The Center for Hunger-Free Communities

Solutions Based on Science and the Human Experience

Children's HealthWatch Publications

As an ongoing study of the Center for Hunger-Free Communities since 2004, we have published extensively on the findings and policy implications of Children's  HealthWatch. Below is a more recent selection of research and policy publications. A more exhaustive list of Center-wide publications can be found under our Research page. Additional research and information about Children's HealthWatch can be found at

(October 2018)

The first two years of life are critical for children's development and growth. When children experience major shifts in their weight trajectories toward either underweight or overweight, pediatric caregivers rely on those data to indicate important information about a child's health. This report card examines weight trajectories among 2,719 children under 24 months of age who participated in the Children's HealthWatch interview twice within an average interval of 12 months. 

(February 2018)

This study evaluated a food insecurity screening and referral program collaboration between Children's Hospital of Philadelphia (CHOP) and Benefits Data Trust (BDT). Of 7,284 families with children under five screened for food insecurity, over one thousand (1,133, 15.6%) reported food insecurity and 630 (55.6%) were referred to a benefits access organization for connection to public benefits and community resources. This study used screening and referral data from CHOP and BDT along with key informant interviews and focus groups with 19 caregivers and 11 clinic staff to evaluate the initiative's effectiveness. Results demonstrate importance of integrated screening and referral consent processes, strong communication, and convenient outreach for families.

(January 2018)

Temporary Assistance for Needy Families (TANF) has limited success in building self-sufficiency, and rarely addresses exposure to trauma as a barrier to employment. The Building Wealth and Health Network's randomized controlled trial tested the effectiveness of financial empowerment combined with trauma-informed peer support against standard TANF programming. Despite high exposure to trauma and adversity, caregivers in the full intervention (financial empowerment and trauma-informed peer support) reported improved self-efficacy and depressive symptoms, and reduced economic hardship compared to the control and partial intervention groups. We conclude that financial empowerment education with trauma-informed peer support is more effective than standard TANF programming at improving behavioral health, reducing hardship, and increasing income. Policymakers may consider adapting TANF to include trauma-informed programming.

(January 2018)

Caregivers of children 0 to 48 months of age were interviewed in five urban medical centers from May 2009 to December 2015. Caregivers reported on the following: caregiver health, maternal depressive symptoms, child’s health, lifetime hospitalizations, developmental risk, and three housing circumstances, which were categorized as being behind on rent in the past 12 months, multiple moves, and child’s lifetime history of homelessness. Of 22,324 families, 34% had at least one of the following adverse housing circumstances: 27% had been behind on rent, 8% had made multiple moves, and 12% had a history of being homeless. We concluded that three forms of housing instability were associated with adverse caregiver and child health among low-income renter households. The American Academy of Pediatrics recommends social screening within health care; providers could consider assessing for behind on rent, multiple moves, and homelessness in high-risk practices.

(October 2017)

This study examined how mothers’ Adverse Childhood Experiences (ACEs) relate to their children’s developmental risk (PEDS) and assessed how the association is mediated through mothers’ depressive symptoms and fair/poor health. Mothers who reported household substance use, mental illness, or an incarcerated household member during childhood were more likely to report at least one child developmental concern on the PEDS. Mothers’ physical and mental health may help to explain the relationship between their own childhood adversity and their children’s development. 

(October 2017)

If mothers experienced adversity in their childhoods, their young children are more likely to experience risks to their physical, social, and cognitive development. Mothers’ physical and mental health may help to explain the relationship between their own childhood adversity and their children’s development.

(January 2017)

Depression is a barrier to employment among low-income caregivers receiving Temporary Assistance for Needy Families (TANF), and adverse childhood experiences (ACEs) and exposure to community violence (ECV) are often associated with depression. Using baseline data of 103 TANF caregivers of young children of the Building Wealth and Health Network Randomized Controlled Trial Pilot, this study investigated associations of two forms of employment-related resilience—self-efficacy and employment hope—with exposure to adversity/violence and depression.

