Governor Josh Stein officially proclaimed June 2026 as Whole Child Health and Well-Being Month in NC.1 The proclamation recognizes that children’s health, wellbeing, education and resilience are foundational to state’s future prosperity.2 The North Carolina Institute of Medicine (NCIOM) is also celebrating a year since the publication of Building Resilience and Promoting Well-Being: An Updated Action Plan for North Carolina’s Children and Families.3 Throughout this next year, NCIOM will continue to highlight evidence supporting the report’s recommendations, and the work of Essentials for Childhood partners.4
The Essentials for Childhood program, funded by the Center for Disease Control (CDC), focuses on state-level work to prevent adverse childhood experiences (ACEs) and promote positive childhood experiences (PCEs).5 Positive childhood experiences (PCEs) are broadly defined as experiences, relationships, and environments that help children feel safe and thrive.6 Historically, much of the focus in addressing children’s needs has centered on preventing or mitigating ACEs. The inclusion of PCEs alongside ongoing ACEs prevention work creates comprehensive strategies with protective elements that foster well-being and resilience.3
PCE-Focused Recommendations from Building Resilience and Promoting Well-Being Report3
| Recommendation #1 | Promote the incorporation of PCEs throughout state and local initiatives, maximize the impact of existing support, and identify additional resources needed.
→ Strategies include assessing existing organizations that promote PCEs, prioritizing the promotion of positive childhood experiences in current initiatives, and identifying appropriate metrics for evaluating initiatives’ impact on positive childhood experiences. |
| Recommendation #3 | North Carolina Early Childhood Foundation, Positive Childhood Alliance NC, MomsRising NC, and NC Child should continue the development and expansion of public awareness campaigns that focus on the role of economic mobility in promoting PCEs, preventing ACEs, and fostering financial stability. |
| Recommendation #15 | The Cecil G. Sheps Center for Health Services Research (UNC Sheps) should collaborate with NC Medicaid to evaluate standard and tailored plans for their alignment with the goals of preventing ACEs, growing PCEs, and promoting economic stability. |
At the population level, adults reporting 3 to 5 positive childhood experiences had a 50% lower likelihood of adult depression or poor mental health than those with reporting 0 to 2 PCEs.7 Reporting a higher number of PCEs in adulthood has been associated with lower adulthood prevalence of chronic physical health conditions, like cancer, diabetes and heart disease.8 Positive childhood experiences may also impact youth mental health. Children who reported more PCEs had lower odds of reporting current anxiety and depression and lower odds of interactions with juvenile court systems.9, 10
For both children and adults, emerging research shows that PCEs can protect against the negative effects of ACEs, particularly when many PCEs co-occur with a smaller number of ACEs.11 , 6 Even for adults who report no ACEs, PCEs can still play a role in improving health and supporting development.7
The evidence on the impacts of PCEs exists because of state-level efforts at public health surveillance, or the collection, analysis, and use of data to inform the prevention of disease.12 The availability and type of state and local level data depend on the definitions and survey tools used to gather the data. Two common measures used to ask adults about PCEs that occurred in their past are the “PCE Scale” developed by Dr. Christina Bethell in 2019 and the Benevolent Childhood Experiences (BCE) scale developed by Dr. Angela Narayan in 2018.7, 13 Additionally, the four core categories of the HOPE framework were developed by Dr. Robert Sege and can be utilized to ask children under the age of 18 about their PCEs in real time.14
The BCE scale was developed for clinical use and is the most utilized scale within peer-reviewed literature, while the PCE scale was designed for use at the population level and is often drawn on for national and state-level surveys.15, 16 The PCE Scale includes seven questions on talking with family about feelings, enjoying community traditions, and having non-parent caring adults and a sense of belonging. Executive Director of Positive Childhood Alliance NC (PCANC) Sharon Hirsch reviews all seven factors of the PCE Scale and four core components of the HOPE framework in her blog, “The Power of Positive Childhoods: A New Path to Health and Hope.”17
Federal agencies like CDC utilize these scales and frameworks to develop PCE questions for health surveys. There are three primary national surveys where questions about PCEs may be asked. One key distinction to note amongst the surveys is the age of the survey population: children 0-18 (NSCH), middle and high school students (YRBS), and adults (BRFSS).
