Abstract
Importance
Children with developmental delays face significant health challenges, including oral health problems, that disrupt dietary habits and contribute to food insufficiency.
Objective
To examine the association between oral health problems and food insufficiency among children with developmental delays.
Design
Cross-sectional design using the 2022 National Survey of Children’s Health database.
Setting
National survey.
Participants
Participants were 1,483 children ages 3–17 yr with developmental delays.
Outcomes and Measures
Food insufficiency was rated on a 4-point scale and oral health problems as problem present versus no problem. The ordinal logistic regression models were adjusted for child, health, and socioeconomic variables.
Results
Among participants, 26.2% had oral health problems. Oral health problems were significantly associated with food insufficiency (adjusted odds ratio [AOR] = 1.72, 95% confidence interval [CI] [1.14, 2.60]). Poor maternal mental health (AOR = 4.14, 95% CI [2.24, 7.68]) and low-income households (AOR = 9.82, 95% CI [5.00, 19.36]) were strongly associated with food insufficiency.
Conclusions and Relevance
Findings demonstrate that oral health problems, maternal mental health, and socioeconomic disparities are interrelated determinants of food insufficiency among children with developmental delays. Occupational therapists can address these issues through caregiver training and advocacy to enhance access to oral health and nutritional resources.
Plain-Language Summary
Children with developmental delays frequently experience oral health issues, such as cavities and chewing difficulties, which are linked with poor nutrition and food insufficiency. Using national survey data, this study examined associations among oral health problems, maternal mental health, and family income in relation to food insufficiency. Findings indicate that food insufficiency was more often reported when children had oral health problems, particularly among families with low income or mothers with poor mental health. These results highlight the need for accessible dental care, caregiver support, and food assistance programs. Occupational therapists can support families by promoting oral health strategies, stress management, and resource connections to strengthen food sufficiency and overall health.
Using national survey data, this study examined associations among oral health problems, maternal mental health, and family income in relation to food insufficiency among children with developmental delays.
Children with developmental delays face challenges in physical, cognitive, and social development, often making life more difficult for them and their families (Centers for Disease Control and Prevention [CDC], 2020a). These delays can arise from biological factors (e.g., genetic conditions, central nervous system impairments, preterm birth, low birth weight) or environmental influences such as prenatal stress, poor nutrition, and limited early stimulation (Boyle et al., 2011; CDC, 2020b).
Oral health problems and unmet dental care needs are especially common in this population (Mehta et al., 2024; Yusuf et al., 2020). National data indicate that children with neurodevelopmental disabilities are about 40% more likely to experience oral health problems, such as dental pain, bleeding gums, and untreated caries (cavities), than their peers without disabilities (Yusuf et al., 2020). This elevated risk has been linked with behavioral challenges, medication side effects, and motor impairments, which hinder oral hygiene and dental visits (Mehta et al., 2024). Even with regular tooth brushing, poor oral hygiene is frequently observed, underscoring the need for more accessible dental care (Mehta et al., 2024). Although children without developmental disabilities face some oral health barriers, children with developmental delay often face additional obstacles, such as communication difficulties, sensory sensitivities, and a shortage of providers trained to meet their needs (Kumar et al., 2017; Zahran et al., 2023).
Many children with developmental delays struggle with dental caries, misaligned teeth, weakened oral muscles, and difficulties in chewing and swallowing (Lewis, 2009). These problems cause discomfort and may limit dietary variety, which has been associated with nutritional risks and oral health disparities (Al-Maweri & Zimmer, 2015; Al-Sehaibany, 2017; Cermak et al., 2010). The link between poor oral health and nutrition remains unclear. Socioeconomic disadvantages have been associated with oral health problems in this group (Mehta et al., 2024; Yusuf et al., 2020). Furthermore, poor oral health may have implications for children’s emotional and social functioning. Discomfort and dietary limitations caused by oral problems can lead to frustration, reduced participation in mealtimes, and social withdrawal, which may, over time, be associated with behavioral challenges or reduced quality of life (Blomqvist et al., 2014; Finlayson et al., 2007; Grantham-McGregor et al., 2007).
