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The Impact of Adverse and Positive Childhood Experiences on Rural Children, with Elizabeth Crouch

Date: July 5, 2022
Duration: 25 minutes

Elizabeth Crouch An interview with Elizabeth Crouch, PhD, director of the Rural and Minority Health Research Center, discussing insights on rural adverse and positive childhood experiences based on her research.

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Organizations and resources mentioned in this episode:


Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. Today, we'll be talking about adverse and positive childhood experiences in rural America.

We're talking today with Dr. Elizabeth Crouch from the Rural and Minority Health Research Center, which is part of the Arnold School of Public Health at the University of South Carolina. Thank you for joining us, Dr. Crouch.

Dr. Elizabeth Crouch: Thank you so much for having me.

Andrew Nelson: Yeah, absolutely. You recently helped research and write a brief entitled Rural Urban Differences in Adverse and Positive Childhood Experiences, Results from the National Survey of Children's Health. First of all, can you tell us what are adverse childhood experiences and positive childhood experiences and how do they affect individuals and communities?

Dr. Elizabeth Crouch: First of all, I want to take acknowledgement to the Federal Office of Rural Health Policy, which funded our work for this part of our research center. It is one of four projects funded in 2020, 2021. Some of the first things is what are ACEs, what are adverse childhood experiences? Our acronym, you may have heard before, is ACEs. You had traumatic events that occur in a child's life before the age of 18. There's various definitions and ways to measure them. But overall, you want to describe them, they're instances of abuse, neglect, household dysfunction. And the reason we care so much about them is that they are traumatic experiences as a child that may be associated with negative health and wellbeing outcomes as an adult.

Various ways to measure these, one, the way these are measured in this study was using the National Survey of Children's Health. It's asking guardians or caregivers about their kids and it's asking the caregiver has their child experience someone in the house who is suicidal or mentally ill, whether alcohol or drugs in the home, was there a parent in jail, was there divorce, was a child a witness to domestic violence? As well as asking about things such as parental death, racial discrimination, and low income.

So, kind of the reason this work was spurred was that the National Advisory Committee on Rural Health and Human Services decided to go into a community and learn about some of the issues. And in 2018, their work was looking at exploring the rural context for adverse childhood experiences and I gave a talk based on our public use data set that, where we did use public use version of the National Survey Children's Health, which has limited numbers of states we can examine, because geography's not available for all 50 states in the public use data set. And some recommendations came out of that, including further research where we can look at all 50 states and see different issues that may occur with ACEs. And so, we just want to get acknowledged the commitment to looking at ACEs among the rural community and people that are invested in rural.

Positive child experiences are kind of the flip of this, right? So, they are positive life events, such as having a mentor, having a safe, stable relationship. Both positive and traumatic event experiences are associated with health and wellbeing and outcomes as an adult. We know that positive childhood experiences can prevent ACEs, reduce toxic stress, and promote healing. So, there's often some programs, et cetera, that can help to intervene on ACEs or prevent the ACEs occurring. Some of these may be helped to implement positive childhood experiences.

Andrew Nelson: Yeah. Can you tell us about some of the differences your study found between rural and urban ACEs and PCEs?

Dr. Elizabeth Crouch: Sure. So, prior research we had done, that we used the publicly available data set, was published in 2019 in the Journal of Rural Health which looked at rural and urban differences in adverse childhood experiences across a national sample. We did a PCE study using the publicly used data in 2020. Here's what we found from that. So, from the first one we found that rural children were more likely to experience nearly all ACEs and the most significant was economic hardships. They were much more likely to experience economic hardship than their counterparts. They were also more likely to experience substance use, mental illness, neighborhood violence, incarceration, parental death, and parental separation/divorce. We also found that counts of ACEs matter. So, the higher number you may have, you may be more likely to experience adverse events in adulthood. So, meeting an ACE score, if you will.

Kind of the common denominator that's been kind of the big numbers are four and above. We found that rural children were more likely than the urban counterparts to have four or more ACEs by a significant amount. So 6.9% of rural children had four or more ACEs compared to 3.8% of urban children. Rural children are much less likely to have zero ACEs. They're more likely to have at least one than their urban counterparts. Similarly, for PCEs, there's some positive experiences to talk about in rural. So, for example, rural children were more likely to have at least two of the PCEs than their urban counterparts and these were, they were more likely to volunteer in their community school or church, which is a measure of constructive social engagement. Rural children were also more likely to have a mentor outside of their home, a measure of being in a supportive, nurturing community.

