Advertisement

Family, Neighborhood And Parent Resilience Are Inversely Associated With Reported Depression In Adolescents Exposed to ACEs

  • Esther C. McGowan
    Correspondence
    Corresponding Author. Esther C. McGowan MD, MS, Assistant Clinical Professor, Health Sciences, Department of Pediatrics, University of California, Riverside, School of Medicine | UCR Health, 79430 Highway 111|Suite 102, La Quinta, CA 92253
    Affiliations
    Assistant Clinical Professor, Health Sciences, Department of Pediatrics, University of California, Riverside, School of Medicine | UCR Health
    Search for articles by this author
  • Suzette O. Oyeku
    Affiliations
    Chief, Division of Academic General Pediatrics, Professor of Pediatrics, Director, Academic General Pediatrics Fellowship, The Children's Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of Medicine
    Search for articles by this author
  • Sylvia W. Lim
    Affiliations
    Associate Professor of Pediatrics, Associate Director, Academic General Pediatrics Fellowship, The Children's Hospital at Montefiore, The Pediatric Hospital for Albert Einstein College of Medicine, Division of Academic General Pediatrics
    Search for articles by this author
Open AccessPublished:October 19, 2022DOI:https://doi.org/10.1016/j.acap.2022.10.009

      Abstract

      Objective

      To examine the association of 1) extrinsic resilience factors and 2) adverse Childhood experiences (ACEs) with a caregiver reported diagnosis of depression in a nationally representative sample of adolescents.

      Methods

      A cross sectional analysis of the 2016-2017 National Survey of Children's Health, restricted to adolescents 12 to 17 years old was conducted. The dependent variable was caregiver reported depression: no current diagnosis vs. current diagnosis of depression. Independent variables were reported ACEs dichotomized as lower (0-3) or higher (4 or more), and specific resilience factors: family resilience, neighborhood cohesion and caregiver emotional support. Resilience factors were analyzed as a composite score dichotomized as lower (0-3) or higher (4 or more) and individually. Purposeful selection multivariable logistic regression model building was used to estimate the associations between reported diagnosis of depression, ACEs and resilience factors adjusting for demographic covariates.

      Results

      Study sample consisted of 29,617 (weighted N=24,834,232) adolescents, 6% with current reported diagnosis of depression, 8% with higher ACEs and 91% with higher resilience. Family resilience, neighborhood cohesion and caregiver emotional supports were each independently associated with lower odds of reported diagnosis of depression. However, with all resilience factors in the model, only family resilience and neighborhood cohesion (specifically school safety) remained significantly associated with lower odds of reported diagnosis of depression.

      Conclusion(s)

      In this nationally representative sample, family resilience and neighborhood cohesion were associated with lower odds of a reported diagnosis of depression even with confounding ACEs exposure. These factors may be important targets for future intervention.

