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Correspondence: Wendy S. Looman, PhD, APRN, CPNP-PC, School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard St. SE, Minneapolis, MN 55414
Many tools to assess coping in youth fail to engage youth meaningfully in the assessment process. This study aimed to evaluate a brief timeline activity as an interactive way to assess appraisal and coping in pediatric research and practice.
Method
We used a mixed method convergent design to collect and analyze survey and interview data from 231 youths aged 8–17 years in a community-based setting.
Results
The youth engaged readily in the timeline activity and found the activity easy to understand. Relationships among appraisal, coping, subjective well-being and depression were in the hypothesized directions, suggesting the tool supports a valid assessment of appraisals and coping in this age group.
Discussion
The timelining activity is well-accepted by youth and supports reflexivity, prompting youth to share insights on strengths and resilience. The tool may augment existing practices for assessing and intervening in youth mental health in research and practice.
Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society for Developmental and Behavioral Pediatrics, & American Academy of Pediatrics. Promoting optimal development: Screening for behavioral and emotional problems.
Wissow, L. S., Van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children's mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113. doi:10.1016%2Fj.pcl.2015.08.005
Council on Foster Care, Adoption, and Kinship Care, Council on Community Pediatrics, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health Trauma-informed care.
). In addition, many screening tools and questionnaires that purport to measure stress and coping suffer from problems of conceptual clarity or lack of theoretical grounding (
). In this paper, we present a strengths-based, participatory visual approach to the assessment of youth coping and appraisal that has the potential to fill this gap in pediatric research and practice.
THEORETICAL FRAMEWORK: STRESS AND COPING
The coping assessment strategy presented in this paper is grounded in a resilience approach and the transactional model of stress and coping, originally described by
. In this model, coping is managing external and internal demands in the context of one's resources and relationships with the environment. There are two key coping processes in the transactional model: how a person appraises and manages a specific stressful encounter, and changes that occur over time because of coping efforts. Appraisals can be categorized as problem-focused and emotion-focused. Problem-focused coping potential (PFCP) is a person's perception of their ability to change their circumstances to make them more tolerable, and emotion-focused coping potential (EFCP) is one's perception of their ability to handle their circumstances even if they cannot be improved (
). Coping efforts are the strategies a person uses to manage the demands of a stressful situation; these are generally categorized as active, passive, and accommodative (
). Individuals are hypothesized to use different strategies on the basis of their appraisal of their ability to change their circumstances and their ability to handle the situation even if they cannot be improved, and the extent to which the approach is appraised to match the situation (
). As depicted in Figure 1, coping strategies are hypothesized to mediate the relationship between appraisals and outcomes such as well-being and depression (
Assessment of coping in pediatric practice should be guided by evidence around the role of coping in outcomes for youth. Patterns of appraisals and coping strategies have been shown in meta-analyses to be associated with mental health outcomes (
Stress coping strategies as mediators: Toward a better understanding of sexual, substance, and delinquent behavior-related risk-taking among transition-aged youth.
The relationship between stressful events, emotion dysregulation, and anxiety symptoms among youth: Longitudinal support for stress causation but not stress generation.
How to improve the well-being of youths: An exploratory study of the relationships among coping style, emotion regulation, and subjective well-being using the random forest classification and structural equation modeling.
). Coping and emotion regulation have been shown to be central in models of risk and resilience in studies of psychopathology in children and adolescents, though there is less focus on positive outcomes and resilience in community-based, nonclinical samples (
). In general, research that simultaneously explores life stress, coping, and quality of life is rare and typically is limited to specific groups of youth, such as those with existing health issues (
). A recent review of outcomes of appraisal and coping among adults found evidence to support the hypothesis that coping appraisals can support well-being and reduce the risk for depression through positive reframing (
). The assessment aimed to identify a person's appraisal patterns and responses to stress. Experts suggest that labeling strategies as “better” (adaptive) or “worse” (maladaptive) is not useful, recommending instead that assessments include more detailed descriptions of strategies that individuals use to cope with stress and augmenting data from questionnaires with other methods that shed light on youth coping responses (
). Using situation-specific approaches and avoiding measuring coping preferences without situational determinants and behaviors supports findings that will advance the science of coping and its measurement (
). For example, coping with peer rejection is a different challenge than living with a depressed parent. However, many coping questionnaires do not assess the context in which the coping occurs (
One approach to assessing an individual's attempts to manage challenging situations in context is through think-aloud protocols and participatory visual methods, which use interviews and image-based activities to make the thought process more explicit. Think-aloud protocols enable the exploration of how the participant interprets a situation and the factors that influence how they respond to a question (
). Similarly, arts-based or draw-and-tell activities with youth have been shown to facilitate the sharing of more information in an interview process (
). Participatory visual methods have received relatively little attention in the pediatric coping literature, yet these hold promise as “a different way in” to youth's lived experiences, engaging the brain in a way that the respondent may not have the ability to express through words alone (
). Therefore, these methods may augment existing assessment strategies for research and practice with youth.
