Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity

The outcome of flourishing and its predictors have not been well documented among US children, especially those who face adversity. Using data for 2016 and 2017 from the National Survey of Children ’ s Health, we determined the prevalence and predictors of flourishing among US children ages 6 – 17. A three-item index included indicators of flourishing: children ’ s interest and curiosity in learning new things, persistence in completing tasks, and capacity to regulate emotions. The national prevalence of flourishing was 40.3 percent (29.9 – 45.0 percent across states). At each level of adverse childhood experiences, household income, and special health care needs, the prevalence of flourishing increased in a graded fashion with increasing levels of family resilience and connection. Across the sectors of health care, education, and human services, evidence-based programs and policies to increase family resilience and connection could increase flourishing in US children, even as society addresses remediable causes of childhood adversity.

F lourishing and its predictors and links to health outcomes are well documented in adults, including among those facing adversities. [1][2][3][4][5][6] Less is known about flourishing and its correlates among children, especially those who face circumstances such as adverse childhood experiences (ACEs), chronic illness, or poverty. Studies show that flourishing is distinct from an absence of physical or mental illness and other adversities; that flourishing can and does exist amid these circumstances; and that health outcomes vary widely among individuals exposed to similar levels of adversity. 4,6 Understanding the factors that promote flourishing amid adversity is an important public health need for children and families.
A recent systematic review 1 of human flourishing models identified six overlapping positive attributes used to define flourishing: meaning, engagement, positive relationships, competence (or accomplishment), positive emotion, and self-esteem (or self-worth). Among these six attributes, meaning and engagement in life were common to each flourishing model. Positive emotions were least consistently included in definitions of flourishing.
There is a robust literature on flourishing, its specific attributes, and how it is measured and relates to other concepts such as well-being. [1][2][3][4][5][6][7][8][9] In terms of the six attributes listed above, flourishing is similar to measures of subjective wellbeing, such as those used by the World Health Organization 10 and the Organization for Economic Cooperation and Development. 11 However, flourishing is distinct from other comprehensive measures of well-being, such as the Gallup measure, 12 which includes reflective evaluations of life satisfaction, having financial and social needs met, and experiencing physical vitality; the United Nations Children's Fund child well-being measure, 13 which includes objective measures related to material, educational, health, safety, housing, and environmental resources and health behaviors and risks; and a recently developed population well-being measure to explain disparities in life expectancy. 14 Attributes of flourishing identified in research on adults are reflective of goals for promoting the healthy development of children, as set forth in research 15 and national frameworks and guidelines. [16][17][18] This includes healthy social and emotional development and cultivating an open and engaged approach to learning. Because of children's developmental status and reliance on parent or teacher reports of children's attributes for measurement validity reasons, measuring flourishing for children typically focuses on parents' or other adults' reports of observable attributes of children. [19][20][21][22] In contrast, adult measures of flourishing typically rely on self-reports.
Flourishing constructs for children that are amenable to parent-reported measurement have been set forth. [19][20][21][22] Emphasized are indicators of whether children show interest and curiosity in learning new things, are able to regulate emotions and behaviors in challenging situations, and can focus and persist to achieve goals. Studies using attributes of child flourishing such as these document associations with reductions in risky health behaviors and mental health problems in children and youth, 23-25 as well as reductions in physical, mental, and social health problems as adults. 25,26 Beginning with its 2011-12 administration, the National Survey of Children's Health (NSCH) included items developed to assess flourishing among children ages 6 months to 5 years and ages 6-17 years. These items were formulated by an expert panel sponsored by the Health Resources and Services Administration and facilitated by the Child and Adolescent Health Measurement Initiative in partnership with Child Trends. The issues were selected to optimize validity for parent report (tested using cognitive interviewing), align with published models of child flourishing, consider children's developmental status, and minimize survey burden. We focused on children ages 6-17 in this study, since key variables of interest are not available in the NSCH for younger children. The NSCH flourishing items for children ages 6-17 asked parents how well each of three items describes their child: "shows interest and curiosity in learning new things," "works to finish tasks he or she starts," and "stays calm and in control when faced with a challenge." Studies using data from the 2011-12 NSCH found that fewer than 50 percent of US children ages 6-17 were flourishing. [27][28][29][30] After adjustments, modest or insignificant variations were found in flourishing by race, ethnicity, and poverty level and significant, but also modest, asso-ciations between flourishing and obesity, neighborhood and school safety, and parenting practices such as limiting television watching or sharing family meals. [28][29][30] The studies also revealed lower rates of flourishing for children exposed to ACEs. 30 However, children with two or more ACEs whose parent or guardian reported that their child "stays calm and in control when faced with a challenge" were substantially less likely to be identified as having an emotional, mental, or behavioral health condition. 