Measuring Resilience in the Adolescent Population: A Succinct Tool for Outpatient Adolescent Health

doi:10.1016/j.jpeds.2017.06.030

The Journal of Pediatrics

Volume 189, October 2017, Pages 201-206.e3

https://doi.org/10.1016/j.jpeds.2017.06.030 Get rights and content

Objective

To create a valid tool to measure adolescent resilience, and to determine if this tool correlates with current participation in risk behaviors and prior adverse childhood events.

Study design

One hundred adolescents were recruited from primary care clinics in New Jersey for this cross-sectional study. A “7Cs tool” was developed to measure resilience using the 7Cs model of resilience. All participants completed the 7Cs tool, the Adverse Childhood Events Survey, and the Health Survey for Adolescents to identify current risk behaviors. Demographic and background data were also collected. To assess the validity of the 7Cs tool, Cronbach alpha, principal factor analysis, Spearman coefficients, and sensitivity analyses were conducted. The χ² test and ORs were used to determine if any relationships exist between resilience and prior adverse childhood events and risk taking behaviors.

Results

Participants ranged from 13 to 21 years old (65% female). Internal consistency was established using Cronbach alpha (0.7). Lower resilience correlated with higher adverse childhood events (P = .008) and Health Survey for Adolescents scores (P < .001). Lower resilience was associated with increased problems in school (OR 2.6; P = .021), drug use (OR 4.0; P = .004), violent behavior (OR 3.7; P = .002), recent depression (OR 5.0; P < .001), and suicidality (OR 4.1; P = .009). Higher resilience was associated with participation in exercise (P = .001) and activities (P = .01).

Conclusions

The 7Cs tool is an internally validated tool that may be used to screen adolescent resilience and guide pediatricians' counseling against risk behaviors. Further studies will evaluate resilience-building interventions based on results from this study.

Section snippets

Methods

Using a cross-sectional study design, participants were recruited from 2 academic adolescent medicine primary care practices in New Jersey, one located in an urban underserved area and the second in a nearby suburb. Patients ≥13 years of age could participate if able to speak and read English at the eighth-grade level and provide informed consent and assent. Parents or guardians also had to be able to speak and read English at the eighth-grade level and provide informed consent. This study was

Results

One hundred adolescents, ages 13-21 years old, consented and participated in this study (Table II). Frequencies of high-risk behaviors, history of depression, suicidality, and physical and sexual abuse are presented in Table II. Males (n = 35) had higher resilience scores on the 7Cs than females (n = 65), 3.23 ± 2.99 vs 2.85 ± 1.99, respectively. Males (n = 35) had lower adverse childhood events scores than females (n = 65), 1.29 ± 1.20 vs 1.83 ± 1.90, respectively. These differences were not

Discussion

Our results indicate that a new tool to measure resilience was developed with internal consistency and validity for the population studied.¹⁶ This study identified that high 7Cs scores (lower resilience) correlated with high HSA scores, suggesting that adolescents with lower resilience are more likely to engage in risk-taking behaviors. Our results confirm previous findings that increased adverse events experienced in childhood correlate with increased risk taking behaviors.⁵ One promising

References (17)

V.J. Felitti et al.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults
Am J Prev Med
(1998)
J. Breton et al.
Influence of age and gender on protective factors for depression and suicidal behaviors
Neuropsychiatr Enfance Adolesc
(2012)
A.S. Masten
Ordinary magic: resilience processes in development
Am Psychol
(2001)
M. Ann Easterbrooks et al.
Resilience among military youth
Future Child
(2013)
S. Fergus et al.
Adolescent resilience: a framework for understanding healthy development in the face of risk
Annu Rev Public Health
(2005)
D. Gartland et al.
Development of a multi-dimensional measure of resilience in adolescents: the Adolescent Resilience Questionnaire
BMC Med Res Methodol
(2011)
J. Breton et al.
Protective factors against depression and suicidal behaviour in adolescence
Can J Psychiatry
(2015)
R.K. Hodder et al.
A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students
BMC Public Health
(2011)

There are more references available in the full text version of this article.