Although awareness of the unique challenges faced by children with developmental disabilities is growing, there is still limited research on how oral health problems intersect with broader health disparities, such as food insufficiency, particularly for large-scale representative samples. Prior work has shown that children with disabilities more often report unmet dental needs related to cost, limited provider training, or behavioral difficulties (Alwadi et al., 2024). Preventive care remains underutilized in this population, highlighting the importance of systemic approaches to improve access and caregiver support (Mehta et al., 2024).
Beyond individual-level challenges, systemic barriers make challenges such as oral health problems, nutritional risks, and limited access to dental care harder to overcome. Many children with developmental delays face difficulties accessing dental care, including financial constraints, lack of specialized providers, or behavioral challenges that make dental visits stressful (Alwadi et al., 2024; Lewis, 2009). Parental stress and caregiving demands can exacerbate these issues, indirectly affecting a child’s nutrition (McCarthy et al., 2023). Maternal depression and stress have been shown to reduce the likelihood of engaging in preventive health behaviors, including dental care for children, which may contribute indirectly to broader nutritional and health disparities (Finlayson et al., 2007). Despite the existing evidence, much remains to learn about how these factors interact and contribute to long-term health disparities (Adler & Newman, 2002). Therefore, a comprehensive understanding of the associations between oral health problems and food insufficiency among children with developmental delays is needed. Large-scale studies examining child health, family dynamics, and environmental factors can help bridge this gap (Adler & Newman, 2002; Finlayson et al., 2007).
This study investigated the relationship between oral health problems and food insufficiency among children with developmental delays. By using the 2022 National Survey of Children’s Health (NSCH) data (Child and Adolescent Health Measurement Initiative, 2024), we examined these associations while accounting for child demographic characteristics, parental health, and socioeconomic background. This research may inform evidence-based interventions and policies while highlighting individual and systemic challenges underlying oral health and food insufficiency.
Method
Study Data and Sample
This study used data from the 2022 NSCH, a nationally representative survey of children ages 0–17 in the United States that assessed health, health care access, and family or community characteristics (Child and Adolescent Health Measurement Initiative, 2024). Data were publicly available and deidentified. Ethical approval was obtained from the Yonsei University Mirae Campus institutional review board.
We conducted a secondary analysis of the 2022 NSCH cross-sectional data, focusing on children ages 3–17 yr with a current developmental delay. Developmental disabilities were identified through caregiver report of a provider’s diagnosis expected to last more than 12 mo. Children under 3 were excluded. All responses were parent reported and not independently verified.
Study Variables
Dependent Variable: Food Insufficiency
We measured the dependent variable, food insufficiency, by using a 4-point scale. To aid interpretation, we reverse coded the responses so that lower values indicated poorer food availability and higher values indicated better food availability. The reverse-coded response options were the following: 1 = Often we could not afford enough to eat, 2 = Sometimes we could not afford enough to eat, 3 = We could always afford enough to eat but not always the kinds of food we should eat, and 4 = We could always afford to eat good nutritious meals.
Independent Variable: Oral Health Problems
The independent variable was oral health problems, defined as the presence of toothache, gum bleeding, or cavities. The presence of any of these issues was categorized as 1 = problem present, whereas the absence was categorized as 0 = no problem. Oral health problems were treated as a binary variable, with “no problem” used as the reference group.
Covariates
We grouped covariates into three categories based on their characteristics to control for confounding variables. These covariates allowed for a more accurate assessment of the relationship between the independent variable (oral health problems) and the dependent variable (food insufficiency).
Child characteristics.
Gender (female, male) and age (continuous, range = 3∼17 yr) were included as key variables, because eating habits and nutritional intake can vary significantly depending on the child’s growth and developmental stage (Bryant-Waugh et al., 2010). Body mass index (BMI) was categorized as normal (≥5th to < 85th percentile), underweight (<5th percentile), overweight (≥85th to < 95th percentile), and obese (≥95th percentile) and used to evaluate the child’s physical health and its role in food intake patterns (Liu et al., 2018).
