Video Abstract

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OBJECTIVES:

In this study, we present an epidemiological profile of middle childhood (children aged 6–11 years) using the 2016–2017 National Survey of Children’s Health.

METHODS:

We used data from the 2016 and 2017 National Survey of Children’s Health, a national cross-sectional, address-based survey administered annually. The study sample included 21 539 children aged 6 to 11 years. Survey items chosen to create this profile of middle childhood described sociodemographic and family characteristics, health status, and behaviors. Weighted descriptive and bivariate analyses were applied to examine the population and differences by subgroups.

RESULTS:

Most children aged 6 to 11 years were in excellent or very good physical health (89%) and oral health (73%). More than 20% were considered to have special health care needs, and 20% had at least 2 health conditions. Allergies and asthma were the most prevalent physical conditions, whereas attention-deficit/hyperactivity disorder and behavioral or conduct problems were the most prevalent of emotional, behavioral, and/or developmental disorders. More than half of children participated in sports or other activities for at least 60 minutes per day, whereas more than one-third of children had ≥4 hours of parent-reported screen time per day, and nearly two-thirds received ≥9 hours of sleep per night. We found several significant differences in screen time and activity behaviors as children aged and by sex.

CONCLUSIONS:

The middle-childhood population is generally healthy, yet several patterns observed with respect to age and sex indicate a need to examine the emergence and progression of select health-risk behaviors. In this study, we highlight opportunities to implement targeted interventions at earlier ages and different points along the life course.

What’s Known on This Subject:

Middle childhood is an important developmental period between early childhood and adolescence. Although this population is generally considered healthy, certain health-promoting or health-risk behaviors may take shape during this time and influence outcomes in adolescence and adulthood.

What This Study Adds:

No national studies have described the health of the middle-childhood population. We examine sociodemographic, health, family and household, and behavioral characteristics to create an epidemiological profile, establishing a baseline that may be used to track health and development trends.

Middle childhood is a developmental period marked by profound changes as children transition from early childhood to adolescence. Typically initiated when children begin school, cognitive and social capabilities expand as relationships with families, peers, and communities shift.1  Although past work has described the health and influencing factors associated with early childhood and adolescence, little corresponding research exists for middle childhood. This disparity in evidence could be due to the perception that this population is generally healthy but may also be related to the fact that these children have aged out of the intensive period of developmental monitoring associated with early childhood yet do not warrant the attention on health-risk behaviors and incident chronic disease associated with adolescence. Behaviors and habits that develop during this time influence outcomes that manifest during adolescence and adulthood, such as health-promoting or health-risk behaviors and chronic disease incidence. Research has revealed associations between heavy media use in childhood and increased obesity risk as children age and adverse associations with sleep habits in adolescence.24  Similarly, the link between early childhood obesity (and attendant eating and physical activity behaviors) and short- and long-term negative health consequences has been well established.58  Emerging evidence has also revealed the rate of bullying victimization to be higher among those in middle childhood compared with adolescents.9  Finally, several learning, behavioral, and developmental conditions are typically first diagnosed during middle childhood.1 

Children aged 6 to 11 years are a growing part of the population in terms of relative size and diversity, ushering a pressing need for research to better describe their health and well-being and to track trends in their health and development.10  There is a dearth of national studies about middle childhood compared with early childhood or adolescence, partly because of data limitations and the perception of fewer health concerns. Our purpose for this study is to fill this gap and present the first epidemiological profile of middle childhood in the United States by using the National Survey of Children’s Health (NSCH) and provide comprehensive national estimates describing their sociodemographic, health status, behavior, household, and neighborhood characteristics.

We analyzed data from the 2016 and 2017 NSCH. The NSCH is a cross-sectional, address-based household survey of children aged 0 to 17 years that is directed and funded by the Health Resources and Services Administration’s Maternal and Child Health Bureau and conducted by the US Census Bureau. Beginning in 2016, the NSCH has been fielded annually and administered via a Web- or paper-based survey to respondents who are parents or caregivers knowledgeable of the sample child’s health and health care. The overall weighted response rates were 40.7% and 37.4% in 2016 and 2017, respectively, whereas the interview completion rates (the proportion of households known to include children who completed the topical questionnaire) were 69.7% and 70.9%, respectively. Specific information regarding the NSCH methodology and design may be found elsewhere.11 

The NSCH allows for data from multiple years to be appended to obtain multiyear estimates. The 2016 and 2017 NSCH contained information from completed surveys of 50 212 and 21 599 children, respectively. The data sets include survey weights to ensure the generalizability of estimates to the noninstitutionalized population of US children. To obtain population-based estimates and account for nonresponse, for each survey year, a complex weighting scheme is employed that includes nonresponse adjustments and iterative raking to population controls derived from same-year American Community Survey data.12,13  The current study was exempt from institutional review board review because we used publicly available data sets.

The NSCH consists of a screener questionnaire (to determine eligible households with children at sampled addresses) and age-specific topical questionnaires for children aged 0 to 5, 6 to 11, and 12 to 17 years. The screener identifies demographic information for age-eligible children in a household and information used to identify and categorize children with special health care needs (CSHCN).14,15  The more detailed topical questionnaire collects information specific to the randomly-selected sample child, including questions on age-appropriate developmental milestones and behaviors. Although many of the variables included in this analysis originated from the topical questionnaire administered for children aged 6 to 11 years, there were also items that appeared on all 3 sets of topical questionnaires. Survey items selected to create this epidemiological profile cover 3 categories. Sociodemographic, family, and neighborhood characteristics include sex, race and/or ethnicity, indicators of household socioeconomic status, family structure, and neighborhood conditions. Family poverty level, as reported in the NSCH Public Use File, is derived from the US Census Bureau’s poverty thresholds and is capped at 400% to protect the confidentiality of respondents.16  The NSCH contains several questions about the presence of neighborhood characteristics, grouped here as “amenities” (ie, sidewalks or walking paths, parks or playground, recreational or community centers, libraries or bookmobiles) or “detractions” (ie, litter and/or garbage on streets and sidewalks, poorly-maintained or rundown housing, vandalism). Health status indicators include general health status, oral health status, presence of chronic or genetic health conditions, and emotional and behavioral disorders. Parents were also asked about their child having been diagnosed with several chronic, genetic, and emotional and behavioral conditions through the following questions: “Has a doctor or other health care provider ever told you that [your child] has…[condition]?” and “If yes, does [your child] currently have the condition?” The third category covers several behaviors, including school delinquency, physical activity, screen time, and sleep habits. Variables of interest (Supplemental Table 5) were primarily selected: (1) variables associated with known differences in other age groups (eg, emotional and behavioral disorders) and (2) variables that are known risk factors for certain health issues among children (eg, activity engagement, sleep behaviors).

Survey weights were combined from the 2016 and 2017 NSCH data sets and adjusted before study analyses.16  Weighted descriptive analyses were conducted to determine the composition of the middle-childhood population in the United States and the distribution of the aforementioned characteristics among the population. This age group was defined as 6 to 11 years, which is consistent with the Current Population Reports published by the US Census Bureau.17  We also conducted bivariate analyses, applying χ2 tests of independence, to examine differences among children by age subgroup (ie, 6–7, 8–9, and 10–11 years) for select variables. Several demographic variables were imputed for the purpose of raking during weighting procedures, including sex, race and/or ethnicity, and household poverty. Child demographic variables were imputed by using hot-deck imputation, and multiple imputation was applied to the poverty level. Stata version 15 (Stata Corp, College Station, TX) was used to analyze data for this study; statistical significance was determined as P < .05.

