The Association of Adverse Childhood Experiences With Anxiety and Depression for Children and Youth, 8 to 17 Years of Age

ObjectiveTo determine the prevalence of anxiety and depression and examine their association with adverse childhood experiences (ACEs) among children and adolescents ages 8 to 17 years old.MethodsUsing data from the 2016-2017 National Survey of Children's Health, we conducted a cross-sectional study design with a total sample of 39,929. Our exposure and outcome variables included caregiver report of 9 ACE exposures and current anxiety or current depression. Survey sampling weights and SAS survey procedures were implemented to produce nationally representative results.ResultsOur study found that 9% of children had current anxiety while 4% had current depression. Multivariate analysis concluded that all ACE measures were associated with significantly higher odds of both anxiety and depression. Children exposed to 4 or more ACEs had higher odds of anxiety (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.4–2.1) and depression (aOR = 2.2; 95% CI, 1.7–2.9) than children with exposure to fewer than four ACEs. Assessment of the outcomes of anxiety and depression separately showed differential impacts of ACE exposures as associations were stronger with depression for almost all ACE categories.ConclusionsOur study demonstrates a differential association between ACEs and anxiety and depression. This highlights the importance of assessing the impact of ACEs on internalizing behaviors separately. These findings are significant for pediatric providers as diagnosis and treatment for mental health disorders are vital components of pediatric care and further support the American Academy of Pediatrics' recommendation to screen for ACEs.     

Examining the Relationship Between Adverse Childhood Experiences and ADHD Diagnosis and Severity

ObjectiveAlthough prior research has examined the prevalence of ACEs among children with attention deficit-hyperactivity disorder (ADHD), little is known about the household and family settings of children with ADHD. Our study utilizes a recent nationally representative dataset to examine the association between adverse childhood experiences (ACEs), child and household characteristics, and ADHD diagnosis and severity.MethodsUsing the 2017–2018 National Survey of Children's Health (NSCH), our sample consisted of children three years of age or older, as this is the youngest age at which the NSCH begins to ask caregivers if a child has been diagnosed with ADHD (n = 42,068). Multivariable logistic regression was used to examine the association between ACE type, score, and ADHD and ADHD severity, controlling for child and household characteristics.ResultsChildren exposed to four or more ACEs had higher odds of ADHD (aOR 2.16; 95% CI 1.72–2.71) and moderate to severe ADHD (aOR 1.89; 95% CI 1.31–2.72) than children exposed to fewer than four ACEs. Other child characteristics positively associated with ADHD included age and public insurance; other Non-Hispanic races compared to Non-Hispanic White had lower odds of ADHD. Of children reported with ADHD, public insurance was also associated with caregiver-reported moderate to severe ADHD.ConclusionsChildren with ADHD have a higher prevalence of ACEs, making this study important for understanding the relationship between ACEs and ADHD at the population level.     

Depression Screening in Adolescents in the United States: A National Study of Ambulatory Office-Based Practice

ObjectiveTo determine the frequency of depression screening during ambulatory, office-based visits for adolescents seen in general/family medicine or pediatric practices in the United States using nationally representative data; to determine the patient-, provider-, and visit-level factors associated with depression screening during ambulatory visits to inform recommendations to promote screening.MethodsThis cross-sectional study used the 2005–2010 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Data were limited to ambulatory, office-based visits to general/family medicine or pediatrics clinics for adolescents aged 12 to 18 years who did not have a documented diagnosis of depression.ResultsDepression screening was rare (0.2%; 95% confidence interval [CI] 0.1–0.3), and it was 80% less likely to occur during visits for Hispanic compared to non-Hispanic white adolescents (adjusted odds ratio [aOR] 0.2, 95% CI 0.1–0.7). Depression screening was 9.1 times more likely in the Northeast compared to the West (aOR 9.1, 95% CI 2.2–38.1) if there were no visits within past 12 months compared to 6 or more visits (aOR 6.1; 95% CI 1.8–20.4), and if stress management (aOR 24.2, 95% CI 11.8–49.5) or other mental health counseling (aOR 5.2, 95% CI 1.2–23.6) were provided.ConclusionsDepression screening for adolescents is rare and is associated with racial/ethnic and regional disparities. The integration of behavioral and mental health services within the patient-centered medical home might assist providers in identifying and treating depression and in addressing such disparities.     