So, this was kind of the first study to look at differences in rural and urban. So, then we go further and say, okay, well we know that we've got some missing data because of use of this public use data set. FORHP decides to generously fund us to do this research. What gap are we filling in the research here? So, now we'll be looking at all 50 states. And by looking at all 50 states within rural, we're also going to be looking at some racial/ethnic differences and inter-rural differences among for example, American Indian, Alaska Native populations, which were unable to look at the subset of race/ethnicity without having the full data set, if that makes sense. Previously it was suppressed. So, this latest study that was funded by FORHP, we look at all 50 states, we examine racial/ethnic differences in ACEs and PCEs.

And we focus on the degree to which children exposed to ACEs and also experienced PCEs. So for example, rural children were still much more likely to experience economic hardship and the disparity was much larger when we had all 50 states. Separation/divorce, again, much higher, when disparity was much higher between the rural and urban when we looked at all 50 states. Incarceration, household violence, neighborhood violence, mental illness, substance use. Using all 50 states, we found that urban children, on the other hand, were more likely to experience racial/ethnic mistreatment than their rural counterparts. And this is likely just due to the fact that there are a lower percentage of non-White children in rural areas. We also, in our updated study, found that rural children still had much higher counts of ACEs. This was again, a much larger disparity than before. So, this time it's 10.7% of rural children have experienced former ACEs compared to 6.8% of urban children.

So again, this is much higher than before. And, thankfully, we were able to look at differences between racial and ethnic groups as well. And what's interesting, and kind of discouraging, is we found much higher rates of each type of ACE and PCE among American Indian, Alaska Natives, as well as Asian Pacific Islander. So, higher rates of ACEs compared to other minority groups, among rural children. American Indian, Alaska native, and Asian Pacific Islander had much higher rates of every, each type of ACE compared to other minority groups within rural. So, this gives us some areas in which we can learn and to intervene on programming. So, one of the reasons it was funded was when we presented this to the National Advisory Committee on Rural Health back in 2018, we had some representatives from rural tribal communities and they said, “Well, what's happening in tribal with ACEs?”

And we said, “We don't know because we don't access that data.” So, this gave us an opportunity to see what's happening with American Indians and in ACEs among rural kids. So, what we also found was for PCEs, all PCEs were significantly different by race/ethnicity. And again, we found that Asian Pacific Islander children had a lower proportion of each PCE. And we also found lower rates of positive childhood experiences, PCEs, among American Indian, Alaska Native children. So again, we found these disparities that maybe would not have been able to look at this had not been funded to use a restricted data set. So, and the whole point of examining these disparities and knowing what the percentages are is that we now know where we need to implement programming and possibly funding. Nearly all rural children have reported having a guiding mentor.

Children with high ACEs, so four or more ACEs, were less likely to report each of the six of the seven PCEs. If you had had four or more ACEs, you were much less likely to also experience each type of positive childhood experience, which is disheartening because we know that means that these kids have, with higher ACE counts, also have less opportunities to build resilience and to build safe, stable relationships, to combat some of the toxic stress they've experienced with being exposed to ACEs. One of the biggest threats to children's health and growth is disparate, social, emotional wellness. We found that rural children had higher rates of exposure to nearly every type of ACE, with the exception of parental death and racial/ethnic mistreatment. We know that rural children are disproportionately living in homes affected by current substance misuse or mental illness, which has been exacerbated by the pandemic, where we have found higher rates of rural suicide, rural substance use, rural overdoses.

We also know that rural communities are more likely than urban communities to lack effective treatment programs for alcohol and opioid misuse. And so, development of programs that may extend treatment capability through modalities, such as telehealth, may improve some of these things. And we also wanted to give a plug again for these community-based initiatives like Family Based Resource centers, SEEK model, which is safe environment for every kid, where pediatric offices help link families to community supports through social workers and community health workers. We also want to advocate for continued public health surveillance. So COVID-19, everyone talks about it with rural and issues with vaccination, lower vaccination rates in rural, et cetera. And we know that rural children have experienced higher rates of parental death during the COVID-19 pandemic. And so, continued investigation of the prevalence of this is important for intervening for kids' long term and rural areas.

Andrew Nelson: Yeah. I noticed you mentioned a lot of the information you were working with was from public use data sets. Can you tell us a little bit more about how you got that information and what frameworks you used to measure and quantify ACEs and PCEs?

