Accepted Manuscript

Resilience and resilience factors in children in residential care: A

systematic review

Yunfei Lou, Emily P. Taylor, Simona Di Folco

PII: S0190-7409(17)31004-6
DOI: doi:10.1016/j.childyouth.2018.04.010
Reference: CYSR 3778
To appear in: Children and Youth Services Review
Received date: 22 November 2017
Revised date: 4 April 2018
Accepted date: 4 April 2018

Please cite this article as: Yunfei Lou, Emily P. Taylor, Simona Di Folco , Resilience
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Resilience and Resilience Factors in Children in Residential Care: A Systematic Review

Yunfei Lou, MSc, BA

Emily P. Taylor, DClinPsychol, MA(Hons)*

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Simona Di Folco, PhD, MSc, BSc

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*Corresponding author US
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all authors: Centre for Applied Developmental Psychology, Department of Clinical and
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Health Psychology, School of Health in Social Science, University of Edinburgh, Teviot Place,
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Edinburgh, UK, EH8 9AG.

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E-mail: Emily.Taylor@ed.ac.uk

Telephone: +0044(0)131 650 3892

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Abstract

Young people raised in residential care settings are more vulnerable to poor mental

health than peers in the general population. Resilience can protect mental health and promote

recovery from adversity. The lack of a single clear conceptualisation of resilience reflects its

complex, multifaceted nature, but create obstacles for measurement in this population. This

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review explored the conceptualisation, operationalisation and measurement of resilience in

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children and adolescents living in residential care settings. Databases were investigated up to

November 2017 and fifteen studies were included. Among the resilience-related factors found,

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those promoting interpersonal relationships and development of a future focus and motivation
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were particularly noticeable. Overall, adolescents in residential care were reported as being

more vulnerable and presenting more problems compared to peers. Higher levels of resilience
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were associated with better developmental outcomes. Recommendations are made to

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systematically include and evaluate resilience promoting design and interventions in residential

care settings.
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(148 words)
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Keywords: residential care, resilience, vulnerability, systematic review

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1. Introduction

Alternative care may take the form of informal care, including any family environment

where the child is looked after on a temporary or permanent basis by relatives or family friends,

prior to an order of the judicial authority, or formal care, comprising all care provided in a

family environment ordered by a competent administrative body or in private facilities, such as

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foster, kinship, and residential care (United Nations, 2010). Recognising the international

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variations in terminology (e.g. ‘foster children’ in the USA and ‘looked after and accommodated

children’ in the UK), we describe these children as ‘care-experienced’ or in ‘alternative care’,

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unless specified to a particular care setting. Children in alternative care experience elevated
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levels of psychopathology, neurodevelopmental disorders and educational difficulties (Ford,

Vostanis, Meltzer, & Goodman, 2007), compared to their non-care-experienced peers. The
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difficulties often persist into adulthood, with high levels of incarceration, homelessness and
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unemployment, reflecting in part a background of significant early-life adversity (Culhane &

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Taussig, 2009). These difficulties are particularly amplified amongst adolescents accommodated

in residential care, with higher rates of mental illness, including suicidal tendencies, depression
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and post-traumatic stress disorder (PTSD), than youth in other community populations (Gearing
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et al., 2015). Recent evidence suggests a prevalence of psychiatric disorders of 76% in children

in residential care, compared to 8% in the general child population (Jozefiak et al., 2016). This

supports earlier evidence of risk of depression being 50%, twice that of children in foster care

(Dimigen et al., 1999).

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In this context, it is tempting for researchers and practitioners alike to focus on

problems, risk and crisis management, and harm reduction in institutional settings . In doing so,

a strengths-based approach that fosters long-term resilience is de-emphasised.

