OBJECTIVE: This study uses the bioecological model of human development and person-centered methods to describe the underlying patterns of risk and their association with bullying perpetration and victimization among U.S. children.
METHODS: Using the National Survey of Children\'s Health, this study (n = 7319) explored the underlying patterns of risks across six domains (i.e., individual, family, school, neighborhood, economic, and socio-cultural) associated with bullying perpetration and victimization among U.S. elementary school children.
RESULTS: Latent Class Analysis uncovered four patterns of risks. The low risks group (72.4%) showed the lowest rates of bullying perpetration (24.6%) and victimization (57.2%). The individual and environmental risks group (15.3%) presented moderate levels of bullying perpetration (31.8%) and victimization (67.1%). The family risks group (8.3%) showed moderate levels of bullying perpetration (35.9%) and victimization (66.0%). High risks group (4.0%) presented exceptionally high rates of bullying perpetration (59.1%) and victimization (87.3%).
CONCLUSIONS: Results suggest rates of bullying perpetration and victimization differed across the four patterns of risks. Understanding the sources of risk may be critical to alleviate bullying perpetration and victimization among children.
CONCLUSIONS: Findings suggest that child bullying should be approached with customized treatment considering their pattern of risk exposure.

OBJECTIVE: To estimate adverse childhood experience (ACE) prevalence among children and adolescents aged 6-17 years in the United States, to examine factors influencing the prevalence of ACEs over the time period 2016-2019, and to examine the difference in bullying trends compared to ACEs in the NSCH.
METHODS: The National Survey of Children\'s Health (NSCH) is a cross-sectional survey. Participants included respondents who completed the separate surveys for ages 6-11 and 12-17 from 2016 to 2019.
METHODS: Cumulative ACEs were analyzed to determine the change in prevalence of having at least one ACE, overall and stratified by age group.
RESULTS: Overall prevalence was highest among income difficulties (16-26 %); parent/guardian divorced or separated (29-31 %); and bullying (21-48 %). There was a significant time trend for income difficulties (decreased; p < 0.001), lived with anyone with a mental illness (increased; p = 0.004), racial/ethnic mistreatment (increased; p = 0.004), and bullying (increased; p < 0.001). Cumulative prevalence trends without bullying decreased significantly from 2016 to 2019 while prevalence trends for bullying increased significantly during this time frame. Sex, age, and race/ethnicity were significantly associated with some of the ACEs.
CONCLUSIONS: Trend of ACEs varies as prevalence of some ACEs increased while decreasing for others over time. Also, ACEs appear to affect children and adolescents differently according to sex, age group, and racial/ethnic background, which warrants the need to prioritize efforts to decrease the exposure to ACEs.

BACKGROUND: Federal guidelines recommend physical activity throughout the day for preschool-aged children. Time playing outdoors can support physical activity participation, health, and development. Estimates of time playing outdoors among U.S. children aged 3-5 years have not been published.
METHODS: Parent/caregiver-reported data on children aged 3-5 years from the 2021 National Survey of Children\'s Health were analyzed in 2022-23. Chi-square tests were used to identify differences in time playing outdoors by sociodemographic and neighborhood characteristics. Multiple logistic regression analyses were conducted with significant characteristics for weekdays and weekend days.
RESULTS: Among 11,743 children aged 3-5 years, 37% played outdoors for ≤1 hour on weekdays, and 24% played outdoors for ≤1 hour on weekend days. In 9 states, ≥40% of children played outdoors for ≤1 hour on weekdays. Adjusted models for weekdays and weekend days showed a greater likelihood of ≤1 hour playing outdoors among those in all racial/ethnic groups compared to non-Hispanic White, those who lived in metropolitan statistical areas, those who did not participate in child care, and those whose adult proxy disagreed with \"we watch out for each other\'s children in this neighborhood.\" The weekday model showed additional differences by sex, with girls more likely to have ≤1 hour of time playing outdoors.
CONCLUSIONS: Nearly 40% of preschool-aged children play outdoors for ≤1 hour per day on weekdays, with differences by sociodemographic and neighborhood characteristics. Further study and interventions focused on building supportive, equitable communities might increase the amount of time preschool-aged children spend playing outdoors.

