Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016-2021 National Survey of Children's Health
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| Title: | Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016-2021 National Survey of Children's Health |
|---|---|
| Language: | English |
| Authors: | Hélène A. Gussin, Cheng-Shi Shiu, Christianna Danguilan, Iulia Mihaila, Kruti Acharya, Kristin L. Berg (ORCID |
| Source: | Journal of Autism and Developmental Disorders. 2025 55(8):2615-2627. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 13 |
| Publication Date: | 2025 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Early Experience, Trauma, Mental Health, Academic Achievement, Autism Spectrum Disorders, National Surveys, Child Health, Attendance, Student Promotion, Learner Engagement, Depression (Psychology), Symptoms (Individual Disorders) |
| DOI: | 10.1007/s10803-024-06338-x |
| ISSN: | 0162-3257 1573-3432 |
| Abstract: | Purpose: School is an important developmental setting for children. Adverse childhood experiences (ACEs) are linked to overall lower educational attainment and are more prevalent in children with Autism Spectrum Disorder (ASD) than in their neurotypical peers. The aim of this study is to test the association between ACEs and school outcomes among autistic children and whether mental health conditions explain this association. Methods: We combined 2016-2021 data from the National Surveys of Children's Health for children, ages 6-17, identified by parents as having ASD (N = 4,997), to examine the relationship between ACEs and school outcomes (grade progression, school attendance, and engagement). We analyzed depression and anxiety variables to investigate the extent to which mental health can explain the relationships between ACEs and school outcomes. Results: ACEs were significantly associated with school outcomes. With increased ACEs, autistic children experienced a significant decrease in the odds of school attendance, grade progression and school engagement (p < 0.05). Furthermore, although depression and anxiety symptoms were significantly associated with school outcomes, they cannot explain away the enduring, strong relationship between ACEs and level of grade progression, engagement, and school success index. Conclusion: Our findings suggest ACEs predict school success among autistic children, with mental health conditions appearing to mediate the relationship between ACEs and key factors in school success. Efforts should be made to proactively identify and address the impact of ACEs and associated mental health conditions among autistic students. |
| Abstractor: | As Provided |
| Entry Date: | 2025 |
| Accession Number: | EJ1478487 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwGwBdgZIHWBpJqxapyPTVl8AAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDKm2N93yKDmSRxn0hgIBEICBm9fUKWvUy7v1KYrfzWQLimb191fH-UXhOYijdeUxiTNVbTeFHnaGcDoIxNh-xY_kfRUycHUbogyeZL7egOHpnWjqVr2dYAfgZ-rMq83HHUf93W3gr6j2Yiy-Zhfj2dr914Pw8qtIUxIjsRsPoivoyYxVk4VZYb_E0hQNNwubU0YD7KvNFQfgGO0lLbjTmvBhJDNC4s6795xumZQN Text: Availability: 1 Value: <anid>AN0186910014;aut01aug.25;2025Jul29.02:32;v2.2.500</anid> <title id="AN0186910014-1">Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016–2021 National Survey of Children's Health </title> <p>Purpose: School is an important developmental setting for children. Adverse childhood experiences (ACEs) are linked to overall lower educational attainment and are more prevalent in children with Autism Spectrum Disorder (ASD) than in their neurotypical peers. The aim of this study is to test the association between ACEs and school outcomes among autistic children and whether mental health conditions explain this association. Methods: We combined 2016–2021 data from the National Surveys of Children's Health for children, ages 6–17, identified by parents as having ASD (N = 4,997), to examine the relationship between ACEs and school outcomes (grade progression, school attendance, and engagement). We analyzed depression and anxiety variables to investigate the extent to which mental health can explain the relationships between ACEs and school outcomes. Results: ACEs were significantly associated with school outcomes. With increased ACEs, autistic children experienced a significant decrease in the odds of school attendance, grade progression and school engagement (p &lt;.05). Furthermore, although depression and anxiety symptoms were significantly associated with school outcomes, they cannot explain away the enduring, strong relationship between ACEs and level of grade progression, engagement, and school success index. Conclusion: Our findings suggest ACEs predict school success among autistic children, with mental health conditions appearing to mediate the relationship between ACEs and key factors in school success. Efforts should be made to proactively identify and address the impact of ACEs and associated mental health conditions among autistic students.</p> <p>Keywords: National survey of children's health; Autism; Adverse childhood experiences (ACEs); Mental health; School success; Resilience; Medical and Health Sciences Public Health and Health Services Psychology and Cognitive Sciences Psychology</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <p>Adverse childhood experiences (ACEs) are a key social determinant of outcomes across the life course (Felitti et al., [<reflink idref="bib29" id="ref1">29</reflink>]). Defined as household dysfunction and stressors experienced prior to the age of 18 years, ACEs include but are not limited to income insufficiency, single parent household, family violence, and alcohol or substance use (Felitti et al., [<reflink idref="bib29" id="ref2">29</reflink>]; Finkelhor et al., [<reflink idref="bib30" id="ref3">30</reflink>]; Wade et al., [<reflink idref="bib85" id="ref4">85</reflink>]). Recent research has expanded the concept of ACEs to include stressors identified by low-income, urban youth, including exposure to community violence, bullying, discrimination, and living in foster care (Wade [<reflink idref="bib85" id="ref5">85</reflink>], Wade [<reflink idref="bib86" id="ref6">86</reflink>]). While the majority of this research has focused on the negative impact of ACEs on adult physical health (i.e., cancer, cardiovascular disease, diabetes, autoimmune disease, premature mortality; Anda et al., [<reflink idref="bib4" id="ref7">4</reflink>]; Bellis et al., [<reflink idref="bib8" id="ref8">8</reflink>]; Brown et al., [<reflink idref="bib13" id="ref9">13</reflink>]; Brown et al., [<reflink idref="bib14" id="ref10">14</reflink>]; Dube et al., [<reflink idref="bib24" id="ref11">24</reflink>]; Felitti et al., [<reflink idref="bib29" id="ref12">29</reflink>]; Hughes et al., [<reflink idref="bib36" id="ref13">36</reflink>]; Melchior et al., [<reflink idref="bib53" id="ref14">53</reflink>]) and mental health (i.e., depression, anxiety, suicide; Chartier et al., [<reflink idref="bib16" id="ref15">16</reflink>]; Edwards et al., [<reflink idref="bib26" id="ref16">26</reflink>]; Janusek et al., [<reflink idref="bib39" id="ref17">39</reflink>]; Wilson-Genderson et al., [<reflink idref="bib89" id="ref18">89</reflink>]), an emerging body of work has unveiled the role of adversity in educational or school outcomes, particularly among children and young adults (Houtepen et al., [<reflink idref="bib35" id="ref19">35</reflink>]). In this research, ACEs have been linked to key negative school outcomes such as disengagement, grade repetition and absenteeism, spanning from elementary school to college (Bellis et al., [<reflink idref="bib7" id="ref20">7</reflink>]; Blodgett &amp; Lanigan, [<reflink idref="bib12" id="ref21">12</reflink>]; Crouch et al., [<reflink idref="bib19" id="ref22">19</reflink>]; Duke, [<reflink idref="bib25" id="ref23">25</reflink>]; Stempel et al., [<reflink idref="bib73" id="ref24">73</reflink>]). Indeed, one study found that children with two or more ACEs were 2.67 times more likely to repeat a grade in comparison to children without reported ACEs (Bethell et al., [<reflink idref="bib11" id="ref25">11</reflink>]). Studies have also demonstrated a significant, dose response relationship between specific ACEs (e.g., parental incarceration, bullying and economic hardship) and school disengagement, with the odds of disengagement increasing with the number of reported ACEs among elementary and high school children (Baiden et al., [<reflink idref="bib6" id="ref26">6</reflink>]; Webb et al., [<reflink idref="bib87" id="ref27">87</reflink>]).