31 Such children were also more likely to be engaged in school. 32,33 In addition, one study found that a higher proportion of children exhibited this resilience attribute of flourishing when their parent reported that they "can share about ideas and talk about things that really matter" with their child and thought they were handling the day-today demands of raising children "very well." 31 Studies have also shown strong evidence of a link between the attributes of child flourishing, such as resilience, with nurturing parenting and parental coping. [34][35][36][37][38][39][40] To date, no studies have assessed how the parenting and family factors included in the NSCH promote child flourishing across subgroups of children according to their level of adversity, such as exposure to ACEs, poverty, or the presence of special health care needs. Knowledge about this is important for efforts to promote systems of care to improve positive outcomes for children, such as the new Integrated Care for Kids Model advanced by the Centers for Medicare and Medicaid Services. 41 Beginning with the 2016 administration of the NSCH, four new items were added to assess family resilience, and large changes were made to the sampling frame and mode of administration that prevent comparisons with prior years of the NSCH. 42 These changes require the establishment of a new baseline prevalence of flourishing among children for the US and by state. In addition, they provide an opportunity to examine population-level associations between child flourishing and attributes of family resilience and connection that research suggests foster child flourishing, for all children and those facing adversities. [34][35][36][37][38][39][40] This study used 2016 and 2017 NSCH data for US children ages 6-17 to address four objectives: establish the construct validity of a three-item child flourishing index (CFI) by examining its association with school engagement, describe the national and state prevalences of flourishing, determine whether higher scores on a created six-item family resilience and connection index (FRCI) are associated with a greater prevalence of flourishing, and determine whether the strength of the association between FRCI scores and the prevalence of flourishing varies accord-items. Second, one point was assigned for each time a parent responded "very well" to the two additional items listed above.
▸ SCHOOL ENGAGEMENT: Children were classified as meeting criteria for school engagement if their parents reported "definitely true" for both of the following items: their child "cares about doing well in school" and "does all required homework." ▸ SOCIODEMOGRAPHIC FACTORS, SPECIAL HEALTH CARE NEEDS, AND ADVERSE CHILD-HOOD EXPERIENCES: Child age, sex, race and ethnicity, and household income (as a percentage of the federal poverty level) were measured using standard NSCH categories. 44 Children's special health care needs status was assessed, and ACEs measures were created using validated methods documented elsewhere. 45,46 Children with special health care needs are classified as "more complex" when they meet more than the first of the five criteria in the Children with Special Health Care Needs Screener. 46 Analytic Methods ▸ CHILD FLOURISHING INDEX CONSTRUCT VA-LIDITY: Multivariable logistic regression models were used to assess the construct validity of the CFI. These models used school engagement as the outcome (dependent) variable, the CFI items or scores as the predictor variables, and ACEs, special health care needs status, and sociodemographic variables as covariates. A separate regression model was developed for each CFI item, using its response levels as predictors. For the CFI score, the categories of 0 or 1, 2, and 3 were used as predictors.
▸ STATE PREVALENCES OF CHILD FLOURISH-ING: Nested t-tests were used to assess the statistical significance of the difference between each state's prevalence of child flourishing (using CFI criteria) and the national prevalence.
▸ ASSOCIATIONS BETWEEN INDEXES ACROSS CHILD ADVERSITY CATEGORIES: Chi-square tests were used to assess the significance of differences in the prevalence of child flourishing across levels of exposure to ACEs (0, 1, 2 or 3, and 4 or more), household income (four levels, expressed as a percentage of the federal poverty level), special health care needs status ("more complex needs," "less complex needs," and "no special health care needs"), and other sociodemographic characteristics. Multivariable logistic regression analysis was employed to calculate adjusted odds of flourishing by levels of the FRCI score (0 or 1, 2 or 3, and 4-6), after other variables (including ACEs) were controlled for. Finally, the strength of the association between FRCI scores and the prevalence of flourishing was separately evaluated for subgroups of children who faced different levels of adversity as measured by ACEs, household income, and the presence of special health care needs.
Limitations Our study had several limitations. First, this study was cross-sectional and could not establish causal relationships between flourishing and family resilience and connection.
Second, the flourishing measure used in this study was not meant to be definitive and may have overestimated flourishing, since reporting bias among parents tends to be positive and only three items are used in the NSCH to operationalize the measurement of flourishing. If additional items and dimensions were assessed, a lower prevalence of flourishing likely would result, because some children would fail to meet the additional criteria. Additional research is needed-especially to determine measures of flourishing among children with disabilities, for whom the three items in the CFI might not be as meaningfully applied.
Third, the CFI and FRCI have not yet been evaluated for clinical applications, nor are child self-report versions available.
Fourth, the ACEs measure included in the NSCH did not explicitly ask about child sexual abuse or neglect. Research suggests that the experiences that are assessed are likely to co-occur with these unassessed ACEs. Thus, we do not expect children with such experiences to be missed by the NSCH ACEs cumulative risk measure, 46 though some may be.