(May 2016)

Exposure to childhood adversity, including abuse, neglect, and household dysfunction, is associated with negative long-term health and economic outcomes. This study used cross-sectional data from 1,255 female caregivers of children under 4 years surveyed in an urban clinical setting to investigate the association between caregivers’ adverse childhood experiences (ACEs) and household and child food insecurity, taking into account depressive symptoms. Depressive symptoms and ACEs were independently associated with household and child food insecurity, and depressive symptoms modified the association between ACEs and household and child food insecurity. Comprehensive policy interventions incorporating nutrition assistance and behavioral health may address intergenerational transmission of disadvantage.

(February 2016)

The purpose of this research is to assess food insecurity in low-income households with young children with and without special health care needs (SHCN) and evaluate relationships between child Supplemental Security Income (SSI) receipt and food insecurity. A cross-sectional survey of caregivers was conducted at 5 medical centers. Of 6,724 index children, 81.5% screened negative for SHCN, 14.8% positive for SHCN (no SSI), and 3.7% had SHCN and received SSI. Among households with children with SHCN, those with children receiving, versus not receiving SSI, were more likely to report household but not child food insecurity. Low-income households with young children having SHCN are at risk for food insecurity, regardless of child SSI receipt and household participation in other public assistance programs. Policy recommendations include reevaluation of assistance programs' income and medical deduction criteria for households with children with SHCN to decrease the food insecurity risk faced by these children and their families. 


(July 2015)

This study among 51 parents of young children under age four investigated how parents that report marginal, low and very low food security characterize how trade-offs associated with food insecurity affect parents' mental health and child well-being. We carried out 51 semi-structured audio-recorded interviews after participants responded to a survey regarding food security status and maternal depressive symptoms. Among participants reporting both food insecurity and depressive symptoms, we identified three primary areas of concern: trade-offs, mental health, and child well-being. Parents described how trade-offs associated with food insecurity have a profound relationship with their mental health and home environment that strongly affects young children. Partnerships between healthcare providers, policymakers, and parents are essential to successfully address and prevent the poor child health outcomes of toxic stress associated with food insecurity and poverty.

(January 2015)

A summary of the research article "The Relationship between Childhood Adversity and Food Insecurity: 'It's like a bird nesting in your head'" published in Public Health Nutrition.  The article discusses an investigation between Adverse Childhood Experiences (ACEs), including abuse, neglect, and household instability - and current household food insecurity among thirty-one female caregivers who reported household food insecurity. 

(November 2014)

(Maternal and Child Health Journal)

As many as 3.5 million people experience homelessness yearly. Children are disproportionately impacted; from 2007 to 2010 homelessness among children increased by 448,000–1.6 million children, or one in 45 US children. Homeless children experience increased risk of acute ill- nesses, nutritional deficits, physical trauma, developmental delays, chronic disease, emotional and behavioral problems, poor school attendance, and low academic achievement. An increasing body of evidence identifies pregnancy as a uniquely vulnerable time for children’s lifetime health and development.

The goal of the current analysis is to evaluate whether the recalled birth weight and gestational age of young low- income children whose mothers report homelessness dur- ing pregnancy differ from those recalled by mothers who have neither been homeless during the pregnancy nor within the lifetime of the child, as well as from mothers who were housed throughout pregnancy but became homeless after the child’s birth, which we term postnatal homelessness. A finding that prenatal, but not postnatal, homelessness is associated with adverse birth outcomes would suggest that prenatal homelessness is unique, time- dependent risk factor, rather than a marker for other maternal and social characteristics. 

(March 2012)

Often times, low-income families with young children under the age of 4 experience a continuous cycle of hardships (i.e., food insecurity, energy insecurity, and housing insecurity). These experiences have negative consequences on the developing bodies and brains of young children.

(March 2012)

(Public Health Nutrition)

Forty women described exposure to violence ranging from fear of violence to personal experiences with rape. Exposure to violence affected mental health, ability to continue school and obtain work with living wages, and subsequently the ability to afford food. Exposure to violence during childhood and being a perpetrator of violence were both linked to very low food security status and depressive symptoms. Ten of seventeen (59 %) participants reporting very low food security described life-changing violence, compared with three of fifteen (20 %) participants reporting low food security and four of twelve (33 %) reporting food security. Examples of violent experiences among the very low food secure group included exposure to child abuse, neglect and rape that suggest exposure to violence is an important factor in the experience of very low food security.

Descriptions of childhood trauma and life-changing violence are linked with severe food security. Policy makers and clinicians should incorporate violence prevention efforts when addressing hunger. 