Surveys That Ask About Positive Childhood Experiences
| Survey Name± | Surveyed population, frequency, and administration | Questions on Positive Childhood Experiences | Availability of Local Data |
|---|---|---|---|
| National Survey of Children’s Health18 | annually to parents of children ages 0-18 across the US
a set of national questions are designed by the Health Resources and Services Administration (HRSA), states can opt to over-sample19 |
a set of questions aligned with PCEs is part of the core survey20
questions vary based on age of child
not based on a specific PCE framework but can be mapped onto Bethel’s PCE scale and HOPE framework |
publicly available data is available only at state level
census tract data is available to researchers who have submitted a research proposal and be granted special status21 |
| Youth Risk Behavior Survey (YRBS)22 | every two years to public middle and high school students
one national survey administered by the CDC, states can administer their own survey and fund optional modules23, 24
the North Carolina Department of Public Instruction oversees the NC YRBS25 |
optional module includes a set of PCEs questions based off the PCE Scale26
separate questionnaires for middle and high school27, 28
one PCEs question was included on the 2025 NC YRBS, and selected PCE questions were also included on the 2023 NC YRBS.29 |
state-based survey results are typically not available at the county level but select school districts are highlighted24, 30 |
| Behavioral Risk Factor Surveillance System (BRFSS)31 | annually to adults over the age of 18
state administered with three components: questions used by all states, optional CDC modules, and state-added questions, developed by states for their own use32
the North Carolina State Center for Health Statistics oversees the NC BRFSS.33 |
optional PCE module is available for states to add as of 2025
previously, states added their own self- written questions on PCEs
the Bethell “PCE Scale” was used for the Wisconsin BRFSS in 2015 |
can be available at regional, county and census tract level, but availability varies by state and is impacted by factors like response rate33 |
± One additional CDC survey, the Pregnancy Risk Assessment and Monitoring Systems (PRAMS), has optional PCE questions for individuals who have recently given birth but is not currently administered in North Carolina.34
Much of the emerging research in the US on PCEs prevalence and adult health outcomes uses data from the BRFSS. Six states included PCEs questions in their BRFSS throughout the last decade: Wisconsin (2015), Montana (2019), Kansas (2020), South Carolina (2020), California (2021), and Tennessee (2021). While still useful to establish state-level prevalence of PCE amongst adults, the retrospective nature of the BRFSS is limiting because adults’ memories may be affected by recall bias and impacts of new policies cannot be assessed in real-time.
Ensuring North Carolina and its 100 counties have access to PCE data is a goal of the new North Carolina ACEs and PCEs surveillance system, funded by the CDC through the Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action initiative.3 The North Carolina surveillance system currently tracks state-level data from the NSCH on four PCEs. Challenges persist in the collection of county-level data on PCEs amongst youth, which could help identify localized opportunities for action and facilitate the analysis of new policies and program immediately after their implementation.
State-level Data Included in North Carolina PCE Surveillance System
| Positive Childhood Experience7 | Survey Questions from NSCH | NCSH North Carolina Results
(2024) |
NCSH National Results (2024) |
|---|---|---|---|
| Enjoyed participating in community traditions | During the past 12 months, did this child participate in one or more organized activities, ages 6-17 years? | 73.0% said yes | 76.7% said yes |
| Enjoyed participating in community traditions | During the past 12 months, did this child participate in community service or volunteer, ages 6-17 years? | 40.9% said yes | 35.4% said yes |
| Having two non-parent adults who genuinely cared | Other than you or other adults in your home, is there at least one other adult in this child’s school, neighborhood, or community who knows this child well and who they can rely on for advice or guidance, age 6-17 years? | 90.3% said yes | 88.5% said yes |
| Family is supportive during difficult times | Does this child live in a home where the family demonstrates qualities of resilience during difficult times? | 84.5% said ‘all or most of the time’ at all family resilience measures | 85.4% said ‘all or most of the time’ at all family resilience measures |
| Feeling safe and protected by an adult in the home | Does this child live in a supportive neighborhood? | 60.1% said yes | 56.6% said yes |
Source: National Survey of Children’s Health35
Opportunities do exist to expand the availability of data at the county-level on PCEs amongst adults. The NC BRFSS collected data on the prevalence of ACEs in 2012 and 2014 but has not yet included questions on PCEs.36 The addition of PCE questions to the NC BRFSS would establish a local level baseline for PCE prevalence in adults, empower the analysis of PCE impact on adult health in North Carolina, and enable the evaluation of long-term effects of policies and programs.37
North Carolinians are defined by more than the sum of their ACEs and PCEs, and there are many ways to create positive experiences for children.38 Simultaneously, at the population level, more robust PCE surveillance data can give North Carolina leadership strengths-based insights on how to improve the health of the children and families in their communities.
Special thanks to Anna Austin MPH PhD, Ingrid Bou-Saada MA MPH, Kristie Demers-O’Brien, Meghan Shanahan PhD MPH, Melissa Clepper-Faith MD MPH for their feedback on this article.
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Written by
Sarah Dancausse, MPP
Research Specialist, NCIOM
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