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Children with asthma: Initial development of the child resilience model
Date: 03-01-2002; Publication: Pediatric Nursing; Author: Vinson, Judith A

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Pediatric Nursing Practice Applications of Research

Purpose:

The purpose of this study was to develop a clinically relevant conceptual model of resilience in children based on theoretical relationships between family environment, specific child characteristics, and selected health outcomes.

A correlational study method was used to study a nonprobability, volunteer sample of 235 children, diagnosed with asthma on daily medication.

Findings:

Findings revealed that the paths in the inner core of a resilience model were statistically significant.

Fifteen percent of the variance in the illness indices outcome for children with asthma was explained by family environment, specific child characteristics, appraisal and coping, and child perceived quality of life. A child's sense of coherence and self-esteem, as mediated by a child's appraisal of asthma, accounted for 37% of the variance explained in the perceived quality of life.

Conclusions:

Nurses and physicians, committed to working in partnerships with parents, can help foster specific child characteristics that impact the effects of asthma.

The experience of health and illness of children and their families is an important concern of nurses and physicians, particularly for those who are committed to working in partnership with parents. The goal of nursing is health (Jones & Meleis, 1993), and promoting the health of children and families is a major professional goal (Hayman, 1998). The concept of health has been redefined from the absence of disease to include conditions of physical, mental, and social well- being (World Health Organization [WHO], 1947). There is a paradigm shift in the study of disease origins (pathogenesis) to include the origin of health (salutogensis) (Antonovsky, 1979, 1987, 1998). The origin of health is influenced by many factors between the person and his or her environment (Antonovsky, 1984). The phenomenon of resilience is thought to be the interplay between personal characteristics and environmental factors resulting in the ability to overcome adversity (Rutter, 1993; Werner & Smith, 1982, 1992). The psychological profile of resilience provides an understanding of human behavioral responses that lead to effective adaptation but has not been tested in the management of a physical health condition.

The purpose of this article is to describe the development and initial testing of the inner core of a conceptual model of resilience in children managing a health condition. Model development was based on theoretical concepts between the socio-ecological environment and intrapersonal factors that influence a person's outcomes.

Background

The proposed Child Resilience Model presented herein is only the inner core composed of family and child characteristics thought to influence adaptive outcomes (see Figure 1) and is based on six assumptions (see Table 1). The model is nested in a more comprehensive model that considers the constructs of risk, vulnerability, and protective factors (see Figure 2). At this time, the more comprehensive model is simply hypothesized and not validated. Entire models that are complex, comprehensive, and multidimensional may not be testable in one research study and need a planned investigation over time (Pridham, 1998).

The Child Resilience Model incorporates family influences on specific child characteristics in the context of managing a health condition. Chronic illness can impede a child's normal development leaving him or her with few friendships, exclusion from school and developmental activities, and development of behavioral problems (Grey & Thurber, 1991; Holaday & Turner-Henson, 1987; Thompson & Gustafson, 1996). And, while many children with chronic illness lead active and positive lives (Gibson, 1986) managing a health condition, there are long-term impacts on child development, health status, and quality of life issues (Drotar, 1981; Levi & Drotar, 1998). There are six hypothesized paths among the concepts in the Child Resilience Model (see Figure 1).

Conceptual Framework

Model configuration was derived from the theoretical formulations of Bronfenbrenner's (1979) ecology of human development, Antonovsky' s (1979, 1987) salutogenic orientation to life, and the stress and theory coping theory of Lazarus and Folkman (1984). The relationships among the model concepts and the outcomes have been proposed by research and the theoretical literature (Antonovsky, 1979, 1984, 1987; Bronfenbrenner, 1979, 1986; Lazarus Folkman, 1984; Lipowski, 1970-1971). The concepts and measures of the concepts form a structural model with direct and indirect linear relationships that imply casual relationships.

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Figure 1.

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Table 1.

Concepts in the model are based on theoretical and research literature of resilient children: (a) family environment, (b) child characteristics, (c) appraisal and coping, leading to (d) adaptive outcomes. The concept of resilience is derived from studies of vulnerable children at risk for poor or negative outcomes in which protective factors (individual and contextual) buffer risk effects and influence positive adaptation (Garmezy, 1991; Masten & Garmezy, 1985; Rutter, 1990). The picture of resilient children that has emerged over a period of 2 to 3 decades is that of vulnerable children in high-risk situations buffered by protective factors that ultimately lead to successful adaptation. This picture implies an ecological perspective that considers the connections between individuals and their environments.

