Child and Adolescent Health in the United States: The Role of Adverse and Positive Childhood Experiences.

Background: Adverse childhood experiences (ACEs) have been associated with poorer health from childhood into adulthood. There has been limited prior research examining the associations between positive childhood experiences (PCEs) and health among children. Objective: The present study examines the association between PCES and child health, controlling for ACE counts, using a nationally representative sample. Participants and Setting: : The data for this study came from the 2019-2020 National Survey of Children's Health and were limited to children six years of age or older with complete demographic information and information on ACEs, PCEs, and child health (n = 46,913). Methods: Bivariate analyses between PCEs, ACEs, child/adolescent characteristics, or caregiver's characteristics and child/adolescent health were examined using Pearson's Chi-square tests, weighted to produce nationally representative distributions. Multivariable regression models were used to examine the association between selected PCEs and good health, controlling for whether a child had two or more ACEs. Results: In adjusted analyses, children who experienced any of the following PCEs had a higher odds of good health, compared to children who did not experience each type of these PCEs: after school activities (aOR 1.85; 95% CI 1.11-3.09), resilient family (aOR 2.22; 95% CI 1.45-3.41), supportive neighborhood (aOR 1.56; 95% CI 1.01-2.41), and connected caregiver (aOR 1.84; 95% CI 1.22-2.77). Conclusions: Examining and understanding PCEs and how they are associated with child health is a unique opportunity to guide more targeted policies and intervention efforts. Efforts to provide PCEs in schools, homes, and communities may help to reduce health inequities early in childhood.

Changes in Positive Childhood Experiences During the COVID-19 Pandemic.

OBJECTIVE: Changes in family life associated with COVID-19 precautions may have reduced children's access to positive childhood experiences (PCEs). The purpose of this study is to examine the prevalence of PCEs before and during the COVID-19 pandemic among school-age children. METHODS: This cross-sectional study used data from the 2018-19 National Survey of Children's Health (NSCH, n = 42,464) and the 2020-21 NSCH (n = 54,256) to examine the pre-pandemic period (June 2018-January 2020) and compared results to information obtained during the early pandemic period (June 2020-January 2022) using bivariate analyses and Z-tests. RESULTS: PCEs declined in four of the seven PCEs measured, from 2018 to 2019-2020-2021: after-school activities, community volunteerism, guiding mentor, and resilient family, with all differences significant by P < .0001. After-school activities decreased from 79.8% to 72.2%, community volunteering decreased from 43.9% to 35.1%, guiding mentor decreased from 88.8% to 86.3%, and resilient family decreased from 92.7% to 84.6%. PCEs increased for safe neighborhood (64.7-67.2%), supportive neighborhood (55.8-57.5%), and connected caregiver (65.3-94.7%). CONCLUSIONS: As children have experienced higher levels of parental stress and disruption during their lives during the COVID-19 pandemic, policymakers and program makers must find ways to increase exposure to PCEs following the pandemic. The quantification of these PCEs is a great start, with further research needed to describe ways that schools and community organizations have found to expose children to PCEs in safe ways.

Association Between Positive Childhood Experiences and Childhood Flourishing Among US Children.

OBJECTIVE: There has been limited research examining the fostering of positive childhood experiences (PCEs) that could promote flourishing among children. The purpose of this study is to examine the relationship between 7 selected PCEs and the outcome of flourishing, among a nationally based population-level survey sample of children aged 6 to 17 years. METHODS: Data were drawn from the 2018 to 2019 National Survey of Children's Health, with children aged 6 years and older included (n = 40,561). Children were designated as flourishing if they had responses of always or usually to all 3 flourishing items measured by the National Survey of Children's Health, which were (1) showing an interest and curiosity in learning new things, (2) working to finish the task they started, and (3) staying calm and in control when faced with a challenge. To examine the association between PCEs and flourishing, multivariable logistic regression models were used. RESULTS: Children who experienced each type of PCE had higher odds of flourishing: after-school activities (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.58-2.07), community volunteer (aOR, 1.63; 95% CI, 1.47-1.80), guiding mentor (aOR, 1.66; 95% CI, 1.39-2.00), resilient family (aOR, 2.35; 95% CI, 2.08-2.67), safe neighborhood (aOR, 1.43; 95% CI, 1.29-1.60), supportive neighborhood (aOR, 1.57; 95% CI, 1.42-1.74), and connected caregiver (aOR, 3.26; 95% CI, 2.93-3.64). CONCLUSION: Findings demonstrating a significant association between PCEs and flourishing have implications for population-wide approaches to improving the prevalence of flourishing among children and youth.