(Journal of Applied Research on Children, February 2012)

The causes and contexts of food insecurity among children in the U.S. are poorly understood because the prevalence of food insecurity at the child level is low compared to the prevalence of household food insecurity. In addition, caregivers may be reluctant to admit their children may not be getting enough food due to shame or fear they might lose custody of their children.

Based on our ongoing qualitative research with mothers of young children, we suggest that food security among children is related to adverse childhood experiences of caregivers. This translates into poor mental and physical health in adolescence and adulthood, which can lead to inability to secure and maintain meaningful employment that pays a living wage.

In this paper we propose that researchers shift the framework for understanding food insecurity in the United States to adopt a life course approach. This demands we pay greater attention to the lifelong consequences of exposure to trauma or toxic stress—exposure to violence, rape, abuse and neglect, and housing, food, and other forms of deprivation—during childhood. We then describe three case studies of women from our ongoing study to describe a variety of toxic stress exposures and how they have an impact on a woman’s earning potential, her mental health, and attitudes toward raising children. Each woman describes her exposure to violence and deprivation as a child and adolescent, describes experiences with child hunger, and explains how her experiences have shaped her ability to nourish her children. We describe ways in which we can shift the nature of research investigations on food insecurity, and provide recommendations for policy-oriented solutions regarding income support programs, early intervention programs, child and adult mental health services, and violence prevention programs.

(Journal of Applied Research on Children , February 2012)

America’s low-income families struggle to protect their children from multiple threats to their health and growth. Many research and advocacy groups explore the health and educational effects of food insecurity, but less is known about these effects on very young children. Children’s HealthWatch, a group of pediatric clinicians and public health researchers, has continuously collected data on the effects of food insecurity alone and in conjunction with other household hardships since 1998. The group’s peer reviewed research has shown that a number of economic risks at the household level, including food, housing and energy insecurity, tend to be correlated. These insecurities alone or in conjunction increase the risk that a young child will suffer various negative health consequences, including increases in lifetime hospitalizations, parental report of fair or poor health,1 or risk for developmental delays.2 Child food insecurity is an incremental risk indicator above and beyond the risk imposed by household-level food insecurity. The Children’s Healthwatch research also suggests public benefits programs modify some of these effects for families experiencing hardships. This empirical evidence is presented in a variety of public venues outside the usual scientific settings, such as congressional hearings, to support the needs of America’s most vulnerable population through policy change. Children’s HealthWatch research supports legislative solutions to food insecurity, including sustained funding for public programs and re-evaluation of the use of the Thrifty Food Plan as the basis of SNAP benefits calculations. Children’s HealthWatch is one of many models to support the American Academy of Pediatrics’ call to “stand up, speak up, and step up for children.”3 No isolated group or single intervention will solve child poverty or multiple hardships. However, working collaboratively each group has a role to play in supporting the health and well-being of young children and their families.

1. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134:1432-1438.

2. Rose-Jacobs R, Black MM, Casey PH, et al. Household food insecurity: associations with at-risk infant and toddler development. Pediatrics. 2008;121:65-72.

3. AAP leader says to stand up, speak up, and step up for child health [news release]. Boston, MA: American Academy of Pediatrics; October 11, 2008. Accessed January 1, 2012.

(American Journal of Public Health, August 2011)

Objectives. We investigated the association between housing insecurity and the health of very young children.
Methods. Between 1998 and 2007, we interviewed 22069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each child’s household. Our indicators for housing insecurity were crowding (>2 people/bedroom or>1 family/residence) and multiple moves (‡2 moves within the previous year).
Results. After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR]=1.30; 95% confidence interval [CI]=1.18, 1.43), as were multiple moves (AOR=1.91; 95% CI=1.59, 2.28). Crowding was also associated with child food insecurity (AOR=1.47; 95% CI=1.34, 1.63), and so were multiple moves (AOR=2.56; 95% CI=2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR=1.48; 95% CI=1.25, 1.76), developmental risk
(AOR 1.71; 95% CI=1.33, 2.21), and lower weight-for-age z scores (–0.082 vs –0.013; P=.02).
Conclusions. Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.
(Am J Public Health. 2011;101:1508–1514. doi:10.2105/AJPH.2011.300139)


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