PURPOSE
This study aimed to evaluate the validity and utility of a timelining activity and structured interview to assess appraisal and coping in youth. The timelining activity has been previously evaluated as a think-aloud method for supporting the assessment of youth well-being and resilience (
), and a set of appraisal and coping measures have been previously evaluated in the assessment of youth coping in the context of pain and daily stressors (
). This study explored an application of the appraisal and coping measures in a coping-focused adaptation of the timelining activity in a community-based sample of youth. Specific aims of the current study were to (1) evaluate the feasibility and acceptability of the coping-focused timelining activity; (2) evaluate the construct validity of the tool in this application; and (3) explore the added value of the activity as a strengths-based, participatory method for assessing youth appraisals and coping.
METHODS
Design
We used a mixed-methods convergent design in this substudy, which was part of a larger study to develop and test the use of timelining in resilience research with youth. In this study, we concurrently collected quantitative and qualitative data and integrated it by merging and weaving it for analysis and interpretation. The goal of this integration was to support the validity assessment through multiple forms of data and to ensure the inclusion of participants’ voices in our understanding of the findings (
). Cross-sectional data were collected using surveys, an interactive timelining activity, and a structured interview with a state-wide, community-based sample of youth.
Sample and Setting
A convenience sample of 272 youth was recruited from individuals attending state and county fairs in a Midwestern state in the summer of 2022. To be eligible for inclusion, participants needed to be aged 8–17 years and able to understand or read English at a third-grade level or higher. The subsample for this study was 231 youth with data on all relevant measures. The setting was a research experience building in which members of the public attending the fair could participate in one or more minimal-risk studies with University-based researchers. For this study, after the informed consent process, participants completed a survey on an iPad, a timelining activity and a brief interview with a study staff member in a booth with a privacy screen. The total protocol took between 15 and 30 min, with approximately half of this time used for the timeline activity and interview. Participants received a small gift as a token of appreciation for their time. The study staff was nurses or nursing students, and all interviewers had experience with pediatric assessment. At all times, at least one doctorally-prepared pediatric nurse practitioner or psychiatric mental health nurse practitioner was on-site as a study investigator. The local Institutional Review Board approved the research protocol for this study.
Timelining Activity
Timelining in this study consisted of a structured draw-and-tell activity in which participants were guided to draw a line on a graph showing their overall life quality over the past year. In this study, the activity was tailored to focus on coping around a specific challenging experience in the past year, with structured interview questions adapted from existing coping and appraisal measures (see Supplementary Material for the interview guide). Examples of completed timelines are shown in Figure 2. In this activity, the participant was provided a blank graph template on paper with time on the x-axis and overall life quality on the y-axis. Anchors for the x-axis are “a year ago” at the origin and “now” at the far right, with each month of the previous year listed under the line. Anchors for the y-axis are “the worst it could be” at the origin and “the best it could be” at the top, with “OK” at the midpoint. Participants were asked to draw a line using the following prompt:Think about your life in general over the last year, all things considered. We want to know how you would rate your life now, a year ago, and the time in between. Draw a single line on the graph to show how things have been over the year.
FIGURE 2Participant timeline examples.
Each participant was provided a blank graph template with the x- and y-axes labeled as above and instructed to draw a line using the following prompt: “Think about your life in general over the last year, all things considered. We want to know how you would rate your life now, a year ago, and the time in between. Draw a single line on the graph to show how things have been over the year.”
Next, the participant was guided in a structured interview about a point on the line representative of a challenging or stressful situation and their response to situations similar to this challenge.
Measures
The larger study included a set of measures of constructs in the resilience portfolio model (
). Here, we report only on those measures necessary to address the aims of this substudy. These measures focus on assessing feasibility and acceptability, coping appraisals, coping strategies, and well-being outcomes.