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Mental disorders and resilience factors in children exposed to conjugal violence. A cross sectional Tunisian survey
2023, Neuropsychiatrie de l'Enfance et de l'Adolescence
Étudier l’impact psychopathologique de l’exposition à la violence conjugale des parents chez les enfants et les adolescents en consultation de pédopsychiatrie et les facteurs associés à la capacité de résilience face à cette violence.
L’étude était transversale sur un échantillon de 30 enfants et adolescents, âgés entre 6 et 18 ans, exposés à des situations de violence conjugale et suivis au service de pédopsychiatrie de Sfax. L’étude des répercussions psychopathologiques a été réalisée à partir des entretiens pédopsychiatriques. L’évaluation de la résilience a été effectuée par la Child and Youth Resilience Measure.
Les enfants et les adolescents exposés à la violence conjugale étaient atteints de troubles liés à des traumatismes et à des facteurs de stress dans 40 % des cas, de troubles de l’humeur dans 33,3 % des cas et de troubles externalisés dans 6,6 % des cas. Il a été noté que les enfants étaient plus résilients, par rapport aux adolescents, dans le domaine des soins affectifs prodigués par leurs parents (12,66 ± 2,02 vs. 9,46 ± 2,69 chez les adolescents ; p = 0,001). Par contre, les adolescents étaient significativement plus résilients que les enfants dans le domaine des facteurs contextuels englobant la spiritualité (6,46 ± 1,4 vs. 4,53 ± 1,06 ; p = 0,000), l’éducation (11,13 ± 2,13 vs. 8,4 ± 1,54 ; p = 0,000) et la culture (11,13 ± 2,13 vs. 8,4 ± 1,54 ; p = 0,000). La scolarisation de l’enfant et l’absence de trouble psychiatrique chez la mère étaient associées à une meilleure résilience chez les enfants. L’exposition de l’enfant à la violence conjugale en étant à la fois témoin et victime était associée à une moindre capacité de résilience.
L’exposition à la violence conjugale a un retentissement important sur la santé mentale des enfants qui y sont exposés. L’étude de la résilience et des facteurs qui y sont associés pourrait être ainsi utile afin de limiter les répercussions délétères chez les enfants et favoriser un développement harmonieux.
Conjugal violence is a social problem whose impact extends beyond the couple, to the children who are exposed.
To study the psychological impact of exposure to conjugal violence in children and adolescents in child psychiatry consultation and the factors associated with their capacity for resilience.
We conducted a cross-sectional study on a sample of 30 children and adolescents, aged between 6 and 18 years and exposed to conjugal violence. Patients were recruited from the child psychiatry unit of the Hospital University of HediChaker of Sfax. We conducted clinical interviews to identify the psychological impact of conjugal violence on children. The resilience evaluation was done by self or hetero passation of the Child and Youth Resilience Measure (CYRM).
Children and adolescents exposed to conjugal violence suffered from trauma-related disorders and stressors in 40% of cases, mood disorders in 33.3% of cases and externalized disorders in 6.6% of cases. We found that children were more resilient than adolescents in the area of emotional care provided by their parents (12.66 ± 2.02 vs. 9.46 ± 2.69 among adolescents; P = 0.001). In contrast, adolescents were significantly more resilient than children in the area of contextual factors including spirituality (6.46 ± 1.4 vs. 4.53 ± 1.06; P = 0.000), education (11.13 ± 2.13 vs. 8.4 ± 1.54; P = 0.000) and culture (11.13 ± 2.13 vs. 8.4 ± 1.54; P = 0.000). The child's education and good mental health for the mother were associated with better resilience in the children. The child's exposure to conjugal violence by being both a witness and a victim was associated with a reduced capacity for resilience.
Exposure to conjugal violence has a significant impact on the mental health of children exposed. The study of resilience and associated factors could thus be useful in order to limit the deleterious repercussions on children and provide them with harmonious development both on the somatic and psychological levels.
Adverse childhood experiences: A scoping review of measures and methods
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For public health and policy research, the definition of ACEs may be less relevant than their cumulative population burden, whereas clinical researchers and care providers may prioritize specific ACEs and their interactions. While definitions are still being debated, researchers have come to rely on numerous ACE measures as covariates to control for the associations between adversity and independent and dependent variables (Alm et al., 2019) or as constructs for convergent validity (Barger et al., 2017). Thus, how ACEs are defined and studied has significant ramifications for research, policy, and services.
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Less is more. Discovering the latent factors of trait resilience
2022, Journal of Research in Personality
The current paper establishes the latent factors of many direct or proxy trait resilience assessments. Study 1 (n = 849) demonstrates four latent factors (recovery, sustainability, adaptability, and social cohesion) among 61 direct and proxy assessments of resilience. Three of these four factors are best described within a three-factor model of ecological resilience, with an additional social-orientated resilience factor. Study 2 (n = 340) replicates the factors using indicators of the factors found in Study 1. A bifactor model of the four factors provides the best fit of the data, with measurement invariance across broad groups for gender, age, and ethnicity. The findings suggest a ‘mixed model’ of resilience summarising over 30 years of research using direct and proxy assessments of resilience.
Concepts of Resilience in Adolescent Mental Health Research
2021, Journal of Adolescent Health
Citation Excerpt :
At the individual level, the focus is “the extent to which an individual possesses resources to manage adversity and recover emotionally, socially, and physiologically in the aftermath of trauma” [34] (page 133). Barger et al. [35] reiterate the importance of this individual strength that is amassed through a lifetime of experiences. When viewed as an outcome, as opposed to a trait, Briganti and Linkowski [36] argue that there is a greater opportunity to improve an individual's resolve against mental distress after adversity.
