Key Points
Question
What is the association of family-centered care with child flourishing and family resilience and connection overall and among children with and without a history of adverse childhood experiences (ACEs)?
Findings
In this nationally representative cross-sectional study of 110 984 children, the prevalence of child flourishing and family resilience and connection was higher among those who received family-centered care than among those who did not. Estimates were larger among children with a history of ACEs than among those with no history of ACEs.
Meaning
These findings suggest that family-centered care is a practical and measurable approach to pediatric health care that can promote child and family well-being, particularly among those with ACEs.
This cross-sectional study of US children examines associations of family-centered care with child flourishing and family resilience and connection and whether these associations differ by the child’s history of adverse childhood experiences.
Abstract
Importance
Family-centered care is an approach to pediatric health care that recognizes the essential role of the family in ensuring child health and well-being, seeks to establish collaborative partnerships among the child, family, and health care team, and provides a framework for implementing trauma-informed care. However, the association between receiving family-centered care and key measures of child and family well-being, including among families with a history of trauma and adversity, is unknown.
Objectives
To examine associations between family-centered care and child flourishing and family resilience and connection among US children and to assess whether associations differ by the child’s history of adverse childhood experiences (ACEs).
Design, Setting, and Participants
This cross-sectional study used 2021 to 2024 National Survey of Children’s Health data from children aged 6 to 17 years. Analyses were conducted in September to December 2025.
Exposure
Caregiver report of receipt of family-centered care by the child’s physician or other health care practitioners in the past 12 months.
Main Outcomes and Measures
Child flourishing and family resilience and connection based on caregiver response to established measures.
Results
This study assessed 110 984 children (mean [SD] age, 11.5 [0.02], years; 57 302 [51.0%] male and 53 682 [49.0%] female) who had a health care visit in the past 12 months. Adjusted for potential confounders, the prevalence of child flourishing was 8.6 percentage points higher (prevalence difference [PD], 0.086; 95% CI, 0.072-0.101), and the prevalence of family resilience and connection was 8.2 percentage points higher (PD, 0.082; 95% CI, 0.069-0.096) for those who received family-centered care compared with those who did not. Among children with and without ACEs, the prevalence of child flourishing (with ACES: PD, 0.112; 95% CI, 0.089-0.132; without ACEs: PD, 0.068; 95% CI, 0.049-0.087) and family resilience and connection (with ACEs: PD, 0.105; 95% CI, 0.085-0.125; without ACEs: PD, 0.0563; 95% CI, 0.043-0.081) was higher for those who received family-centered care compared with those who did not, with larger estimates among children with ACEs than children without ACEs.
Conclusions and Relevance
Results from this cross-sectional study found that family-centered care was associated with a higher prevalence of child flourishing and family resilience and connection, particularly among those with a history of adversity. These results suggest that family-centered care offers a practical and measurable way for health care professionals to promote well-being for all children and families but particularly for children with a history of ACEs.
Introduction
Pediatricians and other health care professionals play an important role in ensuring the health and well-being of children. Family-centered care is a health care approach that recognizes the essential role of the family in child health and well-being and seeks to establish collaborative, mutually beneficial partnerships among the child, family, and health care team.1 Key principles include listening to and respecting the child and family; maintaining flexibility to tailor services to the family’s needs, beliefs, and cultural values; sharing complete, honest, and unbiased information; offering formal and informal support; and partnering with the child and family in all aspects of care.1
Receiving family-centered care is associated with improved engagement in essential health care services, including a decreased likelihood that children have delayed or missed preventive care2,3 and unmet health care needs.2,4,5,6 Family-centered care is also associated with beneficial outcomes for children and families, including an increased likelihood of positive child health2,4 and, in specific populations, improvements in parents’ self-efficacy,7,8 family functioning,9 and parent and child psychological well-being.7,9,10 Through increased engagement in essential health care services and improvements in child and family health outcomes, family-centered care can promote overall child and family well-being. One prior study11 found that receipt of family-centered care was associated with an increased likelihood of child flourishing among young children (aged 1-5 years).
Children and families with a history of adverse childhood experiences (ACEs) have an increased risk of poor health and psychosocial outcomes, including lower levels of child flourishing and family resilience.12,13 By fostering collaborative partnerships, trust, and responsiveness to family needs, family-centered care provides a framework that supports the delivery of trauma-informed care1,14,15,16 (Table 1), a health care approach that is particularly important for children and families affected by ACEs.17,18 Trauma-informed care is “grounded in an understanding of and responsiveness to the impact of trauma, and emphasizes physical, psychological, and emotional safety for both providers and survivors.”17,18 Although trauma-informed care is a well-established model of care within pediatrics and medicine, it represents a paradigm shift in care delivery.19,20 Moreover, trauma-informed care is often inconsistently measured. Family-centered care offers a practical and measurable pathway to implementing trauma-informed care and to promoting positive health and well-being for children and families, particularly those exposed to ACEs.