Adverse Childhood Experiences and Insufficient Sleep Among U.S. Children and Adolescents

ObjectiveTo examine associations between adverse childhood experiences (ACEs) and age-specific insufficient sleep duration (ISD) in American youth.MethodsData from the 2016–2017 National Survey of Children's Health, a sample of 46,209 youth ages 6 to 17 were analyzed. The main outcome was sleep duration that did not meet the recent recommendations of the American Academy of Sleep Medicine. Nine types of ACEs, as well as a cumulative count of ACEs, were examined as independent variables in unadjusted and adjusted logistic regression models.ResultsApproximately half of U.S. children and adolescents (ages 6–17) experienced at least one ACE and a third did not get sufficient sleep. Among those exposed to any ACE, 40.3% had ISD. Seven of the 9 ACEs examined were significantly associated with a 20% to 60% increase in odds of not getting sufficient sleep (adjusted ORs between 1.2 and 1.6). Children exposed to 2 or more ACEs were nearly twice as likely as those exposed to no ACE to have ISD (adjusted OR = 1.7, 95% CI: 1.5–1.9). Moreover, each individual ACE, except parental death was significantly associated with more than 1 hour less sleep than recommended.ConclusionsThis study reports the association of specific and cumulative ACEs with ISD in a nationally representative sample of American youth. The study findings underscore the importance of screening for both ACEs and insufficient sleep during primary care encounters and addressing potential sleep problems in those exposed to ACEs.     

Adverse Childhood Experience and Adolescent Well-being: Do Protective Factors Matter?

Studies have found traumatic experiences in childhood to have lasting effects across the lifecourse. These adverse childhood experiences (ACEs) include a variety of types of trauma, including psychological, physical or sexual abuse; living in poverty; violence in the home; living with a substance abuser; living with a mentally ill or suicidal person; or living with someone who is or has been imprisoned. Long-term effects among adults have been found in previous studies; but there is limited research on the association between ACEs and adolescent development and even less on potential protective factors to mediate these associations. Utilizing the U.S. 2011–2012 National Survey of Children’s Health, this study examines both the prevalence of ACEs in a nationally representative sample of 12–17 year old adolescents and the cross-sectional relationship between experiencing ACEs and multiple measures of well-being. Potential protective factors are then examined in a mediation model. Results indicate that the more ACEs adolescents experience, the less likely they are to enjoy high levels of well-being. Many factors partially mediate this association, including residing in a safe neighborhood, attending a safe school, and parental monitoring of friends and activities. We conclude that measures of adverse childhood experiences (ACEs) represent an important construct for indicator systems; in addition, these findings indicate that measures of protective factors represent important components of indication systems.     

The Relationship of Reported Neighborhood Conditions With Child Mental Health

ObjectiveAlthough in many studies authors have documented the relationship between neighborhood socioeconomic status and child mental health, few have examined the association between neighborhood conditions and mental health disorders. The objective of this study was to determine whether parent-reported neighborhood conditions are associated with common child mental health disorders.MethodsWe analyzed data on children ages 6 to 17 (N = 64,076) collected through the 2007 National Survey of Children's Health. Primary outcome variables were a child being reported to have a diagnosis of (1) anxiety and/or depression and (2) attention-deficit?hyperactivity disorder (ADHD) and/or disruptive behavior. Main independent variables were parent-reported neighborhood amenities (eg, recreation center), poor physical characteristics (eg, dilapidated housing), social support/trust, neighborhood safety, and school safety. Multivariate logistic regression analyses were conducted to examine associations between neighborhood conditions and (1) anxiety/depression and (2) ADHD/disruptive behavior.ResultsChildren living in a neighborhood with 3 poor physical characteristics had greater odds of anxiety/depression (adjusted odds ratio [AOR] 1.58, 95% confidence interval [95% CI] 1.01–2.46) and ADHD/disruptive behavior (AOR 1.44, 95% CI 1.04–1.99) compared with children living in a neighborhood with no poor physical characteristics. Children of parents who reported living in a neighborhood with low social support/trust had greater odds of depression/anxiety (AOR 1.71, 95% CI 1.28–2.30) and ADHD/disruptive behavior (AOR 1.47, 95% CI 1.19–1.81) than children living in a neighborhood with greater social support/trust.ConclusionsParent perception of neighborhood social support/trust and physical characteristics may be important to assess in clinical settings and should be examined in future study of child mental health burden.     