Examining Bullying Victimization, Bullying Perpetration, and Positive Childhood Experiences.

BACKGROUND: The National Academy of Sciences has recognized bullying as a serious public health issue, with the outcomes of bullying immediate and long-term. The purpose of this study was to examine the relationship between 7 selected positive childhood experiences, such as having a mentor, and bullying victimization, and bullying perpetration. METHODS: We used cross sectional data from the 2019-2020 National Survey of Children's Health, children ages 6 to 17 (n = 43,999). Bivariate analyses were used, with p < .05 deemed significant. To examine the association between experiences and bullying victimization or perpetration, multivariable regression models were used. RESULTS: Children who experienced any of the following positive childhood experiences had a lower odds of perpetration of bullying victimization: resilient family; safe neighborhood; supportive neighborhood; or connected caregiver. The following covariates had a lower odds of perpetrating bullying, across all models: race other than white, female sex, age of 13 or older, primary language not English, and a guardian education of a high school diploma or less. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Schools can play a formative role in promoting positive childhood experiences identified herein. CONCLUSIONS: Findings from this study may be beneficial for educators, policy makers, and child advocacy stakeholders as they design and implement school or community-based youth development programs.

Safe, supportive neighborhoods: Are they associated with childhood oral health?

OBJECTIVE: There has been limited examination of how community-level supports may influence oral health metrics among children. The purpose of our study is to examine the association between two types of community-level positive childhood experiences and oral healthcare and oral health outcomes among children ages 6 to 17 years of age. METHODS: This study uses a cross-sectional data set from the 2018-2019 National Survey of Children's Health. Two oral health metrics were used: preventive dental care, measured as one or more preventive dental visits in the past 12 months, and tooth decay, measured as tooth decay or cavities in the last 12 months. To quantify living in safe, stable, equitable environments, questions on residing in a safe and supportive neighborhood were used. Descriptive statistics and bivariate analyses were used to calculate frequencies, proportions, and unadjusted associations for each variable (n = 40,290). Multivariable logistic regression models were used. RESULTS: In an adjusted analysis, children who lived in a supportive neighborhood had a higher likelihood of receiving a preventive dental visit than children who did not live in a supportive neighborhood (aOR 1.41; 95% CI 1.21-1.65). Children who lived in a safe neighborhood were less likely to have tooth decay than children who did not live in a safe neighborhood (aOR 0.75; 95% CI 0.65-0.86). CONCLUSIONS: The findings from this study highlight the role of social structures in tightening the safety net for oral healthcare in children.

A national examination of poverty and interactive caregiving practices among parents of young children.

Interactive caregiving practices can be protective for the development of the brain in early childhood, particularly for children experiencing poverty. There has been limited research examining the prevalence of interactive caregiving practices in early childhood at the population level across the U.S. The purpose of this study was to describe the prevalence of three interactive caregiver activities: (1) reading, (2) telling stories/singing songs, and (3) eating a meal together, using the 2017-2018 National Survey of Children's Health, among a sample of children age five and younger, and to examine the relationship between these interactive caregiving practices across income levels and by selected potentially confounding household characteristics. Children living in families with incomes below the federal poverty level had lower odds of being read to every day compared to children living in families with incomes at 400% or more above the federal poverty level (aOR 0.70; 95% CI 0.53-0.92). Children living in families within incomes at 100-199% of the federal poverty level had lower odds of being sung to and told stories to every day than children living in families with incomes at 400% or above the federal poverty level (aOR 0.62; 95% CI 0.50-0.78).These findings have long-term implications for children, as interactive caregiving practices are known to improve cognitive activities such as language development, which is associated with educational attainment into adulthood. Finding ways to increase the adoption of interactive caregiving practices may be one way to mitigate disparities in education, especially among families experiencing poverty.

Examining the influence of positive childhood experiences on childhood overweight and obesity using a national sample.