Study Results
Validity Of The Child Flourishing Index We found a significant graded relationship between greater flourishing as shown on the CFI score and the prevalence of school engagement. There was a 56.2-percentage-point difference in school engagement between children meeting zero or one versus meeting all three CFI criteria (33.2 percent versus 89.4 percent) (exhibit 1). Compared to children meeting zero or one CFI criteria, the adjusted odds of school engagement were 14.19 times greater for children meeting all three criteria and 4.97 times greater for children meeting two criteria. A significant graded relationship was also found between parent endorsement of each CFI item (from "not true" to "somewhat true" to "definitely true") and the prevalence of school engagement, but there was a stronger graded relationship between school engagement and levels of the CFI score. (See appendix D for detailed regression findings.) 43 National And State Prevalences Of Child Flourishing The prevalence of flourishing among US children ages 6-17 was 40.3 percent (exhibit 2). This ranged from 29.9 percent to 45.0 percent across states. (See appendix exhibits C1 and C2 for findings for each state.) 43 Variations In Prevalence Of Flourishing By Child Characteristics The prevalence of flourishing varied by about 5 percentage points across age and sex categories, with a higher prevalence observed in older children and females (exhibit 2). Prevalence varied by about 12 percentage points across income categories, with the highest prevalence among children living in households with incomes 400 percent of or higher than the federal poverty level (46.9 percent). Prevalence of flourishing varied about 7 percentage points across racial and ethnic groups. After other factors were adjusted for, race and ethnicity were not significantly associated with flourishing. Prevalence varied most (by 33.2 percentage points) across subgroups of children with special health care needs and second-most (by 27.3 percentage points) by children's level of exposure to ACEs.
Association Of Family Resilience And Connection With Flourishing The FRCI and each of its components showed a graded association with child flourishing. Compared to children with a FRCI score of 0 or 1, those with scores of 2 or 3 and 4-6 had 2.11 times and 3.71 times greater odds of flourishing, respectively, after covariates were adjusted for (exhibit 3). Specifically, a 30.0-percentage-point difference in