Resilience is defined as the ability to cope after a trauma/stressor (Masten et al., 1999;

Masten, 2001) and is further defined as a set of individual features that may offer

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coping/protection in facing adversity (Hoge, Austin, & Pollack, 2007). The capacity to “bounce

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back” from adverse life circumstances (Tugade & Fredrickson, 2011) reflects adaptation and is

an evolutionary survival mechanism. This capacity exists on a continuum ranging from well-

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adapted (and highly resilient) to maladapted (low resilience, predisposed to psychiatric
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disorders) (Ehlert, 2013). Latterly, the definition of resilience has changed from a trait-oriented,

intrinsic, personality trait to an outcome or a process -oriented perspective (Wright, Masten &
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Narayan, 2013), in which mental health can be regained or maintained despite adverse life
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events (Kalisch et al., 2017). The exposure to significant risks or adversity is necessary for the
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emergence of resilience (Chmitorz et al., 2018). This definition opens up the possibility that

resilience, as an outcome, can be modified and predicted by multiple factors , including

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epigenetics, personality traits, and beliefs (Southwick, Bonanno, Masten, Panter-Brick, &
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Yehuda, 2014). Beyond individual features, environmental factors play their role (e.g. social

environment, availability of and access to economic resources). Lastly, resilience can also be

understood as a dynamic and adaptive process, influenced by features of the adversity (e.g.

chronic or acute events, level of exposure, direct or indirect) and played out in multiple possible

trajectories in the aftermath of the event (Bonanno, Romero, & Klein, 2015). One step beyond

this definition is represented by posttraumatic growth (Angel, 2016), in which individuals

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describe improved functioning after exposure to adversity through positive transformation in

multiple domains (e.g. increasing closeness, optimism, spiritual values).

In order to provide evidence of resilience the individual has to display a successful

outcome or adaptation. This could be problematic for care-experienced young people who are

exposed to particularly high and chronic levels of risk, often pre-dating birth, that make

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measurement of pre-adversity functioning difficult. Nonetheless, resilience has been linked to

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better quality of life and health outcomes in care-experienced youth more generally (Chia & Lee,

2015). A review of eight evidence-based interventions aimed at promoting resilience in children

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in foster care reported improved outcomes, including decreased placement disruptions (thus
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reducing the likelihood of entering residential care), improved child attachment to adults,

reduced child behavioural and emotional problems, and increased child strengths (Leve et al.,
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2012). The promotion of resilience has been the focus of frameworks developing children’s
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attachment, self-regulation, and competency (Blaustein & Kinniburgh, 2010; Jones et al., 2011).
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Treatments promoting resilience for children in foster care resulted in positive outcomes

including school attendance and the avoidance of negative outcomes, such as violent
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criminality and use of psychotropic drugs (Jones et al., 2011). It is likely these benefits would
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extend to children in residential care (Dimigen et al., 1999).

Differentiated from foster care, residential care usually focuses on keeping youth safe in

a group and thus pays more attention to the avoidance of negative behaviours, rather than

promoting positive outcomes. As a consequence of risk-averse practices, care environments

may be too restrictive to allow opportunities for resilience to be expressed and developed.

Fostering resilience in residential care settings is therefore of particular relevance given the
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levels of prior adversity and the compromised outcomes currently found. This is reflected in

the evidence base for resilience in residential care where measurement seems to reflect a

problem-focus (or absence of problem), as opposed to a strength-focus. For example, Born,

Chevalier, & Humblet (1997) conceptualised resilience as a rare phenomenon defined by

absence or decrease of delinquent acts.

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Other studies have focused on promoting strengths and resilience in residential-care

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adolescents. Lietz (2004) suggested a new theoretical framework of residential treatment, using

resilience as the foundation and social learning theory as the strategy. Resilience-building and

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social learning theory are hypothesised to work on both internal and external, as well as long-
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term and short-term changes. Three successful case studies examined two groups that were

from residential facilities using this framework (Lietz, 2007; Nourian et al., 2016; Sesma,
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Mannes, & Scales, 2013) and suggested a developmental assets framework, which consisted of
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40 research-based, positive experiences and qualities influencing children’s development. They

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also described the relationship between the strengths-focus framework and the resilience

framework, and suggested that both frameworks shared similarities, such as positive outcomes,
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but differed in other areas such as a lack of previous adverse experiences in the developmental
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assets framework.

