The influence of loss to follow-up in autism screening research: Taking stock and moving forward.

BACKGROUND: How best to improve the early detection of autism spectrum disorder (ASD) is the subject of significant controversy. Some argue that universal ASD screeners are highly accurate, whereas others argue that evidence for this claim is insufficient. Relatedly, there is no clear consensus as to the optimal role of screening for making referral decisions for evaluation and treatment. Published screening research can meaningfully inform these questions-but only through careful consideration of children who do not complete diagnostic follow-up. METHODS: We developed two simulation models that re-analyze the results of a large-scale validation study of the M-CHAT-R/F by Robins et al. (2014, Pediatrics, 133, 37). Model #1 re-analyzes screener accuracy across six scenarios, each reflecting different assumptions regarding loss to follow-up. Model #2 builds on this by closely examining differential attrition at each point of the multi-step detection process. RESULTS: Estimates of sensitivity ranged from 40% to 94% across scenarios, demonstrating that estimates of accuracy depend on assumptions regarding the diagnostic status of children who were lost to follow-up. Across a range of plausible assumptions, data also suggest that children with undiagnosed ASD may be more likely to complete follow-up than children without ASD, highlighting the role of clinicians and caregivers in the detection process. CONCLUSIONS: Using simulation modeling as a quantitative method to examine potential bias in screening studies, analyses suggest that ASD screening tools may be less accurate than is often reported. Models also demonstrate the critical importance of every step in a detection process-including steps that determine whether children should complete an additional evaluation. We conclude that parent and clinician decision-making regarding follow-up may contribute more to detection than is widely assumed.

Conceptualizations of health, ability to act upon those definitions and desire for supports among families from historically marginalized communities.

Respect for parents' values and clinician-parent collaboration is less common among families from historically marginalized communities. We investigated how parents from marginalized communities operationalize health and their preferences for paediatric primary care. We recruited families who spoke English, Haitian Creole or Spanish with at least one child younger than 6 years old. Staff queried families' values and life experiences, perspectives on health and healthcare, social supports and resources. Fourteen interviews with the parents of 26 children were thematically analysed. Interviews revealed the following four themes: (1) parents' definitions of 'health' extend beyond physical health; (2) families' ability to actuate health definitions is complicated by poverty's impact on agency; (3) parents engage in ongoing problem recognition and identify solutions, but enacting solutions can be derailed by barriers and (4) parents want support from professionals and peers who acknowledged the hard work of parenting. Eliciting parents' multidimensional conceptualizations of health can support families' goal achievement and concern identification in the context of isolation, limited agency and few resources. Efforts to improve family centred care and reduce disparities in paediatric primary care must be responsive to the strengths, challenges, resources and priorities of marginalized families.

Child social-emotional and behavioral problems and competencies contribute to changes in developmental functioning during Early Intervention.

This study examined how social-emotional and behavioral (SEB) problems and competencies contribute to changes in developmental functioning among children enrolled in Part C Early Intervention (EI), a U.S. program supporting young children with developmental delays and disabilities. The sample included 1,055 children enrolled in EI from 2011-2019 (mean age at EI entry = 17 months; 64% male; 72% marginalized racial and ethnic backgrounds). Standardized developmental assessments, drawn from administrative records, characterized developmental functioning at EI entry and exit and parents reported SEB functioning. Hierarchical regression analyses revealed that SEB problems and competencies interacted in predicting change in developmental functioning from EI entry to exit. Monitoring, identifying, and addressing SEB problems and competencies may optimize developmental outcomes for young children with developmental delays and disabilities.

Operationalizing Primary Outcomes to Achieve Reach, Effectiveness, and Equity in Multilevel Interventions.