Table 1. Alignment of Family-Centered Care With Foundational Principles of Trauma-Informed Care.
| Theme | Family-centered care as measured by the National Survey of Children’s Health16 | Family-centered care as defined by the American Academy of Pediatrics1 | Foundational components for trauma-informed care as defined by the American Academy of Pediatrics14 |
|---|---|---|---|
| Sufficient time | Pediatrician spends enough time with child | Pediatrician provides formal support | Pediatrician creates a respectful, emotionally safe space in which to engage in discussion |
| Active listening | Pediatrician listens carefully to caregiver and child | Pediatrician listens to and respects the child and family | Pediatrician is fully present and listens in an active, nonjudgmental, attuned way |
| Credible source of information | Pediatrician gives needed information | Pediatrician shares complete, honest, and unbiased information | Pediatrician promotes transparency and trust through clear communication |
| Respect for family values | Pediatrician is sensitive to family values and customs | Pediatrician ensures flexibility so services can be tailored to the needs, beliefs, and cultural values of the family | Pediatrician approaches the family with cultural humility |
| Collaboration | Family feels like partner in care | Pediatrician collaborates with the family at all levels of health care | Pediatrician ensures mutual regard with the caregivers and family |
The aims of this study were to examine associations of family-centered care with child flourishing and family resilience and connection among a nationally representative sample of US children aged 6 to 17 years and to assess whether associations differed by the child’s history of ACEs. Because prior research shows that family-centered care is associated with improvements in parent and child well-being and overall family functioning,7,8,9,10 there is a potential direct association of family-centered care with family resilience and connection. In addition, because family-centered care is associated with an increased use of essential health care services, which promote positive child health and development,2,3,4,5,6 there is a potential direct association with child flourishing. Importantly, there may be also an indirect association of family-centered care with child flourishing through its positive association with family resilience and connection. This mediating pathway is supported by research showing that as family resilience and connection increases, the likelihood of child flourishing also increases.21 Additional research shows that family resilience is a mediator in the association of ACEs with child flourishing, providing additional support for a potential role of family resilience and connection in promoting child flourishing.22,23
Methods
We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Because we used deidentified, publicly available data, this study was determined to be exempt from institutional review board approval by the University of North Carolina at Chapel Hill.
Data Source
We used data from the 2021 to 2024 National Survey of Children’s Health (NSCH), a nationally representative survey administered by the Maternal and Child Health Bureau (MCHB). Each year, a systematic sample of households with children aged 0 to 17 years is selected, and 1 child per household is randomly selected to be the subject of the survey questions. An adult member of the household (ie, caregiver) who is familiar with the child’s health, usually a biological parent, completes the survey on paper or online in English or Spanish.24
Study Population
We limited our sample to children aged 6 to 17 years because some NSCH measures differ for older and younger children. In addition, questions regarding receipt of family-centered care are only asked of those who had a health care visit in the past 12 months (ie, saw a physician, nurse, or other health care professional for a sick visit, well-child checkup, physical examination, hospitalization, or any other kind of care). Thus, our study population was limited to children with a health care visit in the past 12 months. To assess for potential selection bias due to this inclusion criterion, we compared child and family characteristics by receipt of a health care visit and family-centered care in the past 12 months (eTable 1 in Supplement 1). Children who did not have a health care visit were similar to children who had a health care visit and received family-centered care with respect to the prevalence of child flourishing, family resilience and connection, history of ACEs, and caregiver mental health and education. However, they were similar to children who had a health care visit but did not receive family-centered care with respect to racial and ethnic distribution and the percentage with private health insurance, household income less than 100% of the federal poverty level, and a non-English primary language. Thus, children who were excluded due to not having a health care visit in the past 12 months did not systematically resemble either children who received family-centered care or those who did not.
Measures
Our exposure was whether the child and family received family-centered care in the past 12 months. Among children who had a health care visit in the past 12 months, we measured family-centered care using responses to 5 questions: “How often did this child’s doctors or other health care providers: (1) spend enough time with this child, (2) listen carefully to you, (3) show sensitivity to your family’s values and customs, (4) provide the specific information you needed concerning this child, and (5) help you feel like a partner in this child’s care?” Response options included always, usually, sometimes, or never. Consistent with prior research11,25,26 and the MCHB’s framework, we defined family-centered care as a response of always or usually to all 5 questions. In sensitivity analyses, we defined family-centered care as a response of always to all 5 questions given prior research showing important distinctions between responses of always and usually to single question measures of patient experiences.27 In additional sensitivity analyses, we created levels of family-centered care, defining high family-centered care as responses of always to all five questions and moderate family-centered care as remaining responses of always or usually to all 5 questions.
Our outcomes were child flourishing and family resilience and connection. We measured child flourishing using responses to 3 questions: “How often: (1) does this child show interest and curiosity in learning new things, (2) work to finish tasks they start, and (3) stay calm and in control when faced with a challenge?” Response options included always, usually, sometimes, or never. Consistent with the MCHB’s framework,16 we defined child flourishing as a response of always or usually to 2 or more questions. In sensitivity analyses, we defined child flourishing as a response of always or usually to all 3 questions.