Ecological models have relevance in health promotion and practice (Bruhn & Parcel, 1982; Sallis & Owen, 1997). Pridham (1998), in reviewing research implications for health promotion, suggests that theoretical models with an ecological perspective advance the study of children in response to their contextual environments. The phenomenon of resilience is ecological in perspective.

Family Environment

Family environment is a primary influence on the child's emotional and psychological well- being (Bowlby, 1973, 1982, 1988). This is particularly true with children who are ill (Robertson, 1958). Bronfenbrenner (1979) offers a transactional model of human development that provides an explanation of interconnections between the immediate setting of lives (microsystems) and the links to larger and more complex settings whose over-arching patterns and ideologies affect one's interactions with others. This theory addresses the interaction between characteristics of people and their environment and how the interplay between elements of person and environment affect human behavior. The resilience literature cites family emotional warmth and cohesiveness as specific family characteristics that positively influence a child's development (Baldwin, Baldwin, & Cole, 1990; Werner & Smith, 1982); however, the exact mechanism by which this effect is protective is not known (Butter, 1990).

The Child Resilience Model focuses on the micro- and meso-systems of Bronfenbrenner's theory: the child and the care-giving environment. The context of the family and the unique disposition of the child have a synergistic relationship.

Child Characteristics

Specific child characteristics that contribute to adaptive outcomes are sense of coherence, internal locus of control, competence, problem- solving skills, and positive selfregard (Garmezy, 1984; Masten, Best, & Garmezy, 1990; Shure & Spivack, 1979; Werner & Smith, 1982). There is some discussion that these specific and unique characteristics, in the context of environmental risk, help the child elicit positive responses from others and develop a combination of skills and attitudes that contribute to efficient use of whatever abilities the child has to overcome adversity (Werner, 1992).

Based on Antonovsky's (1987) salutogenic theory, certain personal characteristics can be viewed as protective factors that buffer and protect against stress. These are called general resistance resources. Antonovsky's work culminated in the concept of a sense of coherence, which facilitates a "feeling of confidence that one's internal and external environments are predictable, and there is a high probability that things will work out as well as can reasonably be expected (p. viii)." The central concept of the salutogenic theory is the sense of coherence that allows an individual to manage tension states, mobilize resources, promote effective coping, and resolve tension in a salutary (health promoting) manner. A strong sense of coherence provides an individual with the belief that he or she can comprehend and manage stressors that are meaningful to them. The salutogenic theory provides an explanation of a psychologically healthy person. Rutter (1993) stated that "resilience may be fostered by steps that make it more likely that people will feel in control of their lives and become effective in shaping what happens to them (p. 628)."

Appraisal and Coping

The stress and coping theory of Lazarus and Folkman (1984) explains coping as the management of the environment and the intrapsychic tension aroused by a challenge or threat. The theory focuses on the relations between the person and the environment and provides a cognitive- phenomenological perspective by which the individual's coping response is directly related to his or her perception (appraisal) of events. Coping is defined as process-oriented, which focuses on management of outcomes. Coping is an antecedent to adaptive outcomes.

Specific coping patterns are the least reported concept among resilient children; however, it is reported that problem-solving skills that allow the child to either influence his or her environment and alter his or her response to an unchangeable situation contribute to resiliency (Cole, 1967; Frankl, 1959).

Adaptive Outcome

The adaptive outcome concepts in this particular model are health- related quality of life and illness indices thought to capture the health status of children with asthma. Healthrelated quality of life assessment provides an evaluation of the child's perception of a sense of well-being. Health-related quality of life assessments are useful when caring for children with a chronic illness because they (a) provide useful and descriptive information about the child's health status, (b) facilitate evaluation of a child's level of morbidity, and (c) assist health care providers with understanding experiences and consequences associated with illness from the child's perspective (Eiser, 1995; Levi & Drotar, 1998; Mulhern et al., 1989).