Adverse childhood experiences and resilience in childhood and adolescent and young adult cancer patients

Childhood and adolescent and young adult (AYA) cancer survivors experience poor health outcomes in adulthood. Adverse childhood experiences (ACEs) also portend poor health outcomes for the general population. Resilience can mitigate effects of ACEs. We examined the feasibility of assessing ACEs and resilience in childhood and AYA cancer patients. We also described occurrences of ACEs, resilience, and poor health outcomes. Of 52 participants, most rated their study experience favorably, with privacy in answering sensitive questions. Half reported ACEs, and those with ACEs had lower resilience; X²(3, N = 52) = 9.4, p = .02. Further investigations of ACEs and resilience in larger cohorts are warranted to delineate associations with long-term health outcomes.     

The Impact of Maternal Worry on Infant Care Practices

ObjectivesExamine the 1) prevalence of worries among US mothers of infants; 2) association between worries and American Academy of Pediatrics recommended infant care practices (breastfeeding, supine sleep, roomsharing without bedsharing); 3) association of maternal and household characteristics with worries.MethodsWe analyzed a nationally representative sample of 3165 mothers who were surveyed regarding safe sleep and breastfeeding when infants were 2 to 6 months of age in 2011–2014. We examined the prevalence of 8 maternal worries (housing, job, income, neighborhood, family relationships, health, baby's health, family member health). We used multivariable logistic regression to examine associations of A) both overall number of worries and individual worries with each infant care practice; and B) maternal and household characteristics with worries.ResultsTwenty-six percent of mothers reported 0 worries, 26% reported 1–2 worries, 23% reported 3–4 worries, and 25% reported 5–8 worries. Compared to those with 0 worries, mothers with 5–8 worries had increased odds of bedsharing (adjusted odds ratio = 1.60 [1.19–2.14]) and non-supine sleep (aOR = 1.37 [1.07–1.74]). Specific worries associated with increased odds of bedsharing included: housing (aOR = 1.39 [1.09–1.78]), income (aOR = 1.35 [1.09–1.67]), neighborhood (aOR = 1.37 [1.05–1.78]), family relationships (aOR = 1.43 [1.10–1.86]), and health of a family member (aOR = 1.24 [1.06–1.46]). Maternal worries were not associated with infant feeding practices.ConclusionsWe found a high prevalence of worries regarding basic needs, family relationships, and health among US mothers. Greater total worries and several individual worries were associated with higher odds of bedsharing. The “cognitive load” of maternal worries may impact adherence to safe sleep practices and requires further investigation.     

青少年自杀意念与家庭环境和心理弹性之间的关联研究

目的 探讨青少年自杀意念与家庭环境因素和心理弹性之间的关系。方法 采用整群抽样法,于2014年12月对河南省新乡市3 230名初高中生进行一般社会资料问卷及Kutcher青少年抑郁量表（11项）（KADS-11）、家庭环境量表中文版（FES-CV）、中文版心理弹性量表（CD-RISC）评估测评后,采用多因素logistic回归分析和病例对照研究探讨青少年家庭环境和心理弹性与自杀意念之间的关联。结果 有效问卷为2 960份,有自杀意念者247例（8.50%）,其中男性98例,女性149例。多因素logistic回归分析显示,控制了年龄和性别因素后,单亲/再婚家庭模式与青少年自杀意念风险增加有关（OR=2.655）。男性青少年的自杀意念与家庭亲密度（OR=0.750,P < 0.001）及组织性（OR=0.855,P=0.036）呈明显负关联,与家庭矛盾性呈明显正关联（OR=1.159,P=0.017）。女性青少年的自杀意念与家庭亲密度（OR=0.771,P < 0.001）、情感表达（OR=0.815,P=0.001）及知识性（OR=0.915,P=0.037）存在负性关联。CD-RISC量表评估显示,有自杀意念的青少年心理弹性总得分明显低于无自杀意念的青少年（P < 0.05）,有自杀意念青少年该量表中的能力、忍受消极情感、接受变化和控制4个维度的得分均比无自杀意念青少年低（P < 0.05）。结论 青少年家庭环境亲密度是青少年自杀意念的保护因素;男性青少年的家庭组织性和女性青少年家庭情感表达与降低自杀风险有关;增强心理弹性可能有助于降低青少年的自杀意念。     

Relationship of Children's Emotional and Behavioral Disorders With Health Care Utilization and Missed School

