There are growing levels of chaos in the lives of American children, youth, and families. Increasingly, children grow up in households lacking in structure and routine, inundated by background stimulation from noise and crowding, and forced to contend with the frenetic pace of modern life. Although widespread, chaos does not occur randomly in the population. We document that low-income adolescents face higher levels of chaos than their more affluent counterparts and provide longitudinal evidence that some of the adverse effects of poverty on socioemotional adjustment are mediated by exposure to chaotic living conditions.

Cumulative environmental risk exposure among low-income families may contribute to bad health, beginning in early childhood.

No abstract

You can never plan a week or a day ahead... one minute you're fine and the next you just can't deal.-Low-income mother describing daily life (Roy, Tubbs, & Burton, 2004, p. 174) There are many reasons why the lives of children from low-income households are more chaotic than are those from middle-and high-income households. Lowincome parents suffer from a plethora of physical and social stressors. Poor parents juggle overlapping time obligations and have fewer resources than do wealthier parents to deal with the multitude of demands and obligations they face. Low-income parents are less likely to have a dependable car; they cannot afford reliable flexible child care or after-school care; their children are enrolled less often in structured child or youth programs; and low-income parents are less likely to have a partner, who could share household management and parenting responsibilities. Residential and school relocations, which erode social networks, are more common, and family disruptions and turmoil are more frequent among low-income families (Evans, 2004). In this chapter we document linkages between poverty and low socioeconomic status (SES) and chaos, review studies examining chaos as a mediator of poverty's impacts on children, and offer preliminary thoughts about why chaos is problematic for children's development. Chaos, Poverty, and Socioeconomic StatusComponents of chaos associated with poverty and SES include household crowding, noise levels, household routines and rituals, residential and school relocation, and parental partner instability. For each of these components of chaos, we have constructed a summary table. These tables are not included because of length restrictions but can be found at http://www.macses.ucsf.edu/Research/ Social%20Environment/notebook/chaos.html. Chaos is operationalized in a few studies as a composite variable, with these results summarized in Table 7. Herein 225

This study investigated the relationship between child maltreatment and the early onset of problem behaviors in the Elmira Nurse Home Visitation Program. Participants were predominantly low-income and unmarried mothers and their first-born children who were randomized either to receive over 2 years of home-visitation services by nurses or to be placed in a comparison group. Data were drawn from a follow-up study that took place when the children were 15 years of age. Results demonstrated that, in the comparison group, child maltreatment was associated with significant increases in the number of early onset problem behaviors reported by the youth. For the youth in the nurse-visited group there was no relationship between maltreatment and early onset problem behaviors. We suggest that this finding was due to the effects of the intervention in reducing the number as well as the developmental timing of the maltreatment incidents. Results suggest that prenatal and infancy home visiting by nurses can moderate the risk of child maltreatment as a predictor of conduct problems and antisocial behavior among children and youth born into at-risk families.

No abstract

IMPORTANCE Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. OBJECTIVE To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. DESIGN, SETTING, AND PARTICIPANTS The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreationalrelated concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. INTERVENTIONS The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. MAIN OUTCOMES AND MEASURES Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parentreported symptoms. RESULTS Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3-to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, −6.6 to −0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, −7.7 to −0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes.

No abstract