      Key words

      Introduction

      Adverse childhood experiences (ACEs) include traumatic events of childhood such as suffering childhood abuse, neglect and household dysfunction
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      . ACEs also include environmental stressors such as exposure to unsafe neighborhoods, racism/discrimination, and bullying
      • Crouch E
      • Probst JC
      • Radcliff E
      • Bennett KJ
      • McKinney SH.
      Prevalence of adverse childhood experiences (ACEs) among US children.
      • Cronholm PF
      • Forke CM
      • Wade R
      • et al.
      Adverse Childhood Experiences: Expanding the Concept of Adversity.
      • Finkelhor D
      • Shattuck A
      • Turner H
      • Hamby S.
      Improving the adverse childhood experiences study scale.
      . Mounting evidence shows that ACEs impact childhood developmental trajectory, and physical and mental health outcomes
      • Crouch E
      • Probst JC
      • Radcliff E
      • Bennett KJ
      • McKinney SH.
      Prevalence of adverse childhood experiences (ACEs) among US children.
      • Cronholm PF
      • Forke CM
      • Wade R
      • et al.
      Adverse Childhood Experiences: Expanding the Concept of Adversity.
      • Finkelhor D
      • Shattuck A
      • Turner H
      • Hamby S.
      Improving the adverse childhood experiences study scale.
      • Traub F
      • Boynton-Jarrett R.
      Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice.
      • Soleimanpour S
      • Geierstanger S
      • Brindis CD.
      Adverse Childhood Experiences and Resilience: Addressing the Unique Needs of Adolescents.
      • Bethell CD
      • Newacheck P
      • Hawes E
      • Halfon N.
      Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
      • Font SA
      • Maguire-Jack K.
      Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions.
      . Approximately 50% of United States’ (US) children have experienced at least one ACE
      • Bethell CD
      • Newacheck P
      • Hawes E
      • Halfon N.
      Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
      ,
      • Bethell C
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      • Bethell CD
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      Issue Brief: A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive.
      . Eight percent of US children have experienced ≥ 4 ACEs
      • Bethell CD
      • Newacheck P
      • Hawes E
      • Halfon N.
      Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
      ,
      • Bethell C
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      • Bethell CD
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      Issue Brief: A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive.
      ,
      • Bomysoad RN
      • Francis LA.
      Adverse Childhood Experiences and Mental Health Conditions Among Adolescents.
      . Four or more reported ACEs have been shown to be associated with a higher probability of ever being diagnosed with depression as compared with no ACEs
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      ,
      • Font SA
      • Maguire-Jack K.
      Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions.
      . Such childhood experiences have been suggested as “psychiatry's greatest public health challenge.”
      • Sara G
      • Lappin J.
      Childhood trauma: psychiatry's greatest public health challenge?.
      Childhood mental health disorders are a public health emergency with increasing prevalence, financial burden, and negative impact on children, families, and communities
      • Bellis MA
      • Hughes K
      • Ford K
      • et al.
      Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
      . National surveys indicate 21% of adolescents have one or more reported mental health disorders
      • Costello EJ
      • Mustillo S
      • Erkanli A
      • Keeler G
      • Angold A.
      Prevalence and development of psychiatric disorders in childhood and adolescence.
      • Lu W.
      Child and Adolescent Mental Disorders and Health Care Disparities: Results from the National Survey of Children's Health, 2011-2012.
      • Lu W
      • Xiao Y.
      Adverse Childhood Experiences and Adolescent Mental Disorders: Protective Mechanisms of Family Functioning, Social Capital, and Civic Engagement.
      . Adolescence is a unique developmental stage of rapid growth during which physiologic, cognitive, social, and emotional changes occur simultaneously with increased vulnerability to the effects of ACEs
      • Soleimanpour S
      • Geierstanger S
      • Brindis CD.
      Adverse Childhood Experiences and Resilience: Addressing the Unique Needs of Adolescents.
      ,
      • Lu W
      • Xiao Y.
      Adverse Childhood Experiences and Adolescent Mental Disorders: Protective Mechanisms of Family Functioning, Social Capital, and Civic Engagement.
      . Adolescent ACEs have been associated with increased risk of anxiety, depression, substance abuse, behavioral problems, and suicide
      • Bethell CD
      • Newacheck P
      • Hawes E
      • Halfon N.
      Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
      ,
      • Costello EJ
      • Mustillo S
      • Erkanli A
      • Keeler G
      • Angold A.
      Prevalence and development of psychiatric disorders in childhood and adolescence.
      • Lu W.
      Child and Adolescent Mental Disorders and Health Care Disparities: Results from the National Survey of Children's Health, 2011-2012.
      • Lu W
      • Xiao Y.
      Adverse Childhood Experiences and Adolescent Mental Disorders: Protective Mechanisms of Family Functioning, Social Capital, and Civic Engagement.
      American Academy of Pediatrics
      Adverse Childhood Experiences and the Lifelong Consequences of Trauma.
      • Moore KARA.N.
      Adverse Childhood Experience and Adolescent Well-being: Do Protective Factors Matter?.
      • Heron M.
      Deaths: Leading Causes for 2016.
      .
      To address this public health concern, there is growing interest in resilience factors and how they can provide protection in individuals that experience ACEs
      • Traub F
      • Boynton-Jarrett R.
      Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice.
      ,
      • Bellis MA
      • Hughes K
      • Ford K
      • et al.
      Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
      . Despite exposure to ACEs, most children and adolescents do not develop poor health outcomes. This is based on the premise that various resilience factors may mitigate the impact of ACEs on lifelong health course
      • Bellis MA
      • Hughes K
      • Ford K
      • et al.
      Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
      . Resilience refers to the ability to adapt successfully to disturbances that threaten development of a positive life course or the ability to resume one following periods of adversity
      • Bellis MA
      • Hughes K
      • Ford K
      • et al.
      Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
      . A key requirement of resilience is the presence of both risks, such as ACEs, and promotive factors that either help bring about a positive outcome, reduce or avoid a negative outcome
      • Fergus S
      • Zimmerman MA.
      Adolescent resilience: a framework for understanding healthy development in the face of risk.
      . There are multiple domains of resilience. The focus of this study is centered on extrinsic factors. These include family resilience, neighborhood cohesion, and caregiver emotional support
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.
      . Extrinsic resilience utilizes the socio-ecological framework to emphasize the dynamic interaction of individuals and their environment
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.
      . It moves away from conceptualizations of resilience as a static, intrinsic trait
      • Fergus S
      • Zimmerman MA.
      Adolescent resilience: a framework for understanding healthy development in the face of risk.
      .
      The objective of this study was to examine the association of specific extrinsic resilience factors, ACEs, and a diagnosis of depression among a nationally representative sample of adolescents. The specific aims included examining the relationships between 1) exposure to higher ACEs, 2) presence of lower vs higher extrinsic resilience factors, and 3) the individual resilience factors of family resilience, neighborhood cohesion, and caregiver emotional support on reported diagnosis of depression in a nationally representative adolescent population. Limited studies exist that address the potential effect modification of individual extrinsic resilience factors on ACEs and depression in adolescents. We hypothesized that resilience moderates the effect of ACEs on the reported diagnosis of depression. We assessed the potential effect modification of resilience on ACEs and the reported diagnosis of depression in adolescents.

      Methods

      We conducted a cross-sectional analysis using the combined 2016-2017 National Survey of Children's Health (NSCH)

      Child and Adolescent Health Measurement Initiative (2018). “Fast Facts: 2016-2017 National Survey of Children's Health.” Data Resource Center for Child and Adolescent Health, supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB). Available at www.childhealthdata.org. Revised 9/26, 2018.

      to assess the effect of resilience factors on the odds of reported depression in a nationally representative adolescent population.

      Data Source and Study Sample

      The 2016-2017 NSCH is a publicly available, population based, and nationally representative mail and online survey that assess children's health, well-being, family and community characteristics of U.S. households based on parent/caregiver report

      Child and Adolescent Health Measurement Initiative (2018). “Fast Facts: 2016-2017 National Survey of Children's Health.” Data Resource Center for Child and Adolescent Health, supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB). Available at www.childhealthdata.org. Revised 9/26, 2018.

      . We will subsequently refer to parent/caregiver as caregiver in this manuscript. The NSCH is sponsored by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration, an agency in the U.S. Department of Health and Human Services. The National Maternal and Child Health Data Resource Center, led by the Child and Adolescent Health Measurement Initiative (CAHMI), is a national initiative based in the Johns Hopkins Bloomberg School of Public Health, that combined the 2016-2017 data files and constructed variables in collaboration with the MCHB and the National Center for Health Statistics. Complex survey weights provided by the NSCH adjust for nonresponse and unequal selection bias. Results are representative of national and state specific, noninstitutionalized children 0-17 years old. All analyses were performed using established survey weights to account for the complex sampling design per the NSCH guidelines presented in the dataset codebook
      Child and Adolescent Health Measurement Initiative (CAHMI)
      2016-2017 National Survey of Children's Health (2 Years Combined), [(SAS/SPSS/Stata)] Indicator Data Set. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement from the US Department of Health and Human Services, Health Resources and Services Administration (HRSA).
      . Details of the design and implementation of this survey are available through the Data Resource Center website

      Child and Adolescent Health Measurement Initiative (2018). “Fast Facts: 2016-2017 National Survey of Children's Health.” Data Resource Center for Child and Adolescent Health, supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB). Available at www.childhealthdata.org. Revised 9/26, 2018.

      . A total of 71,811 surveys were completed for 2016-2017. We limited our sample to adolescents 12-17 years of age, N=29,617. The study was approved by the Albert Einstein College of Medicine Institutional Review Board.