</p> <p>This growing body of research on ACEs and school outcomes has largely omitted an important minority population, autistic children (e.g., Xu et al., [<reflink idref="bib90" id="ref28">90</reflink>]). Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by impairments in social communication and repetitive sensory-motor behaviors (Lord et al., [<reflink idref="bib49" id="ref29">49</reflink>]) that impacts approximately 2.5% (3.6% in boys and 1.2% in girls) of children in the U.S. (Xu et al., [<reflink idref="bib90" id="ref30">90</reflink>]; Zablotsky et al., [<reflink idref="bib93" id="ref31">93</reflink>]). Evidence suggests that autistic children experience a greater number of ACEs than their neurotypical peers (Berg et al., [<reflink idref="bib9" id="ref32">9</reflink>]; Lee &amp; Barger, [<reflink idref="bib47" id="ref33">47</reflink>]; Rigles, [<reflink idref="bib62" id="ref34">62</reflink>]). In a population-based study of U.S. children, ASD status was significantly and independently associated with higher probability of ACEs, with 10% reporting 4 or more ACEs (Berg et al., [<reflink idref="bib9" id="ref35">9</reflink>]). While this study did not include bullying in its conceptualization of ACEs, subsequent studies that included bullying as an ACE (e.g., Forster et al., [<reflink idref="bib31" id="ref36">31</reflink>]; Rettew &amp; Pawlowski, [<reflink idref="bib61" id="ref37">61</reflink>]) demonstrated that autistic children experience peer-bullying at a rate of three to four times that of neurotypical children, compounding their overall burden of adversity (Adams et al., [<reflink idref="bib1" id="ref38">1</reflink>]; Ashburner et al., [<reflink idref="bib5" id="ref39">5</reflink>]; Hoover &amp; Kaufman, [<reflink idref="bib34" id="ref40">34</reflink>]; Sreckovic et al., [<reflink idref="bib69" id="ref41">69</reflink>]).</p> <p>Despite the higher than average levels of adversity experienced by autistic youth, there is a paucity of studies investigating the role of ACEs in school outcomes among autistic children. In part, this reflects the historical exclusion of autistic individuals from traditional school settings and measures of academic achievement (Cumming &amp; Dickson, [<reflink idref="bib20" id="ref42">20</reflink>]; Keen et al., [<reflink idref="bib42" id="ref43">42</reflink>]; Thurlow et al., [<reflink idref="bib80" id="ref44">80</reflink>]). Recent advances in access and school inclusion have increased the availability of academic outcome data for autistic children (Keen et al., [<reflink idref="bib42" id="ref45">42</reflink>]). Within this limited body of research, most studies have documented school outcome disparities between autistic children and their neurotypical peers, although there is significant heterogeneity in individual outcomes (Garcia &amp; Hahs-Vaughn [<reflink idref="bib32" id="ref46">32</reflink>]; Keen et al., [<reflink idref="bib42" id="ref47">42</reflink>]). Research suggests that poor school outcomes, such as academic achievement, reading comprehension, and arithmetic skills among autistic children cannot be explained by intellectual ability (Estes et al., [<reflink idref="bib28" id="ref48">28</reflink>]; Jones et al., [<reflink idref="bib40" id="ref49">40</reflink>]; Kim et al., [<reflink idref="bib43" id="ref50">43</reflink>]). Furthermore, investigations into particular traits linked to ASD, such as sensory or social skills impairments, have fallen short in explaining adverse school outcomes in this population (Ambrose et al., [<reflink idref="bib3" id="ref51">3</reflink>]). Mental health conditions, notably depression and anxiety, which are more prevalent among autistic children (Gotham et al., [<reflink idref="bib33" id="ref52">33</reflink>]; Lai et al., [<reflink idref="bib46" id="ref53">46</reflink>]; Stadnick et al., [<reflink idref="bib71" id="ref54">71</reflink>]; Uljarević et al., [<reflink idref="bib82" id="ref55">82</reflink>]; van Steensel et al., [<reflink idref="bib84" id="ref56">84</reflink>]), have been associated with school underperformance and disengagement in the general population, and to a limited extent, among autistic children and young adults (Dalsgaard et al., [<reflink idref="bib22" id="ref57">22</reflink>]; Pagerols et al., [<reflink idref="bib57" id="ref58">57</reflink>]). Despite these advances in school outcome research, few studies have examined the role of a potent social determinant, ACEs, in the school outcomes of autistic children.</p> <p>Although autistic children are at higher risk of experiencing both poor school outcomes and ACEs, a significant portion of the current literature fails to take ACEs into account when examining academic outcomes in this population. Furthermore, there is limited understanding of the potential mediating role of mental health conditions in the school outcomes of autistic children who experience ACEs. The aim of this study is to employ a nationally representative dataset to test the association between ACEs and school outcomes among autistic children and whether mental health conditions may mediate this association.</p> <hd id="AN0186910014-2">Methods</hd> <p></p> <hd id="AN0186910014-3">Data Source</hd> <p>The University of Illinois Chicago Institutional Review Board determined that this study was exempt from review.</p> <p>This study utilized data from the 2016, 2017, 2018, 2019, 2020, and 2021 National Survey of Children's Health (NSCH; Child and Adolescent Health Measurement Initiative, [<reflink idref="bib17" id="ref59">17</reflink>]), a nationally representative population-based survey of non-institutionalized U.S. children aged 0–17 years sponsored by the Maternal and Child Health Bureau Health Resources and Services Administration and conducted by the United States Census Bureau (The United States Census Bureau, [<reflink idref="bib79" id="ref60">79</reflink>], [<reflink idref="bib77" id="ref61">77</reflink>], [<reflink idref="bib75" id="ref62">75</reflink>], [<reflink idref="bib74" id="ref63">74</reflink>], [<reflink idref="bib76" id="ref64">76</reflink>], [<reflink idref="bib78" id="ref65">78</reflink>]). Survey domains included children's health status, access to and quality of healthcare, school, family demographics, neighborhood characteristics, and other topics relevant to children's health and wellbeing.</p> <p>The NSCH followed a two-phase data collection approach. First, randomly selected households received a screener questionnaire by mail (or online) to determine if eligible children resided in the household. Second, households with eligible children received questionnaires regarding a randomly selected child, for completion by parents or other caregivers familiar with the child's health and health care, with topics and questions depending on the child's age (0–5 years, 6–11 years, and 12–17 years). Survey weights, composed of a base sampling weight, with adjustments for both screener and topical nonresponse, an adjustment for the selection of a single child within the sample household, and adjustments used to control population counts for various demographics obtained from the American Community Survey one-year data, were applied to alleviate bias in the estimates due to nonresponse and ensure generalizability to the entire population. Detailed weighting plans are included in each year's NSCH methodology reports (Child and Adolescent Health Measurement Initiative, [<reflink idref="bib17" id="ref66">17</reflink>]). The survey oversampled children with special health care needs (Child and Adolescent Health Measurement Initiative, [<reflink idref="bib17" id="ref67">17</reflink>]).</p> <hd id="AN0186910014-4">Sample</hd> <p>The NSCH survey response rate of identified households with eligible children aged 6–17 for 2016, 2017, 2018, 2019, 2020, 2021 was 40.7%, 37.4%, 43.1%, 42.4%, 42.4% and 40.3%, respectively. From these, 4,997 children ages 6–17 with ASD were identified. Autistic children were identified by the parents/caregiver answering "yes" to the question: "Has a doctor or other health care provider EVER told you that this child has Autism or Autism Spectrum Disorder (ASD)? Include diagnoses of Asperger's Disorder or Pervasive Developmental Disorder (PDD)," and "yes" to the question: "Does this child CURRENTLY have the condition?"