Feasibility and acceptability
Feasibility and acceptability of the coping-focused timelining tool were assessed using a visual analog scale, computer-captured time to complete the activity, and open-ended questions about the participant's experience of completing the timeline activity. We asked each participant to rate their perception of how easy or hard the timeline drawing activity was for them on a visual analog scale of 1–10 (1, really easy; 10, really hard). The total time to complete the timeline activity and interview was measured by timestamps in REDCap (
). We collected qualitative data from participants on their overall experience of the activity through a 1:1 interview that included the following open-ended questions: (1) What would you say is most important about the way you drew your line graph? (2) After drawing this line graph and talking about it, what do you think this shows about you and your ability to bounce back after challenges and stress? and (3) Is there anything else you would like to tell us about why you drew the line the way you did? These questions were developed to align with recent policy recommendations from the American Academy of Pediatrics on trauma-informed care, in which the line of questioning moves from “what happened to you?” to “what's strong with you?” (
Council on Foster Care, Adoption, and Kinship Care, Council on Community Pediatrics, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health Trauma-informed care.
, p. 5). The questions are designed to prompt the participant to reflect on their coping appraisals and strategies and capacity for resilience. We used participant responses to these questions to indicate the usefulness and feasibility of using the timeline to engage youth in self-reflection on their resilience.
Coping appraisals
Coping appraisals were operationalized as the participant's perception of the difficulty of the challenging experience identified in the timeline exercise (stressor severity as a primary appraisal, and EFCP and PFCP as secondary appraisals). These questions were adapted from a set of questions described by
, who developed the measures for use with youth in the context of pain and daily stressors in children. As part of the interview, all items were read to the respondent during the timelining activity after they identified a past-year challenge, and response options were presented on a card for the participant to select after each item. Stressor severity was operationalized as the participant's response to the question, “How difficult was it for you when that happened?” (on a scale from 0 [not at all difficult] to 4 [a whole lot]). To measure PFCP, we asked youths to think about the challenging situation identified in the timeline exercise, to indicate whether they thought they could do anything to make the situation better, and then to indicate how sure they were that they could (or could not) make the situation better. Responses to these two questions were combined to create a 9-point PFCP scale ranging from −4 (the respondent was certain they could not make the situation better) to 4 (the respondent was certain they could make the situation better). To measure EFCP, we asked, “when that happened, did you think you would be able to handle it, even if the situation didn't get better?” (with a follow-up question about their certainty about this ability to handle it). As with the EFCP measure, potential EFCP scores ranged from −4 to 4.
Coping strategies
We used three measures of coping strategies described in the previously mentioned study by
. The active coping scale contains three items that reflect strategies to improve one's circumstances (e.g., asking someone for help). The passive coping scale contains three items that reflect negative cognitions and a lack of active problem-solving efforts (e.g., think to yourself that there was nothing you could do, so you did not even try). The accommodative coping scale contains four items that reflect strategies that use acceptance and positive reappraisal (e.g., try to accept it). For each of these sets of items, youth were asked how often they use each strategy when they experience challenges similar to the one identified on their timeline, with responses rated on a 5-point scale ranging from 0 (not at all) to 4 (a whole lot). Cronbach's alpha measures of internal consistency reliability for the active, passive and accommodative coping scales in this sample were 0.61, 0.65 and 0.45, respectively. Although the internal consistency of the accommodative coping measure in this sample was relatively low, we elected to keep all three measures for analysis because of their value as a set in hypothesis testing for this study.
Well-being outcomes
To support the assessment of construct validity through hypothesis testing, we included two outcome measures that should be associated with appraisals and coping on the basis of theory and existing evidence: subjective well-being and symptoms of depression. These measures were included in the survey portion of the protocol, completed by the participant on an iPad. Subjective well-being was operationalized as a score on a measure from the Resilience Portfolio Questionnaire by
. This measure, developed for youth, consists of seven items that assess a person's perception of how well their life is going (e.g., “I am satisfied with my life”). Response options range from 1 (not true about me) to 4 (mostly true about me), with a possible range of scores of 7–28. Depression symptoms were measured using a validated 8-item set from the National Institutes of Health Quality of Life in Neurological Disorders system designed for use with youth (
). This measure includes items to assess self-reported experiences such as negative mood, loss of interest, problems in decision-making, and self-criticism over the past 7 days. Raw scores are transformed into standardized t score distributions with a mean of 50 and a standard deviation of 10, normed in a general pediatric population (
). Cronbach's alpha measures of internal consistency reliability for the subjective well-being and depression scales in this sample were 0.86 and 0.90, respectively.
