Fostering children's resilience

Fostering Children's Resilience Miriam Stewart, PhD Graham Reid, PhD Colin Mangham, PhD

Resilience is relevant to nurses because of its implications for health. Research on the resilience of children and adolescents has proliferated over the past five years. However, the specific processes underlying resilience and outcome variables require further study. Furthermore, few intervention studies have been conducted. This article describes resilience and factors that influence resilience of children, examines the relationship between resilience and health, identifies interventions that foster children's resilience and health, reviews research focusing on children's resilience, and suggests the relevance of resilience to nursing of children. Copyright 9 1997 by W.B. Saunders Company

ELTY IS 15 YEARS OLD. She lives with her mother and her two younger siblings in a two bedroom apartment. Violent crimes take place almost on their doorstep. Kelty has not seen her father in years and her mother has been unemployed since she was born. As an infant, Kelty had an even disposition and adapted easily to the many changes her family experienced. Kelty's mother participated in a local program for mothers of preschoolers and Kelty attended daycare. Kelty's mother has always maintained a firm guiding hand in raising her and they have had a close relationship. Over the years, Kelty has also developed a supportive relationship with her grandmother who lives nearby. In elementary school, Kelty had little difficulty mastering the basics of reading and mathematics and got along well with her peers and teachers. As an adolescent, Kelty is an excellent student, volunteers at the local food bank, and dreams of going to a university. Her teachers and friends describe her as cheerful and always willing to lend a hand. How is it that some children like Kelty, despite the poverty and adversity that they encounter in their lives, manage to survive and, at times, even excel? Is Kelty resilient? Resilience is of particular interest to health professionals, including nurses, because of its implications for health (Baldwin, et al., 1993; Egeland et al., 1993; Werner, 1993). The extensive and continually emerging literature on resilience focuses predominantly on children. The literature emphasizes resilience related to children in poverty (Egeland, Carlson, & Stroufe, 1993; Garmezy, 1991b; Jessor, 1993; Werner, 1993), children in cultural minorities Journalof PediatricNursing,Vol 12, No 1 (February),1997

(Jessor, 1993; McCubbin et al., 1993), children at risk for behavioral problems (Grizenko & Fisher, 1992), and adolescents at risk for substance abuse (Jessor, 1991; Kumpfer & Hopkins, 1993), but rarely focuses on children's health. Although resilience of hospitalized children (Bolig & Weddle, 1988), chronically ill children (Ahmann & Bond, 1992; Brown, Doepke & Kaslow, 1993; Sinnema, 1991) and siblings of chronically ill children (Leonard, 1991) has been treated in clinical papers, there is little research on resilience and children's health. Accordingly, the purpose of this paper is to: (1) describe resilience and factors that influence resilience of children, (2) outline the relationship between resilience and health, (3) identify interventions that foster children's resilience and health, (4) review research focusing on children's resilience, and (5) consider the implications for nursing research and practice.

WHAT IS RESIUENCE? Resilience, or the capacity to "bounce back" in spite of significant stress or adversity, is not a new concept (Garmezy & Nuechterlein, 1972). Resil-

From Dalhousie University, and lzaak Walton Killam Children's Hospital, Halifax, Nova Scotia, Canada. Supported by the National Health Promotion Directorate, Health Canada and an Izaak Walton Killam Children's Hospital Foundation postdoctoral fellowship. Address reprint requests to Miriam Stewart, PhD, School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, Nova Scotia, Canada B3H 3J5. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1201-000453.00/0