Health-related factors.
Maternal mental health (excellent/very good, good, fair/poor) was included because it significantly affects the child’s overall development and health management. Mothers experiencing depression or stress may face difficulties in maintaining their child’s health, influencing oral health and nutritional status (Adeniyi et al., 2024; McCarthy et al., 2023). The presence of smoking in the household (yes/no) was included because it directly affects the child’s health through exposure to environmental factors (Yolton et al., 2005). Regular dental visits (yes/no) were included as a factor influencing the early detection and treatment of oral health problems (Lewis et al., 2005).
Socioeconomic and household context.
Household income was categorized based on the federal poverty level (FPL) divided into four groups (below 99% FPL, 100%–199% FPL, 200%–399% FPL, and 400% or higher FPL). Families with income below 200% FPL often qualify for public assistance, influencing their access to health care, nutritious food, and other resources critical for child development (Mackenbach et al., 2008). Family size (1–2, 3, 4, 5, 6+ members) was included because larger families potentially face more barriers to health care and nutrition access for children (Miller et al., 2014).
Data Analysis
After we excluded cases with missing values, the final dataset included 1,483 participants. Listwise deletion was applied, removing cases with missing data on independent, dependent, or covariate variables. The process is shown in Figure 1.
Flow diagram of the sample selection procedure.
We used ordinal logistic regression as this study’s primary analysis method. This approach is suitable for explaining the relationship between independent and dependent variables when the dependent variable is ordinal. To ensure the appropriateness of this method, we checked the adequacy of sample sizes for each level of the dependent variable. Specifically, sample adequacy was checked: 20 cases for Level 1, 105 cases for Level 2, 549 cases for Level 3, and 809 cases for Level 4. Although Level 1 had fewer cases (1.35%), the overall distribution was sufficient.
We conducted the proportional odds assumption to test the appropriateness of using ordinal logistic regression. This test evaluates whether the relationship between each pair of outcome categories is consistent across levels of the independent variables (Agresti, 2010). The results indicated that the proportional odds assumption was not violated (p > .05). Consequently, the use of ordinal logistic regression was deemed appropriate, and multinomial logistic regression was not necessary.
Covariates were specified a priori based on theoretical plausibility and prior research, consistent with recommendations to control for confounding (Walter & Tiemeier, 2009). They were selected from prior studies showing associations with both food insecurity and oral health (Almajed et al., 2024; Ghazal et al., 2015; Merchant et al., 2024; Negi & Sattler, 2025). The analysis was conducted in stages, with three priori models: Model 1: independent variable (oral health problems) and the dependent variable (food insufficiency). Model 2: added child characteristics (gender, age, and BMI) and health-related factors (maternal mental health, household smoking status, and dental visits). Model 3: added socioeconomic and household context factors such as household income and family size.
Model fit was evaluated based on –2 log likelihood, Akaike information criterion (AIC), and C statistics. All analyses were performed using SAS (Version 9.4), with α < .05.
Results
Sample demographics are presented in Table 1. Among the sample of 1,483 children with developmental delay, 26.16% (n = 388) had oral health problems, and 73.84% (n = 1,095) did not. The percentage of mothers reporting their mental health as average or poor was significantly higher among children with oral health problems compared with those without oral health problems (p < .0001). In addition, the rate of smoking in the household was significantly higher among children with oral health problems (26.55%) compared with those without oral health problems (12.97%, p = .0001). No significant differences were observed between the two groups regarding the child’s gender, age, BMI, household income, or family size.
Comparison of Characteristics Between Groups of Children Who Currently Have Any Developmental Delay, Ages 3–17 yr (N = 1,483)
Note. BMI = body mass index; FPL = federal poverty level.
Table 2 presents the results of the ordinal logistic regression analyses, which explored the relationship between oral health problems and food insufficiency across the three models. In Model 1, an unadjusted model including only the independent variable (oral health problems) and the dependent variable (food insufficiency), children with oral health problems were found to be 2.05 times more likely to experience food insufficiency (95% confidence interval [CI] [1.38, 3.05], p < .01). This model, without controlling for potential confounders, established a baseline understanding of the association between oral health problems and food insufficiency.