The lack of consistent resilience conceptualisation implies disagreement about the

nature of resilience (Nourian et al., 2016) and its influence on individual or systemic outcomes

(Kaplan, 2005). Heterogeneity in the definition of resilience makes it difficult to operationalize

or to develop a “gold standard” measure. Whilst diverse conceptualisations and measures

provide multiple viewpoints and pathways to pursue in prevention and intervention programs
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with children and young people, there is also scope for ambiguity in which practice remains

problem-focused and at odds with theory and research. This review will synthesise the various

conceptualisations of resilience in the evidence base. Individual and environmental (internal

and external) characteristics of resilience will be considered. As resilience has been defined as

related to the achievements of positive outcomes in facing inner and outer adversity (Kaplan,

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2005), the review focuses on indicators of positive outcomes instead of the cessation or

reduction of negative outcomes such as poor mental health, involvement with the criminal

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justice system, substance misuse or homelessness; with a focus on mental health in the context

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of residential child care. AN
2. Method

This review examines the nature of resilience in youth in residential care and
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synthesises the evidence for associations between resilience and behavioural outcomes, with a
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focus on mental health in the context of residential care. Positive measurements of resilience,
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in which the variables of interest were positive characteristics or outcomes were included

whilst studies using measurement of resilience as the absence or reduction of negative

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outcomes were excluded.

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2.1 Inclusion and exclusion criteria

The inclusion criteria for our systematic review were as follows: a) any study design

investigating a population of children and adolescents under 19 years, who had prior or current

experience of residential care settings (e.g. residential care or treatment). Residential care

settings were defined in a broad sense according to UN Guidelines for the Alternative Care of

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Children (United Nations, 2010) as “care provided in any non-family-based group setting, such

as places of safety for emergency care, transit centres in emergency situations, and all other

short- and long-term residential care facilities, including group homes.”(p.6) ; b) studies that

contained an empirical quantitative or qualitative design, methodology and results; c) resilience

was conceptualised and measured as the presence/growth of one or more characteristics

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conceptualised by the study authors as beneficial to wellbeing and development; d) articles

published up to November 2017 were eligible for inclusion; e) the articles sourced had English-

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language abstracts and keywords, were available in full-text (i.e. not conference proceedings)

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and were published in peer-reviewed journals.AN
The exclusion criteria were as follows: studies including a) residential settings that were

specifically for the care and treatment of young people with moderate or profound learning
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disabilities were excluded; b) conceptualisation and measurement of resilience solely as the

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absence of negative outcomes (e.g. psychopathology, delinquency); c) various sample

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populations including residential care but without specification in the results; d) neither

conceptualisation, nor valid measurement of resilience; e) studies only published as

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dissertations were excluded based on the potential lack of peer-review.

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The age restriction is based on most studies’ recruitment of minors under 18, with one

year extended to ensure comprehensive inclusion. As resilience constructs have developed

upon, rather than replaced, earlier theories, we saw no rationale for excluding older studies;

therefore, no date limit was set on publication.

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2.2 Literature Search strategy

This review was performed following the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) checklist and guidelines (Liberati et al., 2009; Moher et

al., 2010). Searches were conducted up to November 2017, with no limit set on the start date.

The following online databases were sourced for a primary search: MEDLINE, ASSIA (Applied

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Social Science Index and Abstracts), PsycINFO, and Your Journals@OVID (including

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PsycARTICLES). Medical Subject Headings (MeSH) were used to increase the efficiency and

precision of literature searching skills allowing to locate articles on a specific topic rather than

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just mentioning it. The search terms were truncated (as indicated by *) and combined with
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Boolean operators as follows: residential OR accommodated AND resilience OR protective AND

child* OR teen* OR youth or young. The secondary search was based on screening references
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of relevant articles and flagging up those potentially relevant. A protocol was registered for this
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study with PROSPERO (Centre for Reviews and Dissemination at the University of York). The

published number was 42016038861.