</p> <hd id="AN0186910014-5">Measures</hd> <p></p> <hd id="AN0186910014-6">Dependent Variables</hd> <hd1 id="AN0186910014-7">School Engagement</hd1> <p>Attendance, grade repetition, homework completion, and caring about school were the school-related items collected in the NSCH questionnaires. School engagement was measured by responses to two questions: "How often does this child care about doing well in school?" and "How often does this child do all required homework?" Parents responded "always," "usually," "sometimes," or "never." Children whose parents reported that their child "always" cares about doing well in school AND does required homework were categorized as "always engaged in school." Children categorized as "always engaged" were considered positive for school engagement.</p> <hd1 id="AN0186910014-8">Grade Progression</hd1> <p>Children who ever missed a grade were identified by parent/caregiver "yes" or "no" response to the following question, "Since starting kindergarten, has this child repeated any grades, age 6–17 years?" Caregiver response of "no" was operationalized as grade progression.</p> <hd1 id="AN0186910014-9">School Attendance</hd1> <p>School attendance was determined based on parents/caregiver response to the question: "During the past 12 months, about how many days did this child miss school because of illness or injury?" Response categories were: 0 days, 1-3 days, 4-6 days, 7-10 days, and 11 or more days. Children who had missed 10 days or fewer were categorized as positive for school attendance (i.e., considered to attend school regularly).</p> <hd id="AN0186910014-10">School Success Index</hd> <p>The School Success Index was created by summing the three aforementioned binary variables: school engagement (0 = absence of engagement, 1 = school engagement), grade progression (0 = repeated a grade, 1 = school progression), and school attendance (0 = irregular/low school attendance, 1 = regular school attendance). The value of the School Success Index ranged from 0 to 3, with higher scores indicating greater school success (as reported by parents/caregivers).</p> <hd id="AN0186910014-11">Independent Variables</hd> <p>Level of ACE exposure was the primary independent variable. The 2016–2019 NSCH included nine ACEs: (<reflink idref="bib1" id="ref68">1</reflink>) hard to cover the basics, like food or housing on the family's income, (<reflink idref="bib2" id="ref69">2</reflink>) parent or guardian divorced or separated, (<reflink idref="bib3" id="ref70">3</reflink>) parent or guardian died, (<reflink idref="bib4" id="ref71">4</reflink>) parent or guardian served time in jail, (<reflink idref="bib5" id="ref72">5</reflink>) saw or heard parents or adults slap, hit, kick, or punch one another in the home, (<reflink idref="bib6" id="ref73">6</reflink>) was a victim of violence or witnessed violence in neighborhood, (<reflink idref="bib7" id="ref74">7</reflink>) lived with anyone who was mentally ill, suicidal, or severely depressed, (<reflink idref="bib8" id="ref75">8</reflink>) lived with anyone who had a problem with alcohol or drugs and (<reflink idref="bib9" id="ref76">9</reflink>) treated or judged unfairly due to race/ethnicity. An additional ACE was added to the 2020 NSCH (treated or judged unfairly because of their sexual orientation or gender identity) but was not included in the analysis to preserve consistency. This study also included (<reflink idref="bib10" id="ref77">10</reflink>) child being bullied, picked on, or excluded by other children as an ACE. All ACEs were dichotomous (yes/no) variables except for family income, discrimination, and bullying, which were Likert scales. If parents responded that insufficient income, incidents of discrimination or incidents of bullying happened "somewhat often" or "very often," then it was coded as an ACE (Somewhat/Very Often = 1). The question format to measure bullying changed in 2018 from dichotomous (Yes/No) child has ever been bullied to a 4-point Likert scale of frequency of bullying (i.e., "During the past 12 months, how often was this child bullied, picked on, or excluded by other children": never, 1–2 times in the past year, 1–2 times per month, 1–2 times per week). The 2018–2021 variable was recoded and dichotomized to be consistent with 2016 and 2017 so that all children who had ever been bullied, regardless of frequency, were classified as having an ACE. Cumulative ACE exposure (or ACE count, range 0–10) was used as the independent variable.</p> <hd id="AN0186910014-12">Covariates</hd> <p>We included measures related to children's mental health, specifically anxiety and depression, in our analysis given the association between mental health and both ACEs and educational outcomes (Leiva et al., [<reflink idref="bib48" id="ref78">48</reflink>]). Children with anxiety (yes/no) and with depression (yes/no) were identified by a parent/caregiver response of "yes" to "Has a doctor or other health care provider EVER told you that this child has [mental health condition]" and "yes" to "Does this child CURRENTLY have the condition." Additionally, a number of child and family demographic variables were included as covariates for analysis, as follows.</p> <p>Child specific characteristics: Age (continuous) categorized as 6–11 and 12–17 years for descriptive purposes, biological sex (male, female), race/ethnicity (the NSCH includes seven race categories and two ethnicity categories, which we collapsed into a single race/ethnicity variable: non-Hispanic white, non-Hispanic Black/African American, Hispanic/Latino, and non-Hispanic other), severity of ASD symptoms (based on parent/caregiver response to the questions, "Is [Autism or Autism Spectrum Disorder] mild, moderate or severe?"), receipt of special education services (yes, no), current insurance status (any/no), visit to health care provider in the past year (yes/no), and number of personal health care providers (0, 1, &gt; 1).</p> <p>Family characteristics: Primary caregiver's education level (≤ high school, high school, &gt; high school [i.e., some college, bachelor's degree, or graduate/ professional degree]), percentage of the federal poverty level (FPL; ≤ 200%, &gt; 200% FPL), and language spoken at home (English, Spanish, Other). In 2020, the FPL for a 4-person household was $26,200, such that 200% FPL equaled a household income of $52,400 (Office of the Assistant Secretary for Planning and Evaluation, [<reflink idref="bib55" id="ref79">55</reflink>]). These demographic variables were incorporated in the analysis because previous research has established their association with educational outcomes (Akhlaghipour et al., [<reflink idref="bib2" id="ref80">2</reflink>]; Kaushhal &amp; Nepomnyaschy [<reflink idref="bib41" id="ref81">41</reflink>]; Roscigno, [<reflink idref="bib64" id="ref82">64</reflink>]).</p> <hd id="AN0186910014-13">Statistical Analysis</hd> <p>Data analysis was restricted to participants with no missing data on all variables, including the outcomes, exposures and covariates. Specifically, total N and sample n were 1,008 and 933 (0.07% missing) for 2016, 494 and 469 (0.05% missing) for 2017, 687 and 651 (0.05% missing) for 2018, 1,030 and 977 (0.06% missing) for 2020, and 1,085 and 1,013 (0.06% missing) for 2021. This resulted in a final sample size of 4,997. All statistical analysis procedures to account for complex survey design and reweighting were performed using Stata version 16 (StataCorp, [<reflink idref="bib72" id="ref83">72</reflink>]). Univariate analysis and generalized linear models with logit link functions were employed to analyze the data.</p> <p>Weighted generalized linear models with logit link functions were used to examine the relationship between ACEs (0–10) and school outcomes, as well as levels of school success. In this model, adjusted odds ratios were calculated in terms of unit change. Depression and anxiety variables were investigated as potential mediators of ACEs and school outcomes. Brant tests were carried out to determine whether the model satisfied the proportional odds assumption. The significance level for all analyses was 0.05.