Ordinal Logistic Regression for the Relationship Between Oral Health Problems and Food Insufficiency
Note. OR = odds ratio; CI = confidence interval; BMI = body mass index; FPL = federal poverty level; AIC = Akaike information criterion.
*p < .05. **p < .01.
In Model 2, adjustments were made for child-related characteristics (gender, age, and BMI) and maternal and family factors (mother’s age, maternal mental health, smoking status, and dental visits). After these adjustments, children with oral health problems were still 1.73 times more likely to experience food insufficiency (95% CI [1.17, 2.56], p < .01). Notably, children whose mothers reported poor mental health were 4.04 times more likely to experience food insufficiency (95% CI [2.31, 7.05], p < .01). Regular dental visits were associated with a significant reduction in food insufficiency, with children who had dental visits being 44% less likely to experience food insufficiency (odds ratio = 0.44, 95% CI [0.28, 0.71], p < .01).
In Model 3, further adjustments were made to include socioeconomic characteristics, such as household income and family size. Children with oral health problems remained 1.72 times more likely to experience food insufficiency (95% CI [1.14, 2.60], p < .01. Household income was strongly associated with food insufficiency. Children from households earning less than 100% of the FPL were 9.82 times more likely to experience food insufficiency (95% CI [5.00, 19.36], p < .01) compared with households earning more than 400% of the FPL.
Key fit statistics indicated that model fit progressively improved from Model 1 to Model 3. The –2 log likelihood and AIC values for Model 2 and Model 3 were identical (−2 log likelihood = 3,796,115.1, AIC = 3,796,121.1). However, Model 3 demonstrated better discrimination, as evidenced by the higher C statistic (0.785) compared with Model 2 (0.717). This indicates that adding socioeconomic characteristics improved the model’s ability to classify outcomes accurately.
Discussion
This study explored the associations between oral health issues and food insufficiency of children with developmental delays, uncovering significant insights into this group’s complex challenges. Oral health problems are associated with chewing and swallowing difficulties, which may relate to lower nutritional intake and dietary quality (Edelstein, 2006). The study showed that children with oral health issues were more likely to experience food insufficiency. This association remained after adjusting for child, health, socioeconomic, and maternal factors. These results emphasize the need to address oral health problems to enhance dietary habits and overall health outcomes for children with developmental delays (Watt & Sheiham, 2012).
Consistent with previous literature, early-life disruptions such as poor oral health, malnutrition, and limited access to care have been associated with long-term developmental delays and reduced educational and health outcomes (Grantham-McGregor et al., 2007). An unexpected discovery was that children who did not visit the dentist were less likely to experience food insufficiency. This unexpected finding may reflect broader financial barriers to dental care among low-income families (Vargas et al., 2003). Families prioritizing dental care may experience financial strain, which has been linked with food insufficiency. On the other hand, families avoiding dental visits might perceive fewer oral health issues, thus experiencing less financial strain. The lower prevalence compared with national estimates (nearly half of U.S. children ages 3–19 with caries) may reflect the limited NSCH measure, which only captured parent-reported oral problems in the past 12 mo, likely underestimating the burden. These findings highlight the need to expand affordable dental care options for children with developmental delays (Lewis et al., 2005).
Building on evidence of caregiver well-being in child health (Goodman et al., 2011), this study found that children of mothers with poor mental health were more likely to face food insufficiency. Maternal depression is linked to reduced preventive caregiving, including oral hygiene and nutrition management, affecting children’s outcomes. Longitudinal studies indicate food insecurity and maternal depression influence each other, with improvements in one associated with improvements in the other (Reesor-Oyer et al., 2021). These bidirectional associations highlight opportunities for intervention. Occupational therapists can connect families with food programs, mental health services, and dental care, thus addressing interconnected risks. Integrated approaches with mental health support may benefit caregivers and children (Walker et al., 2011).