We measured family resilience and connection using a previously established measure21 based on responses to 6 questions. The first 4 questions asked, “When your family faces problems how likely are you to do each of the following: (1) talk together about what to do, (2) work together to solve our problems, (3) know we have strengths to draw on, and (4) stay hopeful even in difficult times.” Response options included all of the time, most of the time, some of the time, and none of the time. We assigned 1 point to responses of all of the time for each of the 4 questions. The final 2 questions asked, “How well can you and this child share ideas or talk about things that really matter?” and “How well do you think you are handling the day to day demands of raising children?” Response options included very well, somewhat well, not very well, and not at all. We assigned 1 point to responses of very well to both items. Consistent with prior research,21,28,29 we summed points assigned to each question and compared children and families who scored high on resilience and connection (4-6 points) with those who scored low or moderate (0-3 points). In sensitivity analyses, we compared children and families with a score of 5 to 6 points with those with scores of 0 to 4 points.
To identify potential confounders, we created a conceptual diagram based on principles of directed acyclic graphs (eFigure 1 in Supplement 1).30 We adjusted multivariable analyses for household income relative to the federal poverty level; primary language spoken in the home; child race and ethnicity (based on caregiver report and included given demonstrated differences in receipt of family-centered care and the likelihood of child flourishing and family resilience and connection by race and ethnicity), health status, health insurance type, and history of ACEs; caregiver emotional health; and the number of pediatricians per 100 000 population in the family’s state of residence (eTable 2 in Supplement 1).
Statistical Analysis
We examined the prevalence of child and family characteristics for children who did and did not receive family-centered care. We also examined the prevalence of child flourishing and family resilience and connection for children who did and did not receive family-centered care separately among children with no ACEs and children with 1 or more ACEs. We did not conduct statistical tests for descriptive comparisons to avoid an overemphasis on P values and focus on the actual size of observed differences.31,32
To examine the association of family-centered care with child flourishing and family resilience and connection, we conducted generalized linear regression with a binomial distribution and identity link to calculate prevalence differences (PDs) and 95% CIs, adjusting for the aforementioned confounders. To interpret results, we relied on the magnitude of the point estimate for the PD and the width and location of the corresponding 95% CIs.32 To assess whether associations differed by the child’s history of ACEs, we conducted analyses separately for children with and without ACEs. To statistically confirm any observed differences in associations for children with and without ACEs, we also constructed regression models for the total sample that included an interaction term between child history of ACEs and receipt of family-centered care.
Because family-centered care may be indirectly associated with child flourishing through improvements in family resilience and connection, we conducted post hoc analyses examining the association of family resilience and connection with child flourishing to assess this potential pathway. Results from this post hoc analysis and existing studies21,22,23 can provide evidence to support this hypothesized mediating pathway.
We conducted analyses in SAS software, version 9.4 (SAS Institute Inc). We conducted complete case analysis (eTable 3 in Supplement 1) and weighted all analyses using the individual-year survey weights divided by 4 (the number of survey years used) to account for the complex sampling design of NSCH.
Results
This study assessed 110 984 children (mean [SD] age, 11.5 [0.02] years; 57 302 [51.0%] male and 53 682 [49.0 %] female; 1.3% American Indian or Alaska Native, 4.6% Asian, 13.8% Black, 0.6% Native Hawaiian or Pacific Islander, 71.4% White, and 8.3% ≥2 races) who had a health care visit in the past 12 months. Overall, 84.5% received family-centered care and 15.5% did not. A higher percentage of children who received family-centered were White (72.4% vs 65.8%) and non-Hispanic (77.8% vs 62.0%), had private health insurance (65.0% vs 46.4%) and no special health care needs (71.7% vs 67.7%), had a caregiver with a college education or more (53.4% vs 37.1%) and excellent or very good mental health (71.1% vs 55.0%), lived in an English-speaking household (89.4% vs 73.1%) and a household with income 400% or more of the federal poverty level (39.2% vs 23.1%), and had no ACEs (57.4% vs 43.7%) compared with children who did not receive family-centered care (Table 2; eTable 4 in Supplement 1). A higher percentage of children who received family-centered care met criteria for flourishing (82.7% vs 69.3%) and family resilience and connection (88.8% vs 74.4%) than children who did not receive family-centered care.