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ience has its roots in psychological and human development theories. There are numerous definitions of resilience in the literature (e.g., Benard, 1991; Cowen, Wyman, Work, & Iker, 1993; Easterbrooks, Davidson, & Chazan, 1993; Egeland, Carlson, & Sroufe, 1993; Garmezy, 1993; Jessor, 1991; Luthar, 1993; Luthar & Ziglar, 1992; Masten & O'Connor, 1989; Richardson, Neiger, Jensen, & Kumpfer, 1990; Rutter, 1990; Rutter, 1993; Werner, 1989; Zeitlin, 1991). Several common themes appear in these definitions. Resilience can be viewed as a complex interplay between certain characteristics of individuals and their broader environments (Egeland, Carlson, & Sroufe, 1993). Resilience consists of a balance between stress (i.e., risk factors), and the ability to cope (i.e., protective factors) (Rutter, 1993; Wemer, 1984). Risk factors and protective factors are integral ingredients in definitions. Risk factors stem from multiple stressful life events, a single traumatic event, or cumulative stress from a variety of personal and environmental factors (Garmezy, 1991; Luthar, 1993; Rutter, 1987). Protective factors ameliorate or decrease the negative influences of being at risk, but may also operate independent of risk. When stresses or risk factors are greater than protective factors, individuals who have been resilient in the past may be overwhelmed (Garmezy, 1993). Resilience is dynamic. Successful coping in one situation strengthens the individual's competence to deal with adversity in the future (Garmezy, 1993; Richardson, et al., 1990; Rutter, 1993). Resilience is developmental, changing with different stages of life (Egeland, Carlson, & Stroufe, 1993; Rutter, 1990; Staudinger, Marsiske, & Baltes, 1993; Wemer, 1993). It has often been applied to people who display successful later adaptation despite earlier risk. Resilience may be particularly important during times of transition, when stresses tend to be greatest. Transitions occur throughout life such as school entry, detachment from parents during adolescence, and childbearing. Transitions also occur in unexpected or externally controlled events such as disaster, family disruption, or unemployment (Luthar & Zigler, 1992). These and other types of stressful situations require increased ability to cope. Based on these common themes--stress, coping, risk factors, protective factors, change over time, transitions--we defined resilience as the capability of individuals to cope successfully in the face of significant change, adversity, or risk. This capability changes over time and is enhanced by protective

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factors in the individual and the environment. In light of the emerging evidence that resilience is relevant to health (Baldwin, et al., 1993; Egeland, Carlson, & Sroufe, 1993; Werner, 1993; Wyman, Cowen, Work, & Parker, 1991), we also suggest that resilience contributes to the maintenance and enhancement of health (Mangham, McGrath, Reid & Stewart, 1995). The potential links between resilience and health are discussed later in the article.

FACTORS INFLUENCING RESILIENCE OF CHILDREN Numerous risk factors and protective factors that can influence children's resilience have been identified in a variety of published studies (Table 1). These 27 projects, most of which have been conducted over the past 5 years, delineate risk and protective factors and examine their influence on resilient outcomes. To illustrate the complexity and diversity of factors that should be taken into account during nursing assessment of children's risks and resources, a brief overview of selected factors at the individual level, family level, and community level will be presented. Initially, however, we should clarify that this article focuses on individuals and therefore on protective or risk factors within the child, family or community, that influence the individual child's resilience. In contrast, McCubbin and colleagues' research emphasizes resilience of families (e.g., McCubbin & McCubbin, 1993). Donnelly (1994) applied McCubbin's Resiliency Model of Family Stress, Adjustment, and Adaptation to the study of parents of children with asthma. We have discussed family resilience in another article.

Individual-Level Risk and Protective Factors Examples of individual risk factors that affect children include chronic illness (O'Dougherty & Wright, 1990), male gender (Rutter, 1990), minority racial status (Baldwin, et al., 1993), antisocial behaviour (Stouthamer-Loeber, Loeber, Fartington, Zhang, van Kammen, Maguin, 1993) and difficult temperament (Rutter, 1990). Examples of protective factors within the individual child include problem-solving abilities (e.g., Garmezy, 1993), trust (Benard, 1991), helpfulness (Hetherington, 1989), positive self-esteem (e.g., Baldwin, et al., 1993), feeling of control over one's life (e.g., Luthar & Zigler, 1992), planning for future events (e.g., Werner, 1993), optimism (e.g., Wyman, Cowan, Work, & Kerley, 1993), and social competence (e.g., Luthar, 1991). Individual protective

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Table 1. Risk and Protective Faclors ldontified in Children's Resilience Research