</p> <hd id="AN0186910014-14">Results</hd> <p>Table 1 provides a summary of child and family population characteristics for children aged 6–17 with ASD from NSCH 2016–2021. The mean age of children in our sample was 11.72 years (95% CI 11.49–11.95) and most (79.28%) were male. Approximately half of the sample (49.91%) were non-Hispanic white, 27.79% were Hispanic/Latino, 14.09% non-Hispanic Black, and 8.22% others (which included Asian, Asian American, and Pacific Islander, or other race/ethnicity). Approximately 50.22% of the sample reported living below 200% of the federal poverty level and the majority of children had some form of health insurance (95.93%). The mean number of ACEs reported for autistic children was 2.02 (95% CI 1.90–2.15). As summarized in Table 1, being bullied or excluded was the most commonly endorsed ACE for autistic children (62.97%), followed by parental/guardian divorce (35.05%) and insufficient income (i.e., "hard to cover basics," 34.01%). Most caregivers (89.43%) reported that their autistic child did not have depression or had a mild form of depression. In contrast, 31.19% reported that their autistic child had moderate or severe anxiety symptoms. Most children (72.74%) received special education services.</p> <p>Table 1 Distributions of key variables among school-aged autistic children</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" /&gt;&lt;th align="left"&gt;&lt;p&gt;% or M&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;(95% CI)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Child Characteristics&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Age&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;11.72&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(11.49&amp;#8211;11.95)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Biological sex&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Female&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.72%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(18.11 &amp;#8722; 23.61%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;79.28%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(76.39 &amp;#8722; 81.89%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Race/ethnicity&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Non-Hispanic white&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;49.91%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(46.42 &amp;#8722; 53.40%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Hispanic/Latino&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27.79%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(23.73 &amp;#8722; 32.25%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Non-Hispanic Black/African American&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.09%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(11.98 &amp;#8722; 16.50%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Non-Hispanic other&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.22%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(7.08 &amp;#8722; 9.51%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;ACEs&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Cumulative ACEs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.02&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.90&amp;#8211;2.15)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hard to cover basics like food or housing&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;34.01%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(30.55 &amp;#8722; 37.65%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Parent/guardian divorced&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;35.05%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(31.81 &amp;#8211; 38.42%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Parent/guardian died&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.60%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(3.44 &amp;#8722; 6.13%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Parent/guardian time in jail&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10.36%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(8.78 &amp;#8722; 12.18%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Adults slap, hit, kick, punch, etc.&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10.12%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(8.41 &amp;#8722; 12.12%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Victim of violence&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7.66%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(6.23 &amp;#8722; 9.39%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Lived with mentally ill&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.96%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(17.47 &amp;#8722; 22.70%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Lived with persons with alcohol/drug problem&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;13.74%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(11.58 &amp;#8722; 16.23%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Treated unfairly because of race&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.03%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(6.35 &amp;#8722; 10.10%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Ever bullied, picked on, or excluded by others&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;62.97%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(59.27 &amp;#8722; 66.53%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;School Outcomes&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Attendance&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;73.94%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(70.22 &amp;#8722; 77.34%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Grade progression&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;85.00%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(82.49 &amp;#8722; 87.21%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;School engagement&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;42.38%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(38.90 &amp;#8722; 45.93%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;School success index&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.88%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(3.43 &amp;#8722; 6.91%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;20.56%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(18.13 &amp;#8722; 23.22%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 2&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;45.34%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(41.82 &amp;#8722; 48.91%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;29.22%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(26.33 &amp;#8722; 32.28%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Child Mental Health&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Current depressive symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; No symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;82.60%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(80.30 &amp;#8722; 84.64%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mild symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6.83%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(5.67 &amp;#8722; 8.20%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Moderate symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.43%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(6.93 &amp;#8722; 10.23%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Severe symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.14%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.45 &amp;#8722; 3.14%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Current Anxiety Symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; No symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;54.09%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(50.59 &amp;#8722; 57.54%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mild symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;14.72%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(12.36 &amp;#8722; 17.44%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Moderate symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;22.82%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(20.32 &amp;#8722; 25.53%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Severe symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.37%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(6.88 &amp;#8722; 10.15%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Service Access&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Health insurance&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Any current insurance&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;95.93%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(93.96 &amp;#8722; 97.28%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Visit health