Table 2. Child and Family Characteristics by Receipt of Family-Centered Care in the Past 12 Monthsa.
| Characteristic | No. (%) of children [95% CI] | |
|---|---|---|
| Did not receive family-centered care (n = 13 800) | Received family-centered care (n = 97 184) | |
| Child age, y | ||
| 6-12 | 7474 (58.6) [56.8-60.3] | 51 548 (58.6) [58.0-59.2] |
| 13-17 | 6326 (41.4) [39.7-43.2] | 45 636 (41.4) [40.8-42.0] |
| Child race | ||
| American Indian or Alaska Native | 229 (2.2) [1.7-2.7] | 784 (1.1) [1.0-1.3] |
| Asianb | 1133 (6.3) [5.6-6.9] | 5117 (4.3) [4.1-4.5]) |
| Black | 1387 (16.8) [15.4-18.2] | 6196 (13.3) [12.8-13.8]) |
| Native Hawaiian or Pacific Islanderc | 128 (1.4) [1.0-1.8] | 341 (0.5) [0.4-0.6]) |
| White | 9677 (65.8) [64.2-67.5] | 76 648 (72.4) [71.8-73] |
| ≥2 Races | 1246 (7.5) [6.7-8.3] | 8098 (8.4) [8.1-8.7] |
| Child ethnicity | ||
| Hispanic | 3026 (38.0) [36.1-39.9] | 12 065 (22.2) [21.6-22.8] |
| Non-Hispanic | 10 774 (62.0) [60.1-63.9] | 85 119 (77.8) [77.2-78.4] |
| Child health insurance | ||
| Public only | 4105 (37.9) [36.1-39.8] | 18 628 (26.4) [25.8-27.0] |
| Private only | 7746 (46.4) [44.6-48.2] | 70 190 (65.0) [64.4-65.6] |
| Private and public | 850 (6.6) [5.7-7.5] | 4339 (5.0) [4.7-5.3]) |
| None | 823 (9.1) [7.9-10.3] | 2749 (3.7) [3.4-3.9] |
| Child special health care needs | ||
| No | 8194 (67.7) [66.1-69.3] | 64 723 (71.7) [71.2-72.3] |
| Yes | 5606 (32.3) [30.7-33.9] | 32 461 (28.3) [27.7-28.8] |
| Caregiver educational level | ||
| Less than high school | 904 (19.1) [17.2-21.0] | 2270 (7.5) [7.0-8.0] |
| High school or GED | 1894 (17.3) [16.0-18.6] | 51 548 (58.6) [58.0-59.2] |
| Some college or trade school | 4261 (26.5) [25.1-28] | 45 636 (41.4) [40.8-42] |
| College or more | 6741 (37.1) [35.5-38.6] | 59 934 (53.4) [52.8-54] |
| Adverse childhood experiences | ||
| 0 | 5779 (43.7) [42-45.5] | 56 729 (57.4) [56.8-58.1] |
| 1 | 3345 (25.6) [24.0-27.2] | 20 403 (22.6) [22.1-23.2] |
| 2-3 | 2831 (20.0) [18.6-21.5] | 13 192 (13.8) [13.4-14.2] |
| ≥4 | 1635 (10.7) [9.6-11.7] | 5878 (6.2) [5.9-6.5] |
| Caregiver employment | ||
| Not working for pay | 2744 (26.0) [24.2-27.7] | 16 954 (21.9) [21.4-22.5] |
| Employed full or part time | 10 481 (74.0) [72.3-75.8] | 77 470 (78.1) [77.5-78.6] |
| Caregiver mental health | ||
| Good, fair, or poor | 6162 (45.0) [43.1-46.8] | 27 995 (28.9) [28.4-29.5] |
| Excellent or very good | 7102 (55.0) [53.2-56.9] | 66 781 (71.1) [70.5-71.6] |
| Primary language spoken in the household | ||
| English | 11 708 (73.1) [71.2-75] | 91 301 (89.4) [89-89.9] |
| Non-English | 2015 (26.9) [25.0-28.8] | 5370 (10.6) [10.1-11] |
| Household income relative to federal poverty level, % | ||
| <100 | 2481 (23.8) [22.2-25.4] | 9570 (14.0) [13.4-14.5] |
| 100-199 | 2754 (24.4) [22.7-26] | 13 810 (17.8) [17.3-18.4] |
| 200-399 | 4151 (28.7) [27.1-30.2] | 28 123 (29) [28.5-29.6] |
| ≥400 | 4414 (23.1) [21.9-24.4] | 45 681 (39.2) [38.6-39.7] |
| Child flourishing | ||
| No | 4727 (30.7) [29.1-32.3] | 17 676 (17.3) [16.9-17.8] |
| Yes | 8952 (69.3) [67.7-70.9] | 78 996 (82.7) [82.2-83.1] |
| Family resilience and connection | ||
| No (low or moderate score) | 3395 (25.6) [23.9-27.2] | 11 179 (11.2) [10.8-11.6] |
| Yes (high score) | 10 254 (74.4) [72.8-76.1] | 85 291 (88.8) [88.4-89.2] |
Abbreviation: GED, General Educational Development.
Data are from the 2021 to 2024 National Survey of Children’s Health.
Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or Other Asian.
Native Hawaiian, Chamorro Samoan, or Other Pacific Islander.
Among children with no ACEs, there was a higher prevalence of child flourishing (87.9% vs 78.7%) and family resilience and connection (91.6% vs 81.0%) for those who received family-centered care than for those who did not (Figure 1). Among children with ACEs, there was a higher prevalence of child flourishing (75.6% vs 61.8%) and high family resilience and connection (85.9% vs 70.5%) for those who received family-centered care than for those who did not.