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2.3 Study selection

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All search hits were recorded, reviewed and screened by the authors. Authors were
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trained to review articles through formal departmental training, with one author, experienced

in conducting systematic reviews, acting as supervisor. Decisions on initial screening of articles

were closely supervised. An article was initially considered irrelevant if the first two inclusion

criteria were not met. Most articles were considered irrelevant (e.g. air pollution,

cardiopulmonary, elderly), and 153 articles were duplicated. Grey literature in the form of 18

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possibly relevant dissertations was recognised and screened, as likely later published in a peer-

reviewed journal. All were subsequently excluded.

[Figure 1 about here]

Secondary searches were conducted on related and relevant articles after screening.

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Fifty-five studies were evaluated and analysed in the secondary search. Six were duplicated

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with the first search, and the rest did not meet all inclusion criteria. All articles reviewed at full-

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text stage were checked by minimum two authors. There was no disagreement. See Figure 1 for

a flowchart of the selection process.

2.4 Data extraction

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Selected articles were closely scrutinised with characteristics and key findings tabulated.
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The findings were then summarised and synthesised based on the research questions.
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2.4 Quality Assessment

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Quality assessments were carried out on every study and disagreement was discussed
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to reach consensus (Supplementary Table B). Included studies consisted of both qualitative and

quantitative research methods, and varied by different study designs, including non-
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comparative studies (e.g. case-series study), qualitative studies (e.g. case description study) and

observational studies (e.g. cross-sectional and cohort studies). For each study design, two extra

questions were included to judge quality. Aside from study designs, the criteria of quality

assessments also included criteria on study question, population, measurements, statistical

analysis and results. In addition, since there have not been any validated tools for cross -

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sectional studies (The University of Nottingham, n.d.) the current assessment criteria were

devised based on National Institutes of Health’s (NIH) assessment tool for observational cohort

and cross-sectional studies and the Effective Public Health Practice Project’s (EPHPP)

assessment tool for quantitative studies. All other questions in the assessment were based on

the Scottish Intercollegiate Guidelines Network (SIGN, 2001), the Critical Appraisal Skills

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Programme’s (CASP) criteria for qualitative studies and cohort studies, and NIH’s criteria

(https://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-

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reduction/tools/case_series) for case-series studies) (see online supplementary Table A for full

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criteria). AN
3. Results

The main characteristics of all included studies are summarised in Table 1.

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3.1 Near-misses

In all, 15 studies were included in this review. Six studies were judged as near-misses as
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they were “borderline cases”, excluded because they either did not delineate residential care
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from other care settings in their analysis (Drapeau, Saint-Jacques, Lépine, Bégin, & Bernard,

2007; Kagan, Douglas, Hornik, & Kratz, 2008; Kagan & Spinazzola, 2013), used a negative
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measurement of resilience (Lodewijks , de Ruiter, & Doreleijers, 2010) or did not coherently

conceptualise or measure resilience (Lietz, 2004, 2007).

3.2 Study quality

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All included studies were reviewed and scored by two reviewers based on the quality

assessment tool. Both reviewers agreed on the final grading results , following the SIGN scoring

system (Guyatt et al., 2008), thus classifying the quality of evidence according to four levels:

high (two points), moderate (one point), low and very low (zero point). Thus, an overall score of

16-20 was considered high quality, 11-15 was considered moderate, 6-10 was considered low

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and 0-5 was considered very low quality. Eleven studies were assessed as above moderate. Two

studies (Collin-Vézina, Coleman, Milne, Sell, & Daigneault, 2011; Malindi & Machenjedze, 2012)

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were rated as overall low quality, only one point away from the moderate level. Three studies

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(Pat-Horenczyk, Shi, Schramm-Yavin, Bar-Halpern, & Tan, 2015; Quisenberry & Foltz, 2013;

Vorria, Ntouma, & Rutter, 2015) were assessed with high quality on overall quality scores
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(Supplementary Table B).
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Only one study did not mention any information about how data was collected, other
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studies all gained some points in relation to data collection (Quisenberry & Foltz, 2013). Three

studies reported successfully addressed bias and attrition in their sampling strategy
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(Supplementary Table B), with sampling rates of eligible populations ranging from 55% to 67%
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(Altshuler & Poertner, 2002; Quisenberry & Foltz, 2013; Vorria et al., 2015). A further three

described sampling strategies and reported samples as representative, but without further
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specification (Maurović, Križanić, & Klasić, 2015; Novotný & Křeménková, 2016; Go, Chu, Barlas,

& Chng, 2017). Other studies did not report opt-in or attrition rates.