care provider in the past year&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Yes&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;87.77%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(85.19 &amp;#8722; 89.95%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Number of personal health care providers&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23.72%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(20.37 &amp;#8722; 27.45%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;46.41%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(43.11 &amp;#8722; 49.47%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#62;1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;29.86%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(27.08 &amp;#8722; 32.80%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Receipt of special education services&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; No&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26.63%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(23.80 &amp;#8722; 29.66%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Yes&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;72.74%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(69.70 &amp;#8722; 75.59%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Caregiver Characteristics&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Age&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;44.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(43.74&amp;#8211;44.85)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Biological sex&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Female&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;73.93%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(70.92 &amp;#8722; 76.73%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;26.07%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(23.27 &amp;#8722; 29.08%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Educational level&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#60; High school&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9.26%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(6.45 &amp;#8722; 13.14%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; High school&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23.17%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(20.03 &amp;#8722; 26.64%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#62; High school&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;67.57%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(63.56 &amp;#8722; 71.33%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Household Characteristics&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Income&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; 1-200% FPL&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;50.22%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(46.73 &amp;#8722; 53.71%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; &amp;#62;200% FPL&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;49.78%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(46.29 &amp;#8722; 53.27%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Language spoken at home&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; English&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;89.44%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(85.82 &amp;#8722; 92.22%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Spanish&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.31%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(5.66 &amp;#8722; 12.03%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Other&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.26%&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.57 &amp;#8722; 3.24%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Note. FPL = Federal poverty level.</p> <p>Table 2 reports the effects of ACEs on adjusted odds ratios for school attendance, grade progression, engagement, and composite school success for autistic children. Models were adjusted for survey years only (Model 1); further adjusted for children's characteristics, service access, caregivers' characteristics, and household characteristics (Model 2); and adjusted again for children's mental health variables (Model 3). Overall, these regression analyses demonstrated that higher ACEs are associated with fewer positive outcomes among autistic children. For every unit increase in ACEs, autistic children experienced a significant decrease in the odds of school attendance (<emph>p</emph> &lt;.01), grade progression (Model 1, <emph>p</emph> &lt;.001; Model 2, <emph>p</emph> &lt;.01) and school engagement (<emph>p</emph> &lt;.01). Additionally, every unit increase in ACEs was associated with a 17–18% decrease (<emph>p</emph> &lt;.001) in the odds of achieving one level higher in the school success index. Model 3, which accounts for mental health variables, indicates that depression and anxiety symptoms were significantly associated with school outcomes and fully explained the relation between ACEs and attendance, and partially explained the relationship between ACEs and grade progression, engagement, and level of school success. Thus, even when controlling for key mental health variables, the association between ACEs and school outcomes remained significant. Indeed, as demonstrated in Table 2, the introduction of the control and mediating variables resulted in changes in the relationship between ACEs and school outcomes. The data also highlighted a significant correlation between child race and school outcomes. Compared to white autistic children, Black autistic children had significantly higher attendance (Model 2 <emph>p</emph> &lt;.01; Model 3: <emph>p</emph> &lt;.05) and school engagement (Models 2 and 3 <emph>p</emph> &lt;.05). Additionally, Black autistic children (vs. white autistic children) had a 49% (<emph>p</emph> &lt;.05) increase in the odds of achieving one level up in the school success index.</p> <p>Table 2 ACEs and school outcomes among school-aged autistic children</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2" /&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Attendance&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Grade Progression&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;School Engagement&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;School Success Index&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;a.O.R.&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;(95% CI)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;a.O.R.&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;(95% CI)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;a.O.R.&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;(95% CI)&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;a.O.R.&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;(95% CI)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Model 1&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;ACEs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.86&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.78&amp;#8211;0.94)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.84&amp;#42;&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.77&amp;#8211;0.91)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.87&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.80&amp;#8211;0.95)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.82&amp;#42;&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.76&amp;#8211;0.88)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Model 2&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;ACEs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.87&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.80&amp;#8211;0.95)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.88&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.82&amp;#8211;0.96)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.87&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.80&amp;#8211;0.95)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.83&amp;#42;&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.77&amp;#8211;0.88)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Race/Ethnicity&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hispanic (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.04&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.64&amp;#8211;1.69)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.28&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.66&amp;#8211;2.48)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.12&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.73&amp;#8211;1.73)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.17&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.75&amp;#8211;1.81)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Black (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2.02&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.19&amp;#8211;3.43)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.89&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.53&amp;#8211;1.48)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.53&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.02&amp;#8211;2.30)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.49&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.06&amp;#8211;2.10)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Others (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.17&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.79&amp;#8211;1.72)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.04&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.70&amp;#8211;1.54)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.06&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.74&amp;#8211;1.50)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.07&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.81&amp;#8211;1.42)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;bold&gt;Model 3&lt;/bold&gt;&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;ACEs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.93&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.85&amp;#8211;1.03)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.89&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.81&amp;#8211;0.97)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.90&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.83&amp;#8211;0.99)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.87&amp;#42;&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.81&amp;#8211;0.94)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Race/Ethnicity&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Hispanic (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.59&amp;#8211;1.68)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.27&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.65&amp;#8211;2.49)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.10&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.70&amp;#8211;1.71)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.14&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.73&amp;#8211;1.80)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Black (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.97&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.11&amp;#8211;3.51)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.80&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.48&amp;#8211;1.32)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.57&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.03&amp;#8211;2.38)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.43&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.99&amp;#8211;2.07)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Others (vs. white)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.12&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.74&amp;#8211;1.69)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.97&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.65&amp;#8211;1.45)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.03&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.71&amp;#8211;1.47)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.03&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.77&amp;#8211;1.38)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Depressive Symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.73&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.59&amp;#8211;0.91)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1.31&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(1.02&amp;#8211;1.69)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.67&amp;#42;&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.55&amp;#8211;0.83)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.76&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.62&amp;#8211;0.94)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Anxiety Symptoms&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.79&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.67&amp;#8211;0.94)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.84&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.72&amp;#8211;0.97)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.92&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.80&amp;#8211;1.07)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;0.83&amp;#42;&amp;#42;&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;(0.73&amp;#8211;0.95)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Note. a.O.R. = adjusted odds ratio, *<emph>p</emph> &lt;.5, **<emph>p</emph> &lt;.01, ***<emph>p</emph> &lt;.001. Note. In Model 1, only survey years were entered into the model. In Model 2, child characteristics, service access, caregiver characteristics, and household characteristics were further entered into the model. In Model 3, child mental health variables were further entered into the model.</p> <p>Figure 1 illustrates the adjusted probabilities of attaining various levels on the school success index by number of reported ACEs. Overall, as the number of ACEs increases, the probability of attaining a school success index of 0 or 1 increases, while the probability of attaining a school success index of 3 decreases. For example, among youth with no reported ACEs, approximately 2% have no positive indicators of school success (i.e. a school success index of 0) while 40% have a school success index of 3, or positive outcomes across all three indicators of school success. Conversely, among youth with 10 reported ACEs, approximately 8% have a school success index of 0 while 15% have a school success index of 3. The relative proportion of the highest and lowest school success indices shifts progressively with an increase in the number of ACEs: the probability of attaining a school success index level of 0 is 3 times higher for youth with 10 ACEs (8%) vs. youth with no ACEs (2%).</p> <p>Graph: Fig. 1 School success index (0 to 3 domains) across cumulative ACEs among school-aged autistic children</p> <hd id="AN0186910014-15">Discussion</hd> <p>To the best of our knowledge, this is the first study to explore ACEs and school outcomes in a nationally representative sample of autistic children. Results indicate that ACEs are significantly associated with reduced school attendance, grade progression, and engagement among autistic children. The reported average count of ACEs among autistic children (<emph>M =</emph> 2.02; 95% CI 1.90–2.15) corresponds with previous findings, and was negatively associated with the school success index, whereby higher ACEs predicted worse school outcomes. For autistic children, each additional ACE was linked to an 11%, 10%, and 13% decrease in the odds of grade progression, school engagement and achieving a higher level on the school success index, respectively. Even after accounting for depression and anxiety, the relationship between ACEs and three of the four school outcomes (i.e., school engagement, grade progression, and school success index) persisted, mirroring broader findings on the detrimental impacts of ACEs on the educational and occupational achievements of individuals in the general population (Bellis et al., [<reflink idref="bib7" id="ref84">7</reflink>]; Blodgett &amp; Lanigan, [<reflink idref="bib12" id="ref85">12</reflink>]; Crouch et al., [<reflink idref="bib19" id="ref86">19</reflink>]; Duke, [<reflink idref="bib25" id="ref87">25</reflink>]; Houtepen et al., [<reflink idref="bib35" id="ref88">35</reflink>]; Stempel et al., [<reflink idref="bib73" id="ref89">73</reflink>]).