The events a person experiences throughout childhood and adolescence, both positive and negative, are directly associated with health and well-being outcomes experienced as an adult. Rural-Urban Differences in Adverse and Positive Childhood Experiences, a recent webinar presented by Rural Health Research Gateway, examined research on the pervasiveness and effects of such experiences among children living in rural and urban areas.
The webinar was moderated by Per Ostmo, program director at Rural Health Research Gateway. Elizabeth Crouch, Ph.D., deputy director of the Rural and Minority Health Research Center at the University of South Carolina, presented her prior and updated research comparing the likelihood of rural children to experience adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) compared to their urban counterparts.
Though ACEs — experienced more frequently among rural children — are related to negative health outcomes, there is hope: the research collected and examined offers a blueprint for potential solutions needed to improve PCE outcomes, and health outcomes, for future generations.
What are ACEs?
ACEs are traumatic events that occur in a child’s life. “They encompass many different things, but generally the broad categories include abuse, neglect, and household dysfunction,” Dr. Crouch said. “These experiences matter because we know that they’re associated with negative health and well-being outcomes as an adult and may affect outcomes for both physical and mental health, as well as risky behaviors into adulthood.”
Other examples of ACEs include having someone in the home who is suicidal or mentally ill, alcohol or drug use in the home, having a parent in jail, or being a witness to divorce or domestic violence.
ACEs are measured via two different methods: either a parent or guardian reports the child’s current experience, or an adult reports remembered experiences from their own childhood. Some measurements of ACEs also identify whether a child has experienced parental death, racial discrimination, financial struggle, or any form of abuse.
According to Dr. Crouch’s prior research on rural-urban differences in ACEs, rural children are more likely to experience nearly all ACEs: economic hardship, household substance use, household mental illness, witness to neighborhood violence, witness to household violence, household incarceration, parental death, and parental separation and divorce.
Rural children are also more likely than urban to have one to three ACEs (33.3% rural, 30.1% urban) and four or more ACEs (6.9% rural, 3.8% urban) and less likely to have zero ACEs (59.9% rural, 66.1% urban).
The only ACEs type experienced more frequently by urban children than rural was racial and ethnic mistreatment. However, this is measured by asking the child or caregiver if any racial or ethnic mistreatment was experienced. As discrimination is often repressed or reduced in an effort to minimize the long-term harm, people may not recognize or acknowledge racial or ethnic mistreatment, potentially misrepresenting the results.
In 2019, Dr. Crouch presented her original research on rural-urban differences among ACEs to a National Advisory Committee on Rural Health and Human Services. Out of this presentation came recommendations for more comprehensive prevention strategies and research.
In a new study, conducted in 2020, Dr. Crouch approached the same topic with a new purpose: to determine whether ACE and PCE exposure differ between rural and urban children, by type and count of experience. The new study was the first to estimate rural-urban differences in ACEs and PCEs using all 50 states and the District of Columbia – a crucial improvement as previous studies lacked significant data from various areas.
Findings from the new study confirmed much of the first report. When comparing ACE exposure by type among children ages 6-17, rural children are more likely to experience: economic hardship, household substance abuse, household mental illness, witness neighborhood and household violence, household incarceration, parental death, and parental separation and divorce. Again, urban children only ranked higher in exposure to racial and ethnic mistreatment.
However, the number of ACEs among children in both rural and urban areas increased significantly in the new data:
- 0 ACEs: 44.1% rural, 52.5% urban.
- 1-3 ACEs: 45.2% rural, 40.7% urban.
- 4+: 10.7% rural, 6.8% urban.
The new study also focused on the degree to which children who are exposed to ACEs also have the potential to strengthen their PCEs. Though rural children face a mix of advantages and disadvantages leading to potential ACE exposure, the creation of community resources and support systems to address the disadvantages can also be an aid in improving PCEs.
By confirming the previous research that rural children consistently have higher exposure to nearly all ACEs assessed, continuing to examine ACEs and PCEs in rural communities can provide insight on areas for improvement.