Our study sample from the 2016 and 2017 NSCH included parent or caregiver responses about 21 539 children aged 6 to 11 years, yielding a weighted estimate of 24.8 million children in the United States. Sociodemographic characteristics are shown in Table 1. Most of these children lived in 2-parent (married or unmarried) households (75.9%) in which the highest household education was more than high school (70%). A majority of children were born in the United States (96%) and lived in an English-speaking household (85%). Approximately 70% of children came from families with household incomes <400% of the federal poverty level, and 41% of households received free or reduced-cost meals in schools. In addition, ∼37% of children were covered by some form of public insurance (eg, Medicaid or State Children’s Health Insurance Program), and 6% were reported to have no health insurance.

TABLE 1

Sociodemographic, Family, and Neighborhood Characteristics of Children Aged 6–11 Years in the United States

No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalencea
Total 21 539 24 846 548 — 
Age, y, mean (SE) — — 8.51 (0.03) 
Sex    
 Female 10 473 12 160 847 48.94 (0.81) 
 Male 11 066 12 685 701 51.06 (0.81) 
Race and/or ethnicityb    
 Non-Hispanic white 14 712 12 460 244 50.15 (0.80) 
 Non-Hispanic African American 1325 3 198 420 12.87 (0.57) 
 Non-Hispanic other or multiracial 2880 255 894 10.3 (0.39) 
 Hispanic 2622 6 628 941 26.68 (0.90) 
Highest household education    
 More than high school 18 036 17 137 937 70.07 (0.89) 
 High school, GED, vocational 2638 4 947 622 20.23 (0.74) 
 Less than high school 494 2 372 576 9.7 (0.74) 
Family structure    
 2 parents, biological or adoptive 15 450 16 661 193 68.76 (0.76) 
 2 parents, stepfamily 1382 1 733 405 7.15 (0.44) 
 Single mother 2693 3 691 185 15.23 (0.58) 
 Other 1627 2 145 728 8.85 (0.45) 
Born in the United States 20 697 23 766 640 96.36 (0.27) 
English spoken at home 19 985 20 915 220 85.37 (0.78) 
Household poverty levelc    
 ≥400% FPL 53 805 43 366 214 29.09 (0.59) 
 200%–399% FPL 39 042 38 896 532 26.09 (0.62) 
 101%–199% FPL 21 629 33 282 146 22.32 (0.68) 
 ≤100% FPL 14 758 33 534 395 22.49 (0.77) 
Participation in government assistance programs in past 12 mo    
 Cash assistance from government welfare program 489 1 098 635 4.59 (0.46) 
 Food stamps or SNAP 2400 5 179 214 21.48 (0.78) 
 Free or reduced-cost meals 5255 9 898 936 41.17 (0.86) 
 WIC benefits 864 2 296 732 9.57 (0.61) 
Current type of insurance coverage    
 Public (all) 5147 9 186 061 37.71 (0.86) 
 Private only 15 322 13 650 205 56.03 (0.85) 
 No insurance 772 1 523 491 6.25 (0.50) 
Neighborhood characteristics    
 Neighborhood amenities score    
  0 neighborhood amenities 2651 3 055 368 12.30 (0.53) 
  1 neighborhood amenities 2253 2 428 299 9.77 (0.44) 
  2+ neighborhood amenities 16 635 19 362 881 77.93 (0.65) 
 Neighborhood detractions score    
  0 neighborhood detractions 17 151 18 712 110 75.31 (0.77) 
  1 neighborhood detraction 2877 3 820 979 15.38 (0.67) 
  2+ neighborhood detractions 1511 2 313 459 9.31 (0.50) 
Child is safe in neighborhood    
 Definitely agree 14 448 15 294 854 63.48 (0.81) 
 Somewhat agree or disagree 6444 8 387 249 34.81 (0.81) 
 Definitely disagree 184 411 815 1.71 (0.24) 
Child is safe in school    
 Definitely agree 17 099 19 204 026 80.46 (0.68) 
 Somewhat agree or disagree 3658 4 536 969 19.01 (0.67) 
 Definitely disagree 59 127 196 0.53 (0.18) 
No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalencea
Total 21 539 24 846 548 — 
Age, y, mean (SE) — — 8.51 (0.03) 
Sex    
 Female 10 473 12 160 847 48.94 (0.81) 
 Male 11 066 12 685 701 51.06 (0.81) 
Race and/or ethnicityb    
 Non-Hispanic white 14 712 12 460 244 50.15 (0.80) 
 Non-Hispanic African American 1325 3 198 420 12.87 (0.57) 
 Non-Hispanic other or multiracial 2880 255 894 10.3 (0.39) 
 Hispanic 2622 6 628 941 26.68 (0.90) 
Highest household education    
 More than high school 18 036 17 137 937 70.07 (0.89) 
 High school, GED, vocational 2638 4 947 622 20.23 (0.74) 
 Less than high school 494 2 372 576 9.7 (0.74) 
Family structure    
 2 parents, biological or adoptive 15 450 16 661 193 68.76 (0.76) 
 2 parents, stepfamily 1382 1 733 405 7.15 (0.44) 
 Single mother 2693 3 691 185 15.23 (0.58) 
 Other 1627 2 145 728 8.85 (0.45) 
Born in the United States 20 697 23 766 640 96.36 (0.27) 
English spoken at home 19 985 20 915 220 85.37 (0.78) 
Household poverty levelc    
 ≥400% FPL 53 805 43 366 214 29.09 (0.59) 
 200%–399% FPL 39 042 38 896 532 26.09 (0.62) 
 101%–199% FPL 21 629 33 282 146 22.32 (0.68) 
 ≤100% FPL 14 758 33 534 395 22.49 (0.77) 
Participation in government assistance programs in past 12 mo    
 Cash assistance from government welfare program 489 1 098 635 4.59 (0.46) 
 Food stamps or SNAP 2400 5 179 214 21.48 (0.78) 
 Free or reduced-cost meals 5255 9 898 936 41.17 (0.86) 
 WIC benefits 864 2 296 732 9.57 (0.61) 
Current type of insurance coverage    
 Public (all) 5147 9 186 061 37.71 (0.86) 
 Private only 15 322 13 650 205 56.03 (0.85) 
 No insurance 772 1 523 491 6.25 (0.50) 
Neighborhood characteristics    
 Neighborhood amenities score    
  0 neighborhood amenities 2651 3 055 368 12.30 (0.53) 
  1 neighborhood amenities 2253 2 428 299 9.77 (0.44) 
  2+ neighborhood amenities 16 635 19 362 881 77.93 (0.65) 
 Neighborhood detractions score    
  0 neighborhood detractions 17 151 18 712 110 75.31 (0.77) 
  1 neighborhood detraction 2877 3 820 979 15.38 (0.67) 
  2+ neighborhood detractions 1511 2 313 459 9.31 (0.50) 
Child is safe in neighborhood    
 Definitely agree 14 448 15 294 854 63.48 (0.81) 
 Somewhat agree or disagree 6444 8 387 249 34.81 (0.81) 
 Definitely disagree 184 411 815 1.71 (0.24) 
Child is safe in school    
 Definitely agree 17 099 19 204 026 80.46 (0.68) 
 Somewhat agree or disagree 3658 4 536 969 19.01 (0.67) 
 Definitely disagree 59 127 196 0.53 (0.18) 

FPL, federal poverty level; GED, general equivalency diploma; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; —, not applicable.

a

Except for age, weighted prevalence values represent percentages (SEs).

b

Non-Hispanic other or multiracial includes individuals who self-identified as Asian American, American Indian or Alaskan native, Native Hawaiian and other Pacific Islander, or non-Hispanic multiracial.

c

Household poverty level is based on the US Census Bureau poverty thresholds.