Illness indices partially capture a morbidity index and should be specific and sensitive to the particular health condition under investigation. For asthma, in this study, the illness indices were the number of school absences, number of hospitalizations, and number of emergency room visits due to asthma symptoms in the 3 months prior to the study interview. Other indices that capture the morbidity of asthma include lung function and needed medications to control asthma symptoms (National Asthma Education Program, National Heart, Lung, and Blood Institute, 1997). Severity of illness information was gathered and reported as demographic data. In the more comprehensive model (see Figure 2), severity of illness would be conceptualized as a risk factor. A risk factor is defined as a statistical correlate of poor outcomes, which is a function of the environment (internal or external) to the child. Certainly there are many more morbidity indices that delineate the level of asthma exacerbation or control than were employed in this study.

Methods

Sample. This correlational survey study was conducted with a nonprobability, volunteer sample of 235 children, each with a parent, recruited from one of three settings: a hospital-based pulmonary and allergy clinic, the office of a private pediatric allergist, and a summer camp specifically for school-aged children diagnosed with asthma and on daily medication. Recruitment of the sample occurred only after approval by the university and health care facility IRBs. Only the investigator conducted the parent-child interviews.

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Figure 2.

Asthma severity classification, based on The Practical Guide for the Diagnosis and Management of Asthma (National Asthma Education and Prevention, National Heart, Lung, and Blood Institute, 1997), was not included in the model testing but used for demographic analysis. Asthma severity is a risk and vulnerability factor not tested in the nested model for this study but warrants further study in relation to the comprehensive model. Classification of asthma severity is based on clinical features before treatment and is a leveled symptom-management approach that changes over time based on prescribed medications and influencing conditions, such as viral infections (National Asthma Education Program, National Heart, Lung, and Blood Institute, 1997), thus, rendering asthma severity a snapshot in a continuum of care. Asthma severity classification, in this study, includes (a) medication- use and (b) parent perception of the child's illness severity. At the time of this study, the medication-use severity category was based on the amount and type of daily medication needed to maintain symptom control. These levels were (a) mild intermittent, (b) mild persistent, (c) moderate persistent, and (d) severe persistent asthma. The parent perceived severity of illness categories were collapsed into three categories (mild, moderate, severe) from the above four categories to consider the child's physical activity limitations due to asthma symptoms.

Instruments. Family Adaptability and Cohesion Scale. The concept of family, an independent variable that has influence on a child, was measured by the Family Adaptability and Cohesion Scale (FACES II) (Olson et al., 1992). It is a 30-item, self-report instrument (1 - Almost Never to 5 - Almost Always) measuring two major dimensions of family: (a) family cohesion (CO) and (b) family adaptability (ADP). ADP is the extent to which the family system is flexible and able to change. CO is the degree to which family members are separated from or connected to their family. High scores indicate adaptability and cohesiveness within the family. Adaptability scores range from 15 to 70, and the scores for cohesiveness can range from 15 to 80. Cronbach's alpha for cohesion has been reported as 0.87 and for adaptability as 0.78. Test-retest reliability between 4 weeks and 5 weeks has been reported as 0.83 for cohesion and 0.80 for adaptability (Olson et al., 1992).

Child Sense of Coherence Scale (CSOC). For this study, the concept child is a person age 7 through 12 years who is diagnosed with asthma, able to complete the study instruments either by interview or self- report, and has a legal guardian. Because the model is based on specific child characteristics thought to contribute to resilience in children, two measures were used to measure these unique dispositions: (a) the CSOC and (b) the Coopersmith Self-Esteem Inventory (SEI). The CSOC, titled "How I Feel: Childrens' Orientation Scale" (Margalit, 1994) is an adaptation of the adult measure of the sense of coherence (Antonovsky, 1987). The CSOC measures three interrelated components that comprise the sense of coherence: comprehensibility, manageability, and meaningfulness. The CSOC is intended for use with schoolage children and is a 16-item Likert scale with a range from 1 (Never) to 4 (Always). Scores for CSOC range from 16 to 64. Higher scores indicate a greater sense of coherence. Both internal reliability coefficients (0.74 for males; 0.73 for females) and significant main effect between high, average, and low achievers (F (2, 268) = 7.57, p < 0.01) have been established.

Coopersmith SEI. The second measurement for the concept child was the 50-item, forced choice SEI, School Form (Coopersmith, 1990) that is an evaluation of the attitude that the child holds toward himself or herself in relation to social, academic, family, and personal areas of experience. The total possible score is 100. Higher scores indicate higher self-esteem. Internal coefficients or reliability in a sample of 7,600 schoolage children ranged from 0.87 to 0.92 (Coopersmith, 1990). It was hypothesized that the concept child would have a direct influence on the concept appraisal.