What are PCEs?
PCEs are positive childhood experiences which can include having a safe and stable environment and relationship with a caregiver or mentor. Similar to traumatic experiences such as ACEs, PCEs are associated with health and well-being in adulthood. Increasing exposure to PCEs during childhood and adolescence can lessen the negative impact of ACEs and can help develop healing skills.
Types of PCEs measured include the resiliency of the family, the presence of a connected caregiver, engagement in after-school activities, a supportive neighborhood, a safe neighborhood, the guidance of a mentor, and engagement in community volunteering. Family resilience is measured by assessing how a family addresses challenges, especially focusing on whether the family communicates effectively.
Dr. Crouch’s 2020 research examining rural-urban differences in positive childhood experiences found similarities in many categories, with family resiliency (92.1% rural, 92.3% urban) nearly the same and connected caregiver reporting exactly split between rural and urban (95.6%). Urban communities saw higher rates of after-school activities, but rural again ranked higher for most PCE types.
Improving ACE-PCE Ratios
Children with high ACE exposure are less likely to have each of these PCE types, and rural children with four or more ACEs often lack PCEs at all. Reducing exposure to ACEs and increasing exposure to PCEs requires an approach rooted in health equity, focused on reducing threats to children’s health and growth.
“We know that traumatic experiences, for example, may lead to riskier behaviors in adulthood, to unintended pregnancy, alcohol misuse – lots of things,” Dr. Crouch said. “But we also know that positive experiences can reduce, ameliorate, or mitigate these experiences.”
“Positive experiences can intervene at any of these points to improve health outcomes and promote healing,” she continued. “We know that positive experiences help people use their own life experience to help them recover.”
The HOPE model (Healthy Outcomes for Positive Experiences) identifies four areas that affect both positive and negative experiences: relationships, environment, engagement, and opportunities. This approach empowers individuals and communities to consider their strengths and connections in ways that extend beyond the labeling of individuals as helpless victims of historical trauma and institutional racism.
“Just because someone has experienced negative outcomes doesn’t necessarily mean they’re going to have negative outcomes into adulthood,” Dr. Crouch said. “We have ways to help people and to recognize their strengths and connections.”
The four building blocks of HOPE include:
- Relationships – with other children, with other adults, and created through interactive activities.
- Environment – safe, equitable and stable; able to live, play, and learn; positive school and home environments.
- Engagement – ability to develop a sense of connectedness and engage in social and civic activities.
- Opportunities for social emotional development – playing with peers; learning self-reflection; collaboration in art, sports, drama, and music.
“Participating in family cultural activities, organized music, sports – ways in which children can feel connected to their communities, whether that’s through civic activities or social activities – all of these can help children develop into becoming more of a secure and healthy adult,” Dr. Crouch said.
Programs that support PCEs by focusing on the building blocks of HOPE promote health development while avoiding stigma and labeling. The CDC recommends a number of approaches for reducing ACEs and building PCEs, using the HOPE model as a foundation:
- Strengthen economic support to families to improve likelihood of stable environment and decrease parental stress.
- Promote social norms that protect against violence and adversity.
- Ensure a strong start for children.
- Educate parents on ACEs and PCEs as well as managing stress.
- Connect youth to caring adults and activities.
- Intervene to lessen immediate harm and long-term harms.
Because a stable and supportive environment and caregiver are critical to strengthening PCEs, improvements must be made to the rural health sector. Rural children disproportionately live in homes affected by substance misuse and mental illness, but these communities are also more likely than urban to lack effective treatment programs for behavioral health.
Rural areas also experience higher shortages in the health workforce, particularly for mental health care and addiction and recovery services. One step toward improvement would be the introduction of more programs that utilize telehealth and other modalities to address local service shortfalls.
According to Dr. Crouch, parental and home-based intervention programs and resources are invaluable as they help with early childhood intervention and can decrease the likelihood of repeating ACEs across generations. Parent education and support can address attachment issues and traumas within the parent-child relationship and help caregivers tune into their children.