Most children lived in neighborhoods with ≥2 amenities (78%) or 0 detractions (75%), yet >10% of parents reported that their neighborhoods had 0 amenities and ≥2 detractions. Many parents reported that they felt their children were not safe in their neighborhoods (36.5%) and in school (19.5%).

As shown in Table 2, a majority of children aged 6 to 11 years were reported to be in excellent or very good physical health (89%) and oral health (73%). An estimated 21% met the criteria for having special health care needs. Analyses of those with current conditions revealed that allergies were the most prevalent physical condition among children (21%), followed by asthma (9.5%) and frequent headaches or migraines (2.6%). When examining emotional, behavioral, and developmental disorders, the most prevalent conditions were attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD) and behavioral or conduct problems (reported among 9% and 8% of children, respectively), followed by anxiety (6.5%). Approximately 3% of children in this age group had a current diagnosis of autism spectrum disorder (ASD). Additionally, nearly 8% had a current learning disability, 6% had a current speech or language disorder, and 6% had a developmental delay. Table 3 reveals significant differences in the prevalence of emotional and behavioral conditions across middle-childhood age subgroups. For example, the prevalence of ADD or ADHD increased from 5.4% among children aged 6 to 7 years to 11.7% among children aged 10 to 11 years (P < .0001). Older age was also associated with an increased prevalence of diagnosed anxiety (P < .0001). We found significant variation for several conditions (ie, behavioral or conduct problems, developmental delay, and speech or language disorder); specifically, prevalence peaked at 8 to 9 years old and decreased among those aged 10 to 11 years.

TABLE 2

Selected Health Status Indicators Among Children Aged 6–11 Years in the United States

No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalence, % (SE)
Total 21 539 24 846 548 — 
General health status    
 Excellent or very good 19 799 22 176 118 89.43 (0.60) 
 Good 1466 2 270 293 9.15 (0.58) 
 Fair or poor 216 350 904 1.41 (0.19) 
General oral health status    
 Excellent or very good 16 785 18 090 778 73.03 (0.76) 
 Good 3642 4 883 942 19.71 (0.67) 
 Fair or poor 1060 1 797 892 7.26 (0.50) 
CSHCN 5480 5 242 276 21.10 (0.61) 
CSHCN qualifying criteria    
 Conditions managed by medication(s) only 1688 1 509 359 6.07 (0.31) 
 Service use needs only 1018 961 152 3.87 (0.30) 
 Conditions managed by medication(s) and service use needs 1523 1 391 729 5.60 (0.29) 
 Functional limitations 1251 1 380 036 5.55 (0.41) 
No. comorbid conditions    
 None 11 940 14 821 255 59.65 (0.77) 
 1 4852 4 984 678 20.06 (0.60) 
 2 2242 2 282 614 9.19 (0.41) 
 ≥3 2505 2 758 002 11.10 (0.51) 
Chronic or genetic health conditions    
 Allergies 5344 5 276 955 21.29 (0.57) 
 Arthritis 32 37 438 0.15 (0.04) 
 Asthma 1954 2 331 885 9.51 (0.47) 
 Blindness 294 382 661 1.55 (0.17) 
 Blood disorders 89 118 328 0.48 (0.11) 
 Brain injury, concussion, head injury 112 102 551 0.41 (0.07) 
 Cerebral palsy 63 54 948 0.22 (0.05) 
 Cystic fibrosis 11 6246 0.02 (0.01) 
 Deafness 264 401 731 1.63 (0.27) 
 Diabetes 75 61 468 0.25 (0.06) 
 Down syndrome 39 30 837 0.12 (0.03) 
 Epilepsy or seizure disorder 155 164 925 0.67 (0.11) 
 Frequent and/or severe headaches or migraines 522 642 217 2.59 (0.23) 
 Heart condition 275 293 662 1.19 (0.14) 
 Other genetic or inherited condition 735 738 142 2.98 (0.22) 
 Tourette’s syndrome 48 40 735 0.16 (0.04) 
Emotional and behavioral disorders, current diagnosis    
 Anxiety problems 1666 1 597 549 6.46 (0.34) 
 ADD or ADHD 2285 2 258 586 9.21 (0.40) 
 Autism or ASD 608 730 102 2.96 (0.35) 
 Behavioral or conduct problems 2017 2 128 325 8.60 (0.42) 
 Depression 396 396 119 1.60 (0.17) 
 Developmental delay 1173 1 376 022 5.57 (0.41) 
 Intellectual disability 236 318 522 1.29 (0.25) 
 Learning disability 1531 1 903 270 7.68 (0.49) 
 Speech or other language disorder 1299 1 544 002 6.24 (0.41) 
 Substance abuse disorder 15 398 0.06 (0.02) 
No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalence, % (SE)
Total 21 539 24 846 548 — 
General health status    
 Excellent or very good 19 799 22 176 118 89.43 (0.60) 
 Good 1466 2 270 293 9.15 (0.58) 
 Fair or poor 216 350 904 1.41 (0.19) 
General oral health status    
 Excellent or very good 16 785 18 090 778 73.03 (0.76) 
 Good 3642 4 883 942 19.71 (0.67) 
 Fair or poor 1060 1 797 892 7.26 (0.50) 
CSHCN 5480 5 242 276 21.10 (0.61) 
CSHCN qualifying criteria    
 Conditions managed by medication(s) only 1688 1 509 359 6.07 (0.31) 
 Service use needs only 1018 961 152 3.87 (0.30) 
 Conditions managed by medication(s) and service use needs 1523 1 391 729 5.60 (0.29) 
 Functional limitations 1251 1 380 036 5.55 (0.41) 
No. comorbid conditions    
 None 11 940 14 821 255 59.65 (0.77) 
 1 4852 4 984 678 20.06 (0.60) 
 2 2242 2 282 614 9.19 (0.41) 
 ≥3 2505 2 758 002 11.10 (0.51) 
Chronic or genetic health conditions    
 Allergies 5344 5 276 955 21.29 (0.57) 
 Arthritis 32 37 438 0.15 (0.04) 
 Asthma 1954 2 331 885 9.51 (0.47) 
 Blindness 294 382 661 1.55 (0.17) 
 Blood disorders 89 118 328 0.48 (0.11) 
 Brain injury, concussion, head injury 112 102 551 0.41 (0.07) 
 Cerebral palsy 63 54 948 0.22 (0.05) 
 Cystic fibrosis 11 6246 0.02 (0.01) 
 Deafness 264 401 731 1.63 (0.27) 
 Diabetes 75 61 468 0.25 (0.06) 
 Down syndrome 39 30 837 0.12 (0.03) 
 Epilepsy or seizure disorder 155 164 925 0.67 (0.11) 
 Frequent and/or severe headaches or migraines 522 642 217 2.59 (0.23) 
 Heart condition 275 293 662 1.19 (0.14) 
 Other genetic or inherited condition 735 738 142 2.98 (0.22) 
 Tourette’s syndrome 48 40 735 0.16 (0.04) 
Emotional and behavioral disorders, current diagnosis    
 Anxiety problems 1666 1 597 549 6.46 (0.34) 
 ADD or ADHD 2285 2 258 586 9.21 (0.40) 
 Autism or ASD 608 730 102 2.96 (0.35) 
 Behavioral or conduct problems 2017 2 128 325 8.60 (0.42) 
 Depression 396 396 119 1.60 (0.17) 
 Developmental delay 1173 1 376 022 5.57 (0.41) 
 Intellectual disability 236 318 522 1.29 (0.25) 
 Learning disability 1531 1 903 270 7.68 (0.49) 
 Speech or other language disorder 1299 1 544 002 6.24 (0.41) 
 Substance abuse disorder 15 398 0.06 (0.02) 

—, not applicable.