Figure 1. Bar Graphs of the Prevalence of Child Flourishing and Family Resilience and Connection for Children Who Did and Did Not Receive Family-Centered Care in the Past 12 Months Stratified by Child History of Adverse Childhood Experiences (ACEs).
Data are from the 2021 to 2024 National Survey of Children’s Health. A total of 1192 children were missing data on ACEs.
In multivariable analyses adjusted for potential confounders, the prevalence of child flourishing was 8.6 percentage points higher (PD, 0.086; 95% CI, 0.072-0.101) and the prevalence of family resilience and connection was 8.2 percentage points higher (PD, 0.082; 95% CI, 0.069-0.096) for those who received family-centered care compared with those who did not (eTable 5 in Supplement 1; Figure 2). Among children with no ACEs, the prevalence of child flourishing was 6.8 percentage points higher (PD, 0.068; 95% CI, 0.049-0.087) and the prevalence of family resilience and connection was 6.3 percentage points higher (PD, 0.0563; 95% CI, 0.043-0.081) for those who received family-centered care compared with those who did not. Among children with ACEs, the prevalence of child flourishing was 11.2 percentage points higher (PD, 0.112; 95% CI, 0.089-0.132) and the prevalence of family resilience and connection was 10.5 percentage points higher (PD, 0.105; 95% CI, 0.085-0.125) for those who received family-centered care compared with those who did not. Results from regression models that included an interaction term between the child’s history of ACEs and receipt of family-centered care showed statistically significant differences in associations according to the child’s history of ACEs (PD for interaction term for child flourishing, 0.050; 95% CI, 0.021-0.793; PD for interaction term for family resilience and connection, 0.0618; 95% CI, 0.034-0.090) (eTable 6 in Supplement 1).
Figure 2. Dot Plot of the Associations Between Receipt of Family-Centered Care and Child Flourishing and Family Resilience and Connection, 2021 to 2024, National Survey of Children’s Health.
Data are from the 2021 to 2024 National Survey of Children’s Health. PD indicates prevalence difference.
aEstimated percentage point change in prevalence for children who received family-centered care compared with children who did not receive family-centered care.
bAdjusted for child age, race and ethnicity, and health insurance type, whether the child has special health care needs; adverse childhood experiences; caregiver educational level, employment, and mental health; primary language spoken in the home; household income relative to the federal poverty level; and number of pediatricians per 100 0000 population for the child’s state of residence.
Results were similar in sensitivity analyses using a higher threshold for family-centered care, although PDs were slightly attenuated compared with primary analyses (eTable 7 in Supplement 1). Results were also similar in sensitivity analyses using levels of family-centered care (eTable 8 in Supplement 1). In analyses with levels of family-centered care, the prevalence of child flourishing and family resilience and connection were higher among those who received high family-centered care and moderate family-centered care compared those who did not received family-centered care, though the PDs were larger in magnitude for those who received high family-centered care than for those who received moderate family-centered care, and adjusted models did not converge for family resilience and connection among children with no ACEs.
Results were also similar in sensitivity analyses using higher thresholds for child flourishing and family resilience and connection, with the exception that the association between family-centered care and child flourishing was similar in magnitude among children with no ACEs and children with ACEs (eTable 9 in Supplement 1).
In post hoc analyses, the prevalence of child flourishing was 19.1 percentage points higher (PD, 0.191; 95% CI, 0.173-0.209) for those with compared with those without family resilience and connection (eTable 10 in Supplement 1). The prevalence of child flourishing was 21.1 percentage points higher (PD, 0.221; 95% CI, 0.187-0.235) among children with ACEs and 16.8 percentage points higher (PD, 0.168; 95% CI, 0.143-0.248) among children with no ACEs for those with compared with those without family resilience and connection.
Discussion
In this cross-sectional study of a nationally representative sample of children and their caregivers, the prevalence of child flourishing and family resilience and connection were higher among children and families that received family-centered care than among those who did not. Family-centered care was associated with child flourishing and family resilience and connection among children with and without a history of ACEs, indicating that family-centered care is important for supporting the health and well-being of all children and families. However, these associations were more pronounced children with ACEs than among children without ACEs, suggesting that although family-centered care is important for all children and families, it may be particularly beneficial for those with a history of trauma and adversity.
The prevalence of child flourishing was 8.6 percentage points higher, and the prevalence of family resilience and connection was 8.2 percentage points higher among children and families who received family-centered care than those who did not. In sensitivity analyses using levels of family-centered care, both high and moderate family-centered care were associated with an increased prevalence of child flourishing and family resilience and connection. Point estimates were greater for high family-centered care than for moderate family-centered care, demonstrating the value of consistent family-centered care for child and family outcomes.
