Determine the national prevalence of currently diagnosed mental health problems Attention-Deficit Hyperactivity Disorder (ADHD),

The aims of this study are to: 

1.Determine the national prevalence of currently diagnosed mental health problems (Attention-Deficit Hyperactivity Disorder (ADHD), behavioral disorder, anxiety and depression) among children aged 3-17 years in the US using data from the National Survey of Children's Health (NSCH). Mental health outcomes with be examined relative to individual, parental, and community or societal contexts of interest. 

2.Examine the associations between ACEs and mental health outcomes (ADHD, behavior disorders, anxiety and depression) in children nationally. Correlates between the cumulative number of ACEs and specific ACE measures with each mental health outcome will be examined. Examine the association between resilience and mental health outcomes in the context of individual, family, and community characteristics. 

Study Design & Study Population

 

A cross-sectional study using secondary data from the 2018 National Survey of Children’s Health (NSCH) was used for this study. The study population consists of noninstitutionalized children between the ages of 3 and 17 nationally whose parents or guardians completed the survey.

Study Measures

 

The presence of current mental conditions will be assessed using survey parent/caregiver’s responses to questions asking whether the doctor had ever told the parent/caregiver that the child had ADHD, anxiety, behavior disorders or depression (yes/no). If yes, a secondary question asked whether the child currently had the condition (yes/no). The following response options are provided based on created variables in the dataset that represent children who currently have the conditions  : “does not have the condition”, “ever told, but does not currently have the condition”, and  “currently has the condition”. If yes was answered to the primary and secondary questions, then the child was assessed as currently having the condition; however, if yes was answered to the primary question and no was answered to the secondary question then the child was assessed as “ever told, but does not currently have the condition”.  If the responses to both the primary and secondary questions were missing, the variables representing children who currently have the conditions were also missing.  For the outcome measures, this will be limited to those children whose caretakers provided definite responses and current cases of the mental health outcomes of interest to reduce the limitation of establishing temporal precedence due to the cross-sectional design of the study. 

A dichotomous variable measuring whether the child currently has the condition will be created and coded as (0) does not currently have condition; or (1) currently has condition, where the response options “do not have the condition”, and “ever told, but does not currently have the condition”, will be categorized as “does not currently have the condition”.

Covariates

 

Demographic information such as child sex, age, race/ethnicity, family structure, household educational level, insurance type, and family poverty/income level will be included in the study. The selection of these variables is consistent with other studies that examined ACEs or mental health outcomes (Elmore & Crouch, 2020; Ghandour et al., 2019) . Sex will be a dichotomous variable coded as female (1) and male (0). Age will be an ordinal variable coded as (0) 12-17; (1) 6-11; and (2) 3-5. Race/ethnicity will be categorized as : White, Non-Hispanic (0), Black, non-Hispanic (1), Hispanic (2) and Other, non-Hispanic/ Multiracial (3). Family structure will be coded as (0) two parents married; (1) two parents unmarried; (2) single parent (3) Nonparent/ other relative (either grandparent/ other family type). The highest household educational attainment  variable will be recoded into two categories (0) less than high school education (no GED) or high school diploma (GED); and  (1) some college or college degree/ higher. The income level of the family is categorized based on the federal poverty level (FPL) guidelines which will be categorized as : (0) <100% FPL; (1) 100-199% FPL; (2) 200-399% FPL; and (3) ≥ 400% FPL. The type of insurance or insurance status of the child will be coded as (0) uninsured; (1) private and public insurance (2)  private insurance; or (3) public insurance. 

Elmore, Crouch, & Kabir Chowdhury, (2020) noted that the mental health of caregivers could impact exposure to ACEs, resilience factors or mental health outcomes among children. As such, the mental or emotional health of the parents or caregivers of the child will be assessed through the survey question directed at the child’s primary caregivers, “In general how is your mental health?” The response options provided were excellent, very good, good, fair or poor. These will be recoded into excellent, very good/good and fair/poor. .Living and playing in safe and equitable environments have been shown to be examples of positive childhood experiences or resilient factors (Sege & Harper Browne, 2017). A response of yes (to be coded as 1) or no (to be coded as 0) to the survey questions, “In your neighborhood is there a park/ playground” or “In your neighborhood is there a recreation center, community center, or boys’ and girls’ club ”  will be used as responses for the variable ‘opportunities for play and physical activity’.  The safe neighborhood variable will be assessed by the question “To what extent do you agree with these statements about your neighborhood or community? This child is safe in our neighborhood?” The response options provided were definitely agree, somewhat agree, somewhat disagree and definitely disagree. These will be recoded into 2 categories : definitely agree or somewhat agree as agree (1) and  somewhat disagree or definitely disagree as disagree (0). 

Medical home initiatives have been identified as an important service for children with special needs. (American Academy of Pediatrics & Medical Home Initiatives for Children With Special Needs Project Advisory Committee., 2002) and is included in this study. Essential qualities of a medical home has been defined as : accessible, continuous, coordinated, compassion, comprehensive, culturally effective and family-centered care (National  Resource Center for Patient-Centered Medical Home, 2020). The medical home variable (measured as 1 for yes and 2 for no) criteria as measured by the NSCH was based on five components which include having a personal doctor or nurse who knows the  child’s health history well, usual source of care, family-centered care,  receiving the necessary help to coordinate the child’s care and obtaining referrals for services.   

Statistical Analysis

 

The characteristics and demographics of the study population will be described and stratified by each mental health outcome (ADHD, anxiety, behavior disorders  and depression).  Given the study variables are categorical, descriptive statistics will be frequencies and percentages using proc survey freq and chi-square analysis which will be used to examine the mental health outcomes relative to individual, parental, and community or societal contexts of interest. Survey weights provided by the Census Bureau will be utilized to account for nonresponse and noncoverage and reflect the US population of all noninstitutionalized children aged 0-17 years.