Appraisal: Children's Asthma Symptom Checklist (CASCL). The concept appraisal is the perception and evaluation piece of the coping process that leads to specific coping patterns. Appraisal involves the person- environment factor that influences judgment prior to coping (Lazarus & Folkman, 1984). Appraisal was measured using the children's version (CASCL) (Fritz Fs Overholser, 1989) of the adult Asthma Symptom Checklist (Kinsman, O'Banion, Resnikoff, Luparello, & Spector, 1973). This Likert- tool is designed to examine both cognitive and the emotional components of threat appraisal as defined by Lazarus and Folkman (1984) and is composed of three factors related to asthma symptoms: general physical symptoms (GPS), panic/fear (PF), and hyperventilation/irritability (HI). Scores range from 1 (Never) to 5 (Always) as the child appraises his or her asthma symptoms. A low score of 1.0 indicates that a child reports that he or she never had this particular asthma symptom during an acute asthma episode, and a high score of 5.0 indicates that the child reported that he or she always had this particular symptom with an acute asthma episode. Fritz and Overholser (1989) reported that functional morbidity indices using medication levels, number of hospitalizations, and the number of emergency room visits were significantly correlated with parent-reported factor scores on the CASCL. It is hypothesized that appraisal influences coping.

Coping: Coping Health Inventory for Children (CHIC). The concept coping is defined as both "cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing and exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141). The 45-item, Likert instrument CHIC (Austin, Patterson, & Huberty, 1991) is an instrument that is completed by parents and samples the domains of coping behaviors in school age children, 6 through 12 years of age, with a chronic physical condition. The CHIC has five subscales that indicate coping patterns: develops competence and optimism (CMPT); feels different and withdraws (DW); is irritable, moody, and acts out (MA); complies with treatment (CWT); and seeks support (SS). The responses for the CHIC range from 1 (Never) to 5 (Always). Higher scores indicate that the child uses more of the coping variable being measured; low scores indicate that the child uses less of the coping variable. Both test-retest reliability for 74 parents with children diagnosed with either asthma or epilepsy ranged form 0.68 to 0.91 for mothers and 0.57 to 0.84 for fathers (Austin et al., 1991). It is hypothesized that coping directly influences the outcomes perceived quality of life and illness indices.

Adaptive Outcome: Pediatric Asthma Quality of Life Questionnaire (PAQLQ). The concept quality of life was measured by the child's completion of the PAQLQ (Juniper et al., 1996). The PAQLQ is a 23-item Likert- scale that measures three domains: activity limitation (5 items), emotional function (8 items), and symptoms (10 items) experienced by the child with asthma in the week prior to completion of the scale. The tool is individualized for each child with the child choosing three items that he or she likes to do on a regular basis and then rating to what extent (1Extremely Bothered to 7-Not Bothered) asthma symptoms have limited the child's activities in the three domains. The PAQLQ has been able to detect within-subject groups (p < 0.0001) in children who had changes in their asthma condition and those children who remained stable during the testing period (Juniper et al., 1996).

Adaptive Outcome: Illness Indices. In this study illness indices were the number of days hospitalized, the number of days missed from school, and the number of emergency room visits, due to asthma in the 3 months preceding the study interview. These data were obtained from parent reports and were coded as numbered days.

Analysis. To test the research model, structural equation modeling was used to examine the relationship among the study variables in the model. This particular model testing is composed of a measurement model and a structural model. The measurement model is the relationship between the measurement instruments and the perceived construct; for example the construct child was measured by CSOC and SEI instruments, and the construct family was measured by the FACE II, which examined cohesiveness and adaptability. The structural model specifies the relationships among the model constructs as determined by theory and research. The strength of association among the model constructs is reported as path coefficients and is tested at a preset level of significance. In this study the level of significance was set at or less than 0.05 (p < 0.05).

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Table 2.