ObjectiveTo assess the association between emotional and behavioral disorders (EBD), missed school days and health care visits while controlling for sociodemographic factors, and comorbid medical conditions in a nationally representative sample.MethodsData from the 2016 National Health Interview Survey were used to assess the associations between EBD, in children aged 4 to 11 and 12 to 17 years, on missed days of school, health care office visits, and emergency department visits. EBD was assessed utilizing a validated screener. Multiple logistic regression was used to control for comorbid medical conditions and sociodemographic factors.ResultsAdolescents who screened positive for anxiety, depression, peer problems, and severe impairment had 4 to 8 times the odds of missing more school than their peers that screened negative. Young children with anxiety had 4 times increased odds of missing more school whereas positive emotional and behavioral health was protective against missing school. Young children and adolescents who screened positive for anxiety, depression, and severe impairment had 3 to 6 and 2 to 4 times the odds of more office visits respectively. Emergency department utilization was significantly increased in adolescents with anxiety and younger children with severe impairment.ConclusionsThis study shows that children with EBD are more likely to have increased office visits and missed days of school, even after adjusting for sociodemographic factors and comorbid medical conditions. Recognition of early associations of EBD can create an opportunity for early identification of children with EBD in the pediatric practice.     

Factors Associated With Firearm Injury Among Pediatric Members of a Large Integrated Healthcare System

Background and ObjectivesFew studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non–self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents.MethodsRetrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non–self-inflicted and self-inflicted firearm injuries.ResultsFor non-self-inflicted injury, the highest relative risk was found for children age 12–17 years old compared to 0–5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12–17 years old and male gender were associated with increased risk.ConclusionsThese results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non–self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.     

Perceived Persuasiveness of Evidence About Adverse Childhood Experiences: Results From a National Survey

ObjectiveAdvocates must make decisions about the types of evidence they emphasize when communicating to cultivate support for adverse childhood experience (ACE) prevention policies. This study sought to characterize public perceptions of the persuasiveness of 12 ACE evidence statements and assess differences by ideology in the strength of these evidence messages as rationales for ACE prevention policies.MethodsA web-based survey of a nationally representative sample of US adults was conducted using the KnowledgePanel (N = 503, completion rate = 60.5%). Respondents read ACE evidence statements and answered questions about the extent to which each was perceived as persuasive. Data were collected and analyzed in 2019.ResultsThe evidence statements perceived as most persuasive (scoring range 3–17) were those about ACEs as risk factors for mental health and substance use conditions (mean = 12.39) and suicide (mean = 12.14); ACEs generating financial costs for society (mean = 12.03); and the consequences of ACEs being preventable by a supportive adult (mean = 11.97). The evidence statements perceived as least persuasive were about ACEs generating health care costs for individuals (mean = 9.42) and ACEs as risk factors for physical health conditions (mean = 9.47). A larger proportion of liberals than conservatives rated every statement as providing a “strong reason” for ACE prevention policies. These differences were largest for evidence about ACEs generating financial costs for society (84.6% vs 42.8%, P < .0001) and socioeconomic disparities in ACEs (65.1% vs 32.9%, P < .0001).ConclusionsMany ACE evidence statements commonly used in policy advocacy differ from those perceived as most persuasive among a nationally representative sample of US adults.     

Examination of relationship factors between psychological resilience and social support in adolescent obesity

PurposeChildhood obesity is one of the most severe public health problems, and psychiatric conditions have been associated with obesity. In this study, we aimed to investigate psychological resilience and possible related factors in adolescents with obesity.MethodThe study included 90 adolescents with obesity and 100 healthy adolescents of similar age. Data were collected using a sociodemographic information form, the Child and Youth Resilience Measure-28 (CYRM-28), and the Multidimensional Scale of Perceived Social Support. Scale scores were compared by Pearson's correlation coefficient test with SPSS-23. Multiple linear regression was performed to describe the relationships between variables.ResultsThe adolescents participating in the study were similar in terms of age and gender. Psychological resilience and social support in the obesity group were lower than in the control group (p < 0.05). A negative relationship was found between body mass index (BMI) and resilience levels of adolescents with obesity, and a positive relationship was found between social support and resilience levels (p = 0.027 and p < 0.001, respectively). The perceived family and significant other social support subscale scores of adolescents in the obesity group were significantly lower than in the control group (p = 0.037 and p = 0.023, respectively). The most related variable with the CYRM-28 was the level of perceived social support: standardized β = 0.409; t(151) = 5.626; p < 0.001.ConclusionA higher BMI has a negative effect on psychological resilience, and family support tends to be lower in these cases. New studies are needed to clarify whether this result is one of the causes of obesity or one of its consequences.     

