Environmental, Family, and Disability Correlates of Flourishing, Anxiety, and Depression Among U.S. Children Aged 6-17 Years: A Cross-Sectional Analysis of the 2023-2024 National Survey of Children's Health.

Background/

Objectives

Children's mental health and positive development are shaped by family, environmental, and individual factors. Although neurodevelopmental disabilities (NDDs) are well-established correlates of poorer mental health outcomes, few national-scale studies have simultaneously modeled positive (flourishing) and negative (anxiety, depression) outcomes within a unified ecological framework. This study examined how parent mental health, peer victimization, neighborhood and school context, and four NDD diagnoses (autism spectrum disorder [ASD], attention-deficit/hyperactivity disorder [ADHD], developmental delay, and learning disability) are associated with flourishing, current anxiety, and current depression in a national sample of U.S. children aged 6-17 years.

Methods

Cross-sectional data from the 2023-2024 National Survey of Children's Health (NSCH; N = 71,172) restricted to ages 6-17 with complete data (unweighted n = 64,263; weighted population estimate ≈ 44.6 million children) were analyzed using Complex Sample logistic regression (SPSS 30), accounting for stratified design (state × stratum), household clustering, and sampling weights. Three hierarchical models were estimated for each outcome. NDD-stratified subgroup analyses (n = 13,971; weighted ≈ 8.6 million) triangulated moderation findings. Multiple imputation (m = 5) sensitivity analyses confirmed robustness.

Results

Weighted prevalence was 60.7% for flourishing, 13.2% for current anxiety, and 5.1% for current depression. In Block 2 models, poorer parent mental health and more frequent bullying victimization were robustly associated with all outcomes (flourishing OR = 0.62 and 0.65; anxiety OR = 1.64 and 1.63; depression OR = 1.95 and 1.75; all p < 0.001). Supportive neighborhood (flourishing OR = 1.40, depression OR = 0.80) and safe school (flourishing OR = 1.20, anxiety OR = 0.87) were protective. ADHD was the strongest disability-specific correlate (flourishing OR = 0.29; anxiety OR = 4.69; depression OR = 4.27). Three of the twelve interaction terms were significant, all involving ADHD. Relative to children without any NDD, subgroup analyses suggested attenuated associations of parent mental health and bullying with anxiety and depression among children with any NDD (e.g., bullying on anxiety: no-NDD aOR = 1.73 vs. Any-NDD 1.52); however, formal interaction tests identified ADHD as the only significant moderator of these associations. On the absolute-risk scale, however, the increase in internalizing problems with more frequent bullying was larger in children with ADHD.

Conclusions

Family mental health support and bullying prevention are universally relevant levers for improving children's mental health and flourishing. Although attenuation of the odds-ratio associations was observed primarily in ADHD-related analyses, specifically for the internalizing outcomes (anxiety and depression), universal anti-bullying and parent mental health interventions remain relevant for children with NDDs, supporting integration into pediatric clinical and public-health programs alongside disability-specific support pathways.