      Measures

        

      Independent Variables

        

      Adverse Childhood experiences

      In the 2016-2017 NSCH, caregivers were asked whether their child had experienced any of nine adverse experiences in childhood (Table1). All questions were derived from a modified version of the Centers for Disease Control (CDC) and Kaiser Permanente Adverse Childhood Experiences Study
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      . ACEs totals were tabulated for responses of having experienced an ACE, and then collapsed into a dichotomous ACEs score of lower “0-3” or higher “≥4”. Four or more ACEs have been associated with poor physical and mental health outcomes in both adults and children
      • Felitti VJ
      • Anda RF
      • Nordenberg D
      • et al.
      Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
      ,
      • Bomysoad RN
      • Francis LA.
      Adverse Childhood Experiences and Mental Health Conditions Among Adolescents.
      ,
      • Crouch E
      • Radcliff E
      • Strompolis M
      • Safe Srivastav A.
      Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs).
      .

      Resilience Factors

      Questions used to assess family resilience, neighborhood cohesion, and caregiver emotional supports are noted inTable 2. Family resilience was measured by a 4-item index established by the NSCH (Table 2)
      • Bethell CD
      • Gombojav N
      • Whitaker RC.
      Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity.
      . For our analysis, we dichotomized family resilience factors as “higher” family resilience for “most” or “all of the time” responses to all 4 questions and “lower” family resilience for “most” or “all of the time” responses to 0-3 questions as defined in the codebook.
      Table 1Adverse Childhood Experiences Questions.
      Parents were asked whether or not their child had experienced any of the following:
      1Hard to get by on family's income*
      2Parent or guardian divorced or separated
      3Parent or guardian died
      4Parent or guardian served time in jail
      5Saw or heard parents or adults slap, hit, kick punch one another in the home
      6Was a victim of violence or witnessed violence in neighborhood
      7Lived with anyone who was mentally ill, suicidal, or severely depressed
      8Lived with anyone who had a problem with alcohol or drugs
      9Treated or judged unfairly due to races/ethnicity
      *Response options of “somewhat often” or “very often” were coded as having this ACE, a response of “rarely” or “never” was coded as not having this ACE.
      Questions 2-9 were coded as having or not having experienced the ACE
      Table 2Specific Resilience Factors Questions.
      Cronbach Alpha
      Family Resilience: When your family faces problems, how likely were you to do each of the following:
      All of the timeMost of the timeSome of the timeNone of the time
      1Talk together about what to do0.905
      2Work together to solve our problems0.907
      3Know we have strength to draw on0.907
      4Stay hopeful even in difficult times0.903
      Neighborhood Cohesion: To what extent do you agree with these statements about your neighborhood or community:
      Definitely agreeSomewhat agreeSomewhat disagreeDefinitely disagree
      1Child lives in a supportive neighborhood if*:

      a) people in my neighborhood help each other out

      b) we watch out for each other's children in this neighborhood

      c) when we encounter difficulties, we know where to go for help in our community


      0.905

      0.905

      0.906
      Definitely agreeSomewhat agreeSomewhat/definitely disagree
      2Child lives in a safe neighborhood0.905
      3Child is safe at school0.938
      Caregiver emotional support:YesNo
      1During the last 12 months, was there someone that you could turn to for day-to-day emotional support with parenting or raising children?0.917
      0.918
      *children were considered to live in supportive neighborhoods if their parents reported “definitely agree” to at least one of the items and “somewhat agree” or “definitely agree” to the other two items
      Neighborhood cohesion was measured using 3 questions. Question 1 was derived from responses to three sub-questions (see Table 2). In the NSCH scoring algorithm, parent responses to question 1 were transformed into a dichotomous variable: living in a supportive neighborhood vs. not living in a supportive neighborhood. Questions 2 and 3 specifically addressed neighborhood and school safety. Caregivers responded on a 4-point Likert scale: never, sometimes, usually, or always. Responses of never, sometimes, or usually/always were analyzed as dummy variables in regression models. Previously published papers have assessed these individual safety variables, highlighting important distinctions and relationships
      • Al-Jadiri A
      • Tybor DJ
      • Mule C
      • Sakai C
      Factors Associated with Resilience in Families of Children with Autism Spectrum Disorder.
      • Kandasamy V
      • Hirai AH
      • Ghandour RM
      • Kogan MD.
      Parental Perception of Flourishing in School-Aged Children: 2011-2012 National Survey of Children's Health.
      • Butler AM
      • Kowalkowski M
      • Jones HA
      • Raphael JL.
      The relationship of reported neighborhood conditions with child mental health.
      . We subsequently analyzed each variable individually.
      Caregiver emotional support was provided as a single dichotomized variable: “having” vs “not having emotional support”. Children whose parents had someone to turn to for day-to-day emotional support with parenting or raising children, either a spouse, family member, close friend, health care provider, places of worship/religious leader, support/advocacy group related to special health care condition, peer support, counselor/other mental health professional or other people, were reported as having emotional support (Table 2).
      Scoring of the resilience factor variables was accomplished using algorithms provided within the NSCH codebook and showed relatively high internal consistency and reliability
      • Bethell C
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      • Bethell CD
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      Issue Brief: A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive.
      ,
      • Al-Jadiri A
      • Tybor DJ
      • Mule C
      • Sakai C
      Factors Associated with Resilience in Families of Children with Autism Spectrum Disorder.
      ,
      • Butler AM
      • Kowalkowski M
      • Jones HA
      • Raphael JL.
      The relationship of reported neighborhood conditions with child mental health.
      ,
      • Blumberg SJ
      • Foster EB
      • Frasier AM
      • et al.
      Design and operation of the National Survey of Children's Health, 2007.
      .