Socioeconomic factors, especially household income, were strongly linked to food insufficiency. Although the association between low income and food insufficiency is consistent with prior research (Gundersen & Ziliak, 2015), this study extends the evidence to children with developmental delays, who may face added risks from increased health care and caregiving demands. Children from families below the FPL threshold were 9.82 times more likely to report food insufficiency than wealthier peers, highlighting financial disparities in access to food and health care (Gundersen & Ziliak, 2015). Moreover, families with incomes between 100% and 199% of the FPL might encounter more food insufficiency than those below 99% because of restricted access to public assistance programs, despite financial difficulties. Further studies should examine how household size, regional cost-of-living variations, and other contextual elements influence these relationships (Rabbitt et al., 2024).
Conversely, factors such as the child’s age, BMI, household smoking status, and family size did not significantly correlate with food insufficiency. These results indicate that although these factors might contribute to food insufficiency in certain groups, their impact may lessen when accounting for more influential factors such as socioeconomic status and oral health issues. Although this study focused on children with developmental delays, it remains unclear whether similar relationships would be observed among typically developing children. Future research comparing both groups could clarify whether these associations tend to be more pronounced among children with developmental delay.
Although covariates were specified a priori, the relationships among oral health, maternal mental health, and socioeconomic factors are complex and may not be fully explained by main effects alone. Future research should consider advanced models, including structural equation modeling, and test for effect modification or interaction between predictors. For example, including poor oral health, maternal mental health, and their interaction term as predictors of food insufficiency may help clarify whether the combined effect of these variables goes beyond their independent contributions (Knol & VanderWeele, 2012). Such approaches would allow a more detailed understanding of how oral health and psychosocial factors together contribute to food insecurity among children with developmental delays.
Tackling these complex challenges requires coordinated interventions. Regular screening for oral health problems and food insufficiency should be part of pediatric care for children with developmental delays. Interdisciplinary approaches have been suggested for managing feeding and oral health challenges (Cermak et al., 2010). Policy measures should focus on increasing access to affordable dental care and food assistance programs, especially for low- and middle-income families (Adler & Newman, 2002).
Implications for Occupational Therapy Practice
Occupational therapists have the potential to significantly reduce the effects of oral health issues and food scarcity on children experiencing developmental delays. This research underscores several areas in which occupational therapy interventions can offer valuable support. ▪ Oral motor and feeding interventions: Occupational therapists can develop feeding interventions targeting oral motor deficits, such as chewing and swallowing difficulties, to improve mealtime efficiency, dietary intake, and nutrition. ▪ Caregiver training and support: Occupational therapists can train caregivers to manage oral health, prepare nutritious meals, and address food-related behaviors while providing stress management guidance to enhance well-being and caregiving capacity. ▪ Advocacy for access to resources: Occupational therapists can connect families with food programs such as food banks, which may help improve mothers’ mental health and children’s oral health. They can also link families to mental health care and work with dentists and pediatricians to provide preventive care, such as fluoride varnish, and treat mothers’ oral health to prevent passing cavity-causing bacteria to children. ▪ Community education and outreach: Occupational therapists–led programs can raise awareness of links between oral health and food security, offering workshops in schools and community centers. ▪ Research and policy development: Occupational therapists can study social determinants, focusing on oral health, nutrition, and socioeconomic factors, to inform policies reducing disparities.
Occupational therapy can use these strategies to address systemic barriers, enhance caregiver capacity, and improve health outcomes for children with developmental delays.
Conclusion
This study established a strong connection between food insufficiency experienced by children with developmental disabilities and factors such as oral health, health conditions, and socioeconomic status, with maternal mental health and household income showing particularly strong associations. Tackling these intertwined issues through comprehensive health care strategies, interventions aimed at caregivers, and specific policy initiatives is vital. Efforts to address oral health issues, support maternal mental health, and reduce socioeconomic inequalities could collectively contribute to improving the well-being of children with developmental disabilities and their families. These results highlight the need for holistic, family-oriented strategies to reduce disparities and improve nutrition and health in this group.