Analysis
Analysis of quantitative data was completed using SPSS software (IBM Statistics 27). Internal consistency reliability was calculated for the coping scales (active, passive, and accommodative) and the outcome measures (subjective well-being and depression). In addition to quantitative data analysis, we reviewed transcribed comments from interviews with participants for patterns and themes, as described more fully below in the section on qualitative integration.
Construct Validity
To evaluate construct validity, we used two hypothesis testing strategies. First, we used bivariate correlations and a comparison of means (analysis of variance [ANOVA]) to assess whether the relationships among constructs measured through the timeline activity were consistent with hypothesized relationships in the stress and coping model. The second strategy to assess construct validity was to test a mediational model of stress and to cope. According to appraisal theory (
), stress appraisals are associated with well-being and depression outcomes through their influence on coping (Figure 1). To test the mediational model, we replicated a series of hierarchical regression analyses reported by
, whose approach was also used to operationalize our appraisal and coping variables. These analyses followed the logic of mediational analyses, which require that a mediator variable must meet the following conditions (as depicted in Figure 1): (1) the independent variable is significantly associated with the mediator variable (path a); (2) the independent variable is significantly associated with the dependent variable (path c); and (3) when the independent variable and the mediator variable are accounted for, the relationship between the mediator and outcome (path b) is statistically significant, and the new coefficient between the independent and dependent variables is smaller than the previous coefficient (path c;
MacKinnon, D. P., Fairchild, A. J., & Fritz, M. S. (2007). Mediation analysis. Annual Review of Psychology, 58, 593–614. doi:10.1146/annurev.psych.58.110405.085542
We conducted three sets of hierarchical regression analyses for each outcome, subjective well-being and depression. We considered the three coping appraisal variables (stressor severity, PFCP, and EFCP) and the three coping strategy variables (active, passive, and accommodative coping) each as a set to evaluate their contributions as predictor variables simultaneously. In the first set of analyses, we regressed the three coping strategy variables on the coping appraisal variables to test whether appraisal predicted coping, the hypothesized mediator. In the second set of analyses, we tested the extent to which appraisal predicted the outcomes when considered alone as a set. Then, the coping variables (the hypothesized mediator) were entered in a third step to determine their contribution to the outcomes when controlling for appraisal. In the third set of analyses, coping variables were entered before the appraisal variables to evaluate the relationship between the appraisal variables and the outcome when controlling for appraisal. This final step enabled the assessment of whether partial or full mediation was present. Because both the appraisal and coping variables were measured as a set rather than as single variables, Sobel's test was not used to examine the significance of the mediation effect.
Qualitative Integration
Qualitative and quantitative data were integrated by merging and weaving in the analysis and interpretation phases (
). To better understand how participants experienced and understood the timelining activity and to evaluate the added value of this activity in assessing youth appraisals and coping, we merged the quantitative survey data with the qualitative data from the timeline interview for each participant. Then, we sorted data from participants into four appraisal groups on the basis of their combination of EFCP and PFCP scores. The grouping was based on transactional coping theory, which hypothesizes that individuals use coping efforts that align with their appraisal of their ability to change their circumstances (high vs. low PFCP) and whether they believe they can handle the situation if it cannot be changed (high vs. low EFCP). Qualitative data analysis consisted of a review of transcribed interviews for all participants for initial themes and patterns within each group and as a whole. Exemplar comments were selected to contextualize the quantitative summaries of data. Research team members who completed the coding and interpretation of qualitative data included doctorally-prepared nurses with experience in pediatric nursing, mixed-methods research, and youth mental health.
RESULTS
Participants were aged from 8 to 17 years (mean 5.5 ± 2.8 years). More than half (51.5%) of the respondents identified as female gender, 44.5% identified as male gender, and 3.3% identified as nonbinary gender. Two-thirds (68%) of the sample reported their race as White, 8.7% identified as Asian, 2.6% as American Indian or Alaskan Native, 1.3% as Black, African, or African American, and 6.5% as multiracial; 13% opted not to report their race or indicated they did not know. Less than 5% of respondents identified as Hispanic or Latinx. Two-thirds (66.2%) of respondents resided in urban areas, and 33.8% were from nonurban areas (including large rural cities and towns and small and isolated towns). Descriptive statistics for the main measures are presented in Table 1. A summary and examples of the types of challenges described by participants in the timeline activity are reported in Table 2. The most common types of past-year challenges described in the timelining activity were school-related (33.8%), mental health-related (15.6%), and friend-related (12.6%).
