall levels of delaying care reported by this sample (28%) were similar to other studies reporting 27%–35.9% of patients experienced delayed routine care early in the pandemic (^{Czeisler, 2020; Giannouchos et al., 2022}). The reasons behind the association between more developmental concerns and delayed routine care were not assessed in this study. Results are consistent, however, with studies documenting that children experiencing documented intellectual or DDs were substantially impacted by COVID-19 restrictions (^{Jeste et al., 2020}). In a study of children with autism, ^{Bhat (2021)} found that younger children, children from low-income families, and children with greater impairment severity were more negatively impacted by the pandemic through service disruptions and found online interactions to be less beneficial (^{Bhat, 2021}). Thus, it is possible that health care providers who were aware of DDs deferred care in order to identify strategies to most safely and effectively support families. Alternatively, caregivers with developmental concerns about their child may seek medical services for their child more frequently than caregivers without developmental concerns. The greater frequency of provider-initiated delays in service may be due to differences in the number of medical visits desired and scheduled by the caregiver during the COVID-19 pandemic (^{Cogswell et al., 2022}).

It is also possible that parents concerned about their child's development were experiencing significant other stressors, making it more difficult to access care for their child. Consistent with ^{Giannouchos et al., (2022)}, who documented that increased delays in routine care were associated with higher levels of mental health problems, parents who delayed care in this study were more likely to be experiencing higher levels of depression. Together, these findings suggest that parenting stress and mental health challenges may have played a role in parents with developmental concerns delaying health care provider visits. Regardless of the source of delay, health care visits that were postponed during the COVID-19 pandemic may contribute to later formal assessment of DDs among children and later linkage to EI services.

Positive screening for maternal depression

The factor most strongly associated with higher odds of reporting developmental concerns results was positive screening for maternal symptoms of depression with the PHQ-2. Respondents had 2.1 times higher odds of reporting a more severe developmental concern for their child if they screened positive for depression symptoms. This study was conducted during the COVID-19 pandemic, which produced many stressors for families due to changes in employment, income, social environment, and childcare needs (^{Cameron et al., 2020; Stamu-O'Brien et al., 2020}). Children were also impacted during this time with school moving to virtual settings and childcare closures, which meant parents were now more involved in their child's education than in prior years (^{Cameron et al., 2020}). During the pandemic, studies showed an increase in the prevalence for maternal depression, ranging from 20% to 64% of mothers screening positive for clinically relevant depression (^{Cameron et al., 2020; Shuffrey et al., 2022}). This increase in depression due to the pandemic is worrisome because it is well established that children of mothers showing depressive symptoms or diagnosed with depression have poorer child development and behavior than their peers (^{Beck, 1998; Goodman et al., 2011; Tuovinen et al., 2018}). It is also possible that having a child with DDs and behavior problems can contribute to higher levels of maternal depressive symptoms (^{Rogers et al., 2020}). This study was not able to evaluate whether maternal mental health conditions preceded the developmental concerns. Further research is needed to study the association of maternal symptoms of depression, access to emotional or practical support, and other characteristics that may impact a child's development and identification of DDs. This study does not have the capacity to analyze many of these associations, and more research is needed among low-income families who may experience a greater number of these stressors to identify how it may impact early identification and access to resources that may be available.

Strengths and limitations

Although this study is representative of the WIC population in the LAC metropolitan area, the sample includes a large percentage of Hispanic participants and may not be generalizable for all WIC populations. A strength of the study is that the 2020 survey year included an augmented sample of Black and Asian families to allow for more representation from these groups. Although a strength of the study was the use of the standardized PHQ-2 to added maternal depression at the time of the survey, whether mothers were previously diagnosed or were undergoing treatment for their symptoms was not assessed, thereby limiting conclusions that can be drawn about the associations between maternal depression and recognition of DDs. Similarly, although use of childcare was assessed, the lack of information on childcare type and quality is a limitation. Finally, a parent's determination of how severe of a developmental concerns may be for their child is subjective. Research has shown that there are differences in how parents and professionals identify developmental concerns, which could lead to under- or overreporting of concerns (^{De Los Reyes et al., 2023}).

CONCLUSION

This study examined the factors associated with increased reporting of child developmental concerns within a low-income population. Results suggest that models of services aimed at improving early detection and screening for child developmental delays, such as HVPs and access to early childhood professionals as well as universal screening by pediatric medical providers, are necessary for the advancement of equitable developmental outcomes in all communities. This study highlights the significant contributions of social, economic, and household characteristics on early detection of child developmental concerns. Advancing policies, programs, and research that aim to improve early detection and access to childhood professionals for all families will be essential to allow all children in low-income households to optimize their development. Also, policies and systems aimed at facilitating a network of coordinated services can improve early identification of developmental delays by early childhood providers in situations (such as the COVID-19 pandemic) when medical care is delayed or screening is not easily accessed. Such advancements could support early detection to increase access to interventions across all types of services accessed by families with very young children.