Beyond Insurance Access: Relational Protective Contexts and Depressive Symptoms Among Adolescent Girls

Background: Adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) are well-established predictors of adolescent depressive symptoms. However, adolescent mental health is also shaped by supports across healthcare, institutional, and broader social contexts. Yet access to care is often operationalized narrowly through insurance coverage or provider contact, leaving other supportive contexts understudied. This question is particularly salient for adolescent girls—and especially for Black girls—facing disproportionate barriers to mental health care. We address this gap by examining the relative contributions of adversity, insurance-based access, parental school engagement, and multilevel PCEs to depressive symptoms among adolescent girls, with subgroup analyses focused on Black girls.

Methods: We conducted a secondary analysis of longitudinal cohort data from six waves of the Future of Families and Child Wellbeing Study, including adolescent girls who completed the age-15 survey (n=1,148, 43% Black, 22% White, 26% Latina, 7% other). Although ACEs were measured longitudinally from birth through age 15, all other variables were assessed at age 15. Depressive symptoms were assessed using the CES-D short form. ACEs were measured as a summed index using parent- and youth-reported exposures (e.g., maltreatment, incarceration, and bullying). PCEs were measured as a summed index of positive experiences across social, school, and neighborhood domains. Medicaid status indicated insurance-based access to care, and parental school engagement reflected parent contact with teachers regarding behavioral, health, and educational concerns. We estimated hierarchical linear regression models in the full sample and separately among Black girls.

Results: As expected, ACEs were positively associated with depressive symptoms (b = 0.413, p <.001, R² = .046), remaining significant after adjustment for race and Medicaid status. Medicaid status was not significantly associated with depressive symptoms. Parental school engagement was positively associated with depressive symptoms (b = 0.287, p < .001) and remained significant after adjustment for all covariates (b = 0.179), suggesting parent–school contact may reflect responses to emerging concerns rather than proactive involvement. PCEs were strongly inversely associated with depressive symptoms (b = −0.487, p < .001), increasing explained variance from .046 to .240 (ΔR² = .194). Among Black girls, ACEs remained positively associated with depressive symptoms (b = 0.219, p = .021), and PCEs showed a strong inverse association (b = -0.445, p < .001). Unlike the full sample, parental school engagement was no longer significant after PCEs were added (b = 0.109, p = .176), and the final model explained 20.2% of the variance in depressive symptoms (R² = .202).

Conclusion: Findings indicate depressive symptoms among adolescent girls are shaped by protective relational contexts alongside adversity exposure. The attenuation of Medicaid status suggests that insurance-based access is insufficient as a standalone indicator of support. The strong PCEs association highlights relational and community-level protective environments as meaningful targets for prevention and intervention. Among Black girls, the persistence of PCE effects alongside the attenuation of school engagement suggests that broader relational protective contexts may matter more than institutional contact alone. Findings point to the value of multilevel interventions that extend beyond clinical access to strengthen relational environments for adolescent girls.