Dr. Elizabeth Crouch: Sure. Yeah. So the National Survey of Children's Health is what we originally used. We used for the public use, we used the 2016 and the 2017. For the updated study, we used a 2016 to the 2018 National Survey of Children's Health. And it's just a mail and online survey where it asked parents or caregivers about their kids through the age of 17. For this study, we used a research data center where we went to go obtain all the information and we had to get special access to do that, et cetera. We had a little over 100,000 kids in our sample, based on the three years of data, from 2016 and 2018. And we did restrict to kids who were six years or older, I forgot to add this in the beginning, thanks Andrew. And so we want to make sure the peak kids who experienced PCEs had to be school age.

So, all kids were six and older and we did restrict to those who had completed the ACE and PCE questions and had complete demographic information. So, we ended up, once we had kids six and older and all those that answered the questions, with about 63,000 kids, 11% of our sample was rural. We were glad to have the opportunity. It's costly, both in time and financial resources to go an RDC to answer some of these questions. So, this was kind of our last bit that was helpful to use, to get the full data set. That National Survey Children's Health has an ACEs questionnaire that you use, but for positive childhood experiences, we are the first people in the country to quantify those using National Survey Children's Health. We have eight publications; you can put Crouch et al. in Google scholar and put positive childhood experiences.

And we have various publications. We've looked at rural differences in positive childhood experiences, racial, ethnic differences in positive childhood experiences among rural kids. We've looked at the relationship between positive childhood experiences in school success. We can go on, but we've got about eight pubs now about positive, where we've quantified positive childhood experiences using this data set.

And again, while they may not be completely, culturally comprehensive, we chose these based on the Healthy Outcomes from Positive Experiences framework, the HOPE framework, if you will, that was put forth by Bob Sege at Tufts. And it has four building blocks that help to build hope among kids with the foundation of health and health equity, one being relationships with other kids, adults, interactive activities, two is environment. Having a safe, stable, equitable environment, a place to live, play, and learn, and to have positive school and home environments, engagement, developing a sense of connectedness in social and civic activities and opportunities for social, emotional development with your peers, with collaboration, art, sports, drama, music, et cetera. So, we do recognize that some of these may not be culturally resonant with all communities, right? There's other positive childhood experiences that kids and different cultures may experience. This is just how a national survey has quantified them.

Andrew Nelson: When you were reviewing this information that you'd gotten from the survey participants, was there anything you were especially surprised by?

Dr. Elizabeth Crouch: I think some of the biggest surprising takeaways were just how much the magnitude of some of these differences between rural and urban kids changed once we had the extra 16 states. When the public use data set were limited to 32 states with geographic information, 16 states without it, we have to go to the RDC, Research Data Center, and access data there. We had all 50 states and just the magnitude of how disparate economic insecurity is, for example, for rural kids, was kind of shocking to me. In the fact that rural kids who had four or more ACEs, which is the high count of ACEs, had such limited access to positive childhood experiences, I think speaks volumes to there are some disparities and access to programming.

Andrew Nelson: Oh yeah, definitely. What are some of the long-term ramifications of ACE and PCE exposures that you found?

Dr. Elizabeth Crouch: So, we know that ACEs can cause, later in life, you might have a higher likelihood, if you have more ACEs, of having a higher risk of having risky behaviors, such as binge drinking, unintended pregnancy, depression, anxiety, because some of these can be quite traumatic. We know that when kids experience ACEs, they may experience this fight or flight thing in their brain where they're feeling a lot toxic stress and high levels of adrenaline, which lead to toxic stress, and so, we know that these kids experiencing ACE may have a lot of stress anxiety. Some of this may sometimes manifest looking like ADHD, where they aren't able to sit still. So, there's some warning signs of trauma. I think one of the interesting things is that we know that positive experiences can help intervene on some of these and create calming measures.

Before COVID, I went to a compassionate schools training in the upstate of our state, which is in Spartanburg. In compassionate schools, I live in South Carolina, there's a large randomized control study right now in Louisville, as well as in Richmond, Virginia, looking at compassionate schools, but it teaches pediatricians, family practice doctors, teachers, where you learn how to calm kids down. Meditational strategies. How do you recognize trauma? Some of that's what we've learned that the symptoms of ADHD can also look, can also mirror how children may react to traumatic events, right? So, soothing techniques, meditational techniques, ways in which to help children cope.

Andrew Nelson: You found that substance abuse and mental illness in the household is going to disproportionately affect rural children. What are some ways in which you think this gap can be addressed?

