Artificial Neural Network Analysis Examining Substance Use Problems Co-Occurring with Anxiety and Depressive Disorders Among Adults Receiving Mental Health Treatment.

Objective: The co-occurrence of anxiety disorders, depressive disorders, and substance use problems was examined. Methods: The Mental Health Client-Level Data dataset was used to conduct logistic regression models and an artificial neural network analysis. Logistic regression analyses were conducted among adults with anxiety (n = 547,473) or depressive disorders (n = 1,610,601) as their primary diagnosis who received treatment in a community mental health center. The artificial neural network analysis was conducted with the entire sample (N = 2,158,074). Results: Approximately 30% of the sample had co-occurring high-risk substance use or substance use disorder. Characteristics including region of treatment receipt, age, education, gender, race and ethnicity, and the presence of co-occurring anxiety and depressive disorders were associated with the co-occurring high-risk substance use or a substance use disorder. Conclusions: Findings from this study highlight the importance of mental health facilities to screen for and provide integrated treatment for co-occurring disorders.

Conceptualizing adverse childhood experiences as a latent factor: Tests of measurement invariance across five racial and ethnic groups.

Adverse childhood experiences (ACEs) are conventionally measured using a cumulative-risk index without consideration of distinct measurement properties across racial and ethnic groups. Drawing from the 2018-2020 National Survey of Children's Health (N = 93,759; 48% female; average age: 9.52 years), we assess the measurement invariance of a latent-factor ACE model across five groups: Hispanic children (14%) and non-Hispanic White (73%), Black (7%), Asian/Pacific Islander (5%), and American Indian/Alaskan Native (1%) children. Results support configural and full metric invariance across groups. However, several ACE item thresholds differed across groups. Findings highlight the potential utility of a latent factor approach and underscore the need to assess differences across racial and ethnic groups in terms of the optimal conceptualization and measurement of ACEs.

Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs.

Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). Design, Setting, and Participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Main Outcomes and Measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Results: Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.

STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Comparing Medicaid Expenditures for Standard and Enhanced Therapeutic Foster Care.

Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive care settings. The purpose of this study was to compare Medicaid expenditures associated with TFC with Medicaid expenditures associated with an enhanced higher-rate service called Intensive Alternative Family Treatment (IAFT). We conducted a secondary analysis of Medicaid claims in North Carolina among children entering care in 2018-2019. Using propensity score analysis with difference-in-difference estimation, we compared monthly Medicaid expenditures before and after initiating TFC and IAFT (N = 5472 person-months). Youth entering IAFT had higher expenditures prior to treatment than those entering TFC. Both standard TFC and IAFT were associated with a downward trend in expenditures following treatment initiation. Both TFC and IAFT reverse a trend of increasing Medicaid costs prior to care among children with high behavioral health needs.

Examining Foster Care Outcomes for American Indian Children in the Context of the Indian Child Welfare Act.

The history of the child welfare system and related institutions with American Indian children and families has been marked by numerous atrocities, including unnecessary separations, assimilation, and trauma. The Indian Child Welfare Act (ICWA) was enacted in 1978 to promote the stability and security of American Indian tribes and families. For children involved in the child welfare system, ICWA prioritizes the placement of American Indian children with family or tribal members. This paper examines placement outcomes for American Indian children using recent national data over 3 years from the Adoption and Foster Care Analysis and Reporting System. Multivariate regression analyses showed that American Indian children were significantly less likely to be placed with same-race/ethnicity caretakers than their non-American Indian counterparts. In addition, American Indian children were not more likely to be placed with relatives or have trial home placement compared to non-American Indian children. These findings suggest that ICWA is not reaching its intended objectives regarding placement goals specified in the law regarding American Indian children. These policy shortcomings have significant implications for American Indian children, families, and tribes in terms of well-being, family connection, and cultural loss.

Duration of medication for opioid use disorder during pregnancy and postpartum by race/ethnicity: Results from 6 state Medicaid programs.