Exhibit 1
Percent of US children ages 6-17 who were engaged in school and adjusted odds ratios, by child flourishing index (CFI) score and score items, 2016-17  SOURCE Authors' analysis of data for 2016 and 2017 from the National Survey of Children's Health. NOTES All percentages are weighted to represent the US population ages 6-17. Statistical significance refers to chi-square tests comparing the percentage of children who are flourishing or have "definitely true" responses to child flourishing index (CFI) items across levels of each characteristic. CI is confidence interval. FPL is federal poverty level. FRCI is family resilience and connection index. a CFI items are given in full in exhibit 1. b Adjusted odds ratios controlled for age, sex, race/ethnicity, income, adverse childhood experiences (ACEs), and special health care needs status. c Not applicable. d Differences in percentages by age category are all significant (p < 0:001) except for "works to finish tasks started" (p > 0:10). e Differences in percentages by race/ethnicity category are all significant (p < 0:001) except for flourishing, which is significant (p < 0:05), and "stays calm and in control when faced with a challenge" which is not significant (p > 0:10). f Six-item score (0-6) with one point for each "all of the time" response to the four family resilience index items, and one point for each "very well" response to the parent-child connection and parent coping items. g Four-item score (0-4) with one point for each "all of the time" response. h Based on response to a single item: "How well can you and this child share ideas or talk about things that really matter?" i Based on response to a single item: "How well do you think you are handling the daily demands of raising children?" ****p < 0:001 flourishing was found between children in the highest FRCI category and those in the lowest (51.5 percent versus 21.5 percent). A 16.6-percentage-point difference was observed between children with an FRCI score of 2 or 3 and those with a score of 0 or 1 (38.1 percent versus 21.5 percent). Across FRCI components, the association with child flourishing was strongest for the parentchild connection component. The adjusted odds of flourishing were 12.55 times greater for children whose parents reported "very well" (versus "not very well or not at all) to the item "how well can you and this child share ideas or talk about things that really matter." The adjusted odds were 3.90 times greater for children whose parents reported "somewhat well." (See appendix F for regression details.) 43 Despite the significant association between ACEs and flourishing (exhibit 2), there were only small changes in the adjusted odds of child flourishing associated with FRCI scores before or after adjusting for ACEs, which indicates that the FRCI is associated with flourishing independent of ACEs. (See appendix exhibit C3 for regression details.) 43 Association Of Family Resilience And Connection With Flourishing Across Levels Of Adversity For groups of children within each level of exposure to ACEs, household income, or special health care needs, there was a similar graded association between flourishing and FRCI scores, with a greater prevalence of flourishing at higher levels of family resilience and connection. Overall, the adjusted odds of flourishing were three to four times greater for children with an FRCI score of 4-6 (compared to a score of 0 or 1) within groups of children at all four levels of exposure to ACEs and at all four levels of household income (exhibit 4). Adjusted odds of flourishing for those with a score of 2 or 3 versus that of 0 or 1 were smaller but also significant.

Culture Of Health
More specifically, the adjusted odds of flourishing for children with a score of 4-6 versus a score of 0 or 1 within the categories of ACEs ranged from 3.15 to 3.88. For children's household income level, this range was 3.67-3.86.
Among children with "more complex" special health care needs, the adjusted odds of flourishing for those with an FRCI score of 4-6 were 3.69 times greater than for those with a score of 0 or 1. The same comparisons within two other groups of children-those with "less complex" needs and those without any special health care needs-produced similar results. (See appendix E for regression details.) 43

Discussion
Approximately 40 percent of school-age children in the US meet criteria for flourishing, as operationalized by an index derived from three items designed to assess flourishing in the National Survey of Children's Health. With only four in ten US children meeting flourishing criteria, populationwide approaches to promoting attributes of flourishing are suggested, even as targeted efforts address the needs of children exposed to adversity. The promising news is that the prevalence of flourishing was associated in a graded fashion with greater levels of family resilience and connection, and the strength of this association was similar across groups of children defined by varying levels of adversity-as measured by exposure to ACEs, household income as a percentage of the federal poverty level, and the presence of special health care needs.
The especially strong association between flourishing and the parent-child connection component of the family resilience and connection index score is consistent with the science showing the primacy of safe, stable, and nurturing relationships to optimal child development. Such relationships are advanced through the

Exhibit 3
Percent of US children ages 6-17 who were flourishing and adjusted odds of flourishing, by family resilience and connection index (FRCI) score and score components, 2016-17 SOURCE Authors' analysis of data from the combined 2016 and 2017 National Survey of Children's Health. NOTES Parent-child connection and parent coping items are explained in the notes to exhibit 2. Flourishing is defined as having a "definitely true" response to all 3 items in the child flourishing index (index score = 3). All percentages are weighted to represent the US population ages 6-17. Statistical significance refers to chi-square tests comparing the percentage of children who were flourishing across the levels of FRCI score or components. CI is confidence interval. a Adjusted odds ratios controlled for age, sex, race/ethnicity, income, adverse childhood experiences (ACEs), and special health care needs status.