When intervention scientists plan a clinical trial of an intervention, they select an outcome metric that operationalizes their definition of intervention success. The outcome metric that is selected has important implications for which interventions are eventually supported for implementation at scale and, therefore, what health benefits (including how much benefit and for whom) are experienced in a population. Particularly when an intervention is to be implemented in a population that experiences a health disparity, the outcome metric that is selected can also have implications for equity. Some outcome metrics risk exacerbating an existing health disparity, while others may decrease disparities for some but have less effect for the larger population. In this study, we use a computer to simulate implementation of a hypothetical multilevel, multicomponent intervention to highlight the tradeoffs that can occur between outcome metrics that reflect different operationalizations of intervention success. In particular, we highlight tradeoffs between overall mean population benefit and the distribution of health benefits in the population, which has direct implications for equity. We suggest that simulations like the one we present can be useful in the planning of a clinical trial for a multilevel and/or multicomponent intervention, since simulated implementation at scale can illustrate potential consequences of candidate operationalization of intervention success, such that unintended consequences for equity can be avoided.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study.

OBJECTIVES: To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. STUDY DESIGN: This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. RESULTS: Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. CONCLUSIONS: Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Guiding Principles for the Conduct of Observational Critical Care Research for Coronavirus Disease 2019 Pandemics and Beyond: The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study Registry.

OBJECTIVES: Use of observational data to inform the response and care of patients during a pandemic faces unique challenges. DESIGN: The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID 2019 Registry Core data and research methodology team convened over virtual meetings throughout March to June 2020 to determine best practice goals for development of a pandemic disease registry to support rapid data collection and analysis. SETTING: International, multi-center registry of hospitalized patients. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Large-scale observational data collection requires: 1) quality assurance and harmonization across many sites; 2) a transparent process for selecting from among many potential research questions; 3) the use of best practices in design of descriptive, predictive, and inferential studies; (4) innovative approaches to characterize random error in the setting of constantly updated data; (5) rapid peer-review and reporting; and (6) transitions from a focus on discovery to implementation. Herein, we describe the guiding principles to best practices and suggestions for innovations to study design and reporting within the coronavirus disease 2019 Viral Infection and Respiratory Illness Universal Study pandemic registry. CONCLUSIONS: Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study coronavirus disease 2019 registry sought to develop and implement prespecified best practices combined with grassroots efforts from clinical sites worldwide in order to develop clinically useful knowledge in response to a pandemic.

Prevalence of Familial Hypercholesterolemia in the 1999 to 2012 United States National Health and Nutrition Examination Surveys (NHANES).

BACKGROUND: The prevalence of familial hypercholesterolemia (FH) is commonly reported as 1 in 500. European reports suggest a higher prevalence; the US FH prevalence is unknown. METHODS AND RESULTS: The 1999 to 2012 National Health and Nutrition Examination Survey (NHANES) participants ≥20 years of age (n=36 949) were analyzed to estimate the prevalence of FH with available Dutch Lipid Clinic criteria, including low-density lipoprotein cholesterol and personal and family history of premature atherosclerotic cardiovascular disease. Prevalence and confidence intervals of probable/definite FH were calculated for the overall population and by age, sex, obesity status (body mass index ≥30 kg/m(2)), and race/ethnicity. Results were extrapolated to the 210 million US adults ≥20 years of age. The estimated overall US prevalence of probable/definite FH was 0.40% (95% confidence interval, 0.32-0.48) or 1 in 250 (95% confidence interval, 1 in 311 to 209), suggesting that 834 500 US adults have FH. Prevalence varied by age, being least common in 20 to 29 year olds (0.06%, 1 in 1557) and most common in 60 to 69 year olds (0.85%, 1 in 118). FH prevalence was similar in men and women (0.40%, 1 in 250) but varied by race/ethnicity (whites: 0.40%, 1 in 249; blacks: 0.47%, 1 in 211; Mexican Americans: 0.24%, 1 in 414; other races: 0.29%, 1 in 343). More obese participants qualified as probable/definite FH (0.58%, 1 in 172) than nonobese (0.31%, 1 in 325). CONCLUSIONS: FH, defined with Dutch Lipid Clinic criteria available in NHANES, affects 1 in 250 US adults. Variations in prevalence by age and obesity status suggest that clinical criteria may not be sufficient to estimate FH prevalence.