Project AIpert-GiUiset al., t 989

Sample

Baldwin et aL, 1993

185 children of divorced parents, grades 2-3 152 high risk families, children 12-14years 150 families, 18 year old children

Batvin et al., 1992

153 White and Hispanic youth

Carro et al., 1993

70 couples postpartum and their children

Cicchetti et al., 1993

Easterbrookset al., 1993

127 disadvantaged, maltreated school age children School age children of motherswith depression (22), bipolar disorder (18), medical illness (18), control (38) 45 children, grades 2-3

Giunta, 1989

309 children, grades 6-8

Grossman et al., 1992

Kaufrnan et al., 1994 Luthar, 1991

199 grade 9 students,lower middle class 144 middle class parents and children, half from divorced families 56 school-age maltreated children 144 inner city adolescents

Luthar & Zigler, 1992

144 inner city adolescents

Luthar et al., 1993

164 socioeconomically disadvantaged grade 9 students

Masten et al., 1988

203 children, grades 3-6

Pellegrini et al., 1987

1O0 children between 9 and 14

Radke-Yarrow& Brown, 1993

18 resilient children and 26 troubled children (10 year study)

Rae-Grant et al., 1988

3294 children, 4-16 years old

Richters& Martinez, 1993 Sheppard & Kashani, 1991

72 children in grades 1-2 in low income, violent neighbourhoad 150 adolescents

Smith et al, 1990

451 high school athletes

Stouthomer-Loeberet aJ., 1993 Tremblay et al., 1993

1,517 boys, grades 1,4, 7

Baldwin et al., 1990

Conrad & Hammen, 1993

Hetherington, 1989

Wyman et al., 1991 Wyman et al., 1992

Wyman et al., 1993

324 grade 1 students;impoverished and law middle class 313 students,grades 4-6 in inner city schools 626 parents, children in grades 4-6 faced major life sh'ess(poverty, drug/alcohol abuse, disordered family) 656 students,grades 4-6 inner city schools

Findings High risk gatusand pear adjudment~ childrer~of divorce. Parental vigilance and supervision protects children from environmental influences,drug use, delinquency, and school failure. Variables that correlate with mental health (self-esteem,intelligence) also link to resilience. Students in intervention group focusedon competenceand smoked lessthan control group; no effect far ethnic influences. Maternal/paternal depressivesymptomsare risk factors for later child maladjustmenL Maltreated children had more maladaptation (aggressive,withdrawn) but able to develop ego resiliency and self-esteem. Child esteem,academic performance, social competence, positive perceptions of mother, maternal social competence, and child's friendships are protective factors. If there are a few ot0portunitiesto develop confidence and competence, resilient children shaw personal competencedespite risk such as economic stressand caregiving inadequacy. Stressful life eventsof adolescentsand parents associated with emotional and behaviourol problems. Protectivefactors are strong predictors of adolescentodopk:dion;no i ~ of r~skand prcsec~e fack~. Protectivefactors include supportive, structured parenting and schoolswith schedulesand discipline. Few maltreated children were classified as resilient. Social expressivenessis protective factor and intelligence is vulnerability/risk mechanism. Intelligence is protective fc~tor; belief in ability to control eventsis also protective. High risk children do well in some competencedomains, but have problems in other competence/adjustment domains; vulnerable to emotional distressover time. Disadvantaged children lesscompetent and more disruptive at high stress levels;boys lesssocially competent than gids. Socialcompetencedistinctfrom academicachievementand IQ Social cx:mprehensionlinkedto socialcompelence. Resilientchildren involved in some sustaining relationship with disturbed parent or family member; at-risk children use problemsolving coping. Family conflict was highest risk factor far disorder; competencedid not have main/direct effect on disorder. Adaptation successof children related to stability and safety of home environment. Commilment and control predict physical health and psychological symptoms; hardiness is predictor of resilience. Social support and psychological coping skills together influence resilience to stressinjury. Protectiveand risk factors cooccur affecting delinquency and nondelinquency. Disruptive behaviour in early grade linked to later delinquency, poor achievers and higher risk for antisocial behaviours. Parenting (consistentdiscipline, optimistic view of child's future) and personal resourcespredict stress-resilientchildren. Resilientchildrenhad nurlurontre~:~:~shil~wilh primary caregivers and stable,consislentfamily enviror~ments. Positiveexpectations of future associatedwith competenceonly in children under high stress,and with socioernotionaladjustment.