Results

Results reported herein include demographic data, significant correlations, and the specific model configuration that was found to be significant. Demographic information about the children and the parent indicated the age range of the children was 7 years to 12 years 11 months with fairly even distribution by year. The mean age of the children when first diagnosed with asthma was 3 years 5 months, with the most frequently reported age of diagnosis as 2 years. Seventy-eight percent of the children were in the mild-intermittent to mild-persistent asthma category based on medication use. Only 8% were taking daily medication for the severe- persistent asthma category. Forty-seven percent of the children were classified by their parents as having mild asthma, and 17% were reported having severe asthma.

Sixty percent of the children were male, 43% were African-American, 51% were Caucasian, with an even distribution among the ages, which ranged from 7 through 12 years. Family income ranged from less than $10,000 per year (27% of the sample) to more than $51,000 per year (21% of the sample). Sixty-seven percent of the mothers worked outside the home. Fifty-two percent of the fathers worked outside the home, and 40% were unemployed.

Family environment, child characteristics and appraisal, coping, quality of life, and illness indices. Table 2 presents significant correlations for family and child independent variables and the dependent variables measuring appraisal, coping, quality of life, and illness indices. Pearson productmoment correlations were computed on all measured variables in the model. Of the family environment variables (cohesiveness and adaptability), there were significant correlations with all five subscales measuring coping styles in child. The dependent variables cohesiveness and adaptability positively correlated with competence and optimism (r = .37; r = .40), complies with treatment (r = .23; r = .33), and social support (r = .27; r = .37). Both independent variables (cohesiveness and adaptability) negatively correlated with difficult and withdraws (r = -.19; r = -.17) and irritable, moody, and acts out (r = -.31; r = -.28). These correlations indicate that families that report higher cohesiveness and adaptability are more likely to have children who score higher on the coping patterns measuring competence and optimism, compliance with treatment, and social support and lower scores on coping patterns measuring difficult and withdrawn, and irritable, moody, and acting out coping behaviors.

The child characteristics sense of coherence and selfesteem negatively correlated with the threat appraisal subscales in the CASCL. This indicates that the greater a child's sense of coherence and self-esteem, the less the child perceived general physical symptoms, hyperventilation, and panic-fear when experiencing an acute asthma episode. There was a similar pattern of intercorrelations found between child characteristics and coping patterns. The greater a child's sense of coherence and self-esteem, the higher the scores found with positive coping patterns (competence and optimism, complies with treatment) and the lower the scores found with negative coping patterns (difficult and withdraws and irritable, moody, and acts out).

Table 3 presents significant intercorrelations between appraisal, coping, quality of life, and school absences. Three of the subscales that measured health-related quality of life (activity limitation, symptoms, and emotional function) were negatively correlated with the appraisal concept measured by the CASCL. This indicates that higher scores in the child's perceived quality of life measurement resulted in lower reported scores in the asthma symptom checklist. Perceived quality of life subscales were also significantly correlated to self- esteem and sense of coherence (see Table 2). This was reported to a greater extent with emotional function than with activity limitations and symptoms (r = .29; r = .23).

The outcome variable school absences was the only illness index that significantly correlated with the coping behaviors and perceived health- related quality of life subscales. These correlations indicate that higher scores for negative coping behaviors (e.g., difficulty and withdraws and irritable, moody and acts out) resulted in more days missed from school. This indicates that coping behaviors in children affect school absences. Also, school absences negatively correlated with perceived quality of life subscales, activity limitation (r= .-. 15), symptoms (r = -.26), and emotional function (r = -.18). This indicates that the more reported school absences, the lower perceived health-related quality of life.

Model Analysis

To test the research model, all variables were entered into a structural equation. Structural equation modeling is composed of a measurement model and a structural model. The measurement model is the relationship between the concept and the instruments measuring the concept (e.g., family measured by cohesiveness and adaptability subscales). The resulting factor loading scores in the measurement model provide information about how well each concept is able to be measured by the instruments. It is considered a validity coefficient. The research model tested, herein, indicated that all the measurement instruments were valid and reliable. See Table 4 for the mean, range, standard deviation, internal reliability coefficient (Cronbach's alpha), factor loading, and R^sup 2^ for each of the measurement instruments.

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Table 3.