      Dependent Variable

        

      Current Depression

      Caregivers were asked whether a doctor or other health care providers had ever told them that their child had depression. Caregivers who answered “yes” were further asked whether the child currently had the condition, and this assessed prevalence of depression. Only children with a reported current diagnosis of depression were considered as a positive diagnosis consistent with previous published literature using the NSCH dataset
      • Bomysoad RN
      • Francis LA.
      Adverse Childhood Experiences and Mental Health Conditions Among Adolescents.
      ,
      • Butler AM
      • Kowalkowski M
      • Jones HA
      • Raphael JL.
      The relationship of reported neighborhood conditions with child mental health.
      ,
      • Ghandour RM
      • Sherman LJ
      • Vladutiu CJ
      • et al.
      Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.
      .
      A panel of experts was consulted for measure development. Assessments of these measures showed relatively high internal consistency and reliability
      • Bethell C
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      • Bethell CD
      • Davis MB
      • Gombojav N
      • Stumbo S
      • Powers K.
      Issue Brief: A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive.
      ,
      • Al-Jadiri A
      • Tybor DJ
      • Mule C
      • Sakai C
      Factors Associated with Resilience in Families of Children with Autism Spectrum Disorder.
      ,
      • Butler AM
      • Kowalkowski M
      • Jones HA
      • Raphael JL.
      The relationship of reported neighborhood conditions with child mental health.
      ,
      • Blumberg SJ
      • Foster EB
      • Frasier AM
      • et al.
      Design and operation of the National Survey of Children's Health, 2007.
      . These measures have subsequently been used in other published articles and in the development of other measures
      • Ghandour RM
      • Sherman LJ
      • Vladutiu CJ
      • et al.
      Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.
      • Baron RM
      • Kenny DA.
      The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
      Stata Statistical Software
      Release 16 [computer program].
      .

      Study Covariates

      Sociodemographic characteristics of one adolescent and caregiver per household were collected in the NSCH. For adolescents, these characteristics reported by the caregiver included: age (in years), sex, race/ethnicity (non-Hispanic white, Hispanic, non-Hispanic black, and multi-racial/other) and insurance type (public only, private only, combination of public and private, uninsured, and other). The characteristics of caregivers included: education (less than high school, high school or GED, some college or technical school, and college degree or higher), caregiver marital status/family structure (2 parents married, 2 parents unmarried, single mother, other), income level of household as percentage of Federal Poverty Level (FPL) (0-99% FPL, 100-199% FPL, 200-399% FPL, 400% FPL or more) and parent nativity (2 US born parents, only one parent born in the US, 2 non-US born parents but child born in the US).

      Statistical analysis

      We used descriptive statistics to calculate proportions of the characteristics of our study population. We used χ
      • Crouch E
      • Probst JC
      • Radcliff E
      • Bennett KJ
      • McKinney SH.
      Prevalence of adverse childhood experiences (ACEs) among US children.
      tests for categorical variables to examine bivariate relationships between “no reported diagnosis” and “current reported diagnosis” of depression, ACEs, each resilience factor, and study covariates. Resilience score was tabulated from the 4 family resilience questions, 3 neighborhood cohesion questions, and 1 caregiver emotional support question, which resulted in a score ranging from 0-8. Histograms of the total resilience factor variable stratified by 1) lower vs higher ACEs and 2) current diagnoses of depression, were visually assessed. These graphs had similar distributions with steepest slope at approximately 4 resilience factors before plateauing. Therefore, resilience was dichotomized to lower (0-3) vs higher (≥4) resilience factors. Sensitivity analysis was conducted with logistic regression models at different levels of dichotomized resilience and with resilience score as an ordinal variable (Appendix table 8).
      As we cannot determine which exposure came first, ACEs or resilience factors, we decided a priori and based on the literature, to test the effect modification of resilience on ACEs and the reported diagnosis of depression in adolescents
      • Baron RM
      • Kenny DA.
      The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
      . The moderator (i.e. resilience factor) would affect the direction and/or strength of the relation between the independent variable (ACEs) and the dependent variable (reported diagnosis of depression)
      • Baron RM
      • Kenny DA.
      The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
      .
      Covariates were chosen based on literature search and clinical importance. We initially included all the demographic covariates with statistically significant association at the 0.05 level with depression in each model. We used purposeful selection multivariable logistic regression model building to assess the associations between the dependent variable, independent variables, and study covariates. Significant variables at alpha 0.05 level in the logistic regression models remained in the final main effect models. The model results are presented as adjusted odds ratio (aOR) with 95% confidence interval. Unweighted likelihood ratio test was used to assess model fit for a model with and without resilience factors. The statistical software could not use weighted models to test likelihood ratio.

      These are the models

      Model 1: assessed the association of a reported diagnosis of depression and ACEs. (See Table 5)
      Model 2A and 2B: assessed the association of a reported diagnosis of depression, ACEs, lower (0-3) vs higher (≥4) resilience factors and related interaction term (See Table 4 and 5)
      We ran tests to see if the data met the assumption of collinearity for variables in the regression models. Model fit was adequate for each model, assessed using Hosmer-Lemeshow goodness-of-fit. Significance was assessed at a 2-tailed ∝ of 0.05. Statistical analyses were performed using Stata/IC (v 16.1, College Station, TX)
      Stata Statistical Software
      Release 16 [computer program].
      .
      Additional statistical analysis was conducted and are presented in the Appendix. We assessed the association of a reported diagnosis of depression, ACEs and all the individual resilience factors, which were included together in one model (See Appendix Table 6). Effect modification was assessed by the inclusion of these interaction terms into the regression models (Appendix Table 7). A statistically significant interaction at α<0.05 was considered positive interaction. We also assessed a model of a reported diagnosis of depression with only the statistically significant resilience factors (Appendix Table 9).

      Results

        

      Study Sample

      Our study sample consisted of 29,617 adolescents between 12-17 years of age, representing an estimated 24,837,790 U.S. adolescents. Table 3 shows reported sample characteristics and the bivariate associations of adolescents with or without a reported diagnosis of depression. There was a statistically significant difference in the association of a reported diagnosis of depression and adolescent sex, race/ethnicity, parent nativity, spoken home language, family structure, highest education of adult in family, insurance status, federal poverty level, ACEs and resilience (Table 3). The analysis showed high Cronbach Alphas (0.91-0.94) and that multicollinearity was not a concern (VIFs=1.24-4.67).
      Table 3Caregiver Report of Adolescent Demographic Characteristics, Stratified By Reported Current Diagnosis Of Depression.
      Weighted Percentage of Adolescents With or Without Reported Diagnosis of Depression(N =24,688,075**)
      CharacteristicWithout Depression(weighted N=23,246,461)With Depression(weighted N=1,441,783)P value*
      Total Adolescents