BACKGROUND: Medication for opioid use disorder (MOUD) is evidence-based treatment during pregnancy and postpartum. Prior studies show racial/ethnic differences in receipt of MOUD during pregnancy. Fewer studies have examined racial/ethnic differences in MOUD receipt and duration during the first year postpartum and in the type of MOUD received during pregnancy and postpartum. METHODS: We used Medicaid administrative data from 6 states to compare the percentage of women with any MOUD and the average proportion of days covered (PDC) with MOUD, overall and by type of MOUD, during pregnancy and four postpartum periods (1-90 days, 91-180 days, 181-270 days, and 271-360 days postpartum) among White non-Hispanic, Black non-Hispanic, and Hispanic women diagnosed with OUD. RESULTS: White non-Hispanic women were more likely to receive any MOUD during pregnancy and all postpartum periods compared to Hispanic and Black non-Hispanic women. For all MOUD types combined and for buprenorphine, White non-Hispanic women had the highest average PDC during pregnancy and each postpartum period, followed by Hispanic women and Black non-Hispanic women (e.g., for all MOUD types, 0.49 vs. 0.41 vs. 0.23 PDC, respectively, during days 1-90 postpartum). For methadone, White non-Hispanic and Hispanic women had similar average PDC during pregnancy and postpartum, and Black non-Hispanic women had substantially lower PDC. CONCLUSIONS: There are stark racial/ethnic differences in MOUD during pregnancy and the first year postpartum. Reducing these inequities is critical to improving health outcomes among pregnant and postpartum women with OUD.

Associations between Work-Family Balance, Parenting Stress, and Marital Conflicts during COVID-19 Pandemic in Singapore.

As part of the "Circuit-breaker" social distancing measure to address COVID-19, the government of Singapore closed schools and workplaces from April to May 2020. Although this helped reduce transmission rates, for working parents, this period had been a challenging experience of working from home while providing care for children full-time. Problems in the work-home interface can have a significant impact on parenting and marital harmony. We analyzed data from 201 married and employed parents in Singapore using online surveys. Latent profile analysis was used to identify profiles of parents' work-family balance (WFB) and spousal and employer support. Linear regression was used to examine links between profiles with parenting stress and marital conflicts. Results indicated three distinct profiles of WFB and social support levels: (a) Strong (43%), (b) Moderate (38%), and (c) Poor (19%). Mothers were more likely than fathers to be in the Moderate and Poor profiles. One key finding is that profiles characterized by poorer WFB were found to be linked with higher parenting stress and increased marital conflicts. There are important variations in parents' abilities to balance work and family and levels of social support received. Lock-downs can affect parenting and marital harmony especially for parents with poor WFB and weak social support. Any attention given to supporting working parents is vital and urgent to counter any problems in the work-family interface during a lockdown.

Generation of the Chemical and Social Stressors Integration Technique (CASS-IT) to identify areas of holistic public health concern: An application to North Carolina.

Due to structural racism and income inequality, exposure to environmental chemicals is tightly linked to socioeconomic factors. In addition, exposure to psychosocial stressors, such as racial discrimination, as well as having limited resources, can increase susceptibility to environmentally induced disease. Yet, studies are often conducted separately in fields of social science and environmental science, reducing the potential for holistic risk estimates. To tackle this gap, we developed the Chemical and Social Stressors Integration Technique (CASS-IT) to integrate environmental chemical and social stressor datasets. The CASS-IT provides a framework to identify distinct geographic areas based on combinations of environmental chemical exposure, social vulnerability, and access to resources. It incorporates two data dimension reduction tools: k-means clustering and latent profile analysis. Here, the CASS-IT was applied to North Carolina (NC) as a case study. Environmental chemical data included toxic metals - arsenic, manganese, and lead - in private drinking well water. Social stressor data were captured by the CDC's social vulnerability index's four domains: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Data on resources were derived from Federal Emergency Management Agency (FEMA's) Resilience and Analysis Planning Tool, which generated measures of health resources, social resources, and information resources. The results highlighted 31 NC counties where exposure to both toxic metals and social stressors are elevated, and health resources are minimal; these are counties in which environmental justice is of utmost concern. A census-tract level analysis was also conducted to demonstrate the utility of CASS-IT at different geographical scales. The tract-level analysis highlighted specific tracts within counties of concern that are particularly high priority. In future research, the CASS-IT can be used to analyze United States-wide environmental datasets providing guidance for targeted public health interventions and reducing environmental disparities.

Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states.