3.3 Characteristics of studies

All studies received above moderate scores in quality of study characteristics. Ten

studies employed a quantitative design, and of these, all but two (Butler & Francis, 2014; Sim, Li

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& Chu, 2016) were cross-sectional designs. Three studies (Malindi & Machenjedze, 2012;

Nourian et al., 2016; Pat-Horenczyk et al., 2015) employed qualitative methodology, one a

quantitative methodology (Maurović et al., 2015), and one (Pat-Horenczyk et al., 2015)

employed a mixed-methods design, incorporating qualitative and quantitative methodologies.

Two studies were follow-up studies (Sim et al., 2016; Vorria et al., 2015). The first (Sim et al.,

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2016) used a convenience sample as part of a larger sample in another cross -sectional study

(Liu et al., 2014). The latter (Vorria et al., 2015) was based on an original study (Vorria et al.,

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2006), although the original research did not meet the inclusion criteria for this review.

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All but one of the studies (Table 1) were conducted in highly developed countries (DCs),
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including Israel, the United States, Singapore, Portugal, Greece, Croatia, Czech Republic,

Netherlands and South Africa (“The World Factbook — Central Intelligence Agency,” n.d. note:
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South Africa has been dropped from the DCs list recently, although it was considered a
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developed country when Malindi and Machenjedze conducted the study in 2012), the

exception being Iran (Nourian et al., 2016).

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3.4 Sample population

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We identified a combined sample of n = 983 children and adolescents, who had

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experienced or were experiencing residential care from infancy to 19 years of age. Residential

settings included group home or institutions, residential treatment, shelters for former street

children and a residential baby centre. One of the studies employed a population of children,

ranging from 11 months to 3 years 5 months, kept in an infancy residential care centre and later

adopted (Vorria et al., 2015). This sample was assessed when the children were 13 years old. All

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studies contained both female and male samples, except for one study (Malindi & Machenjedze,

2012) that considered only male. Six studies specified the multi-ethnic composition with

Caucasian samples predominating but African American, Malay, and Romany youths also being

represented. One study did not report participants’ ethnicity (Maurović et al., 2015). Other

ethnic groups that were mentioned and measured in these studies included Hispanic,

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Aboriginal (Canada), Caribbean, Mediterranean, Chinese, and mixed ethnicities (see Table 1 for

details).

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Adolescents in residential care were reported to be more vulnerable and demonstrated

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more problems than the general youth population on self-report scales assessing resilience and
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health (Altshuler & Poertner, 2002; Butler & Francis, 2014; Collin-Vézina et al., 2011; Sim et al.,

2016) including low levels of self-esteem, emotional comfort, psychosocial stability, work
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performance, poorer peer influences and higher rates of abuse and neglect. When compared
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with other types of alternative care (Sim et al., 2016), adolescents in residential care were
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reported to have higher baseline needs and suffered more types of interpersonal trauma, but

with fewer prior placements and higher baseline strengths (resilience) than adolescents in
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other care settings. Sim, Li & Chu’s (2016) longitudinal design revealed significant differences
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between foster family based and residential care based adolescents: the former expressed

lower levels of needs as their strengths score increased, whilst in adolescents in residential care

higher levels of strengths was positively associated with higher levels of need. Vorria et al .

(2015) found that adolescents adopted out of early residential care (within, on average, the first

20 months of life), later showed no significant differences from typically-raised peers in positive

predictors of resilience (quality of attachment, cognitive performance). These findings suggest

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that keeping adolescents in residential care longer-term is associated with a reduced resilience-

associated benefit, but that longer-term gains do accrue from achieving family-based

permanence in adolescents with early residential care experience.