Thresholds and accuracy in screening tools for early detection of psychopathology.

BACKGROUND: The accuracy of any screening instrument designed to detect psychopathology among children is ideally assessed through rigorous comparison to 'gold standard' tests and interviews. Such comparisons typically yield estimates of what we refer to as 'standard indices of diagnostic accuracy', including sensitivity, specificity, positive predictive value (PPV), and negative predictive value. However, whereas these statistics were originally designed to detect binary signals (e.g., diagnosis present or absent), screening questionnaires commonly used in psychology, psychiatry, and pediatrics typically result in ordinal scores. Thus, a threshold or 'cut score' must be applied to these ordinal scores before accuracy can be evaluated using such standard indices. To better understand the tradeoffs inherent in choosing a particular threshold, we discuss the concept of 'threshold probability'. In contrast to PPV, which reflects the probability that a child whose score falls at or above the screening threshold has the condition of interest, threshold probability refers specifically to the likelihood that a child whose score is equal to a particular screening threshold has the condition of interest. METHOD: The diagnostic accuracy and threshold probability of two well-validated behavioral assessment instruments, the Child Behavior Checklist Total Problem Scale and the Strengths and Difficulties Questionnaire total scale were examined in relation to a structured psychiatric interview in three de-identified datasets. RESULTS: Although both screening measures were effective in identifying groups of children at elevated risk for psychopathology in all samples (odds ratios ranged from 5.2 to 9.7), children who scored at or near the clinical thresholds that optimized sensitivity and specificity were unlikely to meet criteria for psychopathology on gold standard interviews. CONCLUSIONS: Our results are consistent with the view that screening instruments should be interpreted probabilistically, with attention to where along the continuum of positive scores an individual falls.

Using Electronic Health Records to Identify Asthma-Related Acute Care Encounters.

OBJECTIVE: Leveraging "big data" to improve care requires that clinical concepts be operationalized using available data. Electronic health record (EHR) data can be used to evaluate asthma care, but relying solely on diagnosis codes may misclassify asthma-related encounters. We created streamlined, feasible and transparent prototype algorithms for EHR data to classify emergency department (ED) encounters and hospitalizations as "asthma-related." METHODS: As part of an asthma program evaluation, expert clinicians conducted a multi-phase iterative chart review to evaluate 467 pediatric ED encounters and 136 hospitalizations with asthma diagnosis codes from calendar years 2017 and 2019, rating the likelihood that each encounter was actually asthma-related. Using this as a reference standard, we developed rule-based algorithms for EHR data to classify visits. Accuracy was evaluated using sensitivity, specificity, and positive and negative predictive values (PPV, NPV). RESULTS: Clinicians categorized 38% of ED encounters as "definitely" or "probably" asthma-related; 13% as "possibly" asthma-related; and 49% as "probably not" or "definitely not" related to asthma. Based on this reference standard, we created two rule-based algorithms to identify "definitely" or "probably" asthma-related encounters, one using text and non-text EHR fields and another using non-text fields only. Sensitivity, specificity, PPV, and NPV were >95% for the algorithm using text and non-text fields and >87% for the algorithm using only non-text fields compared to the reference standard. We created a two-rule algorithm to identify asthma-related hospitalizations using only non-text fields. CONCLUSIONS: Diagnostic codes alone are insufficient to identify asthma-related visits, but EHR-based prototype algorithms that include additional methods of identification can predict clinician-identified visits with sufficient accuracy.

Using virtual multiteam systems to conduct a multisite randomized clinical trial in the part C early intervention system: Benefits, challenges, and lessons learned.