TABLE 2Summary of past-year challenges reported by participants, with examples
Challenge category
Challenge descriptions in participant words (examples)
n (%)
School-related
Finals, hard classes, bullying, tests
78 (33.8)
Mental health-related
Anxiety, depression, body-insecurity
36 (15.6)
Friend-related
Challenges with friends, friend drama, lost a friend
29 (12.6)
Parent-related
Parents divorced, parent stressed, dad lost job
22 (9.5)
Physical health-related
Had COVID, broke ankle, torn muscle
14 (6.1)
Sibling-related
Fighting with sister, brother did not want to be with me
12 (5.2)
Sports-related
Coach was difficult, did not make nationals, soccer
11 (4.8)
Pet-related
Dog died, cat died, dog was sick
7 (3.0)
Something else
Grandma died, got in trouble, I got lost
22 (9.5)
Note. This table summarizes participant responses (n = 231) to the following prompts: (1) Challenge Category: “Thinking about this point on the graph [when things were challenging or not so great for you, but then things got better after], what kind of a challenge or stressor was this for you? You can select one of the following categories, or we can call it something else if nothing fits,” and (2) Challenge Descriptions: would you like to tell us more about this experience, or shall we just call it “the challenge”? Either one is OK.”
Four of the 272 youths initially enrolled in the main study opted not to complete a timeline. Eighty-five percent (231) had complete data on the survey, timeline, and interview portions of the protocol for this analysis. Of the full sample of 272 youths who consented to the study, 23 (8.5%) opted out of some or all of the interviews; an additional 18 (6.6%) were excluded from this analysis because of missing or incomplete survey data. The youth who opted out of some or all the interview portion of the protocol tended to be slightly younger (the mean age for those who opted out was 10.9 years, and the mean age for the analysis sample was 12.5 years); as a group, they were not otherwise significantly different from those who completed the full interview. The average time to complete the timeline activity and interview was 7.3 ± 2.5 min (median = 6.9). The mean rating for ease of completing the timeline on a scale of 1 (really easy) to 10 (really hard) was 3.3 ± 2.0 (mode = 1, median = 3). Ratings on this item were not significantly different by age or gender. Qualitative responses to interview questions about the timeline experience are summarized below in the section on quantitative-qualitative integration.
Hypothesis Testing: Bivariate Associations
Correlations among main variables, including coping appraisal, coping strategies and outcomes, are provided in Table 3. Consistent with the hypothesized relationships, PFCP, EFCP and active coping was positively correlated with subjective well-being and negatively correlated with depression. In comparison, stressor severity and passive coping were negatively correlated with subjective well-being and positively correlated with symptoms of depression. Figure 3 summarizes subjective well-being and depression scores by appraisal group. ANOVA tests for between-group differences were significant for mean scores on subjective well-being (F[3, 227] = 12.03, p < .001) and depression (F[3, 227] = 6.81, p < .001). Children with both high EFCP and high PFCP had the highest mean score on subjective well-being and the lowest mean score on depression. In contrast, low EFCP and low PFCP scored the lowest on subjective well-being and the highest on depression. Figure 4 shows a summary of coping strategies by appraisal group. Consistent with the hypotheses, individuals with high perceived PFCP had higher scores for active coping strategies, and individuals with low perceived PFCP had higher scores for passive coping strategies. ANOVA tests for between-group differences were significant for active (F[3, 227] = 7.30, p < .001) and passive coping (F[3, 227] = 8.62, p < .001). Appraisal group scores on accommodative coping were not significantly different (F[3, 227] = 1.78, p = .151).
TABLE 3Bivariate correlations among main variables
FIGURE 3Subjective well-being and depression by appraisal group, with interview exemplars.
PFCP, problem-focused coping potential; EFCP, emotion-focused coping potential. Exemplar comments for each appraisal group are color-coded to match the respective boxplots. This figure appears in color online at www.jpedhc.org.
FIGURE 4Mean scores for active, passive and accommodative coping, grouped by appraisal group.
Group means for active and passive coping are significantly different (p < .001). EFCP, emotion-focused coping potential; PFCP, problem-focused coping potential. This figure appears in color online at www.jpedhc.org.