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factors may also encompass characteristics associated with the child's intelligence (Baldwin, et al., 1993; Egeland, Carlson, & Sroufe, 1993; Luthar & Zigler, 1992) such as cognitive skills (Werner, 1993), academic performance (Conrad & Hammen, 1993), reading skills (Rae-Grant et al., 1988; Werner, 1993), and creativity (e.g., Anthony, 1987; Combrinck-Graham, 1989). Another theme in the literature on individualistic protective factors is easy temperament of young children (Rende & Plomin, 1993; Wyman et al., 1991) which can have an impact on adult coping (Werner, 1993). The resilience literature refers to pertinent healthrelated concepts such as coping, self-help, and self-efficacy which may also be viewed as protective factors within the individual. Coping strategies to manage stressors have been discussed in the resilience literature in reference to youth in disadvantaged situations (Jessor, 1993), antisocial children (Patterson, Dishion & Chamberlain, 1993), and chronically ill children and adolescents (e.g., Ahmann & Bond, 1992; Brown, et al., 1993; Leonard, 1991). Enhancement of coping has been identified as a health promotion mechanism (Epp, 1986). Self-help, another health promotion mechanism (Epp, 1986), is briefly acknowledged in a study on resilience of chronically ill children (Ahmann & Bond, 1992). Rutter (in press) contends that interventions which enable self help can foster resilience. Indeed, participation in self help groups can reinforce self help and self-efficacy (Stewart, 1990), another individual protective process involved in resilience (Rutter, 1990). Selfefficacy is mentioned in a report of resilience of hospitalized children (Bolig & Weddle, 1988). Kelty appears to exhibit several protective factors at the individual level; helpfulness, social competence, planning for future events, intelligence and easy temperament.

Family-Level Riskand ProtectiveFactors Family risk factors that affect the individual child encompass parental pathology or illness (e.g., Baldwin, et al., 1993), separation from parents, exposure to violence (Egeland, Carlson, & Sroufe, 1993), and other life stressors such as poverty (Wyman et al., 1993). Young teenage mothers (Egeland, Carlson, & Sroufe, 1993) and large family size (Rae-Grant, et al., 1988) have also been cited as familial risk factors for children. Protective factors for the child, from the family, include positive parent-child attachment and interactions (e.g., Easterbrooks, et al., 1993), parent/

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caregiver expectations of a positive future for the child (Wyman, et al., 1991), rules and responsibilities within the household (e.g., Baldwin, et al., 1993), and a strong extended family network (Wyman, et al., 1991). Regardless of risk conditions, studies of resilience consistently highlight the importance of supportive caregiving in the protective process (e.g., Cicchetti, et al., 1993; Egeland, et al., 1993; Rutter, 1990). The protective factor, social support, is discussed in relation to resilience of hospitalized children (Bolig & Weddle, 1988), chronically ill children and adolescents (e.g., Brown, et al., 1993), and children in poverty and other high risk situations (e.g., Garmezy, 1993; Jessor, 1993). Social support for the child is provided primarily by the family. Kelty's positive relationship and interactions with her mother and a member of her extended family network, her grandmother, are protective. Furthermore, her mother's "firm guiding hand" is likely a protective factor. However, her mother's unemployment and her father's lack of involvement in her care could be considered risk factors.