3.5 Conceptualisation of resilience

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Most studies conceptualised and measured resilience directly, whereas two of the included

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studies used other variables representative of resilience: self-regulation (Pat-Horenczyk et al.,

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2015), and strengths, conceptualised as multiple protective factors (Sim et al., 2016). Go et al.

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(2017) described resilience as strengths and the capacity to apply them, but also external

resources including educational support and family relationships. Novotný & Křeménková (2016)
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conceptualised resilience as education, physical and psychological care, whereas Maurović et al.

(2015) conceptualised resilience as a dynamic process encompassing positive adaptation and

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facilitated by a series of protective factors or mechanisms, including individual and familial

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resources and relationships with professional staff and friends in a residential setting. The more
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recent studies showed agreement about an ecological conceptualisation in which resilience is

facilitated by individual and systemic protective characteristics. This was reflected in those
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papers that broke resilience down into sub-domains (Altshuler & Poertner, 2002; Collin-Vézina
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et al., 2011; Pienaar, Swanepoel, van Rensburg, & Heunis, 2011; Quisenberry & Foltz, 2013;

Davidson-Arad & Navaro-Bitton, 2015).

An ecological conceptualisation of resilience was implied in many of the studies, with

reference to individual (internal stable and dynamic characteristics), environmental (e.g. school,

community policies) and interpersonal domains. These domains, outcomes and possible

correlates were operationalised in various ways. To facilitate synthesis of the

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conceptualisations and variables of significance, we devised a framework (see Fig. 2) describing

the resilience concept and operationalisation (factors), impacts upon resilience and correlates

(or outcomes where a longitudinal design has been employed). Of note, there is significant

cross-over. For example, problem-solving ability is described as part of resilience, a correlate of

resilience and an outcome of resilience, reflecting the difficulties setting clear parameters

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around the resilience construct. Apart from age and gender, impacts upon resilience were all

external: contextual, interpersonal or life events. By contrast, correlates of resilience were all

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internal factors, grouped by us into four areas: positive internal attributes, future vision, moral

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compass and self-regulation. For the latter three groups, the role of significant others in

fostering these capacities is implied. The latter three groups recur in correlates and outcomes
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alongside wellbeing, developmental and interpersonal gains.
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(Insert Figure 2 here)

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3.6 Measurements of resilience

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Resilience was measured by a variety of instruments, including self-report

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questionnaires: The Child Health and Illness Profile-Adolescent Edition (Starfield et al., 1994), as

cited in Altshuler & Poertner, 2002), the Resiliency Scales for Children and Adolescents (RSCA;
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Prince-Embury, 2008, as cited in Butler & Francis, 2014), the Child and Youth Resilience

Measure (CYRM; Ungar et al. 2008, as cited in Collin-Vézina et al., 2011), the Resilience and

Youth Development Module (RYDM; California Healthy Kids Survey, 2003), as cited in Davidson-

Arad, B & Navaro-Bitton, 2015), the Resilience Scale (RS; Wagnild & Young, 1993 as cited in

Mota & Matos, 2015; Nourian et al., 2016), the Adolescent Resiliency Questionnaire (ARQ;

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Gartland, Bond, Olsson, Buzwell, & Sawyer, 2011, as cited in Quisenberry & Foltz, 2013) and the

Protective Mechanisms among Adolescents in Residential Care Questionnaire (PMARQ;

Maurović et al., 2015), designed ad hoc for the purpose of the study.

Two studies (Go et al., 2017; Sim et al., 2016) assessed resilience using part of an

instrument, the Child and Adolescent Needs and Strengths tool (CANS; Lyons, Weiner, Lyons, &

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Maruish, 2004), that was originally designed to measure a different variable. The CANS

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integrates information from multiple sources (Lyons et al., 2004). This type of assessment is

more reliable than single-source self-report measures. Most of the studies included in this

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systematic review used accurate, valid, and reliable measures aimed at capturing a specific
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definition of resilience. However, there was no dominant measure, and consequently it isn’t

possible to recommend a “gold standard” assessment tool, based on our sample.