The results of the three-step mediational analysis are presented in Table 4. In the first analysis, in which coping was predicted from appraisals, EFCP and PFCP but not severity predicted coping in the hypothesized directions. Specifically, active coping was positively associated with appraisals of PFCP. Accommodative coping was positively associated with appraisals of EFCP but was not associated with PFCP, and passive coping was negatively associated with both PFCP and EFCP, all in the hypothesized directions. The model for accommodative coping did not account for a significant amount of variance. In the second set of analyses predicting outcomes from coping, the appraisal variables alone (path c) predicted both subjective well-being and depression as a direct effect, demonstrating a necessary prerequisite for mediation (
In the third set of analyses predicting outcomes from appraisals and coping, the passive coping variable was significantly associated with subjective well-being and symptoms of depression, and the coefficients of the appraisal variables became smaller or insignificant. This result demonstrates that the coping variables mediate between the appraisal and the outcomes. As in previous analyses, accommodative coping was not significant in the model. Appraisals of severity continued to predict both outcomes in the expected directions after controlling for coping. For both outcomes, the contribution of passive coping was weaker when the appraisal variables were entered into the model first, compared with when they entered alone in the third set of analyses. This suggests that the effects of coping on these outcomes may be mediated by the appraisal and/or that the effects of appraisal are mediated by coping. In other words, the path in Figure 1 may be more accurately depicted as bidirectional.
Quantitative-Qualitative Integration
In response to the two questions (“What would you say is most important about the way you drew your line graph?” and “After drawing this line graph and talking about it, what do you think this shows about you as a person and your ability to bounce back after challenges and stress?”) most participants readily elaborated on the characteristics of the timeline and their assessment of how it reflected their coping and resilience. Several youths commented on the variability of the line over time, with comments such as “It shows that I have seasons” and “It shows what time of year I'm feeling best about myself.” Youth also reflected how seasonal or event-based variability reflected situational challenges and their response to them. For example, one participant shared:It started to get higher towards fall, which is when cross country season started, and that really improved my mental health because I met a lot of wonderful people and started to distract myself from the stressors in my life.
Several participants responded to the prompt about how the timeline reflected their ability to “bounce back” with comments that mirrored the sentiment of the question, with responses such as “It shows that I can persevere through it. I just need to have the supports to get through it,” and “It helps me realize what I've gone through and that things eventually get better,” and “It says that I can do it. I can do hard things.”
When grouped according to appraisal patterns, quantitative results were consistent with hypothesized relationships between coping appraisals, coping strategies, and outcomes; qualitative comments shed additional light on these data in our sample. Representative comments for youth in each appraisal group are presented in Figure 3. Many respondents with both high PFCP and high EFCP self-identified as resilient, compared with respondents with both low EFCP and low PFCP. For example, a youth with high PFCP and high EFCP stated, “I can handle stressors pretty well,” whereas a youth with low PFCP and low EFCP noted, “I don't think that I'm good at [bouncing back],” and another said, “Honestly I think it was just the meds.” Overall, comments from youth in all four groups reflect some hope and belief in their ability to cope with hardship and stressful experiences. Several youths observed that looking back at their past year and reflecting on their response to challenging experiences helped them reframe their experiences and coping capacity more positively (e.g., “I'm a little more resilient than I thought I could be” [low EFCP/high PFCP] and “After thinking about things I can come up with things that help me keep going” [low EFCP/low PFCP]). This type of comment, in which an effective coping response was recognized only after reflection, was more common among youth with low EFCP or those who tended to indicate low confidence in their ability to handle an unchangeable stressor at the time it was happening. Youth with high EFCP and high PFCP tended to reflect more confidently on their capacity to bounce back and were more likely to name strategies that supported effective coping, such as, “I just kind of got help, stayed positive, got help and got through it.”
DISCUSSION
Overall, the coping-focused timelining activity and structured interview in this study demonstrated construct validity, feasibility and utility for assessing appraisal and coping in youth. Our results were consistent with a mediational model in which coping mediates the relationship between appraisal and outcomes. The timeline activity meets the need for situation-specific approaches to coping measurement that examine coping efforts and behaviors in context (
). Because the timeline facilitates conversation around the dynamics of a coping response after a stressful experience, this tool fills a noted gap in the literature (
Routine assessment of stress, coping, and social-emotional regulation in children and adolescents requires tools that are easy to administer and that meaningfully engage youth in the assessment process. The timeline activity described here represents a feasible strategy for quickly engaging youth in a coping assessment, meeting the call for this routine assessment in practice (
Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society for Developmental and Behavioral Pediatrics, & American Academy of Pediatrics. Promoting optimal development: Screening for behavioral and emotional problems.