In South Carolina, Dr. Crouch is an evaluator for the Maternal Infant Early Childhood Home Visiting Program (MIECHV). “This program has been shown to improve some of these outcomes for kids and for teaching parents how to safely discipline, how to connect with their kids, how to put their kids to sleep safely – all kinds of things that help with parenting skills and family relationships.”
After-school activities and mentoring programs are recommended to help build social and community engagement. “After-school programs can help get kids engaged, especially into peer-to-peer healthy relationships,” Dr. Crouch said. Connecting youth to caring adults and activities also helps provide interventions for immediate and long-term harm.
To prevent child abuse and neglect, the CDC recommends improving family-friendly work policies, such as the Child Tax Credit and other economic supports for parents. Relieving economic burdens on parents can reduce parental stress and assist in providing a safe and stable environment for the child.
“It’s crucial to ask caregivers about the environments our kids are experiencing,” Dr. Crouch said. “A home where a child is safe and secure: they get proper nutrition, enough sleep, it’s an environment where we can promote high-quality learning and a safe place to interact with and observe other children such as a positive school and learning environment.”
Community initiatives can link families with services they may not be aware of that can provide some of this support. Safe Environment for Every Kid (SEEK), for example, connects families to community support through their primary health care providers. Home visiting programs especially empower families to improve their situations not only for themselves, but for future generations.
“I think home visiting programs are absolutely outstanding,” Dr. Crouch said. “This is one of the things that I help evaluate. They are particularly important for reducing intergenerational trauma.” During the National Advisory Committee on Rural Health and Human Services at which she presented, a woman in the audience mentioned she was able to recognize that she had seven ACEs and her son only had three.
“She understood the importance of reducing intergenerational trauma to improve outcomes for families, including her own,” Dr. Crouch said. “That has stuck with me because I found it to be so remarkable that you can help people by discussing how this works and how outcomes are going to be improved. People want to make these steps, but they want the support to do so.”
Though these programs are all instrumental in improving PCEs and consequentially adult health outcomes, one step is crucial to providing a sustainable foundation for potential solutions: parental mental health services.
“All these programs require interdisciplinary, integrated response, particularly in rural communities,” Dr. Crouch said. “Parents need to understand that ACEs are toxic stress. They also need to understand how it impacts their kids and adolescents and how they can help tune in to know the child, get past the behavior, and help the child get to learn and grow.”
Though community programs and support are vital, ultimately long-term and especially intergenerational change is not possible without assisting families in taking an active role. Educating parents empowers them to encourage healing within themselves and their children. “Children need ample opportunity to develop their own self-awareness and learn how to do emotional self-regulation,” Dr. Crouch said.
Effects of COVID-19 on ACEs
Though the new research offered by Dr. Crouch helps identify a blueprint to potential solutions, it does not account for the impact of the COVID-19 pandemic. The pandemic has brought not only a whirlwind of unprecedented experiences for children, such as virtual schooling and the endless mask debate, but also high rates of parental and caregiver stress and loss.
“One of my biggest concerns as a researcher right now, and a rural health advocate as well as a child advocate, is that COVID-19 caused a lot of family disruption,” Dr. Crouch said. “Parenting stress has gone up, you have less time with your child, you’re trying to work with your child – all these things have had probably some mixed results with how these impacted children.”
Continued public health surveillance is needed to continue monitoring childrens’ ACEs exposure to measure both the effectiveness of community interventions and to assess the effects of the current public health emergency. The trajectory of COVID-19 over time may have placed rural children at increased risk for parental loss due to lower rural vaccination rates and higher rural death rates due to COVID-19.
Currently, no studies that specifically look at rural children’s experience of family disruption due to COVID-19 have been published. However, researchers that look at the loss of primary caregivers throughout the pandemic see this burden falling more heavily on non-white children due to the racial and ethnic disparities in COVID-19 morbidity and mortality.