      (N=24,837,790)
      94.25.8-
      Sex<0.001
      Female48.556.2
      Male51.543.8
      Race/Ethnicity0.006
      Non-Hispanic, White51.258.8
      Other9.79.3
      Hispanic24.217.0
      Non-Hispanic, Black14.814.8
      Parent Nativity**<0.001
      All parents born in the US66.172.7
      Only one parent born outside the US26.813.4
      2 non-US born parents (child born in the US)7.113.9
      Home Language**0.002
      English85.993.7
      Other than English14.36.3
      Family Structure**<0.001
      Two parents, currently married66.748.1
      Single mother16.927.1
      Other family structure9.317.1
      Two parents, not currently married7.17.7
      Highest Education of Adult in Family**0.039
      College degree or higher46.038.0
      Some college or technical school22.927.7
      High school or GED20.923.1
      Less than high school10.211.2
      Insurance Status**<0.001
      Private only60.843.7
      Public only (govt assistance)27.443.1
      Uninsured7.15.0
      Public and private4.88.2
      Federal Poverty Level0.001
      400% FPL or greater31.927.4
      200-399% FPL27.123.2
      100-199% FPL21.523.1
      0-99% FPL19.526.3
      ACEs Category**<0.001
      None to lower (0-3)92.873.6
      Higher (4 or more)7.226.4
      Resilience Score<0.001
      Higher Resilience (4 or more)

      Lower resilience (0-3)
      91.8

      8.2
      77.3

      22.7
      All proportions were weighted to represent the US population ages 12-17.
      *Reported p value of chi-square tests comparing the proportion of children with or without parent reported diagnosis of current depression.
      **missing data resulting in lower N
      Table 4Association Between Caregiver Report of Current Diagnosis of Depression, ACEs (Lower vs Higher) And Resilience (Lower vs Higher).
      Model 2A
      aOR (95% CI)P value
      Sex

      Male


      0.73 (0.60-0.89)


      0.002
      Race/Ethnicity

      Non-Hispanic, Black

      Hispanic

      Other/Multi-racial

      (ref. white)


      0.55 (0.38-0.78)

      0.64 (0.47-0.87)

      0.87 (0.60-1.24)


      0.001

      0.004

      0.43
      Parent Nativity

      Only one parent born outside US

      2 non-US born parents

      (ref. both parents born in the US)


      0.52 (0.36-0.75)

      2.04 (1.19-3.51)


      <0.001

      0.01
      Family Structure

      2 parents, unmarried

      Single mother

      Other

      (ref 2 married patents)


      1.14 (0.78-1.67)

      1.47 (1.16-1.88)

      0.80 (0.54-1.17)


      0.69

      0.002

      0.25
      Insurance status

      Public only

      Mixed public and private

      Uninsured

      (ref Private insurance)


      1.82 (1.44-2.30)

      1.88 (1.20-2.96)

      1.03 (0.67-1.58)


      <0.001

      0.006

      0.91
      ACEs Category

      Higher ACEs (4 or more)


      2.65 (2.01-3.48)


      <0.001
      Resilience Category

      Higher Resilience (4 or more)


      0.34 (0.27-0.45)


      <0.001
      Adjusted odds ratios for all variables in the table: demographic covariates + ACEs +Resilience Category
      CI = confidence interval
      Table 5Association Between Caregiver Report of Current Diagnosis of Depression, ACEs, Resilience and the Interaction Between ACEs And Resilience Category.
      Models 1, 2A and 2B
      VariablesaOR (95% CI)P value
      Model 1
      ACEs Category

      Higher ACEs (4 or more)


      3.08 (2.36-4.01)


      <0.001
      Model 2A (as shown in Table 4)
      ACEs Category

      Higher ACEs (4 or more)



      2.65 (2.01-3.48)


      <0.001
      Resilience Category

      Higher resilience (4 or more)


      0.34 (0.27-0.45)


      <0.001
      Model 2B
      ACEs Category

      Higher ACEs (4 or more)


      2.41 (1.84-3.15)


      <0.001
      Resilience Category

      Higher resilience (4 or more)


      0.306 (0.22-3.49)


      <0.001
      ACEs*Resilience1.40 (0.78-2.49)0.26

      Associations Between Caregiver Report of Current Diagnosis of Depression, Lower vs Higher ACEs and Lower vs Higher Resilience among Adolescents (Table 4)

      All models were adjusted for adolescent sex, race, insurance status, parent nativity and marital status. Higher ACEs were associated with higher odds of a current reported diagnosis of depression (adjusted odds ratio [aOR]: 2.65; 95% confidence interval [CI]: 2.01-3.48), while higher resilience lowered odds of a reported diagnosis of depression (aOR: 0.34; 95% CI: 0.27-0.45) in adolescents. Sensitivity analysis with resilience dichotomized at 0-2 vs ≥3, 0-3 vs ≥4 and 0-4 vs ≥5, and resilience as an ordinal variable showed similar results (Appendix Table 8). Having no parent born in the US compared with 2 US-born parents (aOR: 2.04; 95% CI 1.19-3.51), living in a single mother household compared to a married 2 parent household (aOR: 1.47; 95% CI: 1.16-1.88), having public insurance or mixed public and private insurance compared to private insurance (aOR: 1.82; 95% CI 1.44-2.30 and aOR: 1.88; 95% CI 1.20-2.96 respectively), were associated with higher odds of having a current reported diagnosis of depression. Being Hispanic or non-Hispanic, Black adolescent compared to being non-Hispanic, White was associated with lower odds of reported current diagnosis of depression (aOR: 0.64; 95% CI: 0.47-0.87 and OR: 0.55; 95% CI: 0.38-0.78). Being an adolescent male was also associated with lower odds of having a reported diagnosis of depression (OR: 0.73; 95% CI: 0.60-0.89).

