Appendix Appendix Exhibit A1: Prevalence of Adverse Childhood Experiences Among US Children: By Age Groups and Household Income Level

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Bethell CD, Newacheck P, Hawes E, Halfon N. Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. Health Aff (Millwood). 2014;33(12).

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Appendix

Appendix Exhibit A1: Prevalence of Adverse Childhood Experiences Among US Children: By Age Groups and Household Income Level

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Appendix Exhibit A2: Prevalence of positive and negative health factors by ACEs

Prevalence Among All

Children

Prevalence of Positive or Negative Factors By ACEs Status

Prevalence of factors across individual

ACEs topics (9 ACEs items with highest and lowest prevalence

shown) No ACES One ACEs Two+ ACES

7 Positive Health Related Factors Demonstrates Resilience: (ages 6-17)

(64.7%) 64.7 AOR:1.6271.7 s _AOR:1.2562.9 s 54.6 _Ref Low: 50.5-domestic violence; _{High: 59.1-divorce}

Met protective home environment

criteria (27.8%) 27.8 AOR:1.8436.1 s _AOR:1.2822.8 s 15.6 _Ref Low: 13.4-neighborhood violence; _{High: 20.1-income hardship}

Met safe and supportive neighborhood

criteria (55.6%) 55.6 AOR: 1.4962.9 s AOR:1.1450.6 s 44.6 Ref Low: 40.1-neighborhood violence; High: 52.8-divorce Mother’s physical & mental health

excellent/ very good (56.7%) 56.7 AOR:2.5268.3 s _AOR:1.4748.6 s 35.8 _Ref Low: 31.6-mental health;32.8 _{neigh. violence; High:}

46.5-divorce Usually/always engaged in school (age

6-17) (80.4%)

80.4 87.7 AOR:2.59s

80.8 AOR:1.72s

67.7 Ref

Low: 62.8-neighborhood violence; High: 74.8-discrimination Meets MCHB and NSCH criteria for

having a medical home (54.4%) 54.4 AOR: 1.4361.4 s _{AOR: 1.17}50.4 s 43.5 _Ref Low: 38.4-neighborhood violence; _{High: 50.8-divorce} 4 Negative Health Related Factors

Parents usually/always aggravated with

child (11.3%) 11.3 AOR: .617.7 s _AOR:.8713.2 s 17.6 _Ref Low: 13.8-divorce; High: 21.5-_{neighborhood violence}

Repeated a grade in school (age 6-17)

(9.1%) 9.1 AOR: .595.6 s _AOR:.759.1 s 15.0 _Ref Low: 9.8-discrimination; High: _19.5-jail

Problems getting needed referrals for

services (20.8%) 20.8 AOR: .6214.4 s AOR: .95 23.8 27.5 Ref Low: 23.3-jail; High: 34.5-discrimination Problems getting needed care

coordination (33.9%) 33.9 AOR: .4826.3 s _{AOR: .67}34.9 s 45.5 _Ref Low: 39.4-divorce; High: 52.2-_{discrimination} Note: Adjusted odds ratios from logistic regression reported.

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3 Appendix A3: Multi-Level Modeling Results and Methods Details (more available upon request)

Significant across state variation remains after adjusting for child level characteristics across states using multi-level

modeling. Child level characteristics explain only 33% of across state variation in the prevalence of ACEs. Random effects median odds ratio, after adjusting for individual level child

demographic and CSHCN status is statistically significant at 1.21 (ICC .012). Interpretation: If a child moved from the lowest to highest ACEs prevalence state, the odds that they would experience ACEs is 1.21 time greater regardless of their individual characteristics."

We used multi-level modeling methods described by Carle45 to scale the weights and Korn’s46 zero weight method to subset the data. This allowed us to maintain the complex sampling

structure, correctly include the weights in MLMs, achieve appropriate estimates and standard errors, and maintain our focus on the subsample of interest. Interested readers should see Carle for statistical details. For all multi-level analyses, we used MLwiN, iterative least squares estimation, and computed robust standard errors.

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4 Appendix A4: National Survey of Children’s Health Survey Items Associated With the Medical Home and Adverse Childhood

Experience measures

Medical Home Composite Measure Survey Items (see measurement manual referenced in the paper for extensive information on the design, testing and scoring of this measure)

1. During the past 12 months, did [CHILD’S NAME] need a referral to see any doctors or receive any services? (K5Q10)

- Was getting referrals a big problem, small problem, or not a problem? (K5Q11)

2. Does anyone help you arrange or coordinate [CHILD’S NAME]’s care among the different doctors or services that (he/she) uses? (K5Q20) *asked for children who used more than two services

3. During the past 12 months, have you felt that you could have used extra help arranging or coordinating [CHILD’S NAME]’s care among the different health care providers or services? (K5Q21) *asked for children who used more than two services

- If YES, during the past 12 months, how often did you get as much help as you wanted with arranging or coordinating [CHILD’S NAME]’s care? (K5Q22) *asked for children who used more than two services

4. Overall, are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied with the communication among

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[CHILD’S NAME]’s doctors and other health care providers? (K5Q30)*asked for children who used more than two services 5. Do [CHILD’S NAME]’s doctor or other health care providers need to communicate with (his/her) child care providers, school, or

other programs? (K5Q31) - Overall, are you very satisfied, somewhat satisfied, or very dissatisfied with that

communication? (K5Q32)

6. During the past 12 months, how often did [CHILD’S NAME]’s doctors and other health care providers spend enough time with (him/her)? (K5Q40)

7. During the past 12 months, how often did [CHILD’S NAME]’s doctors and other health care providers listen carefully to you?(K5Q41)

8. When [CHILD’S NAME] is seen by doctors and other health care providers, how often are they sensitive to your family’s values and customs? (K5Q42)

9. Information about a child’s health or health care can include things such as the causes of any health problems, how to care for a child now, and what to expect in the future. During the past 12 months, how often did you get the specific information you

needed from [CHILD’S NAME]’s doctors and other health care providers? (K5Q43)

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10. During the past 12 months, how often did [CHILD’S NAME]’s doctors or other health care providers help you feel like a partner in (his/her) care? (K5Q44)

Adverse Childhood Experiences Survey Items:

1. Since [CHILD’S NAME] was born, how often has it been very hard to get by on your family’s income – hard to cover the

basics like food or housing? Would you say very often, somewhat often, often, rarely, or never?

2. Did [CHILD’S NAME] ever live with a parent or guardian who got divorced or separated after [CHILD’S NAME] was born? 3. Did [CHILD’S NAME] ever live with a parent or guardian who died?

4. Did [CHILD’S NAME] ever live with a parent or guardian who served time in jail or prison after [CHILD’S NAME] was born? 5. Did [CHILD’S NAME] ever see or hear any parents or adults in (his/her) home slap, hit, kick, punch, or beat each other up? 6. Was [CHILD’S NAME] ever the victim of violence or witness any violence in (his/her) neighborhood?

7. Did [CHILD’S NAME] ever live with anyone who was mentally ill or suicidal, or severely depressed for more than a couple of weeks?

8. Did [CHILD’S NAME] ever live with anyone who had a problem with alcohol or drugs? (ACE9) ±

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9. Was [CHILD’S NAME] ever treated or judged unfairly because of (his/her) race or ethnic group? (ACE10) ±

- During the past year, how often was [CHILD’S NAME] treated or judged unfairly? Would you say very often, somewhat often,