Wissow, L. S., Van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children's mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113. doi:10.1016%2Fj.pcl.2015.08.005
). The structured interview was effective in eliciting rich reflections from youth on their perceptions of their ability to change challenging circumstances to make them more tolerable (PFCP) and their ability to handle situations that could not be improved (EFCP), along with their assessment of how their efforts to manage these situations led to short- and long-term outcomes. Although a small percentage of youth elected not to complete the full activity, the fact that more than 90% of all participants completed the timeline and interview component of the protocol is a strong endorsement of the activity as youth-focused and acceptable. This completion rate is particularly notable given the setting at community fairs, in which youth elected to step away from other activities to complete the activity with a nominal reward.
, we found that appraisals and coping contribute to subjective well-being. Except for the accommodative coping measure, the relationships among variables were hypothesized, offering support for the construct validity of these measures used in the study. However, accommodative coping as operationalized was not significant in most analyses and may not be a reliable or valid measure of coping as used in this study. In contrast, many of the interview comments by youth reflected strategies that would be considered accommodative, by definition (i.e., using acceptance and reappraisal), suggesting that a refinement of the items used to measure this construct could be useful. Our findings suggest that the effects of coping on outcomes may be mediated by the appraisal and/or that the effects of appraisal are mediated by coping.
noted that coping appraisals, strategies and outcomes might influence each other in a reciprocal, iterative process over time. Different coping strategies may likely influence future appraisals and strategies on the basis of whether they lead to better or worse outcomes. More research is needed to assess the extent to which youth recollection of past challenging experiences is influenced by social desirability or trust (
) and additional reliability and validity assessments are needed in prospective studies of the timelines tool with youth.
As a think-aloud method for assessing youth resilience, the tool represents a strengths-based, participatory method for use in research and practice with youth that takes < 10 min to complete, on average. This tool can augment data from questionnaires with other methods to shed light on youth coping responses, as recommended in recent reviews of existing methods of coping assessment (
). The activity can help the participant share with the assessor how they interpreted a challenging situation and what factors influenced their response, which is a key benefit of think-aloud protocols in research and practice (
). As other researchers have discovered, this type of activity can provide a richer, more credible reflection of the youth's lived experience, sharing more information than would be revealed by a traditional quantitative screener around a challenging experience (
). Helping youth reflect on and understand how they respond to stress and how their responses lead to outcomes can be a useful approach to youth intervention.
Limitations
We are limited in the ability to draw causal conclusions from the cross-sectional data in this study. The racial and ethnic diversity of our sample closely matched the demographic profile of youth in the state, which is somewhat homogeneous and not reflective of the national demographic profile of youth. Because we recruited participants from state and county fairs, the setting was somewhat informal and may have limited the participant's ability to engage fully in the activity. Some participants who initially began the study opted to end the activity early and were not included in the final sample. Although the main study was grounded in the resilience portfolio model, this analysis was limited to the portion of the model that includes coping and appraisals; the broader model includes additional important factors in resilience, including resources such as supportive relationships and strengths such as meaning-making and future orientation, which may further mediate and moderate the relationships tests in this study. Those model elements are addressed in a separate report that explores relationships among a larger set of variables in the model.
IMPLICATIONS FOR RESEARCH AND PRACTICE
Assessment of youth social-emotional development in pediatric practice should not be considered an “add-on” but a core competency that can be incorporated into the workflow. As a complement to communication skills and a therapeutic alliance, tools that support brief (5–10 min) assessments and interventions are a core component of evidence-based care of children and adolescents (
American Academy of Pediatrics Mental health tools for pediatrics.
in: Earls M.F. Foy J.M. Green C.M. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians. 2nd ed. American Academy of Pediatrics,
2021
Wissow, L. S., Van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children's mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113. doi:10.1016%2Fj.pcl.2015.08.005
). There is evidence that savoring after a stressful event is a meaning-focused coping response in which an individual finds positive value in an experience (
). In both clinical and nonclinical samples, self-reflection and reinterpretation of challenging experiences in the presence of another person have been shown to support therapeutic meaning-making (
). A deeper emphasis on meaning-making as part of the timeline interview might support further reflection on this aspect of coping for youth. The timeline activity may be particularly useful for youth with low EFCP, reframing coping potential around situations beyond their control. Because it supports visualization of patterns and reflections on the outcomes of past coping strategies, the coping-focused timelining activity might also be useful as a component of mental health treatment and self-management programs such as Wellness Recovery Action Planning, which have been successful in helping individuals plan for distressing experiences (
Brief Wellness Recovery Action Planning (WRAP®) as a mental health self-management tool for community adults in Hong Kong: A randomized controlled trial.