Community-LevelRiskand ProtectiveFactors The development of children must also be considered within the social milieu and social context (Bronfenbrenner, 1993). Risk factors in the child's external environment or community embody, for example, low socioeconomic status or poverty (e.g., Alpern & Lyons-Ruth, 1993; Baldwin, et al., 1993), a violent neighborhood (Richters & Martinez, 1993), and a deviant peer group (Quinton, et al., 1993). Factors in the community that can protect the child comprise responsibilities outside the home (e.g., Rutter, 1990), positive school experiences (Egeland, et al., 1993), participation in extracurricular activities (e.g., Werner, 1993), opening of opportunities (e.g., Egeland, et al., 1993), a positive event before or after a stressor (Rutter, 1990), and positive relationships with other adults (Conrad & Hammen, 1993). Kelty's violent neighborhood and low socioeconomic status could be considered community-level risk factors. Her participation in extracurricular activities, positive school experience, and volunteerism are protective factors.

RELATIONSHIP OF RESILIENCEAND HEALTH An examination of the relevance of resilience to the health of children and adults should help to explain the significance of resilience to nursing as a

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health profession. Nurses and other members of the health sector are moving to a holistic, positive view of health which is concerned with quality of life and wellbeing (Rootman & Raeburn, 1994). This shift has implications for comprehending the links between health and resilience. Health can embrace feelings of connectedness, control, meaning, and self-efficacy, all relevant factors in resilience. A focus on resilience moves from an emphasis on pathology and on the factors underlying ill health, to accentuate protective factors and reduced risk (Benard, 1991; Jessor, 1993). The relationship of resilience and health is elucidated in discussions of risk factors, protective factors, and resilient outcomes, in particular, psychological health, physical health, and health behavior. Individual risk factors such as malnutrition and medical conditions (O'Dougherty & Wright, 1990; Resnick & Hutton, 1987), and family risk factors such as parental pathology or illness (Baldwin, et al., 1993; Carro, et al., 1993; Conrad & Hammen, 1993; Easterbrooks, et al., 1993; Egeland, et al., 1993; Radke-Yarrow & Brown, 1993; Rae-Grant, et al., 1988; Schissel, 1993; Werner, 1993) suggest links to physical and psychological health. In this context, documented protective factors at the individual level include good genetics (Hetherington, 1989; Rende & Plomin, 1993; Werner, 1989, 1993). Perhaps the most explicit connection with health, however, pertains to resilient outcomes. Healthrelated outcome variables for children include global psychosocial adjustment (Cicchetti, et al., 1993; Egeland, et al., 1993; Werner, 1993; Wyman, et al., 1991), and lack of emotional symptoms and psychopathology (Baldwin, et al., 1993; Cicchetti, et al., 1993; Conrad & Hammen, 1993; Rae-Grant, et al., 1998; Schissel, 1993; Spencer, et al., 1993). Psychological wellness can be undermined by deprived early experiences, stressful life events, unfavourable social settings, and disempowerment (Cowen, 1991). Indeed, risk factors in mental illness include low socioeconomic status, foster care, maternal psychological distress, and marital distress (Garmezy, 1987). Mental health involves positive psychosocial skills and attitudes (Peters, 1988), such as self-understanding, which is an important psychological process in resilient people (Beardslee, 1989). Several individual child variables that correlate with mental health also mark resilience--self esteem, intelligence, and competence. Competency has been linked to feelings of psychological well-being and negatively related to adolescent suicide (Garmezy & Masten, 1991).