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Centers for Disease Control and Prevention's Essentials for Childhood framework 18 and the national Bright Futures Guidelines. 16 Across the US, efforts are emerging to identify the concrete approaches and resources required to improve resilience and connection within families. 47-50 Many of these strategies, such as those advanced in the Institute of Medicine report on family-focused interventions, 47 focus on families as the key social unit for increasing child flourishing and mitigating the negative effects of adversities. These strategies also emphasize the broader social factors that influence family resilience and connection by including family supports related to housing, jobs, transportation, neighborhood safety, social support, and access to resources.
Across the sectors of health care, education, and human services, evidence-based programs and policies to increase family resilience and connection could increase flourishing in US children, even as society addresses remediable causes of childhood adversity. Efforts such as the emerging national Integrated Care for Kids Model 41 seek to promote well-being and value in children's health care and assessing and tracking child flourishing and family resilience and connection may support these goals. Similarly, assessing child flourishing and family resilience and connection in the context of emerging initiatives to screen for and address ACEs, as in California's Medicaid program, 51 may help target and assess the outcomes of efforts to prevent and mitigate the negative effects of ACEs.
People trying to successfully engage families and children in this process must make them partners and give them a voice. 48,52 Success will also require efforts to increase flourishing among people who provide health care, social, or educational services so that they have sustained meaning and engagement in their work with families. 53,54 Promoting the specific aspects of flourishing assessed here could increase the level of meaning and engagement that children have in their relationships and activities in their homes, schools, and neighborhoods. Success relies on people who wish to create safe, stable, and nurturing relationships with children and families as the basis for intergenerational flourishing in the face of aging, disease, and other unavoidable challenges across the life span. ▪

Exhibit 4
Percent of US children ages 6-17 who were flourishing and adjusted odds of flourishing, by family resilience and connection index (FRCI) score, stratified by number of adverse childhood experiences (ACEs), household income, and special health care needs status, 2016-17 SOURCE Authors' analysis of data from the combined 2016 and 2017 National Survey of Children's Health. NOTES All percentages are weighted to represent the US population of children ages 6-17. Flourishing is defined as having a "definitely true" response to all 3 items in the child flourishing index (index score = 3). All percentages are weighted to represent the US population ages 6-17. CI is confidence interval. FPL is federal poverty level. a Within each level of ACEs, household income, and special health care needs status, the percentage of children who were flourishing differed significantly (p < 0:001) both within and across the three FRCI scores. b Adjusted odds ratios controlled for age, sex, race/ethnicity, household income, ACEs, and special health care needs; the exception is that when one of these variables is the dependent variable (for example, ACEs, household income, special health care needs), that variable was not included in the model as an independent variable. Bethell CD, Gombojav N, Whitaker RC. Family resilience and connection promote flourishing among US children, even amid adversity. Health Aff (Millwood). 2019;38(5). For the 2016 NSCH, the weighted response rate was 40.7% and the interview completion rate, defined as the probability that a household initiating the survey will complete it, was 69.7%. For the 2017 NSCH, the weighted response rate was 37.4%, and the interview completion rate was 70.9%.

A3: Overview of psychometric analysis conducted on key variables
Even though the Child Flourishing Index (CFI) and Family Resilience and Connection Index (FRCI) are indices, and not construed as latent variables, we conducted psychometric testing typically done for scales assessing a single underlying construct. Below is a summary of findings.

Child Flourishing Index (CFI):
Internal consistency (Cronbach's alpha) of the 3item flourishing index was .67. Principle components factor analysis resulted in a single Eigenvalue greater than 1.0 (1.87) that explained 62.5% of variance.
Family Resilience Index (FRI): Psychometric analysis shows an internal consistency (Cronbach alpha) of .89 for the four FRI items. Principle components factor analysis resulted in a single Eigenvalue greater than 1.0 (3.02) that explained 75.6% of variance.

Family Resilience and Connection Index (FRCI):
Internal consistency (Cronbach's alpha) of the 6 item FRCI was .84. Principle components factor analysis resulted in a single Eigenvalue greater than 1.0 (3.43) that explained 57.3% of variance. A second factor with an Eigenvalue of 1.00 explained an additional 16.7% of variance.

A4: Overview of multivariable logistic regression analyses conducted to assess the stability, sensitivity, of adjusted odds ratios
Logistic regression analysis was used to calculate adjusted odds ratios (AORs) estimating the relative odds of flourishing according to each variable category, adjusting for other variables. Sequential logistic regression models were conducted to assess the sensitivity of these associations to the inclusion of other variables. Phase one included child socio-demographics. Subsequent phases included CSHCN status, FRCI, and ACEs, sequentially. Given the formative nature of the FRCI, regression models on flourishing were separately run to calculate AORs for each component of the FRCI. Finally, to assess the stability of associations between the prevalence of child flourishing and the FRCI across various subgroups, these associations were examined in stratified regressions conducted for each level of ACEs, household income assessed by Federal Poverty Level, and CSHCN status.

