Abstract

This study examined trends in adverse childhood experiences (ACEs), positive childhood experiences (PCEs), family resilience, and mental health conditions in rural and urban youth in the United States from 2018-2023. It also assessed whether PCEs and family resilience moderated the association between ACEs and youth mental health and whether these relationships differed by geographic setting and across time. Data were drawn from six years (2018-2023) of the National Survey of Children’s Health (NSCH), a nationally representative, cross-sectional, caregiver-reported survey assessing child wellbeing. The analytic sample included school-age youth (ages 6-17) residing in states that reported metropolitan (urban) versus non-metropolitan (rural) status. Data were stratified by rural and urban residence, allowing for separate analyses to identify prevalence patterns and relational differences across settings. Weighted descriptive statistics summarized annual prevalence of ACEs, PCEs, family resilience, and current mental health conditions. Multinomial logistic regression models assessed associations among ACEs, PCEs, family resilience, and mental health. Moderation was tested using interaction terms (ACEs*PCEs, ACEs*family resilience, and three-way interactions with year) to determine whether PCEs and/or family resilience moderated the impact of ACEs on mental health and whether these effects varied across survey years. ACEs remained stable across years for rural youth but varied significantly for urban youth (p < .001). High PCEs (defined as a higher number of caregiver-endorsed PCE items) declined from 2018 to 2021 in both groups before increasing through 2023. Caregiver-reported mental health conditions increased across years, with anxiety rising from approximately 5-6% to 8-9% and comorbid conditions increasing in both rural and urban youth. Across all models, higher ACE exposure consistently predicted greater odds of anxiety, behavior problems, and comorbid conditions (e.g., moderate/high ACEs: ORs = 2.12-2.17 for anxiety; ORs = 4.28-4.44 for comorbid conditions). High PCEs and high family resilience were associated with lower overall odds of mental health conditions, although the association between family resilience and anxiety was significant only for urban youth. PCEs significantly moderated the ACE-mental health association in both rural and urban youth; however, moderation reflected differences in the pattern of ACE-related risk across PCE groups rather than buffering or attenuation of ACE effects. Year-to-year variation in this moderation occurred only among urban youth. Family resilience moderated the ACE-mental health association in urban youth only. Post-hoc analyses using an alternative PCE measure and income-stratified models further examined moderation patterns and showed that attenuation effects were most pronounced among higher-income youth, while remaining modest among lower-income youth. Findings demonstrate that while ACEs are consistently associated with youth mental health across geographic contexts, PCEs and family resilience show broad promotive effects. However, these promotive effects on youth mental health did not mitigate the impact of ACE exposure. Differences in moderation patterns between rural and urban youth suggest that environmental and structural factors may shape how protective factors operate across settings. More research is needed that captures a more complete range of ACEs and PCEs as well as longitudinal development of mental health over time. Future research should also include a more nuanced measure of rurality. This study underscores the importance of strengthening positive experiences, family supports, and mental health resources across communities and suggests that prevention and intervention strategies may benefit from attention to geographic and socioeconomic variation.

Committee Chair

Melissa Jonson-Reid

Committee Members

Alexis Duncan; Brett Drake; Nicholas Szoko; Patricia Kohl; Wendy Auslander

Degree

Doctor of Philosophy (PhD)

Author's Department

Social Work

Author's School

Brown School

Document Type

Dissertation

Date of Award

3-30-2026

Language

English (en)

Download

Included in

Social Work Commons

Share

COinS