A total of 84.5% of caregivers reported receiving family-centered care in the past year, suggesting that most child health care professionals are incorporating this approach into clinical practice. However, consistent with prior research,4,33 our descriptive analyses showed that populations marginalized by systems and structures of power, including Black, Hispanic, non–English-speaking, and economically disadvantaged children and families, were less likely to receive family-centered care than their counterparts. Focused attention from institutions and clinicians to ensure that all children and families, especially those likely to be underresourced or to experience bias and discrimination, receive family-centered care may yield tangible benefits and reduce inequities in child and family health and well-being.
In primary analyses, associations between family-centered care and child flourishing and family resilience and connection were more pronounced among children with ACEs than among children without ACEs. In these analyses, the outcomes were defined using thresholds consistent MCHB definitions and prior research. In sensitivity analyses applying more stringent thresholds for the outcomes (ie, requiring a response of always for all child flourishing items and defining family resilience and connection as scores of 5-6 rather than 4-6), differences in associations for children with and without ACEs were attenuated. This finding suggests that modification by child history of ACEs is only apparent at more moderate thresholds for the outcomes. Importantly, descriptive analyses showed that the prevalence of child flourishing and family resilience and connection was substantially lower among children with ACEs than among those without ACEs, regardless of whether they received family-centered care. This means that larger gains in child flourishing and family resilience and connection are needed for children and families with a history of ACEs to promote thriving. Family-centered care lays the relational foundation for trauma-informed care.14,15 By fostering a respectful and emotionally safe environment, family-centered care can benefit all children and families.
Family-centered care serves distinct roles, depending on children’s history of ACEs.34,35 For children with ACEs who are exhibiting trauma-related symptoms, family-centered care can support healing and help restore relational health, aligning with tertiary prevention. For children with ACEs who are not symptomatic, family-centered care can foster protective relationships and strengthen caregiver and child resilience, thereby functioning as a secondary prevention strategy. For children without ACEs, family-centered care can proactively promote protective relationships, relational health, and resilience that can help to buffer against potential future adversity, representing a primary prevention strategy.
Limitations
This study has some limitations. First, although we adjusted analyses for a comprehensive set of potential confounders, there is potential for residual or unmeasured confounding. Caregiver report of whether the child and family received family-centered care in the past 12 months may be influenced by unmeasured or poorly measured factors that also affect child flourishing and family resilience and connection. Specifically, the number of pediatricians per 100 000 population is a crude proxy for local health care system capacity and infrastructure. More granular measures are likely needed to fully account for confounding related to health care system factors. Second, all NSCH measures rely on caregiver report and are subject to reporting biases. For example, caregiver report of family-centered care may be influenced by child and family ACEs. Nevertheless, caregiver report of family-centered care, child flourishing, and family resilience and connection remain valuable because they reflect caregiver experiences and perceptions, which are relevant to understanding family functioning and informing clinical practice. Third, some variables had missing data. However, data were missing for less than 5% of all variables included in analyses, and there were no differences in missingness by receipt of family-centered care. Fourth, because family-centered care, child flourishing, and family resilience and connection have ordinal response options on the NSCH, our dichotomized measures may have obscured meaningful variation across responses. However, our results were robust in sensitivity analyses using alternative definitions. Future research may use more nuanced measures, such as examining the association of individual items included in family-centered care with child and family outcomes. Fifth, the cross-sectional design of the study precluded establishing temporality between family-centered care, child flourishing, and family resilience and connection. Future longitudinal research is needed, including to assess potential mediation of the association between family-centered care with child flourishing via family resilience and connection. Last, in our primary analyses, we used measures of family-centered care, family resilience and connection, and child flourishing that are consistent with MCHB definitions. Of note, the MCHB definitions are primarily intended for use as performance measures. Future research and practice should consider using alternative measures, as we did in sensitivity analyses, when the goal is to assess health outcomes.
Conclusions
In this nationally representative cross-sectional study, family-centered care was associated with higher prevalence of child flourishing and family resilience and connection, in particular among children with a history of ACEs. By fostering safe, stable, nurturing relationships, family-centered care offers a practical way to apply trauma-informed care principles and to strengthen resilience among children and families. Integrating family-centered approaches into pediatric care allows clinicians to support the flourishing and resilience of all children.