TABLE 3

Differences by Age and Sex Among Children Aged 6–11 Years in the United States

TotalBoysGirls
Weighted % (SE)PWeighted % (SE)PWeighted % (SE)P
6–7 y8–9 y10–11 y6–7 y8–9 y10–11 y6–7 y8–9 y10–11 y
Health status             
 General health status             
  Excellent or very good 91.71 (0.71) 88.43 (1.16) 88.20 (1.16) .0264 91.88 (0.91) 87.99 (1.66) 87.72 (1.36) .0098 91.54 (1.09) 88.89 (1.63) 88.70 (1.89) .4013 
  Good 7.21 (0.64) 9.59 (1.12) 10.62 (1.14) — 7.40 (0.89) 9.25 (1.56) 10.88 (1.33) — 7.02 (0.92) 9.95 (1.61) 10.34 (1.87) — 
  Fair or poor 1.07 (0.32) 1.97 (0.40) 1.18 (0.27) — 0.72 (0.20) 2.76 (0.71) 1.40 (0.34) — 1.44 (0.62) 1.15 (0.32) 0.96 (0.41) — 
 General oral health status             
  Excellent or very good 76.95 (1.17) 70.76 (1.38) 71.49 (1.36) .0037 77.68 (1.52) 68.85 (1.96) 72.00 (1.74) .0090 76.18 (1.78) 72.74 (1.91) 70.96 (2.08) .1510 
  Good 17.13 (0.97) 20.34 (1.13) 21.61 (1.31) — 16.83 (1.38) 22.21 (1.70) 20.76 (1.64) — 17.45 (1.36) 18.39 (1.45) 22.50 (2.06) — 
  Fair or poor 5.91 (0.78) 8.9 (1.08) 6.89 (0.66) — 5.48 (0.72) 8.94 (1.50) 7.24 (0.85) — 6.37 (1.40) 8.87 (1.56) 6.53 (1.01) — 
 CSHCN 15.80 (0.79) 25.22 (1.28) 22.10 (0.99) .0000 18.92 (1.23) 30.40 (1.85) 26.92 (1.42) .0000 12.53 (0.98) 19.83 (1.70) 17.09 (1.42) .0009 
 Emotional and behavioral disorders             
  Anxiety problems 4.24 (0.41) 7.41 (0.70) 7.67 (0.62) .0000 4.95 (0.65) 9.09 (1.14) 8.96 (0.92) .0013 3.50 (0.49) 5.67 (0.77) 6.34 (0.83) .0114 
  ADD or ADHD 5.44 (0.44) 10.45 (0.75) 11.66 (0.81) .0000 7.07 (0.72) 14.30 (1.25) 15.27 (1.04) .0000 3.73 (0.51) 6.43 (0.76) 7.90 (1.28) .0028 
  Autism or ASD 2.13 (0.32) 3.36 (0.78) 3.36 (0.60) .2111 3.44 (0.59) 5.72 (1.47) 4.37 (0.54) .1899 0.77 (0.21) 0.90 (0.26) 2.31 (1.10) .0497 
  Behavioral or conduct problems 6.98 (0.54) 10.65 (0.96) 8.11 (0.55) .0007 9.88 (0.91) 15.62 (1.65) 11.35 (0.90) .0016 3.94 (0.55) 5.50 (0.80) 4.74 (0.62) .2440 
  Depression 0.97 (0.23) 1.80 (0.37) 2.02 (0.25) .0336 1.61 (0.44) 2.04 (0.49) 2.25 (0.40) .5908 0.30 (0.11) 1.54 (0.54) 1.77 (0.31) .0063 
  Developmental delay 4.04 (0.37) 7.29 (1.01) 5.31 (0.50) .0020 5.43 (0.62) 9.56 (1.60) 6.95 (0.75) .0159 2.58 (0.41) 4.94 (1.19) 3.62 (0.67) .0913 
  Intellectual disability 0.88 (0.19) 1.67 (0.66) 1.30 (0.24) .3071 1.22 (0.32) 2.44 (1.24) 2.04 (0.45) .4020 0.53 (0.18) 0.86 (0.35) 0.53 (0.17) .4859 
  Learning disability 4.00 (0.43) 9.44 (1.06) 9.50 (0.89) .0000 4.94 (0.68) 12.37 (1.64) 11.21 (1.13) .0000 3.01 (0.51) 6.39 (1.32) 7.73 (1.40) .0076 
  Speech or other language disorder 6.63 (0.58) 7.66 (0.97) 4.40 (0.42) .0024 8.66 (1.00) 9.67 (1.46) 5.46 (0.60) .0121 4.49 (0.57) 5.58 (1.26) 3.31 (0.59) .1463 
  Substance abuse disorder 0.02 (0.02) 0.08 (0.05) 0.09 (0.05) .4137 0.09 (0.08) 0.11 (0.08) .4223 0.04 (0.04) 0.07 (0.06) 0.06 (0.05) .9283 
Activity participation             
 Participation on sports teams or sports lessons 52.39 (1.48) 60.65 (1.44) 59.67 (1.39) .0001 56.38 (2.16) 65.20 (2.00) 63.12 (1.97) .0064 48.17 (2.01) 55.88 (2.09) 56.07 (1.93) .0073 
 Participation in clubs or organizations 38.05 (1.39) 49.78 (1.42) 53.13 (1.39) .0000 37.13 (1.93) 46.05 (1.90) 49.78 (1.97) .0000 39.02 (1.99) 53.70 (2.09) 56.65 (1.98) .0000 
 Participation in organized activities or lessons 42.25 (1.41) 44.92 (1.39) 50.95 (1.38) .0000 30.91 (1.75) 34.23 (1.71) 40.50 (1.84) .0006 54.18 (2.06) 56.05 (2.10) 61.80 (2.00) .0247 
 Participation in community service or volunteer work 25.65 (1.23) 32.11 (1.21) 36.65 (1.21) .0000 23.54 (1.54) 28.01 (1.53) 35.65 (1.73) .0000 27.87 (1.90) 36.38 (1.89) 37.70 (1.69) .0003 
 Participation in paid work or regular job 1.37 (0.24) 4.49 (0.57) 9.14 (0.58) .0000 1.30 (0.30) 6.65 (1.05) 10.25 (0.87) .0000 1.43 (0.39) 2.21 (0.32) 7.98 (0.77) .0000 
 Exercise, play sport, or physical activity for 60 min             
  0–3 d/wk 40.79 (1.49) 43.78 (1.40) 47.02 (1.37) .0002 40.48 (2.17) 43.42 (1.95) 44.14 (1.96) .1934 41.11 (2.03) 44.16 (2.03) 50.03 (1.90) .0007 
  4–6 d/wk 28.14 (1.17) 26.93 (1.15) 29.48 (1.17) — 27.03 (1.60) 25.28 (1.46) 28.63 (1.74) — 29.30 (1.69) 28.67 (1.78) 30.36 (1.56) — 