      Association Between Caregiver Report of Current Diagnosis of Depression, ACEs, Resilience and the Interaction Between ACEs and Resilience Category (Table 5)

      Next, we examined the role of resilience in the relationship between ACEs exposure and depression. When adjusting for demographic covariates, adolescents with higher ACEs had threefold higher odds of having a reported diagnosis of depression (aOR 3.08; 95% CI 2.36-4.01) Further adjustment for resilience lowers the odds by 14% (aOR: 2.65; 95% CI 2.01-3.48)
      After adjustment for covariates and individual resilience factors, adolescents with higher ACEs had increased odds of having a reported diagnosis of depression (aOR 2.49 95% CI: 1.90-3.26) (Appendix Table 6). Higher family resilience was associated with lower odds of having a reported diagnosis of depression (aOR: 0.49, 95%CI: 0.40-0.61), adjusting for other covariates (Appendix Table 6). Caregivers who somewhat agreed their adolescent was safe at school (aOR: 1.62; 95% CI: 1.29-2.05) or somewhat/definitely disagreed (aOR: 4.49; 95%CI: 2.92-6.92) had increased odds of reported diagnosis of depression compared to caregivers who definitely agreed, when adjusting for other covariates (Appendix Table 6).
      Each resilience factor when added one at a time, lowered the odds of an adolescents’ reported diagnosis of depression and lowered the odds of adolescents with higher ACEs having a reported diagnosis of depression in the logistic regression model (Appendix Table 7). Neighborhood cohesion, specifically school safety had the largest decrease of 15.26% in the effect of higher ACEs on reported diagnosis of depression in adolescents: (OR: 3.08; 95%CI 2.36-4.01 compared to OR: 2.61; 95%CI: 1.99-3.42) (Appendix Table 7). Interaction terms of resilience factors and ACEs added to logistic regression models were not statistically significant (Appendix Table 7).

      Discussion

      In this analysis of a nationally representative adolescent population, we found that higher extrinsic resilience (≥ 4 resilience factors) was associated with lower odds of a reported current diagnosis of depression. This finding is consistent with other studies that have shown the mitigating effect of resilience on negative health outcomes
      • Bellis MA
      • Hughes K
      • Ford K
      • et al.
      Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
      ,
      • Moore KARA.N.
      Adverse Childhood Experience and Adolescent Well-being: Do Protective Factors Matter?.
      ,
      • Ungar M
      • Theron L.
      Resilience and mental health: how multisystemic processes contribute to positive outcomes.
      . Unique to this study was the focus on the extrinsic resilience factors of family resilience, neighborhood cohesion, and caregiver emotional support in relation to reported diagnosis of depression among adolescents. We found that even for adolescents with higher ACEs exposure, adjusting for extrinsic resilience factors lowered the odds of a reported current diagnosis of depression by 14%. We found that each specific resilience factor, independently and significantly lowered the odds of a reported diagnosis of depression even when adjusting for ACE exposure. Notably, there was no effect modification between extrinsic factors and ACEs on the reported diagnosis of depression. This suggests an alternate relationship of ACEs and resilience. Komro et al. suggest that prevention of ACEs is the most effective when started early in life
      • Komro KA
      • Tobler AL
      • Delisle AL
      • O'Mara RJ
      • Wagenaar AC
      Beyond the clinic: improving child health through evidence-based community development.
      . They suggest improving resilience throughout childhood and adolescence could provide additional protection
      • Komro KA
      • Tobler AL
      • Delisle AL
      • O'Mara RJ
      • Wagenaar AC
      Beyond the clinic: improving child health through evidence-based community development.
      . More studies are needed to assess the temporal relationship of ACEs and resilience on negative health outcomes such as depression. Future studies conducting mediation analyses to further asses this relationship should be considered.
      When identifying resilience factors to address mental health issues, prior studies focused on intrinsic factors such as an individual's ability to cope with stress and adversity
      • Connor KM
      • Davidson JR.
      Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC).
      . Our study highlights the importance of family and community based resilience. Whiteker et al. also found that family connection in childhood may influence flourishing decades later, even with early adversity
      • Whitaker RC
      • Dearth-Wesley T
      • Herman AN.
      Childhood Family Connection and Adult Flourishing: Associations Across Levels of Childhood Adversity.
      . When we adjusted for all resilience factors concurrently in one model, only family resilience and neighborhood cohesion, specifically school safety, maintained statistical significance. Our study suggests that these two resilience factors could be key players in mitigating the diagnosis of depression in adolescents. An interesting question for future studies is if there is any additional benefit to increasing resilience beyond a specific threshold, such as in individuals with high family resilience and neighborhood cohesion? These are important considerations especially in resource limited areas where targeted interventions may be designed to promote specific, high yield resilience factors. Also, which resilience factor predominates may be sample dependent.
      Another interesting finding of our study was the protective role school safety played relative to the other resilience factors. Adolescents in the US spend nearly half of their waking time at school
      • Ozer EJ
      • Weinstein RS.
      Urban adolescents' exposure to community violence: the role of support, school safety, and social constraints in a school-based sample of boys and girls.
      . Sadly, some adolescents report being victimized or engaging in or being exposed to violence in school which increases concerns about school safety
      • Naik AD
      • Lawrence B
      • Kiefer L
      • et al.
      Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression.
      . This study adds to the growing literatures that advocate for school safety initiatives, which could utilize the social-ecological framework to promote resilience
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.

      Karen LeMoine JL. What are effective Interventions for building resilience among at risk Youth? [Literature review article]. 2014.

      . For example, focusing on interactions between families and schools working together to mutually support a young person's positive development
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.

      Karen LeMoine JL. What are effective Interventions for building resilience among at risk Youth? [Literature review article]. 2014.