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High risk children who exhibit difficulties in some competence domains may be vulnerable to emotional distress over time (Luthar, et al., 1993). Commitment and control, as individual-level protective factors, interact with stress to predict psychological symptoms in males (Sheppard & Kashani, 1991). Nonresilient children have lower mental health scores than resilient children (e.g., Baldwin, et al,, 1993). Other aspects of well-being that need to be studied as outcomes of resilience include behavioral competence, social relationships, academic and vocational achievement, and physical health (Luthar, 1993; Sheppard & Kashani, 1991; Staudinger, et al., 1993; Werner, 1993). However, the resilience literature illuminates the relationship with psychological health more clearly than the association with physical health. Although resilience in children who have a chronic physical illness has been investigated (Brown, et al., 1993), few studies have examined physical health as an outcome variable with respect to resilience. Zeitlin (1991) reviewed protective factors related to positive nutritional status of infants in impoverished environments. The role of protective factors and risk factors in the development of the immunological disease AIDS (Rolf & Johnson, 1990) has been studied. Resilient men with AIDS, who have high levels of perceived control, experience fewer somatic problems (Rabkin, et al., 1993). In this context, the field of psychoneuroimmunology has begun to uncover the links between psycho-social variables and physical health outcomes (Kiecolt-Glaser & Glaser, 1988). Stressful events can alter immunological activity. Studies which report the onset of cancer and other immune disorders after bereavement, divorce, and separation of family members (Ader & Cohen, 1994; Geiser, 1989) may have implications for the resilience of children and adolescents. Interventions that enhance supportive relationships may have positive effects on immunity. Health behaviors may serve as protective factors in relation to physical and psychological wellbeing. Therefore, health behaviors (e.g., proper nutrition, exercise) may be another promising area of investigation which has rarely been examined from the perspective of resilience. It is noteworthy that adolescent risk behaviours are the focus of a few resilience studies (e.g., Jessor, 1991, 1993). Some resilience programs, discussed in the next section of the article, focus on health behaviors such as smoking and alcohol use.

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INTERVENTIONS THAT FOSTERCHILDREN'S RESILIENCEAND IMPLICATIONS FOR NURSING PRACTICE Nurses working in hospitals and community agencies that care for children can identify risk factors and protective factors that reside within individual children, their families, and their communities in their assessments. Nurses can intervene to foster children's resilience in the hospital, home, school, and community. These interventions can have implications for children's health and health behavior. Intervention programs should simultaneously reduce risk and promote protection, be directed at multiple risk behaviors, and acknowledge the salience of the social environment of children and adolescents. Social support has been emphasized in interventions, reported in the literature, that aimed to promote resilience of youth in the family (Ahmann & Bond, 1992; Bronfenbrenher, 1993) and school (Kenkel, 1986; Kumpfer & Hopkins, 1993; Trickett & Birman, 1989; Weissberg, et al., 1989). An overview of reported interdisciplinary resilience programs is offered to illustrate the potential for nursing contributions and involvement.

Support Programs in Schools Many community-based nurses work in schools. Garmezy (1991) reported that support and success at school may instill feelings of self-esteem and self-efficacy in children from disadvantaged backgrounds. Wemer (1990) noted that a positive relationship with teachers may form a protective buffer in child and adolescent development. Research on resiliency also recommends peer helping, as well as mentoring, to enhance children's support, expectations, and participation (Benard, 1991), although the influence of peer support on adjustment and competence has not been well studied (Bond & Compas, 1989). A few interventions have fostered support in schools. For example, the Yale-New Haven Primary Prevention Project, that supports students' involvement in decision-making, is reported to have a positive impact on achievement, attendance, and behavior (Kumpfer & Hopkins, 1993). Felner and Adams (1988) reported reduced antisocial behaviors and increased life-skill development with the supportive School Transitional Environment Program (STEP), targeted at students making the transition from elementary to secondary school.

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Skill Development Programs in Schools A few school-based intervention programs promote resilience of children by fostering skills which have been identified as protective factors rather than by providing support. Project Competence (Masten & O'Connor, 1989) aims to enhance stress resistance and social competence of schoolage children at risk for psychopathology, based on either maternal diagnosis or manifest disturbance. Another program, designed to promote social competence of young adolescents, improved their interpersonal and problem solving skills, and their adjustment (Caplan, Weissberg, Grober, et al., 1992). A third program, Skills for Adolescence, emphasized social competence, as well as cognitive problem solving and coping skills, as one approach to promoting mental health (Peters, 1988). Other programs have sought to enhance coping skills (Compas, Phares, & Ledoux, 1989), problem solving skills (Coie, Rabiner, & Lochman, 1989), and social skills (Elias, et al., t986). For example, Cowen, Wyman, and Work, et al. (1993) conducted a 12-session, school-based program for children, in grades four to six, who had experienced numerous stressful life events. The program emphasized social problem-solving, coping with solvable and unsolvable problems, support seeking, and building self-efficacy. Children who participated in this program had significant decreases in learning problems and increases in self-efficacy (Cowen et al., 1993).