  Every day per week 31.07 (1.29) 29.28 (1.33) 23.50 (1.12) — 32.48 (1.74) 31.29 (1.76) 27.22 (1.65) — 29.58 (1.92) 27.17 (2.02) 19.60 (1.50) — 
Screen time             
 Time spent in front of a television per weekday, h             
  <2 55.14 (1.43) 52.36 (1.40) 47.54 (1.34) .0068 52.97 (2.03) 49.47 (1.91) 45.03 (1.89) .0813 57.40 (2.00) 55.42 (2.02) 50.19 (1.89) .1324 
  2–3 38.98 (1.38) 40.76 (1.37) 45.03 (1.38) — 40.78 (1.97) 42.30 (1.91) 46.14 (1.96) — 37.10 (1.94) 39.13 (1.97) 43.85 (1.93) — 
  4+ 5.88 (0.78) 6.88 (0.78) 7.43 (0.71) — 6.25 (1.16) 8.23 (1.24) 8.83 (1.14) — 5.49 (1.03) 5.45 (0.91) 5.95 (0.83) — 
 Time spent using devices doing things other than schoolwork per weekday, h             
  <2 70.87 (1.40) 62.59 (1.37) 52.91 (1.36) .0000 70.06 (1.95) 61.41 (1.88) 54.92 (1.91) .0000 71.72 (2.00) 63.84 (2.02) 50.80 (1.89) .0000 
  2–3 24.36 (1.34) 30.97 (1.32) 38.82 (1.36) — 24.58 (1.87) 32.27 (1.79) 36.29 (1.86) — 24.13 (1.93) 29.60 (1.95) 41.48 (1.95) — 
  4+ 4.77 (0.64) 6.43 (0.70) 8.27 (0.62) — 5.36 (0.93) 6.31 (0.99) 8.79 (0.86) — 4.15 (0.88) 6.56 (1.00) 7.71 (0.90) — 
 Total screen time average per weekday, h             
  <2 33.34 (1.29) 27.46 (1.20) 21.59 (1.01) .0000 31.02 (1.70) 24.26 (1.50) 20.40 (1.43) .0001 35.75 (1.92) 30.85 (1.87) 22.83 (1.41) .0000 
  2–3 38.72 (1.40) 39.83 (1.39) 38.51 (1.33) — 38.58 (2.03) 40.90 (1.93) 39.86 (1.98) — 38.86 (1.94) 38.70 (2.01) 37.09 (1.76) — 
  4+ 27.95 (1.37) 32.71 (1.32) 39.91 (1.34) — 30.40 (1.99) 34.84 (1.83) 39.74 (1.86) — 25.38 (1.88) 30.45 (1.89) 40.08 (1.95) — 
Sleep time             
 Average hours of sleep per day             
  ≤6 0.90 (0.19) 1.61 (0.36) 2.36 (0.38) .0000 0.99 (0.29) 1.38 (0.41) 2.43 (0.44) .0000 0.82 (0.25) 1.85 (0.60) 2.29 (0.63) .0005 
  7–8 27.28 (1.42) 31.95 (1.40) 38.92 (1.39) — 27.84 (1.97) 33.05 (1.96) 40.79 (2.02) — 26.70 (2.06) 30.81 (1.98) 36.95 (1.87) — 
  9+ 71.81 (1.42) 66.44 (1.41) 58.72 (1.38) — 71.17 (1.98) 65.57 (1.97) 56.78 (2.00) — 72.48 (2.06) 67.34 (2.01) 60.76 (1.89) — 
TotalBoysGirls
Weighted % (SE)PWeighted % (SE)PWeighted % (SE)P
6–7 y8–9 y10–11 y6–7 y8–9 y10–11 y6–7 y8–9 y10–11 y
Health status             
 General health status             
  Excellent or very good 91.71 (0.71) 88.43 (1.16) 88.20 (1.16) .0264 91.88 (0.91) 87.99 (1.66) 87.72 (1.36) .0098 91.54 (1.09) 88.89 (1.63) 88.70 (1.89) .4013 
  Good 7.21 (0.64) 9.59 (1.12) 10.62 (1.14) — 7.40 (0.89) 9.25 (1.56) 10.88 (1.33) — 7.02 (0.92) 9.95 (1.61) 10.34 (1.87) — 
  Fair or poor 1.07 (0.32) 1.97 (0.40) 1.18 (0.27) — 0.72 (0.20) 2.76 (0.71) 1.40 (0.34) — 1.44 (0.62) 1.15 (0.32) 0.96 (0.41) — 
 General oral health status             
  Excellent or very good 76.95 (1.17) 70.76 (1.38) 71.49 (1.36) .0037 77.68 (1.52) 68.85 (1.96) 72.00 (1.74) .0090 76.18 (1.78) 72.74 (1.91) 70.96 (2.08) .1510 
  Good 17.13 (0.97) 20.34 (1.13) 21.61 (1.31) — 16.83 (1.38) 22.21 (1.70) 20.76 (1.64) — 17.45 (1.36) 18.39 (1.45) 22.50 (2.06) — 
  Fair or poor 5.91 (0.78) 8.9 (1.08) 6.89 (0.66) — 5.48 (0.72) 8.94 (1.50) 7.24 (0.85) — 6.37 (1.40) 8.87 (1.56) 6.53 (1.01) — 
 CSHCN 15.80 (0.79) 25.22 (1.28) 22.10 (0.99) .0000 18.92 (1.23) 30.40 (1.85) 26.92 (1.42) .0000 12.53 (0.98) 19.83 (1.70) 17.09 (1.42) .0009 
 Emotional and behavioral disorders             
  Anxiety problems 4.24 (0.41) 7.41 (0.70) 7.67 (0.62) .0000 4.95 (0.65) 9.09 (1.14) 8.96 (0.92) .0013 3.50 (0.49) 5.67 (0.77) 6.34 (0.83) .0114 
  ADD or ADHD 5.44 (0.44) 10.45 (0.75) 11.66 (0.81) .0000 7.07 (0.72) 14.30 (1.25) 15.27 (1.04) .0000 3.73 (0.51) 6.43 (0.76) 7.90 (1.28) .0028 
  Autism or ASD 2.13 (0.32) 3.36 (0.78) 3.36 (0.60) .2111 3.44 (0.59) 5.72 (1.47) 4.37 (0.54) .1899 0.77 (0.21) 0.90 (0.26) 2.31 (1.10) .0497 
  Behavioral or conduct problems 6.98 (0.54) 10.65 (0.96) 8.11 (0.55) .0007 9.88 (0.91) 15.62 (1.65) 11.35 (0.90) .0016 3.94 (0.55) 5.50 (0.80) 4.74 (0.62) .2440 
  Depression 0.97 (0.23) 1.80 (0.37) 2.02 (0.25) .0336 1.61 (0.44) 2.04 (0.49) 2.25 (0.40) .5908 0.30 (0.11) 1.54 (0.54) 1.77 (0.31) .0063 