      .
      We also found interesting associations between demographic characteristics and a reported diagnosis of depression in adolescents. Notably, living with a single mother and having public insurance, which are proxy indicators of socio-economic status (SES), were associated with higher odds of a reported current diagnosis of depression. We also found that having no parent born in the US versus 2 US-born parents was associated with higher odds of a reported current diagnosis of depression. This was consistent with growing social determinants of health literature highlighting children of lower SES and racial and ethnic minorities are at increased risk of deleterious health outcomes
      • Komro KA
      • Tobler AL
      • Delisle AL
      • O'Mara RJ
      • Wagenaar AC
      Beyond the clinic: improving child health through evidence-based community development.
      . We found that being Hispanic or non-Hispanic, Black compared to being non-Hispanic, White or having only one parent born in the US compared to 2 US-born parents was associated with lower odds of reported current diagnosis of depression. A possible hypothesis is that minority populations may have limited access to care thus reducing opportunities for diagnosis. Another hypothesis is that individuals from minority backgrounds might be less willing to disclose mental health symptoms due to stigmatization concerns
      US Surgeon General releases report on mental health: culture, race, and ethnicity.
      . After adjusting for these demographic covariates, higher family resilience and neighborhood cohesion still lowered the odds of an adolescent's reported diagnosis of depression. This reinforces how well-functioning family support systems could help protect minority children from the negative behavioral and health-related consequences of stress
      • Perreira KM
      • Marchante AN
      • Schwartz SJ
      • et al.
      Stress and Resilience: Key Correlates of Mental Health and Substance Use in the Hispanic Community Health Study of Latino Youth.
      .
      Finally, caregiver emotional support is significantly associated with lower odds of reported current diagnosis of depression when considered individually without other resilience factors. The social-ecological framework highlights how different distal social interaction has the potential to influence child development indirectly
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.
      . Communities that facilitate social networks provide supportive caregiver relationships, which promote quality child rearing
      • Ungar M
      • Ghazinour M
      • Richter J.
      Annual Research Review: What is resilience within the social ecology of human development?.
      .
      Currently, many adolescents and their caregivers are facing an unprecedented global pandemic with numerous idiosyncratic factors (e.g. financial hardships, virtual schooling) that are affecting their physical, psychological and emotional well-being
      • de Figueiredo CS
      • Sandre PC
      • Portugal LCL
      • et al.
      COVID-19 pandemic impact on children and adolescents' mental health: Biological, environmental, and social factors.
      . Promoting extrinsic resilience could be one of many solutions. As Brown et al. highlighted in Let's Not Settle for Getting Back to “Normal” – Addressing ACEs and Health Behaviors in the Wake of the COVID-19 Pandemic, health providers have the unique opportunity to redefine a new “normal” by taking this opportunity to advance policy and clinical care to address ACEs and improve health outcomes
      • Brown CL
      • Palakshappa D.
      Let's Not Settle for Getting Back to "Normal" - Addressing ACEs and Health Behaviors in the Wake of the COVID-19 Pandemic.
      .

      Limitations

      Our findings should be viewed in the context of several limitations. Although, our analysis was weighted, we cannot make assumptions that our results can be applied to all adolescents. The sample demographics were skewed towards US-born, non-Hispanic, White, college educated, upper socioeconomic populations and therefore associations may not account for nuanced relationships present in differing subpopulations.
      Given the cross-sectional design, the results could only be interpreted as associations with no inferences made about causal relationships. As this was a nationally distributed survey, questions were already predetermined, and measures of resilience were not based on validated screening tools although a panel of experts was consulted for measure development. The survey relies on a caregiver's report of a diagnosis of depression, the validity or method of diagnosis cannot be verified. Notably ACEs and resilience factors were also parent reported and limited in number based on the survey questions. Other potential confounding factors could not be completely eliminated. The potential effect of timing of ACEs experiences could not be examined because information of the specific age of childhood ACEs was not collected. Finally, potential for recall bias or even normal but inaccurate responses to socially desirable worded questions may have yielded unreliable responses and might explain surprisingly high rates of resilience in the population.

      Conclusion

      In this nationally representative sample, family resilience, neighborhood cohesion, and caregiver emotional support were associated with lower odds of reported diagnosis of depression even when adjusting for ACEs. The results of our study are encouraging and should guide further research for systemic interventions to boost extrinsic resilience factors. Future directions include verifying these relationships in more diverse populations, tailoring targeted resilience interventions to communities and adolescents with complex pyscho-social circumstances utilizing the social-ecological framework. Building multi-level, targeted resilience interventions could be our beacon of hope and may lead to better outcomes.

      Declaration of Competing Interest

      The authors have no financial relationships to disclose and no conflicts of interest to resolve.

      Acknowledgements

      The research was supported by NIH/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA Grant Number UL1TR002556. Funding supported the primary author's academic training for the Master's in Clinical Research in the Albert Einstein College of Medicine's Clinical Research Training Program (CRTP). The funding supported training in study design, data analysis and interpretation.

      What's New

      The novel application of socioecological framework to examine the potential effect modification of multiple extrinsic resilience factors on youth exposed to ACEs. This analysis found extrinsic resilience lowers the odds of a reported diagnosis of depression in adolescents.