BACKGROUND/AIMS: COVID-19 necessitated a shift to virtual data collection for many research projects, providing the opportunity for novel approaches to carrying out multi-site clinical trials. Virtual multiteam systems (VMTS) are a type of team structure in which multiple geographically dispersed teams collaborate using technology-mediated communication. The article presents a case study of our use of VMTS, in response to COVID-19, to carry out a multisite randomized hybrid effectiveness-implementation trial of a caregiver-implemented intervention. METHODS: We describe how we modified our team structure from predominantly site-specific, co-located teams to predominantly cross-site, virtual teams. We then present examples of how we have conducted the two primary data collection activities virtually. To demonstrate the feasibility of this approach, we present participant demographic information, the percent of cross-site data collection activities, and fidelity data. RESULTS: In the first 20 months of data collection, we have enrolled 108 EI providers and 132 families, with 17% and 9% attrition respectively. The family sample is highly diverse in terms of race/ethnicity, parent education, and household income. The majority of provider training activities and roughly 50% of family assessment activities have been conducted cross-site. Fidelity is high, with no differences across site. CONCLUSIONS: Our data illustrate the feasibility of using virtual teams, training, and assessment in a multisite clinical trial in the Part C system. We discuss the strengths and challenges of this approach, as well as lessons learned to facilitate the planning of future multisite randomized clinical trials which may benefit from this approach. CLINICAL TRIALS: NCT05114538.

Bilingual and Monolingual Autistic Toddlers: Language and Social Communication Skills.

Parents of children diagnosed with autism spectrum disorders (ASD) express concern about raising their children bilingually, and often hear advice from professionals against the use of bilingualism. The current study examined the relation between bilingualism and the language and social communication skills of toddlers diagnosed with ASD (N = 353) in the US, while controlling for socioeconomic risk factors. Structural equation modeling showed no differences in language skills between bilingual Spanish-English speaking children and monolingual English-speaking (p = .596) or monolingual Spanish-speaking (p = .963) children and showed a bilingual advantage on socialization skills when comparing bilingual and monolingual English-speaking children (p = .001). Parents of autistic children exposed to Spanish and English should be encouraged to raise their child bilingually if it best suits familial needs.

Prevalence and Co-Occurrence of Developmental and Emotional-Behavioral Problems in Young Children.

OBJECTIVE: A limited number of studies have estimated the prevalence of emotional-behavioral disorders among young children. None have assessed their co-occurrence with developmental delays using standardized assessment tools. Our objective was to estimate the prevalence of emotional-behavioral disorders and their co-occurrence with developmental delays among young children (2-5.5 years). METHODS: Parents of young children (N = 987) enrolled from pediatric waiting rooms completed developmental-behavioral screening questionnaires. Based on results, 585 families were invited to and 439 completed evaluations that included structured diagnostic interviews with parents to assess child psychopathology (Preschool Age Psychiatric Assessment (PAPA)), developmental testing with children (including the Bayley Scales of Infant and Toddler Development, third Edition for children ≤ 42 months; Differential Ability Scales, second Edition for older children), and videotaped observation to establish whether autism risk was sufficient to warrant further evaluation. RESULTS: According to PAPA algorithms, 23.0% of children met criteria for a DSM-IV disorder, while 9% qualified for a developmental delay. Presence of delay doubled the odds of having a DSM-IV disorder (OR = 2.1; CI: 1.02-4.3), and presence of disorder doubled the odds of having a moderate-to-severe developmental delay (OR=2.0; CI: 1.10-3.50). Prevalence of DSM-IV disorders (48.8% (95% CI: 33.5-64.5%)) and developmental delays (57.5% (95% CI: 41.7-71.9%)) were both higher among children at risk for autism. While developmental delay did not vary by race/ethnicity, prevalence of DSM-IV disorders was lower among African-American/Black (10.6%; CI: 2.9-18.3) and Hispanic/Latino children (11.1%; CI: 4.3-17.9). CONCLUSIONS: Developmental delays and emotional-behavioral disorders among young children seen in pediatric settings are characterized by high prevalence and substantial co-occurrence.