  Developmental delay 4.04 (0.37) 7.29 (1.01) 5.31 (0.50) .0020 5.43 (0.62) 9.56 (1.60) 6.95 (0.75) .0159 2.58 (0.41) 4.94 (1.19) 3.62 (0.67) .0913 
  Intellectual disability 0.88 (0.19) 1.67 (0.66) 1.30 (0.24) .3071 1.22 (0.32) 2.44 (1.24) 2.04 (0.45) .4020 0.53 (0.18) 0.86 (0.35) 0.53 (0.17) .4859 
  Learning disability 4.00 (0.43) 9.44 (1.06) 9.50 (0.89) .0000 4.94 (0.68) 12.37 (1.64) 11.21 (1.13) .0000 3.01 (0.51) 6.39 (1.32) 7.73 (1.40) .0076 
  Speech or other language disorder 6.63 (0.58) 7.66 (0.97) 4.40 (0.42) .0024 8.66 (1.00) 9.67 (1.46) 5.46 (0.60) .0121 4.49 (0.57) 5.58 (1.26) 3.31 (0.59) .1463 
  Substance abuse disorder 0.02 (0.02) 0.08 (0.05) 0.09 (0.05) .4137 0.09 (0.08) 0.11 (0.08) .4223 0.04 (0.04) 0.07 (0.06) 0.06 (0.05) .9283 
Activity participation             
 Participation on sports teams or sports lessons 52.39 (1.48) 60.65 (1.44) 59.67 (1.39) .0001 56.38 (2.16) 65.20 (2.00) 63.12 (1.97) .0064 48.17 (2.01) 55.88 (2.09) 56.07 (1.93) .0073 
 Participation in clubs or organizations 38.05 (1.39) 49.78 (1.42) 53.13 (1.39) .0000 37.13 (1.93) 46.05 (1.90) 49.78 (1.97) .0000 39.02 (1.99) 53.70 (2.09) 56.65 (1.98) .0000 
 Participation in organized activities or lessons 42.25 (1.41) 44.92 (1.39) 50.95 (1.38) .0000 30.91 (1.75) 34.23 (1.71) 40.50 (1.84) .0006 54.18 (2.06) 56.05 (2.10) 61.80 (2.00) .0247 
 Participation in community service or volunteer work 25.65 (1.23) 32.11 (1.21) 36.65 (1.21) .0000 23.54 (1.54) 28.01 (1.53) 35.65 (1.73) .0000 27.87 (1.90) 36.38 (1.89) 37.70 (1.69) .0003 
 Participation in paid work or regular job 1.37 (0.24) 4.49 (0.57) 9.14 (0.58) .0000 1.30 (0.30) 6.65 (1.05) 10.25 (0.87) .0000 1.43 (0.39) 2.21 (0.32) 7.98 (0.77) .0000 
 Exercise, play sport, or physical activity for 60 min             
  0–3 d/wk 40.79 (1.49) 43.78 (1.40) 47.02 (1.37) .0002 40.48 (2.17) 43.42 (1.95) 44.14 (1.96) .1934 41.11 (2.03) 44.16 (2.03) 50.03 (1.90) .0007 
  4–6 d/wk 28.14 (1.17) 26.93 (1.15) 29.48 (1.17) — 27.03 (1.60) 25.28 (1.46) 28.63 (1.74) — 29.30 (1.69) 28.67 (1.78) 30.36 (1.56) — 
  Every day per week 31.07 (1.29) 29.28 (1.33) 23.50 (1.12) — 32.48 (1.74) 31.29 (1.76) 27.22 (1.65) — 29.58 (1.92) 27.17 (2.02) 19.60 (1.50) — 
Screen time             
 Time spent in front of a television per weekday, h             
  <2 55.14 (1.43) 52.36 (1.40) 47.54 (1.34) .0068 52.97 (2.03) 49.47 (1.91) 45.03 (1.89) .0813 57.40 (2.00) 55.42 (2.02) 50.19 (1.89) .1324 
  2–3 38.98 (1.38) 40.76 (1.37) 45.03 (1.38) — 40.78 (1.97) 42.30 (1.91) 46.14 (1.96) — 37.10 (1.94) 39.13 (1.97) 43.85 (1.93) — 
  4+ 5.88 (0.78) 6.88 (0.78) 7.43 (0.71) — 6.25 (1.16) 8.23 (1.24) 8.83 (1.14) — 5.49 (1.03) 5.45 (0.91) 5.95 (0.83) — 
 Time spent using devices doing things other than schoolwork per weekday, h             
  <2 70.87 (1.40) 62.59 (1.37) 52.91 (1.36) .0000 70.06 (1.95) 61.41 (1.88) 54.92 (1.91) .0000 71.72 (2.00) 63.84 (2.02) 50.80 (1.89) .0000 
  2–3 24.36 (1.34) 30.97 (1.32) 38.82 (1.36) — 24.58 (1.87) 32.27 (1.79) 36.29 (1.86) — 24.13 (1.93) 29.60 (1.95) 41.48 (1.95) — 
  4+ 4.77 (0.64) 6.43 (0.70) 8.27 (0.62) — 5.36 (0.93) 6.31 (0.99) 8.79 (0.86) — 4.15 (0.88) 6.56 (1.00) 7.71 (0.90) — 
 Total screen time average per weekday, h             
  <2 33.34 (1.29) 27.46 (1.20) 21.59 (1.01) .0000 31.02 (1.70) 24.26 (1.50) 20.40 (1.43) .0001 35.75 (1.92) 30.85 (1.87) 22.83 (1.41) .0000 
  2–3 38.72 (1.40) 39.83 (1.39) 38.51 (1.33) — 38.58 (2.03) 40.90 (1.93) 39.86 (1.98) — 38.86 (1.94) 38.70 (2.01) 37.09 (1.76) — 
  4+ 27.95 (1.37) 32.71 (1.32) 39.91 (1.34) — 30.40 (1.99) 34.84 (1.83) 39.74 (1.86) — 25.38 (1.88) 30.45 (1.89) 40.08 (1.95) — 
Sleep time             
 Average hours of sleep per day             
  ≤6 0.90 (0.19) 1.61 (0.36) 2.36 (0.38) .0000 0.99 (0.29) 1.38 (0.41) 2.43 (0.44) .0000 0.82 (0.25) 1.85 (0.60) 2.29 (0.63) .0005 
  7–8 27.28 (1.42) 31.95 (1.40) 38.92 (1.39) — 27.84 (1.97) 33.05 (1.96) 40.79 (2.02) — 26.70 (2.06) 30.81 (1.98) 36.95 (1.87) — 
  9+ 71.81 (1.42) 66.44 (1.41) 58.72 (1.38) — 71.17 (1.98) 65.57 (1.97) 56.78 (2.00) — 72.48 (2.06) 67.34 (2.01) 60.76 (1.89) — 