</p> <p>Screening for ACEs is not routinely performed in school-aged children (Cibralic et al., [<reflink idref="bib18" id="ref90">18</reflink>]; Dube, [<reflink idref="bib23" id="ref91">23</reflink>]). However, prior research has highlighted that autistic children experience higher rates of trauma (Stack &amp; Lucyshyn, [<reflink idref="bib70" id="ref92">70</reflink>]) and adversity, which potentially compromises their health and social outcomes (Berg et al., [<reflink idref="bib10" id="ref93">10</reflink>]). Our findings, which suggest that ACEs are correlated with school success among autistic children, highlight the potential utility of proactive screening and intervention to address ACEs in this population. Such measures could be critical for autistic children for whom school engagement is key to accessing developmental therapies that significantly influence their health and developmental trajectories (Hume et al., [<reflink idref="bib37" id="ref94">37</reflink>]).</p> <p>Attendance poses a significant challenge for autistic children who, on average, miss 5 days of school per month (Totsika et al., [<reflink idref="bib81" id="ref95">81</reflink>]). Absences due to illness and/or injury, potentially exacerbated by self-injurious behaviors in this population, highlight the complex health challenges autistic children face (Rattaz et al., [<reflink idref="bib59" id="ref96">59</reflink>]). Research demonstrates that autistic children generally have poorer health and higher healthcare needs, leading to increased rates of hospitalization (Cummings et al., [<reflink idref="bib21" id="ref97">21</reflink>]; Kuo &amp; Torrest, [<reflink idref="bib45" id="ref98">45</reflink>]). Additionally, studies have linked ACEs to negative health outcomes in youth with IDD, including ASD. (Rigles, [<reflink idref="bib62" id="ref99">62</reflink>]; Berg et al., [<reflink idref="bib9" id="ref100">9</reflink>]). Based upon these findings, future research should broaden the exploration of ACEs to encompass health outcomes in relation to school attendance and school success among autistic children.</p> <p>Unaddressed bullying may significantly impact the school engagement of autistic children. In our study, bullying was the most common ACE experienced by autistic elementary and high school-aged children. Numerous studies have linked peer bullying to lower student engagement across school settings (e.g., Yang et al., [<reflink idref="bib91" id="ref101">91</reflink>]). Promoting integration of autistic students in the class room and a positive social climate may be important targets for bullying reduction. Marini and colleagues ([<reflink idref="bib51" id="ref102">51</reflink>]) demonstrated that, in students aged 11–14 years, perceived social integration fully mediated the association between the presence of disability and victimization experiences. Intervention strategies that target classroom social dynamics and foster a neuroaffirmative culture in the classroom could potentially reduce peer bullying of autistic students (Marini et al., [<reflink idref="bib51" id="ref103">51</reflink>]). A more inclusive learning environment that recognizes and values neurodivergence could reduce stigma, promote positive peer interactions, and create a more supportive classroom for autistic students to thrive (Hutson &amp; McGinley, [<reflink idref="bib38" id="ref104">38</reflink>]; Shuck et al., [<reflink idref="bib67" id="ref105">67</reflink>]). Additionally, direct instruction in social/communication skills (Rose &amp; Gage, [<reflink idref="bib65" id="ref106">65</reflink>]) and a Multi-Tiered System of Supports (MTSS) which involves targeted teacher training are promising approaches to intervene in and mitigate the negative impacts of peer bullying on autistic children (Robinson et al., [<reflink idref="bib63" id="ref107">63</reflink>]).</p> <p>In our study, a notable proportion of autistic children had moderate or severe depression symptoms (10%) and almost 1in 3 had moderate or severe anxiety symptoms. These mental health challenges were independently associated with less favorable outcomes in school attendance and grade progression, regardless of ACE exposure. Indeed, our findings suggested that symptoms of anxiety and depression may partially mediate the impact of ACEs on grade progression, school engagement, and overall school success in autistic children, while fully accounting for their effects on attendance. This finding echoes the broader literature on the pivotal role of child mental health in school performance (e.g., Carter Leno et al., [<reflink idref="bib15" id="ref108">15</reflink>]; Lundy et al., [<reflink idref="bib50" id="ref109">50</reflink>]; Owens et al., [<reflink idref="bib56" id="ref110">56</reflink>]; Reschly et al., [<reflink idref="bib60" id="ref111">60</reflink>]) and underscores the potential of therapeutic interventions to enhance school outcomes for vulnerable autistic students. Research suggests that therapeutic interventions, including cognitive behavioral therapy, mindfulness-based therapy, zootherapy, neurofeedback, and pharmacological treatment, can be effective in reducing anxiety and depression in autistic individuals (Marta et al., [<reflink idref="bib52" id="ref112">52</reflink>]; Pezzimenti et al., [<reflink idref="bib58" id="ref113">58</reflink>]; Russell et al., [<reflink idref="bib66" id="ref114">66</reflink>]; Spek et al., [<reflink idref="bib68" id="ref115">68</reflink>]).</p> <p>Resilience, defined as the capacity to thrive in the face of adversity, can reduce the negative effects of ACEs on school outcomes in autistic children (Bethell et al., [<reflink idref="bib11" id="ref116">11</reflink>]; Elsabbagh, [<reflink idref="bib27" id="ref117">27</reflink>]; Yusuf et al., [<reflink idref="bib92" id="ref118">92</reflink>]; Bellis et al., [<reflink idref="bib7" id="ref119">7</reflink>]). Our research revealed that Black autistic children had higher school engagement and attendance compared to their white counterparts, regardless of ACEs. This finding suggests increased resilience within Black families and may reflect their greater diversity of coping strategies, leveraging of Black cultural capital and heightened optimism, as documented in previous studies (e.g., Kim et al., [<reflink idref="bib44" id="ref120">44</reflink>]; Morgan &amp; Stahmer, [<reflink idref="bib54" id="ref121">54</reflink>]; Webber et al., [<reflink idref="bib88" id="ref122">88</reflink>]). Family characteristics and attachment to caregivers have been demonstrated to mitigate the negative impacts of ACEs (van der Kolk, [<reflink idref="bib83" id="ref123">83</reflink>]). Studies also indicate that factors like parenting self-efficacy and educational support can play a role in fostering resilience, leading to positive developmental outcomes in autistic children (Yusuf et al., [<reflink idref="bib92" id="ref124">92</reflink>]). Future research can further disentangle the role of family dynamics, supportive relationships and cultural capital in cultivating resilience and promoting positive school outcomes in autistic children who experience ACEs.</p> <p>The main strength of the present study is that the data were collected on a large, nationally representative sample of U.S. children and adolescents. Additionally, because the NSCH questionnaires included items related to a broad range of demographic and health topics, analysis could be adjusted for relevant covariates. There were several limitations to this analysis. First, the use of self-report survey questionnaires for all measures may introduce measurement error, potential recall bias, and misreporting. Given the sensitive nature of ACEs, prevalence of household violence or substance use might be underreported by caregivers. In addition, the health information collected was based on caregiver report, which may differ from electronic medical record data (e.g., diagnosis of child depression and anxiety). Second, the ACE questions in the 2016–2021 NSCH were not comprehensive. In particular, they did not include questions about neglect or abuse (physical, emotional, and sexual abuse), nor ask parents/caregivers about alternative causes for their child's school absence (e.g., school avoidance, anxiety) beyond "illness or injury." Third, the NSCH data is based on a cross-sectional design, which does not allow for inference about causal relationships. Fourth, this study does not include a comparison group of school-aged children with other disabilities or mental health conditions; therefore, it cannot be ascertained whether findings are specific to autistic children, or if increased ACEs may predict poorer school outcomes in other groups of disabled children. In addition, although the analysis controlled for multiple child and family characteristics, some meaningful school characteristics (e.g., percent of student population that is minoritized, percent of student population on free and reduced lunch), which could potentially have an impact on outcomes, were not collected by NSCH and could not be incorporated in our analysis. Finally, although variables center on experiences of autistic children, and reported outcomes focus on measures of school success, data were collected exclusively from parent/caregiver surveys and included neither youth self-reports nor teacher-reports, which may provide further insight into self-perception, school behavior, and social dynamics and bullying. Future research collecting data directly from autistic children and from teachers will be essential to investigate whether present findings can be replicated or further explained based on their lived experience and perceptions.