The Relationship Between Adverse Childhood Experiences and Weight-Related Health Behaviors in a National Sample of Children

ObjectiveTo examine how adverse childhood experiences (ACEs) relate to healthy weight behaviors in children.MethodsWe examined data from the 2016 National Survey of Children's Health. ACE scores were calculated from 6 measures of household dysfunction. Outcome measures included 5 healthy weight behaviors. Logistic regression models assessed associations between ACEs and healthy weight behaviors controlling for sociodemographic variables.ResultsChildren 6 to 17 years of age (n = 32,528) with 0 ACEs had increased odds of: watching 2 hours or less of television daily (6–12 years: odds ratio [OR] 1.46; 95% confidence interval [CI], 1.20–1.80, 13–17 years: OR 1.64; 95% CI, 1.39–1.94), using electronics for 2 hours or less daily (6–12 years: OR 1.44; 95% CI, 1.15–1.80, 13–17 years: OR 1.86; 95% CI, 1.60–2.16), sharing 4 or more family meals per week (6–12 years: OR 1.39; 95% CI, 1.17–1.66, 13–17 years: OR 1.68; 95% CI, 1.44–1.95), and getting adequate age-specific sleep (6–12 years: OR 1.50; 95% CI, 1.26–1.79, 13–17 years: OR 1.31; 95% CI, 1.11–1.55) when compared to children with one or more ACEs. Children 13 to 17 years of age with 0 ACEs had increased odds of exercising for 60 minutes daily (OR 1.27; 95% CI, 1.02–1.58) when compared to children with one or more ACEs. There was an overall gradient dose pattern; the odds of engaging in a healthy weight behavior decreased as the number of ACEs increased, with mixed significance levels.ConclusionsIn children, ACE exposure is associated with decreased healthy weight behaviors and behavior counseling alone may be insufficient. Trauma-informed care to address intra-familial adversity may be necessary.     

Association of Pediatric Mortality With the Child Opportunity Index Among Children Presenting to the Emergency Department

ObjectiveChild health and development is influenced by neighborhood context. The Child Opportunity Index (COI) is a multidimensional measure of neighborhood conditions. We sought to evaluate the association of COI with mortality among children presenting to the emergency department (ED).MethodsWe performed a multicenter cross-sectional study of pediatric (<18 years) ED encounters from a statewide dataset from 2016 to 2020. We constructed a multivariable logistic regression model to evaluate the association between COI and in-hospital mortality after adjusting for sociodemographic characteristics and medical complexity.ResultsAmong 4,653,070 included encounters, in-hospital mortality occurred in 1855 (0.04%). There was a higher proportion of encounters with mortality in the lower COI categories relative to the higher COI categories (0.053%, 0.038%, 0.031%, 0.034%, 0.034% ranging from Very Low to Very High, respectively). In adjusted models, child residence in Low (adjusted odds ratio 1.26; 95% confidence interval [CI], 1.04–1.53) and Very Low (adjusted odds ratio 1.58; 95% CI, 1.31–1.90) COI neighborhoods was associated with mortality relative to residence in Very High COI neighborhoods. This association was noted across all domains of COI (education, health and environment, and social and economic), using an expanded definition of mortality, using nationally normed COI, and excluding patients with complex chronic conditions. Other factors associated with increased odds of mortality included age, medical complexity, payor status, age, and race and ethnicity.ConclusionsUnderstanding the association of neighborhood context on child mortality can inform public health interventions to improve child mortality rates and reduce disparities.     

Moderating Effects of Components of Resilience on Obesity Across Income Strata in the National Survey of Children's Health

Objective

This study examined whether components of resilience at the family or child level are associated with a decreased risk of obesity in children after accounting for community-, family-, and individual-level stressors associated with an increased risk of obesity.

Associations of Passive and Mentally Active Screen Time With Perceived School Performance of 197,439 Adolescents Across 38 Countries