      References

        • Felitti VJ
        • Anda RF
        • Nordenberg D
        • et al.
        Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
        American journal of preventive medicine. 1998; 14: 245-258
        • Crouch E
        • Probst JC
        • Radcliff E
        • Bennett KJ
        • McKinney SH.
        Prevalence of adverse childhood experiences (ACEs) among US children.
        Child Abuse Negl. 2019; 92: 209-218
        • Cronholm PF
        • Forke CM
        • Wade R
        • et al.
        Adverse Childhood Experiences: Expanding the Concept of Adversity.
        American journal of preventive medicine. 2015; 49: 354-361
        • Finkelhor D
        • Shattuck A
        • Turner H
        • Hamby S.
        Improving the adverse childhood experiences study scale.
        JAMA Pediatr. 2013; 167: 70-75
        • Traub F
        • Boynton-Jarrett R.
        Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice.
        Pediatrics. 2017; 139
        • Soleimanpour S
        • Geierstanger S
        • Brindis CD.
        Adverse Childhood Experiences and Resilience: Addressing the Unique Needs of Adolescents.
        Acad Pediatr. 2017; 17: S108-S114
        • Bethell CD
        • Newacheck P
        • Hawes E
        • Halfon N.
        Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience.
        Health Aff (Millwood). 2014; 33: 2106-2115
        • Font SA
        • Maguire-Jack K.
        Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions.
        Child Abuse Negl. 2016; 51: 390-399
        • Bethell C
        • Davis MB
        • Gombojav N
        • Stumbo S
        • Powers K.
        • Bethell CD
        • Davis MB
        • Gombojav N
        • Stumbo S
        • Powers K.
        Issue Brief: A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive.
        Johns Hopkins Bloomberg School of Public Health, 2017
        • Bomysoad RN
        • Francis LA.
        Adverse Childhood Experiences and Mental Health Conditions Among Adolescents.
        J Adolesc Health. 2020; 67: 868-870
        • Sara G
        • Lappin J.
        Childhood trauma: psychiatry's greatest public health challenge?.
        Lancet Public Health. 2017; 2: e300-e301
        • Bellis MA
        • Hughes K
        • Ford K
        • et al.
        Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance.
        BMC Public Health. 2018; 18: 792
        • Costello EJ
        • Mustillo S
        • Erkanli A
        • Keeler G
        • Angold A.
        Prevalence and development of psychiatric disorders in childhood and adolescence.
        Arch Gen Psychiatry. 2003; 60: 837-844
        • Lu W.
        Child and Adolescent Mental Disorders and Health Care Disparities: Results from the National Survey of Children's Health, 2011-2012.
        J Health Care Poor Underserved. 2017; 28: 988-1011
        • Lu W
        • Xiao Y.
        Adverse Childhood Experiences and Adolescent Mental Disorders: Protective Mechanisms of Family Functioning, Social Capital, and Civic Engagement.
        Health Behavior Research. 2019; 2
        • American Academy of Pediatrics
        Adverse Childhood Experiences and the Lifelong Consequences of Trauma.
        American Academy of Pediatrics. 2014; (Elk Grove Village, IL: AAP)
        • Moore KARA.N.
        Adverse Childhood Experience and Adolescent Well-being: Do Protective Factors Matter?.
        Child Ind Res. 2016; 9: 299-316
        • Heron M.
        Deaths: Leading Causes for 2016.
        Natl Vital Stat Rep. 2018; 67: 1-77
        • Fergus S
        • Zimmerman MA.
        Adolescent resilience: a framework for understanding healthy development in the face of risk.
        Annu Rev Public Health. 2005; 26: 399-419
        • Ungar M
        • Ghazinour M
        • Richter J.
        Annual Research Review: What is resilience within the social ecology of human development?.
        J Child Psychol Psychiatry. 2013; 54: 348-366
      1. Child and Adolescent Health Measurement Initiative (2018). “Fast Facts: 2016-2017 National Survey of Children's Health.” Data Resource Center for Child and Adolescent Health, supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB). Available at www.childhealthdata.org. Revised 9/26, 2018.

        • Child and Adolescent Health Measurement Initiative (CAHMI)
        2016-2017 National Survey of Children's Health (2 Years Combined), [(SAS/SPSS/Stata)] Indicator Data Set. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement from the US Department of Health and Human Services, Health Resources and Services Administration (HRSA).
        Maternal and Child Health Bureau (MCHB), 2019
        • Crouch E
        • Radcliff E
        • Strompolis M
        • Safe Srivastav A.
        Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs).
        J Child Adolesc Trauma. 2019; 12: 165-173
        • Bethell CD
        • Gombojav N
        • Whitaker RC.
        Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity.
        Health Aff (Millwood). 2019; 38: 729-737
        • Al-Jadiri A
        • Tybor DJ
        • Mule C
        • Sakai C
        Factors Associated with Resilience in Families of Children with Autism Spectrum Disorder.
        J Dev Behav Pediatr. 2021; 42: 16-22
        • Kandasamy V
        • Hirai AH
        • Ghandour RM
        • Kogan MD.
        Parental Perception of Flourishing in School-Aged Children: 2011-2012 National Survey of Children's Health.
        J Dev Behav Pediatr. 2018; 39: 497-507
        • Butler AM
        • Kowalkowski M
        • Jones HA
        • Raphael JL.
        The relationship of reported neighborhood conditions with child mental health.
        Acad Pediatr. 2012; 12: 523-531
        • Blumberg SJ
        • Foster EB
        • Frasier AM
        • et al.
        Design and operation of the National Survey of Children's Health, 2007.
        Vital Health Stat. 2012; 1: 1-149
        • Ghandour RM
        • Sherman LJ
        • Vladutiu CJ
        • et al.
        Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.
        J Pediatr. 2019; 206 (256-267 e253)
        • Baron RM
        • Kenny DA.
        The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
        J Pers Soc Psychol. 1986; 51: 1173-1182
        • Stata Statistical Software
        Release 16 [computer program].
        StataCorp LLC, College Station, TX2019
        • Ungar M
        • Theron L.
        Resilience and mental health: how multisystemic processes contribute to positive outcomes.
        Lancet Psychiatry. 2020; 7: 441-448
        • Komro KA
        • Tobler AL
        • Delisle AL
        • O'Mara RJ
        • Wagenaar AC
        Beyond the clinic: improving child health through evidence-based community development.
        BMC Pediatr. 2013; 13: 172
        • Connor KM
        • Davidson JR.
        Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC).
        Depress Anxiety. 2003; 18: 76-82
        • Whitaker RC
        • Dearth-Wesley T
        • Herman AN.
        Childhood Family Connection and Adult Flourishing: Associations Across Levels of Childhood Adversity.
        Acad Pediatr. 2021; 21: 1380-1387
        • Ozer EJ
        • Weinstein RS.
        Urban adolescents' exposure to community violence: the role of support, school safety, and social constraints in a school-based sample of boys and girls.
        J Clin Child Adolesc Psychol. 2004; 33: 463-476
        • Naik AD
        • Lawrence B
        • Kiefer L
        • et al.
        Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression.
        Fam Pract. 2015; 32: 216-223
      2. Karen LeMoine JL. What are effective Interventions for building resilience among at risk Youth? [Literature review article]. 2014.

      3. US Surgeon General releases report on mental health: culture, race, and ethnicity.
        Public Health Rep. 2001; 116: 376
        • Perreira KM
        • Marchante AN
        • Schwartz SJ
        • et al.
        Stress and Resilience: Key Correlates of Mental Health and Substance Use in the Hispanic Community Health Study of Latino Youth.
        J Immigr Minor Health. 2019; 21: 4-13
        • de Figueiredo CS
        • Sandre PC
        • Portugal LCL
        • et al.
        COVID-19 pandemic impact on children and adolescents' mental health: Biological, environmental, and social factors.
        Prog Neuropsychopharmacol Biol Psychiatry. 2021; 106110171
        • Brown CL
        • Palakshappa D.
        Let's Not Settle for Getting Back to "Normal" - Addressing ACEs and Health Behaviors in the Wake of the COVID-19 Pandemic.
        Acad Pediatr. 2021; 21: 1307-1308