—, not applicable.

Behaviors and reported activities among children aged 6 to 11 years are shown in Table 4. More than 22% of parents reported that their child had been bullied, picked on, or excluded by other children, and 7% of children exhibited bullying behavior to others. In the NSCH, parents were also asked a set of questions on schooling and activities: “Compared to other children his or her age, how much difficulty does this child have making or keeping friends?” Nearly 20% of parents reported that their child had difficulty making or keeping friends compared with other children their own age. Approximately 22% of children had missed ≥4 days of school because of illness or injury during the past year, and most parents (88%) reported never or only once having been contacted regarding a problem with their child at school during the past year. More than 95% of children reportedly met indicators associated with school performance (eg, showing interest or curiosity in learning new things, caring about doing well in school).

TABLE 4

Behaviors and Activities Among Children Aged 6–11 Years in the United States

No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalence, % (SE)
Total 21 539 24 846 548 — 
Developmental indicators    
 Interest curiosity 21 340 24 547 983 99.28 (0.23) 
 Works to finish tasks started 20 641 23 685 026 96.70 (0.37) 
 Stays calm and in control when challenged 19 658 22 499 664 92.15 (0.45) 
 Cares about doing well in school 20 757 23 802 542 97.71 (0.29) 
 Does all required homework 20 585 23 641 249 96.98 (0.32) 
 Bullied, picked on, or excluded by others 5149 5 474 710 22.41 (0.66) 
 Bullies others, picks on them, or excludes them 1356 1 678 609 6.86 (0.41) 
 Argues too much 7397 8 287 105 33.92 (0.76) 
School delinquency and social issues    
 Days of missed school because of illness or injury    
  0 d 5150 7 180 845 29.50 (0.79) 
  1–3 d 10 839 11 652 349 47.87 (0.81) 
  4–10 d 4578 4 803 340 19.73 (0.63) 
  11+ d 560 656 371 2.70 (0.23) 
  Child not enrolled in school 55 46 044 0.19 (0.06) 
 Adult contacted about child problems in school    
  Never 15 466 17 994 923 74.08 (0.70) 
  Once 2884 3 379 672 13.91 (0.60) 
  2+ times 2742 2 915 270 12.00 (0.45) 
 Child repeated grade 828 1 259 462 5.19 (0.37) 
 Difficulty making or keeping friends 4360 4 569 124 18.74 (0.62) 
Activity participation    
 Participation on sports teams or sports lessons 14 377 13 995 798 57.61 (0.84) 
 Participation in clubs or organizations 11 523 11 354 295 47.05 (0.81) 
 Participation in organized activities or lessons 11 231 11 055 612 46.04 (0.80) 
 Participation in community service or volunteer work 7801 7 562 636 31.50 (0.70) 
 No. extracurricular activities    
  None 3050 5 509 796 22.17 (0.79) 
  1 4272 5 596 764 22.52 (0.69) 
  ≥2 14 217 13 739 988 55.30 (0.82) 
 Exercise, play sport, or physical activity for 60 min    
  0–3 d/wk 8300 10 681 874 43.88 (0.82) 
  4–6 d/wk 6998 6 859 598 28.18 (0.67) 
  Every day 5856 6 802 271 27.94 (0.72) 
Screen time    
 Time spent in front of a television per weekday, h    
  <2 11 702 12 672 582 51.67 (0.81) 
  2–3 8535 10 201 545 41.59 (0.80) 
  4+ 1097 1 651 295 6.73 (0.44) 
 Time spent using devices doing things other than schoolwork per weekday, h    
  <2 14 094 15 234 692 62.09 (0.80) 
  2–3 6098 7 708 893 31.42 (0.78) 
  4+ 1148 1 594 039 6.50 (0.38) 
 Total screen time average per weekday, h    
  <2 6437 6 712 594 27.44 (0.68) 
  2–3 8647 9 547 516 39.02 (0.79) 
  4+ 6201 8 205 276 33.54 (0.78) 
Sleep    
 How often child goes to bed at the same time    
  Rarely or never 293 488 732 1.99 (0.23) 
  Usually or sometimes 13 346 14 562 676 59.21 (0.82) 
  Always 7724 9 542 952 38.80 (0.81) 
 Average hours of sleep per day    
  ≤6 248 395 446 1.63 (0.19) 
  7–8 5783 7 957 558 32.74 (0.81) 
  9+ 15 103 15 952 540 65.63 (0.81) 
No. in Sample (Unweighted)No. in US Population (Weighted)Weighted Prevalence, % (SE)
Total 21 539 24 846 548 — 
Developmental indicators    
 Interest curiosity 21 340 24 547 983 99.28 (0.23) 
 Works to finish tasks started 20 641 23 685 026 96.70 (0.37) 
 Stays calm and in control when challenged 19 658 22 499 664 92.15 (0.45) 
 Cares about doing well in school 20 757 23 802 542 97.71 (0.29) 
 Does all required homework 20 585 23 641 249 96.98 (0.32) 
 Bullied, picked on, or excluded by others 5149 5 474 710 22.41 (0.66) 
 Bullies others, picks on them, or excludes them 1356 1 678 609 6.86 (0.41) 
 Argues too much 7397 8 287 105 33.92 (0.76) 
School delinquency and social issues    
 Days of missed school because of illness or injury    
  0 d 5150 7 180 845 29.50 (0.79) 
  1–3 d 10 839 11 652 349 47.87 (0.81) 
  4–10 d 4578 4 803 340 19.73 (0.63) 
  11+ d 560 656 371 2.70 (0.23) 
  Child not enrolled in school 55 46 044 0.19 (0.06) 
 Adult contacted about child problems in school    
  Never 15 466 17 994 923 74.08 (0.70) 
  Once 2884 3 379 672 13.91 (0.60) 
  2+ times 2742 2 915 270 12.00 (0.45) 
 Child repeated grade 828 1 259 462 5.19 (0.37) 
 Difficulty making or keeping friends 4360 4 569 124 18.74 (0.62) 
Activity participation    
 Participation on sports teams or sports lessons 14 377 13 995 798 57.61 (0.84) 
 Participation in clubs or organizations 11 523 11 354 295 47.05 (0.81) 
 Participation in organized activities or lessons 11 231 11 055 612 46.04 (0.80) 
 Participation in community service or volunteer work 7801 7 562 636 31.50 (0.70) 
 No. extracurricular activities    
  None 3050 5 509 796 22.17 (0.79) 
  1 4272 5 596 764 22.52 (0.69) 
  ≥2 14 217 13 739 988 55.30 (0.82) 
 Exercise, play sport, or physical activity for 60 min    
  0–3 d/wk 8300 10 681 874 43.88 (0.82) 
  4–6 d/wk 6998 6 859 598 28.18 (0.67) 
  Every day 5856 6 802 271 27.94 (0.72) 
Screen time    
 Time spent in front of a television per weekday, h    
  <2 11 702 12 672 582 51.67 (0.81) 
  2–3 8535 10 201 545 41.59 (0.80) 
  4+ 1097 1 651 295 6.73 (0.44) 
 Time spent using devices doing things other than schoolwork per weekday, h    
  <2 14 094 15 234 692 62.09 (0.80) 
  2–3 6098 7 708 893 31.42 (0.78) 
  4+ 1148 1 594 039 6.50 (0.38) 
 Total screen time average per weekday, h    
  <2 6437 6 712 594 27.44 (0.68) 
  2–3 8647 9 547 516 39.02 (0.79) 
  4+ 6201 8 205 276 33.54 (0.78) 
Sleep    
 How often child goes to bed at the same time    
  Rarely or never 293 488 732 1.99 (0.23) 
  Usually or sometimes 13 346 14 562 676 59.21 (0.82) 
  Always 7724 9 542 952 38.80 (0.81) 
 Average hours of sleep per day    
  ≤6 248 395 446 1.63 (0.19) 
  7–8 5783 7 957 558 32.74 (0.81) 
  9+ 15 103 15 952 540 65.63 (0.81) 

—, not applicable.