ObjectiveTo examine the associations of passive (ie, television) and active (ie, electronic games, computer use) screen time (ST) with perceived school performance of adolescents across gender.MethodsData were from the 2014 Health Behaviour in School-aged Children survey conducted across 38 European countries and Canada. Perceived school performance was assessed using an item and dichotomized as high (good/very good) versus the remainder (average/below-average as reference). Participants reported hours per day of time spent watching television, playing electronic games, and using a computer in their free time. Multilevel logistic regression was used to estimate the associations.ResultsA total of 197,439 adolescents (average age 13.6 [standard deviation 1.63] years; 51% girls) were analyzed. Multivariable modeling showed that engaging in >2 h/d of ST was progressively and adversely associated with high performance in both boys and girls. Adolescents reporting >4 h/d of television time (≤1 h/d as reference) had 32% lower odds in boys (odds ratio [OR] 0.68; 95% confidence interval [CI]: 0.65–0.71) and 39% lower odds in girls (OR 0.61; 95% CI, 0.58–0.65) of reporting high performance. Playing electronic games for >4 h/d was associated with high performance with odds being 38% lower in boys (OR 0.62; 95% CI, 0.59–0.66) and 45% lower in girls (OR 0.55; 95% CI, 0.52–0.57). Sex differences in the estimates were mixed.ConclusionsHigh screen use, whether active or passive, was adversely associated with perceived high school performance, with association estimates being slightly stronger in girls than boys, and for mentally active than passive screen use. Discouraging high levels of screen use of any type could be beneficial to school performance.     

Family Experience of Caregiver Burden and Health Care Usage in a Statewide Medical Home Program

ObjectiveTo evaluate family-reported caregiver experiences and health care utilization of patients enrolled in the Pennsylvania Medical Home Program (PA-MHP) statewide practice network and compare results to PA-MHP practices’ Medical Home Index (MHI) scores. We hypothesized families enrolled in higher-scoring patient-and-family-centered medical homes (PCMH) on completed MHIs would report decreased caregiver burden and improved health care utilization.MethodsWe analyzed surveys completed by families receiving care coordination services in PA-MHP's network and each practice's mean MHI score. A total of 3221 caregivers completed surveys evaluating hours spent coordinating care/week, missed school/workdays, sick visits, and emergency department (ED) visits. A total of 222 providers from 54 participating PA-MHP practices completed the nationally recognized MHI. Family/practice demographics were collected. We developed multivariate logistic regression models assessing independent associations among family survey outcomes and corresponding practices’ MHI scores.ResultsFamilies enrolled in high-scoring PCMHs had decreased odds of spending >1 h/wk coordinating care (odds ratio [OR] 0.82, adjusted OR [aOR]: 0.70, 95% confidence interval [CI] 0.55–0.90), missing workdays in the past 6 months (OR 0.82, aOR: 0.72, 95% CI 0.69–0.97), and ED visits in the past 12 months (OR 0.83, aOR: 0.81, 95% CI 0.65–0.99) in comparison to families enrolled in lower-scoring PCMHs. Families enrolled in higher-scoring PCMHs did not report fewer sick visits despite fewer ED visits, indicating more appropriate health care utilization. High-scoring PCMHs had lower percentages of publicly insured and low-income children.ConclusionsHigher-scoring PCMHs are associated with decreased caregiver burden and improved health care utilization across diverse PA practices. Future studies should evaluate interventions uniformly improving PCMH quality and equity.     

Childhood Family Connection and Adult Flourishing: Associations Across Levels of Childhood Adversity

ObjectiveTo investigate whether higher levels of childhood family connection were associated with greater adult flourishing and if this association was present across levels of adverse childhood experiences (ACEs) and childhood socioeconomic disadvantage (SED).MethodsWe pooled cross-sectional data from telephone and mailed surveys in the Midlife in the United States study that were collected from 2 nationally representative cohorts (2004–06 and 2011–14) of English-speaking, US adults, aged 25 to 74 years. Adult flourishing z score, standardized to the study population, was created from Ryff's 42-item Psychological Well-being Scale and quartiles of childhood family connection from a 7-item scale assessing parental attention, affection, and communication during childhood.ResultsData were analyzed for the 4199 (72.0% of 5834) participants with complete data. The mean age of participants was 53.9 years and 85.4% were White. After adjusting for covariates, including adult chronic disease, ACEs, and childhood and current SED, mean (95% CI) flourishing z scores increased from the lowest to highest quartiles of family connection: −0.41 (−0.49, −0.33), −0.18 (−0.25, −0.12), −0.01 (−0.07, 0.06), and 0.25 (0.18, 0.32), respectively. For each 1 SD increase in the family connection score, there was a 0.25 (95% CI, 0.20, 0.29) unit increase in the adjusted flourishing z score. This positive association was also present across levels of ACEs and childhood SED.ConclusionsGreater childhood family connection was associated with greater flourishing in US adults across levels of childhood adversity. Supporting family connection in childhood may influence flourishing decades later, even with early adversity.