</p> <p>School engagement, attendance and grade progression are key factors in school success. Furthermore, depression and anxiety comorbidities among youth can compromise the achievement and maintenance of educational and employment goals. Our findings suggest ACEs predict school success among autistic children. However, mental health conditions appear to partially mediate the relationship between ACEs and key factors in school success. Efforts should be made to proactively identify and address the impact of ACEs and associated mental health conditions among autistic students. Additionally, further research is needed to explore innovative methods to integrate mental health support into existing educational and transition services for autistic children.</p> <hd id="AN0186910014-16">Acknowledgements</hd> <p>The authors would like to thank Dr. Victoria Persky at the University of Illinois Chicago for helpful discussions during preparation of this manuscript.</p> <hd id="AN0186910014-17">Author Contributions</hd> <p>All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Hélène Gussin, Cheng-Shi Shiu, Christianna Danguilan, Iulia Mihaila, Kruti Acharya and Kristin Berg. The first draft of the manuscript was written by Hélène Gussin and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.</p> <hd id="AN0186910014-18">Funding</hd> <p>No external funding was received for this research.</p> <hd id="AN0186910014-19">Declarations</hd> <p></p> <hd id="AN0186910014-20">Conflict of Interest</hd> <p>The authors have no relevant financial or non-financial interests to disclose.</p> <hd id="AN0186910014-21">Research Involving Human Participants and/or Animals</hd> <p>This article does not contain any studies with human participants or animals performed by any of the authors.</p> <hd id="AN0186910014-22">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0186910014-23"> <title> References </title> <blist> <bibl id="bib1" idref="ref38" type="bt">1</bibl> <bibtext> Adams R, Taylor J, Duncan A, Bishop S. Peer victimization and Educational outcomes in Mainstreamed adolescents with Autism Spectrum disorder (ASD). 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| Header | DbId: eric DbLabel: ERIC An: EJ1478487 AccessLevel: 3 PubType: Academic Journal PubTypeId: academicJournal PreciseRelevancyScore: 0 |
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| Items | – Name: Title Label: Title Group: Ti Data: Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016-2021 National Survey of Children's Health – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Hélène+A%2E+Gussin%22">Hélène A. Gussin</searchLink><br /><searchLink fieldCode="AR" term="%22Cheng-Shi+Shiu%22">Cheng-Shi Shiu</searchLink><br /><searchLink fieldCode="AR" term="%22Christianna+Danguilan%22">Christianna Danguilan</searchLink><br /><searchLink fieldCode="AR" term="%22Iulia+Mihaila%22">Iulia Mihaila</searchLink><br /><searchLink fieldCode="AR" term="%22Kruti+Acharya%22">Kruti Acharya</searchLink><br /><searchLink fieldCode="AR" term="%22Kristin+L%2E+Berg%22">Kristin L. Berg</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-1452-2005">0000-0003-1452-2005</externalLink>) – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. 2025 55(8):2615-2627. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 13 – Name: DatePubCY Label: Publication Date Group: Date Data: 2025 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Early+Experience%22">Early Experience</searchLink><br /><searchLink fieldCode="DE" term="%22Trauma%22">Trauma</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Academic+Achievement%22">Academic Achievement</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22National+Surveys%22">National Surveys</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Health%22">Child Health</searchLink><br /><searchLink fieldCode="DE" term="%22Attendance%22">Attendance</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Promotion%22">Student Promotion</searchLink><br /><searchLink fieldCode="DE" term="%22Learner+Engagement%22">Learner Engagement</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10803-024-06338-x – Name: ISSN Label: ISSN Group: ISSN Data: 0162-3257<br />1573-3432 – Name: Abstract Label: Abstract Group: Ab Data: Purpose: School is an important developmental setting for children. Adverse childhood experiences (ACEs) are linked to overall lower educational attainment and are more prevalent in children with Autism Spectrum Disorder (ASD) than in their neurotypical peers. The aim of this study is to test the association between ACEs and school outcomes among autistic children and whether mental health conditions explain this association. Methods: We combined 2016-2021 data from the National Surveys of Children's Health for children, ages 6-17, identified by parents as having ASD (N = 4,997), to examine the relationship between ACEs and school outcomes (grade progression, school attendance, and engagement). We analyzed depression and anxiety variables to investigate the extent to which mental health can explain the relationships between ACEs and school outcomes. Results: ACEs were significantly associated with school outcomes. With increased ACEs, autistic children experienced a significant decrease in the odds of school attendance, grade progression and school engagement (p < 0.05). Furthermore, although depression and anxiety symptoms were significantly associated with school outcomes, they cannot explain away the enduring, strong relationship between ACEs and level of grade progression, engagement, and school success index. Conclusion: Our findings suggest ACEs predict school success among autistic children, with mental health conditions appearing to mediate the relationship between ACEs and key factors in school success. Efforts should be made to proactively identify and address the impact of ACEs and associated mental health conditions among autistic students. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2025 – Name: AN Label: Accession Number Group: ID Data: EJ1478487 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s10803-024-06338-x Languages: – Text: English PhysicalDescription: Pagination: PageCount: 13 StartPage: 2615 Subjects: – SubjectFull: Early Experience Type: general – SubjectFull: Trauma Type: general – SubjectFull: Mental Health Type: general – SubjectFull: Academic Achievement Type: general – SubjectFull: Autism Spectrum Disorders Type: general – SubjectFull: National Surveys Type: general – SubjectFull: Child Health Type: general – SubjectFull: Attendance Type: general – SubjectFull: Student Promotion Type: general – SubjectFull: Learner Engagement Type: general – SubjectFull: Depression (Psychology) Type: general – SubjectFull: Symptoms (Individual Disorders) Type: general Titles: – TitleFull: Impact of Adverse Childhood Experiences and Mental Health on School Success in Autistic Children: Findings from the 2016-2021 National Survey of Children's Health Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Hélène A. Gussin – PersonEntity: Name: NameFull: Cheng-Shi Shiu – PersonEntity: Name: NameFull: Christianna Danguilan – PersonEntity: Name: NameFull: Iulia Mihaila – PersonEntity: Name: NameFull: Kruti Acharya – PersonEntity: Name: NameFull: Kristin L. Berg IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 08 Type: published Y: 2025 Identifiers: – Type: issn-print Value: 0162-3257 – Type: issn-electronic Value: 1573-3432 Numbering: – Type: volume Value: 55 – Type: issue Value: 8 Titles: – TitleFull: Journal of Autism and Developmental Disorders Type: main |
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