Adolescent Parenting Programs Nurses can also contribute to community-based programs aimed at fostering adolescents' resilience and responsibility. Nurses could participate in projects similar to the following two programs that targeted adolescent parenting. Project Steep focuses on first time mothers who were abused or neglected as children. This project aims to improve self-esteem through an empowerment approach to parenting and life management (Egeland & Erickson, 1990). The Parents Too Soon Program in Illinois is intended to prevent teen pregnancy and to help adolescents make healthy choices. Family support, peer support, adult mentors, role modelling, and special education are incorporated in the program (Randolph & Bogdanovich, 1990). The program appears to improve confidence, selfcontrol, and expectation---components of resili e n c e - a s well as health behaviors.

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Health BehaviorPrograms Finally, nurses in the hospital and the community can promote positive health behaviors of children and adolescents. Although most community-based health promotion programs have not specifically emphasized resilience, they are clearly relevant to the resilience of children and adolescents. The Minnesota Heart Health Youth Program (Perry & Jessor, 1985) and the North Karelia Youth Smoking Prevention Strategy that focused on behavioral capability, expectations, and the environment, diminished prevalence of smoking by students. Another program, the Life Skills Training Program (Dusenbury & Botvin, 1992) has helped to decrease smoking, alcohol, and other drug use. This program is being adapted for use in inner cities with high risk youth. Given Kelty's positive relationships with peers and teachers and given her social competence skills, it appears that support programs in school would be the most relevant of the four types of interventions for her, and that indeed she may already have benefitted from teacher and peer support. It is noteworthy that few of these resilience intervention programs have evaluated both physical and psychological health-related outcomes or have used standardized measures of interpersonal skills, competence, social adjustment, self-efficacy, or control (Cowen, et al., 1993). This gap suggests directions for research.

RESILIENCERESEARCHAND IMPUCATIONS FOR NURSING RESEARCH Previous Research Research on the resilience of children and adolescents has proliferated over the past 5 years (see Table 1). Eight of these studies used very large samples (e.g., Blum, et al., 1992; Giunta, 1989; Rae-Grant, et al., 1988; Rodgers, 1991; Smith et al., 1990; Werner, 1989; Wyman, et al., 1991, 1992). Others were longitudinal investigations following children from ages 3 (Wyman, et al., 1993), to 10 (Radke-Yarrow & Brown, 1993), to 18 (Baldwin, et al., 1993), to as many as 32 years (Werner, 1989, 1993). Empirical studies (like the nonempirical literature noted in the introduction) focus on children of divorced parents (AlpertGillis, et al., 1989; Hetherington, 1989), maltreated children (Cicchetti, et al., 1993; Kaufman, et al., 1994), children of mentally or physically ill parents (Carro, et al., 1993; Conrad & Hammen, 1993; Ladewig, et al., 1992; Radke-Yarrow, 1993), chil-

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dren from cultural minorities (Blum, et al., 1992; Botvin, et al., 1992) or lower socioeconomic groups (Baldwin, et al., 1993; Grossman, et al., 1992; Luthar, 1991; Luthar, et al., 1993; Luthar & Zigler, 1992; Wyman, et al., 1991, 1993), and children in violent communities (Richters & Martinez, 1993) and other high risk circumstances (Baldwin, et al., 1990). Other investigations emphasize risk factors associated with behavior problems and delinquent behaviour (Giunta, 1989; Easterbrooks et al., 1993; Rae-Grant, et al., 1988; Stouthamer-Loeber, et al., 1993; Tremblay, et al., 1992). Only a few studies pinpointed health outcomes (see Table 1).