BACKGROUND: Adolescents with autism spectrum disorder (ASD) are at an increased risk of overweight/obesity and adverse childhood experiences (ACEs).
OBJECTIVE: This study examined whether ACEs increased the odds of overweight/obesity in adolescents with ASD.
METHODS: This cross-sectional study used National Survey of Children\'s Health (NSCH) 2018-2019 data (N = 31,533 children ages 10-17 years, including n = 480 children with mild ASD and n = 423 children with moderate/severe ASD with normal or overweight/obese BMI). Parent-reported body mass index (BMI) was coded as overweight/obesity vs. normal weight. The independent variable was the count of nine ACEs. Binary logistic regression was conducted, controlling for social ecological factors.
RESULTS: The odds of overweight/obesity in adolescents with ASD with 1-2 ACEs (OR 1.3, CI 1.1-1.4) and 3+ ACEs (OR 1.6, CI 1.3-2.0) were higher than those with 0 ACEs; odds increased with higher counts of ACEs. Household income level was the most significant sociodemographic influence on odds of obesity in adolescents with ASD (0-99 % Federal Poverty Level: OR 1.9, CI 1.6-2.3). Adolescents with moderate/severe ASD (OR 1.7, CI 1.2-2.5) and mild ASD (OR 1.6, CI 1.0-2.4) had higher odds of overweight/obesity after accounting for ACEs, race/ethnicity, sex, household income, and physical activity.
CONCLUSIONS: Findings indicated ACEs are associated with ASD, which calls for integration of ACEs information within trauma-informed care practices for obesity prevention and intervention for adolescents with ASD. Persistent disparities of overweight/obesity exist by race/ethnicity, sex, and household income within this population, which indicates the need for tailoring trauma-informed approaches to the unique needs of this population.

BACKGROUND: Youth with disabilities are five times more likely to experience anxiety or depression than peers without disabilities. Engagement in sufficient daily physical activity (PA), adequate nightly sleep, and limited daily screen time (collectively known as 24-h movement guidelines) is associated with lower odds of anxiety and depression for peers without disabilities. Extending the investigation of these modifiable behaviors to youth with disabilities is warranted.
OBJECTIVE: To estimate the association between meeting 24-h movement guidelines and anxiety and depression among a nationally representative sample of youth with disabilities.
METHODS: A cross-sectional secondary analysis of the 2019-2020 NSCH was conducted and included youth 6-17 years old who were currently receiving special education services. Weighted prevalence estimates and logistic regressions were employed to estimate the association between meeting guidelines (separately and combined) and current anxiety or depression status.
RESULTS: Compared to youth with disabilities who met the guideline, those not meeting the sleep or screen time guidelines, independently, had significantly higher odds of depression, or anxiety (aOR range 1.53, 2.31 respectively). Comparable odds were observed between those meeting the PA guidelines, alone or in combination, and those meeting none of the 24-h movement guidelines.
CONCLUSIONS: Adequate nightly sleep, and limited screen time, were significantly associated with anxiety and depression among youth with disabilities, a pattern consistent to peers without disabilities. Yet, meeting more than one guideline did not further reduce odds of poor mental health, warranting further investigation of compounding benefits of the 24-h guidelines within this population.