The structural model specifies the relationships among the concepts as determined by theory and research. The path coefficients between the concepts explain the strength of association and the direction of the relationships. In this study, the structural model was reconfigured based on the theoretical and research literature in association with the goodness-of-fit indices. It was discovered that the hypothesized structural model of child resilience, showing paths between the concepts, was in need of reconfiguration. The original model (see Figure 1) hypothesized paths between family environment, specific child characteristics, threat appraisal, child coping styles, and the outcome measures perceived health-related quality of life and illness indices. Based on the research data in this sample of children, six significant paths were identified among the model concepts slightly different than hypothesized. Modification indices suggested adding a direct path between appraisal and quality of life and a direct path between quality of life and illness indices. The path between appraisal and coping did not prove to be viable with this sample. Therefore, the resulting six significant paths in the revised inner core Child Resilience Model are from (a) family to child, (b) child to appraisal, (c) appraisal to quality of life, (d) family to child coping, (e) child coping to illness indices, and (f) child perceived quality of life to illness indices (see Figure 3). The findings suggest, at least in this sample of children diagnosed with asthma, that health-related quality of life becomes an outcome variable and that it also influences illness indices. The findings also suggest that appraisal does not have a direct link to coping, as hypothesized in the stress and coping literature.

Thirty-seven percent of the variance (R2) in quality of life is explained by the concepts family, child, and appraisal. Fifteen percent of the variance found in illness indices can be explained by the combined direct and indirect effect of the model concepts family, child, appraisal, coping, and quality of life. The path coefficients were statistically significant and were in the hypothesized direction. The final Goodness- of-Fit Index (GFI) was 0.89 and the Adjusted Goodness-of-Fit Index (AGFI) was 0.84 indicating a good fitting model. While the Chi-square improved with each respecification of the model, it never reached nonsignificance.

Discussion

Results of the structural equation modeling indicate that there is a model consisting of family environment variables, specific child characteristics, and appraisal and coping patterns that influence health-related quality of life and illness indices for children with a health condition. The findings in this study are consistent with the phenomenon of psychological resilience; children who successfully overcome adversity.

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Figure 3.

Children, in this study, were influenced by family environment and, in turn, influenced dependent and outcome variables. This is consistent with Bronfenbrenner's (1979, 1986) ecology of human development and the determinants of childhood directly influenced by family. In the risk and resilience literature, it is reported that children who are at risk and come from families that demonstrate warmth and cohesiveness seem to do better than their at-risk counterparts (Werner & Smith, 1982, 1992). The model of resilience in this study demonstrated a path coefficient between family and child (0.26, t = 2.98, p < 0.005). Surprisingly, the family environment did not play a larger role in the influence on specific child characteristics. The squared multiple correlation coefficient was 0.07 (error estimate 0.93), meaning that 7% of the variance in the construct child, as measured by CSOC and SEI, was explained by the construct family. This left 93% of the variance between child and family to be explained by something other than family environment. This would indicate that more factors representing the construct family need to be examined to explain the influence of the family on the child's self-esteem and sense of coherence. A closer examination of other measures of family may help explain stronger, underlying constructs that explain the development of selfesteem, sense of coherence, problem- solving skills, and competence in children.

Despite the weak, though statistically significant link between family environment and child characteristics, the measurements for the concept child were found to be valid measures. The factor loading for each measurement of a construct is considered a validity index. In this study the factor loading for self-esteem was 0.91 (p < 0.005) and sense of coherence was 0.74 (p < 0.005) indicating a valid measure for this sample. It is hard to interpret these child characteristics' influence on appraisal and coping, since there is no specific stress and coping model to explain the process in children (Ryan-Wenger, Sharrer, & Wynd, 2000). The Lazarus and Folkman (1984) stress and coping model has been applied to children; however, it was specifically developed and tested for adults. Results from this study found that child characteristics directly influence threat appraisal (r = -0.38, p < 0.005) and child coping patterns influenced illness indices, specifically school absences. There were interesting intercorrelations between self-esteem, child sense of coherence, and the three measures of threat appraisal. These scores indicate higher scores of selfesteem and sense of coherence were related to lower scores for panic/fear, hyperventilation, and general symptoms. It is surprising to note that a strong structural path emerged between threat appraisal and quality of life (r = -0.60, p < 0.005). There were also significant intercorrelations between the CASCL subscales and the PAQLQ. These intercorrelations indicate that the more a child appraises his or her asthma symptoms (e.g., panic/fear as "always being present" during an acute asthma episode), the lower the perceived health-related quality of life. In this study, coping patterns indicated that more moodiness, acting-out, and/or feeling different and withdrawing correlated with children who had more absences from school.

