|| Practice Applications of Research
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
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.
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.
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).
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.
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 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.
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).
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.
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
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
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.
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.
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.
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.
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.
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
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
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.
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
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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.