eFigure. Conceptual diagram
eTable 1. Child and family characteristics by receipt of a healthcare visit and family-centered care in the past 12 months, 2021-2024 National Survey of Children’s Health (N=134.002)
eTable 2. Confounder definitions
eTable 3. Study population flow chart, 2021-2024 National Survey of Children’s Health
eTable 4. Child and family characteristics by receipt of family-centered care in the past 12 months, 2021-2024 National Survey of Children’s Health (Weighted N= 51,968,875)
eTable 5. Associations between receipt of family-centered care and child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 6. Associations between receipt of family-centered care and child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 7. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using higher thresholds for family-centered care, 2021-2024 National Survey of Children’s Health
eTable 8. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using levels of family-centered care, 2021-2024 National Survey of Children’s Health
eTable 9. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using higher thresholds for child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 10. Post-hoc analyses for associations between family resilience and connection and child flourishing, 2021-2024 National Survey of Children’s Health
Data Sharing Statement
References
- 1.Committee on Hospital Care and Institute for Patient-and Family-Centered Care . Patient-and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394-404. doi: 10.1542/peds.2011-3084 [DOI] [PubMed] [Google Scholar]
- 2.Arthur NSM, Blewett LA. Contributions of key components of a medical home on child health outcomes. Matern Child Health J. 2023;27(3):476-486. doi: 10.1007/s10995-022-03539-7 [DOI] [PubMed] [Google Scholar]
- 3.Tabet M, Kirby RS, Boyd R, Xaverius P. Family-centered care and delayed or missed pediatric preventive care due to the COVID-19 pandemic. Acad Pediatr. 2024;24(5):848-855. doi: 10.1016/j.acap.2024.02.014 [DOI] [PubMed] [Google Scholar]
- 4.Fleary SA. Association between the medical home model of care and demographic characteristics in US children. Clin Pediatr (Phila). 2019;58(3):270-281. doi: 10.1177/0009922818813568 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lindly OJ, Zuckerman KE, Mistry KB. Clarifying the predictive value of family-centered care and shared decision making for pediatric healthcare outcomes using the medical expenditure panel survey. Health Serv Res. 2017;52(1):313-345. doi: 10.1111/1475-6773.12488 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Lindly OJ, Geldhof GJ, Acock AC, Sakuma KK, Zuckerman KE, Thorburn S. Family-centered care measurement and associations with unmet health care need among US children. Acad Pediatr. 2017;17(6):656-664. doi: 10.1016/j.acap.2016.10.018 [DOI] [PubMed] [Google Scholar]
- 7.Salvador Á, Crespo C, Barros L. The benefits of family-centered care for parental self-efficacy and psychological well-being in parents of children with cancer. J Child Fam Stud. 2019;28(7):1926-1936. doi: 10.1007/s10826-019-01418-4 [DOI] [Google Scholar]
- 8.Shields L, Zhou H, Taylor M, Hunter J, Munns A, Watts R. Family-centred care for hospitalised children aged 0-12 Years: A systematic review of quasi-experimental studies. JBI Libr Syst Rev. 2012;10(39):2559-2592. doi: 10.11124/jbisrir-2012-32 [DOI] [PubMed] [Google Scholar]
- 9.Kuhlthau KA, Bloom S, Van Cleave J, et al. Evidence for family-centered care for children with special health care needs: a systematic review. Acad Pediatr. 2011;11(2):136-143. doi: 10.1016/j.acap.2010.12.014 [DOI] [PubMed] [Google Scholar]
- 10.McCalman J, Heyeres M, Campbell S, et al. Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review. BMC Pregnancy Childbirth. 2017;17(1):71. doi: 10.1186/s12884-017-1247-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Donney JF, Ghandour RM, Kogan MD, Lewin A. Family-centered care and flourishing in early childhood. Am J Prev Med. 2022;63(5):743-750. doi: 10.1016/j.amepre.2022.06.015 [DOI] [PubMed] [Google Scholar]
- 12.Hughes K, Bellis MA, Hardcastle KA, et al. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Public Health. 2017;2(8):e356-e366. doi: 10.1016/S2468-2667(17)30118-4 [DOI] [PubMed] [Google Scholar]
- 13.Thompson EM, Corcoran F, Hodges HR. Adverse childhood experiences and resilience: family resilience as a promotive factor in young children’s flourishing. SAGE Open. 2024;14(4). doi: 10.1177/21582440241302899 [DOI] [Google Scholar]
- 14.Forkey H, Szilagyi M, Kelly ET, Duffee J; Council on Foster Care, Adoption, and Kinship Care, Council on Community Pediatrics, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health . Trauma-informed care. Pediatrics. 2021;148(2):e2021052580. doi: 10.1542/peds.2021-052580 [DOI] [PubMed] [Google Scholar]
- 15.Marsac ML, Kassam-Adams N, Hildenbrand AK, et al. Implementing a trauma-informed approach in pediatric health care networks. JAMA Pediatr. 2016;170(1):70-77. doi: 10.1001/jamapediatrics.2015.2206 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Data Resource Center for Child & Adolescent Health . NSCH codebooks. 2025. Accessed December 29, 2025. https://www.childhealthdata.org/learn-about-the-nsch/nsch-codebooks
- 17.Hopper EK, Bassuk EL, Olivet J. Shelter from the storm: trauma-informed care in homelessness services settings. Open Health Serv Policy J. 2010;3(2):80-100. doi: 10.2174/1874924001003020080 [DOI] [Google Scholar]
- 18.Substance Abuse and Mental Health Services Administration . SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. 2014. Accessed February 13, 2026. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf
- 19.Huo Y, Couzner L, Windsor T, Laver K, Dissanayaka NN, Cations M. Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implement Sci Commun. 2023;4(1):49. doi: 10.1186/s43058-023-00428-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Sala-Hamrick KJ, Isakson B, De Gonzalez SDC, et al. Trauma-informed pediatric primary care: facilitators and challenges to the implementation process. J Behav Health Serv Res. 2021;48(3):363-381. doi: 10.1007/s11414-020-09741-1 [DOI] [PubMed] [Google Scholar]
- 21.Bethell CD, Gombojav N, Whitaker RC. Family resilience and connection promote flourishing among US children, even amid adversity. Health Aff (Millwood). 2019;38(5):729-737. doi: 10.1377/hlthaff.2018.05425 [DOI] [PubMed] [Google Scholar]
- 22.Thompson EM, Corcoran F, Hodges HR. Adverse childhood experiences and resilience: Family resilience as a promotive factor in young children’s flourishing. SAGE Open. 2024;14(4). doi: 10.1177/2158244024130289 [DOI] [Google Scholar]
- 23.Goldstein E, Topitzes J, Miller-Cribbs J, Brown RL. Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing. Pediatr Res. 2021;89(7):1861-1869. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Data Resource Center for Child & Adolescent Health . NSCH Survey Methodology. 2025. Accessed December 29, 2025. https://www.childhealthdata.org/learn-about-the-nsch/methods
- 25.Toomey SL, Chien AT, Elliott MN, Ratner J, Schuster MA. Disparities in unmet need for care coordination: the national survey of children’s health. Pediatrics. 2013;131(2):217-224. doi: 10.1542/peds.2012-1535 [DOI] [PubMed] [Google Scholar]
- 26.Coker TR, Rodriguez MA, Flores G. Family-centered care for US children with special health care needs: who gets it and why? Pediatrics. 2010;125(6):1159-1167. doi: 10.1542/peds.2009-1994 [DOI] [PubMed] [Google Scholar]
- 27.Drake KM, Hargraves JL, Lloyd S, Gallagher PM, Cleary PD. The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group survey. Health Serv Res. 2014;49(4):1387-1399. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Song J, Fogarty K, Suk R, Gillen M. Behavioral and mental health problems in adolescents with ADHD: exploring the role of family resilience. J Affect Disord. 2021;294:450-458. doi: 10.1016/j.jad.2021.07.073 [DOI] [PubMed] [Google Scholar]
- 29.Frank M, Austin AE. The association of food hardship with family resilience and connection: does participation in Supplemental Nutrition Assistance Program modify this association? Acad Pediatr. 2025;25(4):102807. doi: 10.1016/j.acap.2025.102807 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Austin AE, Desrosiers TA, Shanahan ME. Directed acyclic graphs: an under-utilized tool for child maltreatment research. Child Abuse Negl. 2019;91:78-87. doi: 10.1016/j.chiabu.2019.02.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Hayes-Larson E, Kezios KL, Mooney SJ, Lovasi G. Who is in this study, anyway? guidelines for a useful Table 1. J Clin Epidemiol. 2019;114:125-132. doi: 10.1016/j.jclinepi.2019.06.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.American Statistical Association . Statement on statistical significance and P values. 2016. Accessed February 13, 2026. https://www.amstat.org/asa/files/pdfs/P-ValueStatement.pdf
- 33.Azuine RE, Singh GK, Ghandour RM, Kogan MD. Geographic, racial/ethnic, and sociodemographic disparities in parent-reported receipt of family-centered care among US children. Int J Family Med. 2015;2015(1):168521. doi: 10.1155/2015/168521 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Garner A, Yogman M; Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics, Council on Early Childhood . Preventing childhood toxic stress: partnering with families and communities to promote relational health. Pediatrics. 2021;148(2):e2021052582. doi: 10.1542/peds.2021-052582 [DOI] [PubMed] [Google Scholar]
- 35.Sherin KM, Stillerman AJ, Chandrasekar L, Went NS, Niebuhr DW. Recommendations for population-based applications of the adverse childhood experiences study: position statement by the American College of Preventive Medicine. AJPM Focus. 2022;1(2):100039. doi: 10.1016/j.focus.2022.100039 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure. Conceptual diagram
eTable 1. Child and family characteristics by receipt of a healthcare visit and family-centered care in the past 12 months, 2021-2024 National Survey of Children’s Health (N=134.002)
eTable 2. Confounder definitions
eTable 3. Study population flow chart, 2021-2024 National Survey of Children’s Health
eTable 4. Child and family characteristics by receipt of family-centered care in the past 12 months, 2021-2024 National Survey of Children’s Health (Weighted N= 51,968,875)
eTable 5. Associations between receipt of family-centered care and child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 6. Associations between receipt of family-centered care and child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 7. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using higher thresholds for family-centered care, 2021-2024 National Survey of Children’s Health
eTable 8. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using levels of family-centered care, 2021-2024 National Survey of Children’s Health
eTable 9. Sensitivity analyses for associations between receipt of family-centered care and child flourishing and family resilience and connection using higher thresholds for child flourishing and family resilience and connection, 2021-2024 National Survey of Children’s Health
eTable 10. Post-hoc analyses for associations between family resilience and connection and child flourishing, 2021-2024 National Survey of Children’s Health
Data Sharing Statement