Strengthening the resilience of adolescents is central to promoting long-term mental health outcomes, but resilience is a widely used term, often applied in different ways. We explored how resilience is understood in the adolescent mental health literature and developed a framework that synthesizes the core characteristics of different resilience concepts.
Systematic searches of electronic databases, hand searches of reference lists and known work on resilience, and multidisciplinary team discussions were employed, and articles with explicit conceptualizations of resilience in adolescent mental health literature were included. After screening 9,562 articles, 105 articles were retained, analyzed and used to refine a framework.
Three dimensions capture the various concepts of resilience, each with two end points: (1) resilience as withstanding adversity without any distress versus overcoming the distress resulting from adversity; (2) resilience as an existing trait versus as a process over time; and (3) resilience of individuals versus resilience of groups.
Concepts of resilience in adolescence can be clearly categorized within three distinct dimensions. Referring to this framework may help to clarify and compare different concepts of resilience of adolescents in mental health research as well as at a policy level and in clinical contexts.
The Role of Patient and Parental Resilience in Adolescents with Chronic Musculoskeletal Pain
2019, Journal of Pediatrics
Citation Excerpt :
This questionnaire was administered to both patients and their parents. The 7Cs Tool is a questionnaire developed for adolescents, ages ≥13 years, to measure resilience using the following components: competence, confidence, connection, character, contribution, coping, and control.3 Each component has 3 statements built on a Likert scale.
To assess the level of resilience among patients with chronic musculoskeletal pain and their parents and to determine factors associated with patient and parental resilience.
Cross-sectional cohort study of children aged 13-17 years diagnosed with chronic musculoskeletal pain and their parents. Patient–parent pairs were seen for initial consultation in the pediatric rheumatology pain clinic at Children's Hospital of Philadelphia between March and May 2018 and were administered a series of questionnaires including measures of resilience (Connor-Davidson Resilience Scale 10 item, The 14-item Resilience Scale, and the 7Cs of Resilience Tool). We calculated Pearson correlation coefficients to examine the relationship between the variables of interest and resilience.
According to all resilience measures, patients and parents had low to moderate levels of resilience. These levels were lower than those previously reported among healthy populations, as well as those with chronic medical conditions. According to the Connor-Davidson Resilience Scale 10 item, patient-level resilience was negatively correlated with pain level (r = −0.48), physical disability (r = −0.54), and symptom severity (r = −0.53). The level of resilience among patients was positively correlated with energy level (r = 0.57) and health-related quality of life (r = 0.64). Parental resilience was positively correlated with parental mental health (r = 0.61).
Higher patient resilience was correlated with reduced disease severity among adolescents with chronic musculoskeletal pain. Future research should explore whether fostering resilience in adolescents with chronic musculoskeletal pain via the application of resilience-training interventions mitigates disease burden in this vulnerable patient population.
Perceived overweight/obesity, low resilience, and body size dissatisfaction among adolescents
2019, Obesity Research and Clinical Practice
Citation Excerpt :
Our study had several limitations. The subjects in this study had higher 7Cs scores (lower resilience) compared to the population studied by Barger et al. that was used to validate the 7Cs tool [18]. The mean score was higher (4.0 vs. 3.0), the standard deviation was wider (3.0 vs. 2.4), and the total score range was wider (0–14 vs. 0–10).
The obesity epidemic has been compounded by the stress of weight stigmatization. Resilience helps adolescents achieve positive outcomes during times of stress. This study aimed to determine relationships between overweight/obesity, perceived overweight/obesity, body size dissatisfaction (BSD), and/or resilience using a novel assessment tool among adolescents, and to determine if a modifiable factor such as resilience holds potential for treatments for BSD.
Adolescents, ages 13–21, were recruited from clinics at an academic medical center. Weight, height, demographic characteristics, BSD, and resilience were assessed via questionnaires and health records. A model of predictive variables for BSD was tested, and an adjusted analysis was performed using logistic regression.
Eighty-five adolescents participated: 48% overweight/obese, 32% BSD, and 53% low resilience (LR). There was no association between actual and perceived overweight/obesity and LR (P = 0.386 and P = 0.123, respectively). Perceived overweight/obesity was five times (AOR 5.3; 95% CI = 1.6–14.5; P = 0.004) and LR was six times (AOR 6.4; 95% CI = 1.9–22.4; P = 0.003) more likely to be associated with BSD. The strongest sub-component of LR associated with BSD, was low confidence (OR 4.7; 95% CI = 1.4–15.2; P = 0.008).
LR and perceived overweight/obesity are independently associated with BSD. This finding is important because resilience can be improved, thus highlighting a need for future studies involving resilience building interventions to decrease BSD.

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: The authors declare no conflicts of interest.

^*: Present Address: Children's National Medical Center Pediatric Residency-Community Health Track, Washington, DC.

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Original ArticlesMeasuring Resilience in the Adolescent Population: A Succinct Tool for Outpatient Adolescent Health

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am J Prev Med

Neuropsychiatr Enfance Adolesc

Ordinary magic: resilience processes in development

Am Psychol

Resilience among military youth

Future Child

Adolescent resilience: a framework for understanding healthy development in the face of risk

Annu Rev Public Health

Development of a multi-dimensional measure of resilience in adolescents: the Adolescent Resilience Questionnaire

BMC Med Res Methodol

Protective factors against depression and suicidal behaviour in adolescence

Can J Psychiatry

A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students

BMC Public Health

Original Articles
Measuring Resilience in the Adolescent Population: A Succinct Tool for Outpatient Adolescent Health