Future research might explore characteristics of youth for whom the activity is most beneficial as a supplemental assessment or as an intervention to support reflexivity and meaning-making around a challenging experience. Routine coping assessments such as the timeline activity can also identify youth who may benefit from further screening, referrals and interventions and can aid in identifying shared goals for treatment outcomes (
). The activity might be useful for professionals in various clinical and nonclinical settings, including primary care, mental health, and schools. Ongoing attempts to study coping and resilience in diverse samples are necessary to build a body of valid and trustworthy evidence on equitable, health-promoting environments for youth who experience a range of risks and adversities (
Designing resilience research: Using multiple methods to investigate risk exposure, promotive and protective processes, and contextually relevant outcomes for children and youth.
). Research, policy, and program development will benefit from more inclusion of youth voices and an approach to resilience that is strengths-based and focused on positive outcomes rather than problems and pathology (
The coping-focused timelining activity is a brief assessment tool that is feasible to administer in a community-based setting and was well-accepted by youth aged 8–17 years. The tool validly assesses youth self-perceptions of coping appraisals and coping strategies in the context of a challenging experience in the past year, engaging youth meaningfully in a strengths-based, participatory assessment. Implications for practice include using the activity in clinical and community-based settings with youth to assess coping and appraisal and as an intervention to support self-reflection and reinterpretation of challenging experiences. Prospective studies to examine the tool's effectiveness as an intervention with diverse samples will further advance the science related to coping and well-being in youth.
The authors wish to acknowledge Ellen Demerath, Logan Spector, Annie Hotop, and the University of Minnesota School of Nursing Driven to Discover research mechanism and the contributions of Denise Blankenship and the student volunteers for the Tip Top Kids study.
in: Earls M.F. Foy J.M. Green C.M. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians. 2nd ed. American Academy of Pediatrics,
2021
Stress coping strategies as mediators: Toward a better understanding of sexual, substance, and delinquent behavior-related risk-taking among transition-aged youth.
Council on Foster Care, Adoption, and Kinship Care, Council on Community Pediatrics, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health
How to improve the well-being of youths: An exploratory study of the relationships among coping style, emotion regulation, and subjective well-being using the random forest classification and structural equation modeling.
MacKinnon, D. P., Fairchild, A. J., & Fritz, M. S. (2007). Mediation analysis. Annual Review of Psychology, 58, 593–614. doi:10.1146/annurev.psych.58.110405.085542
Brief Wellness Recovery Action Planning (WRAP®) as a mental health self-management tool for community adults in Hong Kong: A randomized controlled trial.
The relationship between stressful events, emotion dysregulation, and anxiety symptoms among youth: Longitudinal support for stress causation but not stress generation.
Designing resilience research: Using multiple methods to investigate risk exposure, promotive and protective processes, and contextually relevant outcomes for children and youth.
Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood, Society for Developmental and Behavioral Pediatrics, & American Academy of Pediatrics.
Promoting optimal development: Screening for behavioral and emotional problems.
Wissow, L. S., Van Ginneken, N., Chandna, J., & Rahman, A. (2016). Integrating children's mental health into primary care. Pediatric Clinics of North America, 63(1), 97–113. doi:10.1016%2Fj.pcl.2015.08.005
Wendy S. Looman, Professor, School of Nursing, University of Minnesota, Minneapolis, MN.
Donna Eull, Clinical Associate Professor, School of Nursing, University of Minnesota, Minneapolis, MN.
Elena Geiger-Simpson, Clinical Assistant Professor, School of Nursing, University of Minnesota, Minneapolis, MN.
Jiwoo Lee, Assistant Professor, School of Nursing, University of Minnesota, Minneapolis, MN.
Paula V. Nersesian, Assistant Professor, School of Nursing, University of Southern Maine, Portland, ME.
Adrianna N. Bell, PhD Student, School of Nursing, University of Minnesota, Minneapolis, MN.
Angela L. Miller, PhD Student, School of Nursing, University of Minnesota, Minneapolis, MN.
Article info
Publication history
Published online: March 06, 2023
Editor: Martha Swartz
Publication stage
In Press Corrected Proof
Footnotes
This work was supported by the University of Minnesota School of Nursing Foundation and the School of Nursing Office of Nursing Research and Scholarship. Lee was supported by a career development award funded by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health award number 1K23HD107179 (PI: Lee)
The University of Minnesota Institutional Review Board approved the protocol for this study.
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