BACKGROUND: Follow-up after residential treatment is considered best practice in supporting patients with opioid use disorder (OUD) in their recovery. Yet, little is known about rates of follow-up after discharge. The objective of this analysis was to measure rates of follow-up and use of medications for OUD (MOUD) after residential treatment among Medicaid enrollees in 10 states, and to understand the enrollee and episode characteristics that are associated with both outcomes. METHODS: Using a distributed research network to analyze Medicaid claims data, we estimated the likelihood of 4 outcomes occurring within 7 and 30 days post-discharge from residential treatment for OUD using multinomial logit regression: no follow-up or MOUD, follow-up visit only, MOUD only, or both follow-up and MOUD. We used meta-analysis techniques to pool state-specific estimates into global estimates. RESULTS: We identified 90,639 episodes of residential treatment for OUD for 69,017 enrollees from 2018 to 2019. We found that 62.5% and 46.9% of episodes did not receive any follow-up or MOUD at 7 days and 30 days, respectively. In adjusted analyses, co-occurring mental health conditions, longer lengths of stay, prior receipt of MOUD or behavioral health counseling, and a recent ED visit for OUD were associated with a greater likelihood of receiving follow-up treatment including MOUD after discharge. CONCLUSIONS: Forty-seven percent of residential treatment episodes for Medicaid enrollees are not followed by an outpatient visit or MOUD, and thus are not following best practices.

Design, Implementation, and Evolution of the Medicaid Outcomes Distributed Research Network (MODRN).

BACKGROUND: In the US, Medicaid covers over 80 million Americans. Comparing access, quality, and costs across Medicaid programs can provide policymakers with much-needed information. As each Medicaid agency collects its member data, multiple barriers prevent sharing Medicaid data between states. To address this gap, the Medicaid Outcomes Distributed Research Network (MODRN) developed a research network of states to conduct rapid multi-state analyses without sharing individual-level data across states. OBJECTIVE: To describe goals, design, implementation, and evolution of MODRN to inform other research networks. METHODS: MODRN implemented a distributed research network using a common data model, with each state analyzing its own data; developed standardized measure specifications and statistical software code to conduct analyses; and disseminated findings to state and federal Medicaid policymakers. Based on feedback on Medicaid agency priorities, MODRN first sought to inform Medicaid policy to improve opioid use disorder treatment, particularly medication treatment. RESULTS: Since its 2017 inception, MODRN created 21 opioid use disorder quality measures in 13 states. MODRN modified its common data model over time to include additional elements. Initial barriers included harmonizing utilization data from Medicaid billing codes across states and adapting statistical methods to combine state-level results. The network demonstrated its utility and addressed barriers to conducting multi-state analyses of Medicaid administrative data. CONCLUSIONS: MODRN created a new, scalable, successful model for conducting policy research while complying with federal and state regulations to protect beneficiary health information. Platforms like MODRN may prove useful for emerging health challenges to facilitate evidence-based policymaking in Medicaid programs.

Duration of medication treatment for opioid-use disorder and risk of overdose among Medicaid enrollees in 11 states: a retrospective cohort study.

BACKGROUND AND AIMS: Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries. DESIGN: Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment. SETTING AND PARTICIPANTS: Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017. MEASUREMENTS: MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim. FINDINGS: Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001). CONCLUSIONS: Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Antipsychotic medications and admission to psychiatric residential treatment facilities among youth in foster care diagnosed with disruptive behavior disorders.

Many youth in foster care are diagnosed with disruptive behavior disorder (DBD), a diagnosis indicative of aggression and behavior problems. These youth, who are at high risk for being placed in psychiatric residential treatment facilities (PRTF), are commonly prescribed antipsychotic (AP) medications off-label. However, treating children in the community is an important goal, and although AP medications can have severe side effects, these prescriptions may help to achieve this goal. In this study, we used Medicaid data to determine whether AP medications reduce the risk of admission to PRTF among two groups of children with DBD: those with DBD only and those who were diagnosed with DBD in addition to at least one of two conditions indicated for AP prescribing (psychosis and bipolar disorder.) Event history models show that AP medications are associated with a high rate of admission, which are likely due to the higher mental and behavioral health needs of youth who are prescribed. However, youth diagnosed with both DBD and indications who are prescribed an AP medication have one-tenth the rate of admission of similar youth who are not prescribed. For youth with DBD only, the findings are inconclusive. Given these mixed results, practitioners should follow clinical guidelines; ensuring youth are treated with psychosocial interventions and other psychotropic medications prior to AP prescribing. Agencies should attempt to address systemic factors such as shortages of foster homes, increased availability of therapeutic foster care, and implementation of in-home prevention services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Prenatal Syphilis Screening Among Medicaid Enrollees in 6 Southern States.