Most children aged 6 to 11 years were active: 58% participated in sports during the past 12 months (ie, on a sports team or in a sports lesson), and 56% participated in exercise, a sport, or another physical activity for at least 60 minutes most days of the week. Regarding screen time, nearly one-half of all children reportedly watched >2 hours of television per weekday, whereas nearly 40% spent >2 hours per weekday using devices for purposes other than schoolwork. Overall, parents reported that more than one-third of children had ≥4 hours per weekday of total screen time (ie, watching television and/or using devices). In the NSCH, parents were also asked several questions about children’s bedtime and sleep habits. Nearly 60% of children usually or sometimes went to bed at the same time every night, and two-thirds (66%) reportedly received an average of ≥9 hours per day of sleep.

Table 3 shows how screen time and sleep behaviors varied by children’s age and sex. The percentage of children spending ≥4 hours per weekday using devices for purposes other than schoolwork significantly increased from 4.8% of those aged 6 to 7 years to 8.2% of those aged 10 to 11 years (P < .0001). A similarly significant increase was seen regarding total average screen time of ≥4 hours per weekday (from 28.0% of younger children to 40% of older children; P < .0001). Conversely, there was a significant decrease in the percentage of children receiving the recommended minimum of 9 hours of sleep per day; 71.8% of those aged 6 to 7 years reported ≥9 hours of sleep per day, yet this proportion dropped to 58.7% of older children (P < .0001). Patterns in screen time and physical activity were also notably different for boys compared with girls at different ages, with a 15-percentage-point increase in the proportion of girls averaging ≥4 hours of total screen time per weekday between ages 6 to 7 and 10 to 11 years (compared with a 9-percentage-point increase among their male counterparts) and a 10-percentage-point decline in the proportion of girls meeting physical activity guidelines between these ages (compared with a 5-percentage-point decline for boys of the same age).

With this epidemiological profile of middle childhood, we are the first to examine this population using a comprehensive range of indicators from a large nationally representative data set. Our analysis included a range of factors and confirmed that the population of children aged 6 to 11 years in the United States is generally healthy according to most traditional indicators of health and well-being. Most were in good health, despite the fact that 4 in 10 experienced ≥1 chronic conditions, and had access to health-affirming family- and community-level factors.

Several notable patterns were observed with respect to age. We found a significant increase in the prevalence of diagnosed ADHD with age, which is consistent with findings reported by Visser at al,18  who found the average age at ADD or ADHD diagnosis among children to be ∼7 years. We also found significant differences in the prevalence of developmental delays; specifically, a peak prevalence at 8 to 9 years of age, followed by a drop before early adolescence. This could be due to the receipt of routine screening among school-aged children and early intervention services, which have been reported to occur primarily for children ages 9 to 12 years.19 

Results also indicated a significant increase in the prevalence of diagnosed anxiety problems as children aged (from 4.2% of children aged 6 to 7 years to 7.7% of children aged 10 to 11 years) as well as higher diagnoses of anxiety among boys than girls. Earlier onset of anxiety, compared with other mental health conditions, has been documented with increasing prevalence across adolescence.20,21  Our results are among the few to reveal similar findings in the preceding age group of middle childhood and could reflect an increasing prevalence of early-onset mental health conditions or enhanced screening or symptom recognition among providers or caregivers. Our findings on sex differences in anxiety diagnoses (ie, greater prevalence of anxiety among boys) are surprising given that research has shown girls to be at greater risk for exhibiting anxiety symptoms during early adolescence.2224  These results suggest that additional risk factors beyond sex may impact anxiety prevalence among children and may inform several opportunities in a child’s life course for targeted screening and intervention.

Results regarding sleep, screen time, and physical activity behaviors are concerning and merit further consideration. Although most children aged 6 to 11 years are reported to get the recommended 9 to 12 hours of sleep per day, the proportion of children obtaining this duration of sleep significantly decreases as children age. Sleep insufficiency in children has been shown to be associated with behavior and learning problems, emotional disturbances, and increased risk for several physical and emotional and behavioral conditions developing into adolescence.25,26  We observed similar patterns regarding parent-reported screen time and electronic device use for children. More than one-third of children had ≥4 hours per weekday of total screen time using devices for non-schoolwork purposes; both screen time and time using electronic devices significantly increased with increasing age. These findings align with past work that has shown increasing use of devices and digital media among children at younger ages.4,27,28  Although there are no longer firm guidelines for screen time in middle childhood, parents are advised to limit use of digital media for entertainment purposes and prioritize that children get recommended daily amounts of sleep and physical activity.29  This guidance extends into adolescence, supported by studies that have found associations between increased screen time at younger ages and insufficient sleep and sleep disturbances in adolescence.30,31  Finally, although more than half of children were reported to have participated in 60 minutes of physical activity most days of the week, <30% did so every day, as recommended in the Physical Activity Guidelines for Americans.32  More importantly, the proportion of children doing so every day significantly decreases with age and varies by sex, with significant declines observed among girls. The interplay between declining rates of physical activity and increasing rates of screen time among girls highlights the importance of tracking such indicators for younger children and the opportunity to intervene at earlier ages.

This study has limitations. First, the cross-sectional data only allow us to draw associations, rather than causal relationships, between variables. Second, response bias may have been introduced because the NSCH contained parent-reported data. Although research has revealed strong agreement between parental report and clinical records for diagnoses made in the past year, there is little research examining the validity of parent-reported information for behavioral outcomes, including sleep and activity. Despite this dearth, our methodology and reliance on parental report is consistent with most existing studies in which similar outcomes in children have been examined.3,27  In addition, the weighted response rate of ∼40% for both survey years and an interviewed sample that appears to live in areas associated with higher levels of income and education suggest the possibility of nonresponse bias. However, extensive nonresponse bias analyses conducted at several different phases of the survey indicate that there was no strong or consistent evidence of nonresponse bias.12,13 

This study lends credence to the perception that children in middle childhood are generally healthy and thriving but highlights the fragility of this picture by sounding an early warning around the emergence and progression of selected health-risk behaviors. Findings establish a benchmark from which we can examine how health status and behaviors among these children evolve over time (through longitudinal or trend analyses). Further research could add an important layer to existing work on adolescent health and health behaviors; for example, focusing on the association of risk behaviors in middle childhood with the likelihood of certain behaviors and health outcomes in adolescence. This may inform targeted interventions for middle-childhood subgroups, with implications for optimal screening and service delivery for children at younger ages. With this study, we also lay the groundwork for future researchers examining differences by sociodemographic characteristics beyond age and sex (eg, differences by family and neighborhood factors), and by health care access and use. Such efforts should prioritize the interplay between and among these factors to elucidate which factors (alone and in combination) may serve as significant risk and protective forces within the middle-childhood population.

Dr Parasuraman conceptualized and designed the study, conducted data analyses, drafted the initial manuscript, and revised the manuscript on the basis of review feedback from coauthors; Dr Ghandour conceptualized the study and critically reviewed and revised the manuscript through several drafts; Dr Kogan conceptualized the study, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The views expressed in this article are those of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US Government.

FUNDING: No external funding.

     
  • ADD

    attention-deficit disorder

  •  
  • ADHD

    attention-deficit/hyperactivity disorder

  •  
  • ASD

    autism spectrum disorder

  •  
  • CSHCN

    children with special health care needs

  •  
  • NSCH

    National Survey of Children’s Health

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data