Positive childhood experiences (PCEs) promote healthy social development, improve overall wellness, and help to moderate and prevent exposure to adverse childhood experiences. There has been limited research examining the association between positive childhood experiences and overweight or obesity status in children. The purpose of this study was to examine whether experiencing positive childhood experiences are associated with lower rates of overweight or obesity status in children between 10 and 17 years of age, using cross-sectional data from the 2018-2019 National Survey of Children's Health (n = 28,771), a nationally representative mail and online survey. Frequencies, proportions, and unadjusted associations for each variable were calculated using descriptive statistics and bivariate analyses. To examine the association between overweight or obesity and PCEs, multivariable regression models were used. Compared to children who were underweight or had a healthy weight, children who were overweight or obese were less likely to: participate after school activities (78.1%, p < 0.0001), volunteer in their community, school, or church (45.6%, p < 0.0001), have a mentor they feel comfortable going to for guidance (87.0%, p = 0.02), live in a safe neighborhood (61.3%, p < 0.0001), live in a supportive neighborhood (50.4%, p < 0.0001), and to live with a resilient family (78.3%; p = 0.0099). In adjusted analysis, among children exposed to two or more ACEs, children residing in a supportive neighborhood were less likely to be overweight or obese (aOR 0.87; 0.77-0.98). Our findings suggest that certain PCEs may mitigate overweight and obesity when children have experienced at least some childhood trauma.

Positive Childhood Experiences Promote School Success.

OBJECTIVES: Educational attainment has been demonstrated as a protective factor for the physical and mental health of children into adulthood, yet there has been limited research on the association between positive childhood experiences (PCEs) and school success. The purpose of this study is to examine the associations between PCEs and challenges to school success. METHODS: This cross-sectional study used data of 33,450 children from the 2017-2018 National Survey of Children's Health to examine PCEs and two challenges to school success (school absenteeism and repeated grades), using multivariable logistic regression analysis. RESULTS: The most prevalent types of PCEs were mentor for advice or guidance (89.8%), family resilience (81.1%), and after-school activity participation (79.8%). Children who participated in after-school activities had lower odds of reported school absenteeism (aOR 0.59; 95% CI 0.46-0.76) and repeating a grade (aOR 0.75; 95% CI 0.59-0.97) than their counterparts. Children who shared ideas with their caregiver had lower odds of repeating a grade (aOR 0.78; 95% CI 0.63-0.97) than children who did not share ideas with their caregiver. Children who lived in a supportive neighborhood were less likely to have reported school absenteeism than children who did not live in a supportive neighborhood (aOR 0.77; 95% CI 0.60-0.98). CONCLUSIONS FOR PRACTICE: Participation in after-school activities had optimal associations with both school absenteeism and repeated grade, suggesting its potential protective effect for school success. Promoting PCEs at the school, family, and community levels may help address school absenteeism and grade retention.

Examining the Relationship Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.

OBJECTIVE: Although prior research has examined the prevalence of ACEs among children with attention deficit-hyperactivity disorder (ADHD), little is known about the household and family settings of children with ADHD. Our study utilizes a recent nationally representative dataset to examine the association between adverse childhood experiences (ACEs), child and household characteristics, and ADHD diagnosis and severity. METHODS: Using the 2017-2018 National Survey of Children's Health (NSCH), our sample consisted of children three years of age or older, as this is the youngest age at which the NSCH begins to ask caregivers if a child has been diagnosed with ADHD (n = 42,068). Multivariable logistic regression was used to examine the association between ACE type, score, and ADHD and ADHD severity, controlling for child and household characteristics. RESULTS: Children exposed to four or more ACEs had higher odds of ADHD (aOR 2.16; 95% CI 1.72-2.71) and moderate to severe ADHD (aOR 1.89; 95% CI 1.31-2.72) than children exposed to fewer than four ACEs. Other child characteristics positively associated with ADHD included age and public insurance; other Non-Hispanic races compared to Non-Hispanic White had lower odds of ADHD. Of children reported with ADHD, public insurance was also associated with caregiver-reported moderate to severe ADHD. CONCLUSIONS: Children with ADHD have a higher prevalence of ACEs, making this study important for understanding the relationship between ACEs and ADHD at the population level.

Racial/ethnic differences in positive childhood experiences across a national sample.