Dr. Elizabeth Crouch: Well, I think with substance abuse, we talked about a little bit about finding alternate ways for rural communities to receive treatments, whether that's through telehealth, various treatment modalities, helping get primary care providers in rural engaged in providing alternate treatments for opioid use. So, I think it depends on the rural community where we're at. There's some great work being done in our school of public health, Dr. Christina Andrews, who's now had like, three R01s addressing how do we fund substance misuse treatment? What programming is there? What funding is available for there? What insurance covers currently. So, part of her R01 is basically data scraping all these Medicaid plans from across the country to figure out what Medicaid is willing to pay for in different areas. I think it's quite fascinating.

Andrew Nelson: Yeah. That is interesting. You've already spoken about this a little bit, but what do you think are some important ways that ACEs can be prevented and PCEs can be encouraged or increased in rural communities?

Dr. Elizabeth Crouch: Yeah. So, I am part of the evaluation team for the Maternal Infant Early Childhood Home Visiting Program in South Carolina. I think home visiting is one field where it's really awesome because you're getting kids at early ages. Parents are at the beginning of their parenting journey and helping them learn positive coping strategies, how to parent safely, how to discipline safely, and how to deal with their own depression and anxiety. Children's Trust of South Carolina, I'm based in South Carolina, so I'm giving tips from our own state, but we do a lot of work with.

They're a quasi-state agency, and they do an implementation of a lot of federal funding and programs. One of those being MIECHV, Maternal Infant Early Child Home Visiting Program, but they also did things like triple P, which is positive parenting practices. Where you want to, teaching kids, maybe adults parents with older kids, and the later elementary, middle school, again, parenting tips. I think again, the primary care provider's office can be a great place for social support service coordination. If you can get grant funding for a community health worker or a social worker, that's harder in rural communities, right? Unless there's government funding to do so.

Andrew Nelson: Sure. It's good to hear that a lot of these ACEs can, to some extent, at least be offset by increasing the amount of positive childhood experiences children can have. What kind of support is needed by people who have experienced numerous ACEs like that, like the above four category that you mentioned earlier? And to what extent do you think that support is currently available in rural areas?

Dr. Elizabeth Crouch: So, I think we can't make a blanket statement that all people with four or more ACEs are going to have a worse time. I think it's very person-level specific based on what's needed. Right? But I do think we know that there's health professional shortage areas of mental health professionals in rural areas, which means there's going to be less people to help cope with the ramifications of ACEs as adults age. So, I think that is really important to investigate. Right? How do we improve health professional shortage areas of mental health workers, mental health professionals, mental health providers in rural areas.

Andrew Nelson: Yeah. Earlier you mentioned some options like involvement in church or volunteering. Are there any other resources you'd specifically recommend for rural communities and providers that want to address adverse childhood experiences and increase the likelihood or availability of positive childhood experiences?

Dr. Elizabeth Crouch: We know that there are various interventions recommended from the CDC in order to reduce ACEs and build PCEs. Some of these we've suggested in our policy brief to FORHP included strengthening economic supports for families, because we know that rural children have had much higher rates of economic insecurity than the urban counterparts. And that disparity was much higher when we used the full 50 state data set. We know that promoting social norms that protect against violence and adversity through public education campaigns, by standard approaches, using programs that use men and boys as allies and prevention. These could also help to ensure a strong start for kids.

We always advocate again for after school programs, home visiting programs that can help intervene in families, and parenting programs that may also help. Economic supports promoting social norms, teaching skills, and those health sector solutions, where we have primary care providers engaged with their communities and helping them connect with social workers or community health workers to programming for, I think the main thing is, it has to be like an overarching community framework for this, right? You can't just be just providers, just schools. Like, how are we as a community addressing some of these issues?

Andrew Nelson: Yeah, sure. I know that recently you've been working on a total of three different briefs that all deal with different aspects of ACEs and PCEs. And we've been talking about the first one today and the second one, which deals with racial and ethnic differences was just published in May of 2022. What can you tell us about the third brief and when it might be published?

Dr. Elizabeth Crouch: Sure. I think the last brief is really a key fact sheet where we look at among rural kids and adolescents who have had four or more ACEs, what does their PCE exposure look like? I did want to say that we have a new study funded for this year that will be looking at children's mental health pre and during the COVID-19 pandemic, again, using the National Survey of Children's Health. We're going to be looking at whether anxiety and depression changes over time between rural and urban kids, and then across time pre and during the pandemic. So, hopefully this gives some insight into how the pandemic may have affected the mental health of children, both in rural and urban areas and if there's any differences that are existing this far.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to Dr. Elizabeth Crouch from the Arnold School of Public Health. Look in our show notes for more information about her work and visit for all things pertaining to rural health. Join us next time as we begin a multi-part series about maternal health, here on Exploring Rural Health.