PROJECT SUMMARY The overarching goal of the Enriching ECHO with High-risk Pregnancies and Children with Disabilities (Enriching ECHO) cohort is to advance disabilities inclusivity in ECHO research by studying children with a spectrum of disability and by leveraging existing data from ECHO participants with disabilities. Our scientific premise is that psychosocial environmental exposures (e.g., SDH, stress, social environment, discrimination) and modifiable personal factors (e.g., parenting style, social supports, mental health) impact the physical and emotional health of children with disabilities resulting in definable outcomes of function, well-being, and participation in community and family life. Our hypothesis is that we can identify specific environmental factors associated with better -than- expected positive health outcomes along the continuumof disability to typical development. The EnrichingECHO cohort will address this hypothesis via the following specific aims: Aim 1: Leveraging ECHO core data elements, we will (a) compare trajectories of children with and without disabilities over time, from birth to school age (5-6 years), with positive health (child well-being) as the primary outcome. We will evaluate the effect of (b) pre-natal environmental and psychosocial exposures and (c) post- natal nutrition, sleep health, and physical activity on positive health trajectories in these child cohorts over time.. Aim 2: In the entire cohort (a) we will identify maternal pre- and peri-natal psychosocial exposures associated with post-natal outcomes (e.g., birth defects, birthweight, prematurity, early life disabilities) in high -risk and uncomplicated pregnancies. (b) We will test which pre-, peri-, and post-natal factors best predict the primary outcome of child well-being (positive health) at school-age, adjusting for co-linearity effects. (c) Comparing the cohorts of children with and without disability, we will examine whether parenting style and caregiver social support are modifiable exposures associated with better-than-expected positive health. Aim 3: To ensure significance and impact on ECHO science, the Enhancing ECHO cohort emphasizes diversity and inclusion of underrepresented groups by engaging mothers and offspring with a range of disabilities. Our approach will (a) recruit participants with high-risk pregnancies who are most likely to deliver children with disabilities and include individuals with disabilities who are often excluded from research studies. We will ( b) collaborate with community stakeholders with disabilities to design engagement, retention, and dissemination strategies, and (c) standardize early ECHO surveillance for disabilities across cohorts. Aim 4: In a cohort of ECHO participants with second pregnancies, we will explore whether the peri-natal environmental exposures associated with positive child health in the older ECHO sibling (identified in Aim 2b) are predictive of post-natal birth outcomes in the second ECHO pregnancy.

PROJECT NARRATIVE The overarching goal of the Enriching ECHO with High-risk Pregnancies and Children with Disabilities (Enriching ECHO) cohort is to advance disabilities inclusivity in ECHO research by studying children with a spectrum of disability and by leveraging existing data from ECHO participants with disabilities. Our scientific premise is that psychosocial environmental exposures (e.g., social determinants of health, stress, social environment, discrimination) and modifiable personal factors (e.g., parenting style, social supports, mental health) impact the physical and emotional health of children with disabilities resulting in definable outcomes of function, well-being, and participation in community and family life. Our hypothesis is that we can identify specific modifiable environmental factors associated with better-than-expected positive health outcomes along the continuum of disability to typical development that allow children with disabilities (and, by extension, all children) to thrive.