BACKGROUND: Examination of racial/ethnic differences in positive childhood experiences (PCEs) is needed, as the absence of supportive factors may hinder children from healthy processing and mitigation of adversity. OBJECTIVE: The purpose of this study was to examine the prevalence of PCEs in a nationally representative sample of children and determine whether PCE exposure differed across race and ethnic groups. PARTICIPANTS AND SETTING: Data were drawn from the nationally representative 2017-2018 National Survey of Children's Health (NSCH) (n = 33,747). METHODS: Descriptive statistics and bivariate analyses were used in order to calculate frequencies, proportions, and unadjusted associations for each variable. Multivariable regression models were used to examine the association between race/ethnicity and PCEs. RESULTS: All racial-ethnic minority groups of children had a lower likelihood of mentorship, living in a safe neighborhood, or living in a supportive neighborhood, than their Non-Hispanic White counterparts. Non-Hispanic Black children had a lower likelihood of having a mentor for advice or guidance (aOR 0.50; 95 % CI 0.38-0.62), living in a safe neighborhood (aOR 0.62; 95 % CI 0.52-0.73), and living in a supportive neighborhood (aOR 0.75; 95 % CI 0.64-0.87) than Non-Hispanic white children. CONCLUSIONS: The information from this study highlights the negative disparities borne by racial/ethnic minority populations. Findings can be used to inform policymakers, program developers, and stakeholders on where to target interventions and how to bring together families and communities to not only confront adversity in childhood, but also to leverage community and family-level assets to create PCEs for all children.

Rural-Urban Differences in Positive Childhood Experiences Across a National Sample.

PURPOSE: The purpose of this study was to examine the prevalence of positive childhood experience (PCE) and adverse childhood experience (ACE) exposures in 31 states plus the District of Columbia and to estimate exposure differences between rural and urban children. METHODS: A cross-sectional study was conducted with a sample of 19,251 respondents from the 2017-2018 National Survey of Children's Health (NSCH), a nationally representative sample of US children. Sociodemographic information, residence, and PCE and ACE responses were utilized. To calculate frequencies, proportions, and unadjusted associations for each variable, descriptive statistics and bivariate analyses were used. Multivariable regression models were used to examine the association between residence and PCEs that showed significance in bivariate analyses. FINDINGS: In adjusted analyses of PCEs, there was no significant difference between rural and urban children for after-school activities. However, rural children were more likely to volunteer in the community, school, or church than were urban children (aOR 1.32; 95% CI: 1.14-1.54). Rural children also had greater odds of having a mentor for advice or guidance, compared to urban children (aOR 1.8; 95% CI: 1.40-2.52). CONCLUSIONS: An examination of both PCEs and ACEs provides policy makers, program developers, and other stakeholders the opportunity to determine needs of rural children and where to target interventions. Furthering the understanding of PCEs and ACEs is important to bring individuals, families, and communities together to both address childhood adversity and utilize existing family and community-level assets.

Rural-Urban Differences in Adverse Childhood Experiences Across a National Sample of Children.

PURPOSE: The purpose of this study was to examine the prevalence of adverse childhood experiences (ACEs) exposure in 34 states and the District of Columbia, and whether exposure differs between rural and urban residents. METHODS: This cross-sectional study used data from the 2016 National Survey of Children's Health (NSCH), restricted to states in which rural versus urban residence was indicated in the public use data (n = 25,977 respondents). Bivariate analyses were used to estimate unadjusted associations. Multivariable regression models were run to examine the association between residence (rural or urban) and ACE counts of 4 or more. FINDINGS: Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined: parental separation/divorce, parental death, household incarceration, household violence, household mental illness, household substance abuse, and economic hardship. In adjusted analysis, there was no significant difference for rural children compared to urban children. The odds of 4 or more ACEs decrease as poverty levels decline, with children residing 0%-99% below the federal poverty line more likely to have reported 4 or more ACEs, compared to children residing 400% or above the federal poverty line (aOR 4.02; CI: 2.65-6.11). CONCLUSIONS: Our findings suggest that poverty is a key policy lever that may mitigate the burden of ACE exposure. The findings of this study may be instructive for policymakers and program planners as they develop interventions to stop, reduce, or mitigate ACE exposure and the long-term impact of ACEs among children in rural America.

Exploring associations between adverse childhood experiences and oral health among children and adolescents.