Child Flourishing Index, age 6-17 years
This index was constructed based on the number of "definitely true" responses by parents to three survey items (possible score 0-3). Parents are asked how well each of the three items describes their child: "shows interest and curiosity in learning new things," "works to finish tasks he or she starts," and "stays calm and in control when faced with a challenge." Those children with an index of 3 were classified as flourishing ("definitely true" for all three descriptions). More information is available at the CAHMI's Data Resource Center's website http://childhealthdata.org/browse/survey?s=2&y=24&r=1

Family Resilience Index (FRI)
This index was constructed based on the number of "all of the time" responses by parents to four survey items (possible score 0-4). These items ask how often the child's family members do certain things when the family faces problems: "talk together about what to do," "work together to solve problems," "know they have strengths to draw on," and "stay hopeful even in difficult times."

Resilience and Connection Index (FRCI)
This index was constructed from six items (possible score 0-6). One point was assigned for each "all of the time" response by parents to the four Family Resilience Index items. Another point was assigned for each "very well" response to two additional items that asked parents how well they "share ideas or talk about things that really matter" with their child (parent-child connection) and how well they are "handling the day-to-day demands of raising children" (parental coping).

Adverse Childhood Experiences (ACEs)
Count of categories of exposure to adverse childhood experiences based on nine items assessed in the National Survey of Children's Health (NSCH): very hard to get by on income (somewhat often or very often); parent/guardian divorced or separated; parent/guardian died; parent/guardian served time in jail; child saw or heard physical violence in the home; child was a victim of violence or witnessed neighborhood violence; child lived with anyone who was mentally ill, suicidal, or severely depressed; child lived with anyone who had a problem with alcohol or drugs; and child treated or judged unfairly because of his/her race/ethnicity. 46

School Engagement, 6-17 years
Children are considered to be engaged in school if their parents reported "definitely true" reported "definitely true" to both of the following items: their child "cares about doing well in school" and "does all required homework." 44

Children with Special Health Care Needs (CSHCN)
Using the validated Children with Special Health Care Needs (CSHCN) Screener, children are classified as having an ongoing condition requiring more than routine health services. 45 The 5-item CSHCN Screener identifies children with special health needs based on the definition provided by the federal Maternal and Child Health Bureau (MCHB). CSHCN are classified as "more complex" if they qualify on one or more of the four screening criteria addressing elevated need or use of specialized services, therapies, or functional limitations. Children in this group may need or use prescription medications, but also meet one of the four other CSHCN Screener criteria. CSHCN with "less complex' needs experience chronic health conditions that are managed primarily through prescription medication. Source: Authors' analysis of the combined 2016 and 2017 National Survey of Children's Health. All estimates weighted to present the US child population* ages 6-17 years. NA: Sample size insufficient to reliably estimate difference across states for this variable. ****p<.0001 for differences in prevalence within subgroups based on chi square tests of independence a Family Resilience and Connection Index (FRCI)(0-6) was constructed based "all of the time "responses to each of the 4 family resilience index (0-4) questions plus 2 additional points for the following item responses: "very well" responses to "parents and children share ideas or talk about things that really matter" (parent-child connection) and "parents handle daily demands of raising children" (parental coping). See Technical Appendix B for more information on how each component of the FRCI. 43 b Family resilience index (0-4) was constructed based on the number of "all of the time" responses to four survey items. These items ask how often the child's family members do certain things when the family faces problems: talk together about what to do, work together about what to do, knows they have strengths to draw on, stay hopeful even in difficult times. c Family resilience index is scored based on the number of "all of the time or most of the time" responses to four survey items.

Appendix Exhibit C3: Results of Sensitivity Analysis: Association between child flourishing (age 6-17 years) and adverse childhood experiences (ACEs) when the Family Resilience and Connection Index (FRCI) is or is not included in the model and when ACEs is or is not included in the model. AOR: Adjusted Odds Ratios. All AORs significant based on 95% confidence intervals
Source: Authors' analysis of the combined 2016 and 2017 National Survey of Children's Health. All AORs are statistically significant after adjusting for age, sex, race/ethnicity, income and ACEs or FRCI (where appropriate).