BACKGROUND: Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are two of the most common neurodevelopmental disorders with comorbidity rates of up to 70%. Population-based studies show differential rates of ADHD and ASD diagnosis based on sociodemographic variables. However, no studies to date have examined the role of sociodemographic factors on the likelihood of receiving an ADHD, ASD, or comorbid ASD + ADHD diagnosis in a large, nationally representative sample.
OBJECTIVE: This study aims to examine the impact of sociodemographic factors on the odds of experiencing ASD-only, ADHD-only, or both diagnoses for children in the United States.
METHODS: Using a mixed effects multinomial logistic modeling approach and data from the 2016-2018 National Survey of Children\'s Health, we estimated the association between sociodemographic variables and the log odds of being in each diagnostic group.
RESULTS: Sociodemographic variables were differentially related to the three diagnostic groups: ASD-only, ADHD-only, and ASD + ADHD. Compared to girls, boys experienced higher odds of all three diagnosis categories. White children had higher odds of having an ADHD-only or ASD + ADHD diagnosis compared to non-Hispanic (NH) Black, NH multiple/other race, and Hispanic children. Odds ratios for levels of parent education, household income, and birth characteristics showed varying trends across diagnostic groups.
CONCLUSIONS: Overall, our findings point to unique sets of risk factors differentially associated ASD and ADHD, with lower income standing out as an important factor associated with receiving a diagnosis of ASD + ADHD.

OBJECTIVE: Recent updates of geographic variations, trends, and sociodemographic disparities in obesity prevalence among US adolescents are limited. The study aimed to fill those research gaps.
METHODS: Serial cross-sectional analysis of the US nationally representative study.
METHODS: Data from six cycles of the National Survey of Children\'s Health (2016, 2017, 2018, 2019, 2020, and 2021) with information on physical health at the national and state level were used. A total of 107,274 adolescents aged 10-17 years old were included with sociodemographic data (age, sex, race/ethnicity, parental education level, and family income) and state of residence. Logistic regression models were used to estimate the odds ratios (ORs) associated with obesity across sociodemographic groups. In addition, ORs were calculated to compare obesity rates between the pandemic period (2020-2021) and the pre-pandemic period (2018-2019) overall and by sociodemographic subgroups. Survey analysis procedures were used to account for complex survey designs to derive representative estimates.
RESULTS: From 2016 to 2021, obesity prevalence increased from 16.1% (95% confidence interval [CI], 14.9%-17.4%) to 17.6% (95% CI, 16.4%-18.9%) (P-trend = 0.04). The combined prevalence of obesity varies substantially by state, from 9.34% (95% CI, 6.96%-12.4%; Colorado) to 27.1% (95% CI, 23.1%-31.5%; Mississippi) for adolescents aged 10-13 years and ranged from 9.86% (95% CI, 7.63%-12.7%; Utah) to 22.4% (95% CI, 19.0%-26.1%; West Virginia) for adolescents aged 14-17 years. Except for subgroups male gender and parents with college degrees or above, the prevalence of obesity showed stable trends across sociodemographic subgroups. Compared to the pre-pandemic period, the multivariable-adjusted ORs of obesity were 1.18 (95% CI, 1.06-1.32) for male adolescents, 1.16 (95% CI, 1.04-1.28) for non-Hispanic White adolescents, 1.81 (95% CI, 1.15-2.84) for non-Hispanic Asian adolescents, 1.26 (95% CI, 1.05-1.52) for adolescents whose parents had a high school education, and 1.15 (95% CI, 1.0-1.33) for adolescents whose parents had a college degree or higher.
CONCLUSIONS: The prevalence of obesity among US adolescents increased significantly between 2016 and 2021. The prevalence of obesity was relatively high in southern states. Those with low household income, low parental education, or being non-Hispanic Black or Hispanic were also more likely to be obese. Compared to the pre-pandemic period, several groups of adolescents increased their likelihood of obesity during the pandemic period.