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Table 4.

The PAQLQ is a self-report, health-related quality of life measure. Health-related quality of life instruments are measures that determine subjective dimensions of health such as emotion, pain, and morbidity dimensions and serve three primary purposes: discrimination, evaluation, and prediction (Guyatt, Feeny, & Patrick, 1993; Kirshner & Guyatt, 1985 as cited in Feeny et al., 1998). Such instruments in research and clinical practice with children are taking on increasing importance, particularly in chronic conditions (Drotar, 1998). In this study 37% of the variance in the quality of life construct was explained by family environment, child characteristics, and threat appraisal, indicating that these concepts may serve, in some way, as buffers to perceived inconvenience of asthma symptoms into the everyday life of a child. Interestingly, in this study, a direct path emerged between health-related quality of life and illness indicators (school absences, emergency room visits, and hospitalizations).

Implications for Nursing and Future Research

The model of resilience proposed and tested in this study helps nurses visualize the paths by which children are influenced toward a state of health and well-being. This study demonstrates that the constructs found from relevant theoretical and research literature regarding resilient children can be transposed into a model of resilience in children managing a health condition. This study demonstrates that family environment has a direct and significant influence on a child' s sense of coherence, self-esteem, and coping styles. This study also demonstrates that children's characteristics impact perceived threat appraisal of asthma symptoms, which impact directly health-related quality of life and indirectly illness indices.

Nurses who are committed to working in partnership with parents can help parents understand how their children appraise asthma symptoms and cope with the stress associated with asthma. Accurate appraisal of asthma symptoms and positive coping styles lead to better management of asthma symptoms. How a child feels about himself or herself and how a child senses manageability over his or her environment influence appraisal of asthma symptoms and perceived quality of life. Exploring with the child his or her perceived sense of control and management over circumstances may serve as a key to helping the child feel less panic and fear during an acute asthma episode.

It is critical that nurse researchers and clinicians study and understand how family environments and specific child characteristics influence coping and adaptation in the face of a chronic health condition. In this study it would indicate that more factors representing the construct family need to be examined to explain the influence of the family on the child's self-esteem and sense of coherence. A closer examination of other measures of family may help explain stronger, underlying constructs that influence the development of self-esteem, sense of coherence, problem-solving skills, and competence in children.

More research needs to be done concerning how healthrelated quality of life impacts a child's management of a health condition and resulting illness indices. Quality of life subscales were directly influenced by threat appraisal and indirectly influenced by child characteristics in this study. Coping subscales did not seem to have a direct influence on quality of life measures but did on school absences. One explanation for this may be the fact that the parent completed the FACES If and the CHIC while the child completed the CASCL and the PAQLQ. More research is needed to determine concordance between parent and child self-reports.

Conclusion

The findings of this study have clear implications for clinical practice to help children manage a health condition. The findings suggest that the constructs of psychological resilience can be imposed in managing a health condition such as asthma. Families are important and provide environments in which children thrive and prosper. Nurses influence family functioning and assist children with promoting health and managing health conditions. Benner and Wrubel (1989) stated that health is a "basic resilience" (p. 156); and that health incorporates a sense of coherence that reflects well-being. Well-being is the "lived experience of health" (Benner & Wrubel, p. 160).

In this study a Child Resilience Model was developed and tested. The constructs of resilience appear to influence health outcomes; a goal of nursing. It is important that researchers study the context of successful adaptation in children. The study of resilience and the factors that contribute to its development is within the domain of nursing.

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Janice S. Hayes, PhD, RN

Judith A. Vinson, PhD, RN, is Associate Professor and Associate Dean for Academic Affairs, Michigan State University, College of Nursing, East Lansing, MI.

The Practice Applications of Research section presents reports of research that are clinically focused and discuss the nursing application of the findings. If you are interested in author guidelines and/or assistance, contact Janice S. Hayes, PhD, RN; Section Editor; Pediatric Nursing; East Holly Avenue Box 56; Pitman, NJ 08071-0056; (856) 256- 2300 or FAX (856) 256-2345.

Image Caption: Figure 1.

Vinson, Judith A, Children with asthma: Initial development of the child resilience model. , Pediatric Nursing, 03-01-2002, pp 149.

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