INTRODUCTION: The rates of syphilis among pregnant women and infants have increased in recent years, particularly in the U.S. South. Although state policies require prenatal syphilis testing, recent screening rates comparable across Southern states are not known. The purpose of this study is to measure syphilis screening among Medicaid enrollees with delivery in states in the U.S. South. METHODS: A total of 6 state-university research partnerships in the U.S. South developed a distributed research network to analyze Medicaid claims data using a common analytic approach for enrollees with delivery in fiscal years 2017-2018 and 2018-2019 (combined N=504,943). In 2020-2021, each state calculated the percentage of enrollees with delivery with a syphilis screen test during the first trimester, third trimester, and at any point during pregnancy. Percentages for those with first-trimester enrollment were compared with the percentages of those who enrolled in Medicaid later in pregnancy. RESULTS: Prenatal syphilis screening during pregnancy ranged from 56% to 91%. Screening was higher among those enrolled in Medicaid during the first trimester than in those enrolled later in pregnancy. CONCLUSIONS: Despite state laws requiring syphilis screening during pregnancy, screening was much lower than 100%, and states varied in syphilis screening rates among Medicaid enrollees. Findings indicate that access to Medicaid in the first trimester is associated with higher rates of syphilis screening and that efforts to improve access to screening in practice settings are needed.

Mediating Effects of Parental Stress on Harsh Parenting and Parent-Child Relationship during Coronavirus (COVID-19) Pandemic in Singapore.

Because of the Coronavirus (COVID-19) pandemic, "Circuit-breaker" safety distancing was implemented in Singapore from April to May 2020. Schools and workplaces were closed and parents had to balance telecommuting with parenting responsibilities. Coupled with the high degree of economic uncertainty and reduced social support, these circumstances are hypothesized to increase parenting stress. Based on the Parental Stress Model, this study aims to understand how parents' perceived impact of COVID-19 increased harsh parenting and reduced parent-child relationship closeness through the mediating effects of parenting stress. We collected data from 258 parents living in Singapore using online surveys disseminated through Facebook and community organizations. Our predictor was the perceived impact of COVID-19. Parental stress (mediator) was measured with the Parental Stress Scale. Two outcomes were used: parent-child relationship closeness and harsh parenting (spanking, yelling). Using mediation analysis in the SEM framework, we tested the indirect effects using bias-corrected bootstrap confidence intervals. Our results indicated that parenting stress was a significant mediator in the relationship between the perceived impact of COVID-19 and (a) parent-child closeness (indirect effect = -.30, Bootstrap 99% CI[-.59, -.11]) and (b) harsh parenting (indirect effect = .58, Bootstrap 99% CI[.25, .94]). The impact of COVID-19 and stay-home orders can increase parenting stress. This, in turn, has a negative impact on parenting by affecting parents' relationship with their children and increasing the use of harsh parenting. Given that these are risk factors for potential child abuse, supporting parents and mitigating the impact of COVID-19 are important.

Racial discrimination and other adverse childhood experiences as risk factors for internalizing mental health concerns among Black youth.

Adverse childhood experiences (ACEs) have been consistently linked to a reduction in healthy psychological adjustment among youth. Emergent evidence suggests that there are culturally specific ACEs, such as racial discrimination, that are particularly harmful to the mental health of Black youth. However, the psychological impact of racial discrimination on the mental health of Black youth relative to other ACEs remains underexplored. The present study aimed to address this gap by examining the extent to which racial discrimination was associated with other ACEs and elucidating the unique associations between children's experiences of racial discrimination and internalizing problems (i.e., depression, anxiety), after controlling for other ACEs. Data consisted of a subsample of Black children from the National Survey of Children's Health (N = 8,672; Mage  = 9.8 years; 51.1% male). Bivariate analyses illustrated that racial discrimination was positively associated with the co-occurrence of all other ACEs measured within the current study. Multivariable analyses using generalized linear mixed models revealed that racial discrimination was significantly associated with youth diagnoses of depression, adjusted odds ratio (aOR) = 1.35, 95% CI [1.23, 1.49], and anxiety, aOR = 1.39, 95% CI [1.31, 1.47], after controlling for other ACEs and sociodemographic covariates. The findings demonstrate that racial discrimination is comparably associated with youth internalizing problems relative to ACEs conventionally examined within the childhood trauma literature. The importance of these results, including how this knowledge can be leveraged to inform clinical practice and policy to promote the positive mental health of Black youth, are also discussed.

A Quasi-Experimental Study of the Effects of Pre-Kindergarten Education on Pediatric Asthma.