OBJECTIVES: The aim of this article is to examine the association between preventive dental care and adverse childhood experiences (ACEs), and the association between tooth decay and ACEs, controlling for preventive dental care. METHODS: A cross-sectional study was conducted with a sample of 33,395 respondents from the 2016 National Survey of Children's Health, a nationally representative sample of US children. Sociodemographic information, ACE questions, and oral health and health-care utilization information were used. Descriptive statistics, bivariate analyses, and multivariable regression models were performed. RESULTS: Children with four or more ACEs were less likely to have a preventive dental visit than children with less than four ACEs (79.7 percent versus 88.7 percent, P < 0.0001). Children with four or more ACEs were more likely to have tooth decay (26.7 percent versus 12.5 percent, P < 0.0001) than their counterparts. Children exposed to four or more ACEs had lower odds of receiving preventive dental visits than children exposed to less than four ACEs (aOR 0.67; 95 percent CI 0.50-0.89). Children with four or more ACEs had higher odds of decayed teeth than children exposed to fewer than four ACEs (aOR 2.08; 95 percent CI 1.61-2.70), even after controlling for preventive dental care. CONCLUSIONS: Pediatricians, dental hygienists, and dentists need to be aware of how childhood trauma may hinder both caregivers and children from engaging in preventive oral health care or dental treatment. The information provided in our study can inform policies and programs that support children's oral health, through the identification and mitigation of childhood trauma.

Challenges to School Success and the Role of Adverse Childhood Experiences.

OBJECTIVE: To examine the association between adverse childhood experiences (ACEs), by multiple types and counts of ACEs, and challenges to school success. METHODS: A cross-sectional study was conducted using data from the 2016 National Survey of Children's Health using the ACE module and 3 measures of challenges to school success: lack of school engagement, school absenteeism, and repeated grade. RESULTS: In multivariable analysis adjusting for selected demographic and other characteristics, children with 4 or more ACEs had higher odds of nonengagement in school (adjusted odds ratio [aOR] 2.15; 95% confidence interval [CI], 1.51-3.07), reported school absenteeism (aOR 1.75; 95% CI, 1.12-2.73), and of repeating a grade (aOR 1.71; 95% CI, 1.19-2.47, Table 4) than children with exposure to less than 4 ACEs. Risk factors for all 3 challenges to school success included age of child and special health care needs, with older children and children with special health care needs more likely to have challenges to school success, across all 3 measures. CONCLUSIONS: Our findings confirm that ACEs can have an impact in childhood and adolescence, not just later in adulthood, as demonstrated by the association between ACEs and measures of school success. These findings further illuminate the connection between ACEs and childhood outcomes of education and health. Future research should examine frameworks that effectively support collaboration between educators, social service providers, and pediatricians as they seek to prevent or reduce the impact of ACEs and other childhood trauma.

The intersectionality of adverse childhood experiences, race/ethnicity, and income: Implications for policy.

Adverse childhood experiences (ACEs) are traumatic events that occur in a child's life. These negative experiences have been related to poor adult health and wellbeing outcomes. While previous research has established that ACEs are common, poor adult health outcomes occur at higher rates for persons of color and those with low-incomes compared to their relative counterparts. Examining the intersectionality of ACE, race/ethnicity, and income is important for targeted prevention and intervention efforts, especially as policies at the state and national level are created to address these inequities. The current study examined the prevalence of ACE by race/ethnicity and income. Results of the analyses demonstrate the need for policy makers and others to use tools to examine the unintended consequences of policy change or action. Racial equity impact assessments can be used to examine the impact of a policy change or action to prevent or address ACE on communities of color.

Prevalence of adverse childhood experiences (ACEs) among US children.

OBJECTIVE: The purpose of this study was to estimate the prevalence of adverse childhood experiences (ACEs) among children in the United States and to examine the relationship between child and family characteristics and the likelihood of reported exposure to ACEs. METHODS: Data were drawn from the nationally representative 2016 National Survey of Children's Health (NSCH). Parent-reported child ACE exposure was measured using counts of those reporting zero ACEs, one to three ACEs, and four or more ACEs. RESULTS: The study sample included 45,287 children. The most prevalent types of ACE exposure experienced by children were economic hardship (22.5%) and parent or guardian divorce or separation (21.9%). Older children (34.7%), Non-Hispanic African American children (34.7%), children with special health care needs (SHCN; 36.3%), children living in poverty (37.2%), and children living in rural areas (30.5%) were more likely to be exposed to parental divorce or separation than their counterparts. Five cross-cutting factors emerged as important across outcomes: child's age, family structure, poverty, type of health insurance, and SHCN status. CONCLUSIONS: We found high prevalence rates of economic hardship on a national level. Our findings of higher prevalence among rural children further suggest the importance of the intersection of place and ACEs. Therefore, the geographic component of ACEs must be considered by policymakers. The identification of predictive factors related to high ACE exposure can inform early interventions at the national level.