From Descriptive to Predictive: Linking Early Childhood Developmental and Behavioral Screening Results With Educational Outcomes in Kindergarten.

OBJECTIVE: To assess the predictive value of a pediatric screening tool by linking 2 independent databases: an educational database that includes data from standardized academic assessments administered during kindergarten and a pediatric database that includes screening results. METHODS: A database that includes results of the Survey of Well-being of Young Children (SWYC) completed during pediatric visits were linked to an educational database that includes STAR Early Literacy examinations in kindergarten. Linear multilevel regression modeling was used to examine if screening results on the developmental and behavioral sections of the most recently completed SWYC form predicted trends in the percentile rank on the STAR exam over the school year, adjusting for potential confounders. RESULTS: Linking the 2 databases resulted in a sample of 586 children who were administered at least one SWYC evaluation between 24 and 48 months and completed at least one STAR Early Literacy examination in kindergarten. The sample represents a diverse population with 55% Hispanic children, 25% Non-Hispanic black children, and 91% of children receiving a subsidized lunch. After adjusting for confounders, children with a positive developmental or behavioral screen had significantly lower percentile ranks on the STAR exam. CONCLUSIONS: Early developmental and behavioral screening results predicted performance on the STAR exam in kindergarten. Children with developmental and behavioral concerns may be less ready to enter kindergarten than peers without such concerns. These preliminary findings provide proof-of-principle of the potential utility of developmental screening tools in identifying children with reduced school readiness who may benefit from intervention prior to kindergarten.

Overcoming tensions between family-centered care and fidelity within Early Intervention implementation research.

LAY ABSTRACT: Early Intervention systems provide therapeutic services to families of young children birth to 3 years with developmental delays and are considered a natural access point to services for young children and their families. Research studies in the autism field have been interested in training providers to deliver evidence-based practices in Early Intervention systems to increase access to services for young children with an increased likelihood of being autistic. However, research has often overlooked that Early Intervention systems prioritize family-centered care, an approach to working with families that honors and respects their values and choices and that provides supports to strengthen family functioning. This commentary points out that family-centered care deserves greater attention in research being done in Early Intervention systems. We describe how family-centered care may shape how interventions are delivered, and discuss directions for future research to evaluate the impact of family-centered care alongside intervention delivery.

Assessing the Validity of the Baby Pediatric Symptom Checklist Using a Nationally Representative Household Survey.

OBJECTIVE: The Baby Pediatric Symptom Checklist (BPSC) is a screening tool developed for detecting behavioral or emotional concerns among parents of children younger than 18 months. Nationally representative survey data have not yet been used to assess the validity of the BPSC, nor to evaluate its appropriateness for use among children between 18 and 23 months old. The current study assesses the validity of the BPSC using data from the National Health Interview Survey (NHIS). METHODS: Data from the 2019 NHIS were used to evaluate the 12-item BPSC screening tool among a nationally representative sample of children 2 to 23 months. Confirmatory factor analysis (CFA) and differential item functioning (DIF) were used to assess construct and predictive validity and test how response items differed by selected sociodemographics. Quantile regression was used to calculate 50th, 70th, and 90th percentiles for age-based normative curves of the previously established domains of irritability, inflexibility, and difficulty with routines. RESULTS: A 3-factor CFA produced comparable results to the original study. Tests of DIF did not reveal any significant effects for the child's sex, race and Hispanic origin, household urbanization level, number of children in family, or respondent type (mother, father, other). In addition, DIF was not found between children aged 2 to 17 months and 18 to 23 months. Age-based normative data were calculated for each subscale. CONCLUSIONS: The use of the BPSC in a nationally representative survey produced findings comparable to those of the original-validation study. The NHIS can be used to track BPSC scores over time at the population-level.

Pediatric Provider and Staff Burnout in Federally Qualified Community Health Centers.