Research Prospectus Resilience processes and outcomes: The specific processes or mechanisms underlying resilient adaptation require further study (Grossman, et al., 1992). How is it, for example, that having a positive relationship with an adult outside a dysfunctional home protects an adolescent from maladaptive outcomes? Similarly, how do protective factors operate over time? What is it about a secure parent-child relationship that helps develop children's sense of self-esteem, which in turn may motivate them to pursue higher education? Prospective, longitudinal studies are needed (Coie, et al., 1993; Luthar & Zigler, 1992; Masten & O'Connor, 1989; Rae-Grant, 1991) to follow fluctuations in risk and protective factors over time and to clarify the processes of resilience. Careful consideration must also be given to the outcome variables that are assessed. Strong relationships have been detected between children's environmental risk factors and their behavior (Rutter, in press). Furthermore, abuse has been found to be associated with diminished classroom competence (Trickett & Birman, 1994), and unstable or unsafe homes have been linked with failure to adapt (Richters & Martinez, 1993). Nevertheless, healthrelated outcomes of resilience require further study. In particular, there is a need to examine physical health outcomes and multiple indicators of children's adjustment. In this context, one essential role of research will be to test the linkage between resilience and health-related concepts such as social support and coping that enable children's adjustment to physical health problems or avert such problems. For example, Smith, et al. (1990) observed the combined effects of coping and social support in influencing adolescent resilience to injuries. Some studies have reported the impact of peer support on greater self-worth and adjustment to illness in

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diabetic children (Kager & Holden, 1992), as well as on fewer behavior problems in physically handicapped or chronically ill children (Wallander & Varni, 1989). Classmate and teacher support have been associated with greater self-esteem of children with disabilities (Varni, Setoguchi, Rappaport, & Talbot, 1992). Finally, parental support continues to be an important factor in resilience and in health-related outcomes (Barrera & GarrisonJones, 1992; Wallander & Varni, 1989). Intervention Research Most resilience research points to the need for support interventions focused on the child's environment. Other studies indicate the need for socialcompetence skill development. Despite the prevalence of resilience programs, noted in the previous section, few have undergone an extensive empirical evaluation (Alpert-Gillis, et al., 1989; Pellegrini, et al., 1987). Nurses could help to evaluate resilience programs already in place within schools and the community and could design and test new interventions directed at individual, family, and communitylevel protective factors. For example, they could target high risk children in hospital who are injured, ill, or socioeconomically disadvantaged and implement support-education interventions that promote their social competence and support-seeking skills and foster their interactions with healthy and ill peers. As Youngblat, Brennan, and Svegart (1994) suggest, nurses can provide anticipatory guidance to families of children with critical illness, contribute to support groups for these families, and work with the schools these children attend. This can enhance protective factors in the family and community. In the community, children who are apparent survivors of divorce or abuse could receive supplemental support from nurses, or nurses could refer these children to other potential supporters such as volunteers, teachers, coaches, or clergy. In summary, nurses should ensure that their studies build on previous resilience research focused on children

and adolescents, document resilient processes and outcomes, incorporate sound conceptual foundations that illuminate the relationship between resilience and health, and design and evaluate interventions appropriate for children.

CONCLUSION Resilience is relevant to pediatric nursing primarily because it has important implications for children's health and health behavior. Although resilience research has emphasized mental health outcomes, resilience may also be associated with the physical health and health behavior of children. Community- and hospital-based nurses working with children can assess their potential for resilience by early identification of risk factors and protective factors. Furthermore, they can implement interventions that augment and mobilize the protective factors associated with children's resili e n c e - i n particular by increasing their supportive resources from the family, school, and community. The impact of these interventions on the health, health behavior, and competence of children should be tested in longitudinal research. "Children are capable of overcoming great o d d s . . , if their life conditions help them to develop expectations of a responsive environment and views of themselves as competent" (Wyman, Cowen, Work, & Kerley, 1993, p. 65). This poses exciting challenges for nurses who aim to foster resilience and to promote the health of children such as Kelty.

ACKNOWLEDGMENTS Experts on resilience and health promotion in Canada, the United States, and Europe were interviewed by telephone and in focus groups. The project was conducted with the support of Judy Boyce and the Atlantic Health Promotion Research Center. The article is based on the keynote address, by the first author, at the International Symposium on Resilience in Children in Toronto, Ontario, Canada.

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