To evaluate the association of external factors of resilience, neighborhood, and family resilience with healthcare use.
A cross-sectional, observational study was conducted using data from the 2016-2017 National Survey of Children\'s Health. Children aged 4-17 years were included. Multiple logistic regression was used to determine aOR and 95% CIs for association between levels of family resilience, neighborhood resilience and outcome measures: presence of medical home, and ≥2 emergency department (ED) visits per year while adjusting for adverse childhood experiences (ACEs), chronic conditions, and sociodemographic factors.
We included 58 336 children aged 4-17 years, representing a population of 57 688 434. Overall, 8.0%, 13.1%, and 78.9% lived in families with low, moderate, and high resilience, respectively; 56.1% identified their neighborhood as resilient. Of these children, 47.5% had a medical home and 4.2% reported ≥2 ED visits in the past year. A child with high family resilience had 60% increased odds of having a medical home (OR, 1.60; 95% CI, 1.37-1.87), and a child with moderate family resilience or resilient neighborhood had a 30% increase (OR, 1.32 [95% CI, 1.10-1.59] and OR, 1.31 [95% CI, 1.20-1.43], respectively). There was no association between resilience factors and ED use, although children with increased ACEs had increased ED use.
Children from resilient families and neighborhoods have an increased odds of receiving care in a medical home after adjusting for the effects of ACEs, chronic conditions, and sociodemographic factors, but no association was seen with ED use.

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often characterized by long-term impairments in family, academic, and social settings. Measuring the prevalence of ADHD is important as treatment options increase around the U.S. Prevalence data helps inform decisions by care providers, policymakers, and public health officials about allocating resources for ADHD. In addition, measuring geographic variation in prevalence estimates can facilitate hypothesis generation for future analytic work. Most U.S. studies of ADHD prevalence among children focus on national or demographic group rates.
Using a small area estimation approach and data from the 2016 to 2018 National Survey of Children\'s Health, we estimated childhood ADHD prevalence estimates at the census regional division, state, and county levels. The sample included approximately 70,000 children aged 5-17 years.
The national ADHD rate was estimated to be 12.9% (95% Confidence Interval: 11.5%, 14.4%). Counties in the West South Central, East South Central, New England, and South Atlantic divisions had higher estimated rates of childhood ADHD (55.1%, 53.6%, 49.3%, and 46.2% of the counties had rates of 16% or greater, respectively) compared to counties in the Mountain, Mid Atlantic, West North Central, Pacific, and East North Central divisions (2.1%, 4%, 5.8%, 6.9%, and 11.7% of the counties had rates of 16% or greater, respectively).
These local-level rates are useful for decision-makers to target programs and direct sufficient ADHD resources based on communities\' needs.

There is a lack of nationally representative studies examining the co-occurrence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) in children. This study examines comorbid mental, behavioral, and developmental disorders (MBDDs) and associated treatment modalities for children with co-occurring ASD and ADHD. Cross-sectional analyses were conducted using data from the pooled 2016-2018 National Survey of Children\'s Health (sample n = 102,341). Nationally representative prevalences were estimated for sociodemographic variables, comorbidities, psychotropic medication, and behavioral treatment. We assessed multivariable associations between co-occurring ASD + ADHD and MBDDs, use of psychotropic medication, and receipt of behavioral treatment after adjustment for sociodemographic confounders. Compared to children with ASD without co-occurring ADHD, children with ASD + ADHD had higher prevalence of most MBDDs, including anxiety (AOR 4.03 [95% CI 2.77, 4.87]), depression (AOR 3.08 [95% CI 1.77, 5.36]), behavior or conduct problems (AOR 4.06 [95% CI 2.72, 6.06]), and other mental health conditions. Similarly, compared to children with ADHD without ASD, children with ASD + ADHD had higher odds of anxiety (AOR 3.49 [95% CI 2.65, 4.61]), depression (AOR 1.67 [95% CI 1.21, 2.29]), behavior or conduct problems (AOR 2.31 [95% CI 1.68, 3.17]), and other mental health conditions. Children with ASD + ADHD were significantly more likely to take psychotropic medication than children with ASD without ADHD. Among children with ASD + ADHD, males had higher odds of receiving behavioral treatment, whereas older children and adolescents were more likely to take psychotropic medication. A multidisciplinary approach is necessary to support the complex needs of these children.