This study examined changes in provider and staff burnout in 4 Boston-area federally qualified community health centers (FQHCs) participating in a pediatric behavioral health integration project. Utilizing the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSSMP), the study found that emotional exhaustion among primary care providers ( M = 20.5; confidence interval [CI], 17.8-23.2) was higher ( P = .001) than that among behavioral health clinicians ( M = 13.6; CI, 10.4-16.8) and ( P = .00005) community health workers ( M = 10.8; CI, 7.3-14.2). Emotional exhaustion among staff increased ( P = .04) from baseline ( M = 16.8; CI, 15.0-18.6) to follow-up ( M = 20.8; CI, 17.5-24.2), but burnout at follow-up was lower than national averages. FQHCs are integral in caring for marginalized patients; therefore, supporting a stable workforce by minimizing burnout is essential.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative.

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers.

OBJECTIVE: The purpose of this study is to understand change in parent-reported outcomes of mental health symptoms, health-related quality of life (QoL), and school-related functioning among children receiving mental health care at 3 federally qualified health centers engaging in a comprehensive pediatric mental health integration model. METHODS: Trained personnel enrolled English- or Spanish-speaking families of 6- to 12-year-old children who had recently started receiving integrated mental health care and surveyed their parent/caregiver at 3 time points: entry into the cohort, 6-month follow-up, and 12-month follow-up (unique N = 51). Primary outcomes included validated measures of child symptoms, child health-related QoL, and child school-related functioning. Secondary outcomes focused on parental functioning and included validated measures of parental stress and depressive and internalizing symptoms. A multilevel mixed-effects generalized linear model was used to estimate the change in parent-reported outcomes over time, with inverse probability weights used to address attrition. Additional analyses were conducted to determine the degree to which changes in symptoms over time were associated with improvements in school-related functioning. RESULTS: Over 12 months, children's mental health symptoms, health-related QoL, and school-related functional outcomes significantly improved. No changes in parental functioning were observed. In addition, improvements in mental health symptoms and health-related QoL were associated with improvements in school-related functional outcomes over time. CONCLUSION: Findings demonstrate that outcomes of children who received integrated mental health care improved over time, both in regard to mental health and school functioning.

Associations of preschool reactive bed-sharing with sociodemographic factors, sleep disturbance, and psychopathology.

OBJECTIVE: To advance understanding of early childhood bed-sharing and its clinical significance, we examined reactive bed-sharing rates, sociodemographic correlates, persistence, and concurrent and longitudinal associations with sleep disturbances and psychopathology. METHODS: Data from a representative cohort of 917 children (mean age 3.8 years) recruited from primary pediatric clinics in a Southeastern city for a preschool anxiety study were used. Sociodemographics and diagnostic classifications for sleep disturbances and psychopathology were obtained using the Preschool Age Psychiatric Assessment (PAPA), a structured diagnostic interview administered to caregivers. A subsample of 187 children was re-assessed approximately 24.7 months after the initial PAPA interview. RESULTS: Reactive bed-sharing was reported by 38.4% of parents, 22.9% nightly and 15.5% weekly, and declined with age. At follow-up, 48.9% of nightly bed-sharers and 88.7% of weekly bed-sharers were no longer bed-sharing. Sociodemographics associated with nightly bed-sharing were Black and (combined) American Indian, Alaska Native and Asian race and ethnicity, low income and parent education less than high school. Concurrently, bed-sharing nightly was associated with separation anxiety and sleep terrors; bed-sharing weekly was associated with sleep terrors and difficulty staying asleep. No longitudinal associations were found between reactive bed-sharing and sleep disturbances or psychopathology after controlling for sociodemographics, baseline status of the outcome and time between interviews. CONCLUSIONS: Reactive bed-sharing is relatively common among preschoolers, varies significantly by sociodemographic factors, declines during the preschool years and is more persistent among nightly than weekly bed-sharers. Reactive bed-sharing may be an indicator of sleep disturbances and/or anxiety but there is no evidence that bed-sharing is an antecedent or consequence of sleep disturbances or psychopathology.