Homelessness in Childhood and Adverse Childhood Experiences (ACEs).

Objectives Research on adverse childhood experiences (ACEs) has provided a valuable framework for understanding associations between childhood maltreatment and family dysfunction and later poor health outcomes. However, increasing research suggests the number and types of childhood adversities measured warrants further examination. This study examines ACE exposure among adults who experienced homelessness in childhood, another type of childhood adversity. Methods This cross-sectional, descriptive study used the 2016 South Carolina (SC) Behavioral Risk Factor Surveillance System (BRFSS) survey and additional ACE modules to examine ACE exposure among SC adults and childhood homelessness. Standard descriptive statistics were calculated for each variable. Bivariate analysis compared types and number of ACEs by childhood homeless status. All analyses used survey sampling weights that accounted for the BRFSS sampling strategy. Results Data from 7490 respondents were weighted for analyses. Among the 215 respondents who reported homelessness in childhood, 68.1% reported experiencing four or more ACEs. In contrast, only 16.3% of respondents who reported no homelessness in childhood reported experiencing four or more ACEs. The percent of respondents was significantly higher for each of 11 ACEs among those who reported childhood homelessness, compared to those who did not. Conclusions for Practice Adults who reported homelessness in childhood also reported significantly greater exposure to higher numbers and types of ACEs than adults reporting no childhood homelessness. Study findings can be important in informing additional indicators important to the assessment of ACEs and to program developers or organizations that provide housing assistance to at-risk families and children.

Exploring the association between parenting stress and a child's exposure to adverse childhood experiences (ACEs).

Nearly half of U.S. children age 0-17 have been exposed to adverse childhood experiences (ACEs), accounting for over 34 million of children nationwide. Parenting stress (negative feelings related to the demands of parenting) is a primary risk factor for child maltreatment and neglect; yet has been an overlooked factor for ACEs. Understanding the degree of parenting stress and its subsequent associations with ACEs will facilitate future designations of relevant interventions to keep children safe. We analyzed 2016 data from the National Survey of Children's Health to examine whether increased levels of parenting stress are associated with higher counts of ACEs among children. About 4.4% of caregivers reported "high parenting stress" and children living with them were three times more likely (OR: 3.05; 95% CI: 2.23-4.15) to experience four or more ACEs by the age of 18. Lowering parenting stress through parenting interventions could decrease the level of childhood trauma experienced by a child or may lessen one type of stress in a home where many other stressors exist.

Safe, Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs).

Protective factors can build resilience and potentially moderate the long-term impact of adverse childhood experiences (ACEs). To better understand the role of protective factors, this study examines the relationship of two protective factors focused on safe, stable and nurturing relationships, ACEs, and self-reported mental and physical health outcomes among a representative adult sample from the South Carolina Behavioral Risk Factor Surveillance System. Protective factors were assessed as potential moderators of ACEs and poor self-reported physical and mental health in multivariate logistic regression analyses. Respondents exposed to four or more ACEs who grew up with an adult who made them feel safe and protected were less likely to report frequent mental distress or poor health. The use of protective factors may be an effective prevention strategy for ACEs and its associated outcomes and may serve as a mechanism to "break the cycle" of childhood trauma.

Are We Serving the Most At-Risk Communities? Examining the Reach of a South Carolina Home Visiting Program.

In addition to individual-level characteristics, characteristics of the social and physical environments in which individuals reside may adversely impact health outcomes. Careful attention to the role of "place" can result in programs that successfully deliver services to those most at risk. This retrospective, cross-sectional study used geocoded residential addresses from 3090 households enrolled in a South Carolina (SC) home visiting program, 2013-2016, and corresponding years of data for maternal and child health outcomes obtained from vital records data. ZIP Code Tabulation Areas (ZCTAs) served as the primary geographic unit of analysis. ZCTAS with high volumes of birth or adverse maternal and child health outcomes for any of 10 indicators were flagged. Distribution of enrolled households across highest-risk ZCTAs was calculated. Of 379 ZCTAS with reported data, 152 had 8 or more risk flags. Of the 152 highest-risk ZCTAs, 33 also had high birth volumes. Fifty-seven of the 152 highest-risk ZCTAs had no enrollees; seven of the 33 highest-risk/highest-volume ZCTAS had no enrollees. Service delivery gaps existed despite a statewide, county-level needs assessment conducted prior to program implementation. This study suggests methods to identify service areas of need, as an ongoing effort toward program improvement.