Ensuring access to pre-kindergarten (Pre-K) education remains a pressing policy issue in the United States. Prior research has shown the positive effects that Pre-K has on children's cognitive development. However, studies on its effects on children's health outcomes are scarce. This study aimed to investigate the effects of the Pre-K program on pediatric asthma. Children's individual data from existing research conducted in North Carolina were linked with state Medicaid claims data from 2011-2017. There were 51,408 observations (person-month unit) of 279 children enrolled in Pre-K and 333 unenrolled children. Asthma was identified using the ICD 9/10 codes. A difference-in-differences model was adopted using a panel analysis with three time periods: before, during, and after Pre-K. The explanatory variables were interaction terms between Pre-K enrollment and (a) before vs. during period and (b) during vs. after period. The results indicated that children enrolled in Pre-K had a greater risk of asthma diagnosis during Pre-K (b = 0.0145, p = 0.058). Conversely, in the post-intervention period, the enrolled children had a lower of receiving an asthma diagnosis (b = -0.0216, p = 0.002). These findings indicate that Pre-K may increase the use of asthma-related health services in the short term and decrease the service use after participants leave the program.

Health Care Access and Quality Among Children Exposed to Adversity: Implications for Universal Screening of Adverse Childhood Experiences.

OBJECTIVES:  Given recent advances toward universal screening for Adverse Childhood Experiences (ACEs), our objective was to investigate whether children with higher ACEs experience poorer quality of provider care and greater challenges accessing needed mental health treatment. METHODS: This study uses a nationally representative sample of US children aged 0-17 years drawn from the National Survey on Children's Health for 2016-2019. Caregivers and parents completed surveys between June 2016 and February 2020 (N = 131,774). Logistic regression models adjusting for identified covariates were used to test associations between a child's number of ACEs, their quality of provider care, and their access to mental health treatment. All analyses used appropriate survey weighting commands. RESULTS: High ACEs (4 or more) were associated with lower quality of provider care, including effective care coordination [OR 0.45, 95% CI (0.38, 0.52)], family-centered care [OR 0.49, 95% CI (0.41, 0.58)], shared decision making [OR 0.50, 95% CI (0.39, 0.85)], and referrals for care [OR 0.58, 95% CI (0.43, 0.80)]; children with high ACEs were also less likely to have a medical home [OR 0.66, 95% CI (0.57, 0.76)]. High ACEs were also significantly associated with greater difficulty accessing mental health treatment [OR 0.55, 95% CI (0.43, 0.70)]. Similar results were found for children in the moderate ACE (2-3) and low ACE (1) groups. CONCLUSIONS FOR PRACTICE: Findings indicate that greater ACEs were associated with poorer quality medical care and greater difficulty accessing needed mental health treatment. Because findings indicate that children with high ACEs may be the least likely to receive quality care or necessary mental health treatment to address this adversity, universal screening for ACEs should be considered with caution.

Clusters of adverse childhood experiences and unmet need for care coordination.

BACKGROUND: The lack of consensus on how to measure ACEs limits our estimation of their impact on health outcomes and understanding of which ACE clusters drive unmet care coordination (CC) needs. OBJECTIVES: 1) Identify latent classes of ACEs among a representative group of U.S. children; 2) Examine the association between these classes and unmet needs for CC. PARTICIPANT AND SETTING: Using the 2016-2017 National Survey of Children's Health, we sampled children ages 0-17 the who had seen >1 healthcare provider within 12 months (n = 38,758). METHODS: We conducted latent class analyses and weighted logistic regression analyses to examine associations between latent classes and unmet need for CC. RESULTS: We identified seven distinct classes: household poverty and parental divorce, household poverty and parental death, household poverty only, household substance abuse and witnessing violence, multiple ACEs, household poverty and child discrimination, and household poverty and household mental illness. Children in the following classes had the greatest odds of unmet need for CC: household poverty only (AOR 2.0; 95% CI, 1.42-2.84), household poverty and household mental illness (AOR 1.67; 95% CI, 1.15-2.44), multiple ACEs (AOR 2.31; 95% CI, 1.53-3.50), and household poverty and child discrimination (AOR 3.55; 95% CI, 1.71-7.37). CONCLUSIONS: Children who experienced specific combinations of ACEs, have an increased risk of unmet need for CC, with those experiencing both poverty and discrimination having the highest odds of unmet need for CC. Discrimination widens the gap of unmet CC need for poor children.