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[Table 1 about here]

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3.7 Associations between resilience and psychosocial outcomes

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Higher levels of resilience were associated with better outcomes or performance,

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including higher levels of positive development (Quisenberry & Foltz, 2013), a more pro-social

orientation (Malindi & Machenjedze, 2012), better wellbeing (low to moderate association)
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(Mota & Matos, 2015) and higher positive coping strategies, as well as lower general distress

(Pat-Horenczyk et al., 2015), improved academic performance (Novotný & Křeménková, 2016),

reduced risk of anger or conduct problems (Go et al., 2017), and higher self-reported happiness

(Maurović et al., 2015).

4. Discussion

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This review analysed 15 studies focused on the resilience of children and adolescents in

residential care. Resilience was variously and multifactorially conceptualised, as we anticipated,

reflecting the continued absence of a dominant measure or method. Whilst resilience

conceptualisation was not always clearly explicated, all studies included in this review either

conceptualised or measured resilience on a strengths basis. These conceptualisations and study

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variables were synthesised to produce a model of resilience characteristics and

correlates/outcomes. This model reflects the available evidence and demonstrates that

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external factors are incorporated into research, but that resilience as a fundamentally internal

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attribute remains a popular, if not reductive, conceptualisation. Thus, we found measurement

of individual and contextual features associated with resilience development in young people
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who have experienced severe adversity and who are being accommodated in residential units
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rather than family-based alternative care.

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Whilst baseline wellbeing was typically lower than for other care-experienced
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populations, there was evidence of ample opportunities to foster resilience growth in

residential care settings. Controllable factors such as making caring and interested adults
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available, providing educational support, and fostering a sense of a future and motivation
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towards that future were all found to contribute to positive outcomes. Mentoring is one way of

providing this support with evidence of positive impact on developmental outcomes including

mental health, educational attainment, peer relationships, and placement outcomes (Duke,

Farruggia, & Germo, 2017).

4.1 Quality and limitations of the studies

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The strengths of included studies were the appropriate study design, valid

methodologies, and clearly explained results. Each study had a strong focus on youths in

residential care. Five of them employed a comparison group (Butler & Francis, 2014; Davidson-

Arad & Navaro-Bitton, 2015; Go et al., 2017; Novotný & Křeménková, 2016; Sim et al., 2016;

Vorria et al., 2015), so that differences between groups and within individuals could be

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measured. We found a wide range of measures, including ad hoc measures (Maurović et al.,

2015) and non-replicable interview approaches. Reporting limitations were evident with

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reliability and validity information missing in some cases. Collating these measures provides a

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useful overview for prospective researchers, and we hope to see a smaller number of measures

emerge as consistently reliable and valid in relation to current conceptualisations of resilience.

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Although most studies were carried out in developed countries, the sample variety of
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this review was still strong, as studies on adolescents from different cultural and ethnical
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backgrounds (e.g. Singapore, South Africa, Western Europe) were included, making the results
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more reliable and easier to generalise. However, small sample sizes reduced the generalizability

of some findings. This may be due to the scale and type of residential care provision in different
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countries, and reflects a global move away from large-scale institutions towards smaller group
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home settings. A recommendation for reporting is clear explication of the setting and

population to allow international comparison – the wide variety in intervention frameworks,

policies, and terminology introduces significant challenges for evidence synthesis.

The variety of study designs (e.g. qualitative studies) increased the difficulties in

evaluating resilience and the results. Measurement of baseline resilience should be prioritised

in future studies, and there is a clear need for more long-term longitudinal data collection. The
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preponderance of cross-sectional research allows for preliminary hypotheses about the longer-

term effects of resilience factors on development and wellbeing, but empirical evidence is

needed to test these.

To ensure quality, dissertations that had not been subsequently published in peer-

reviewed journals were excluded, regardless of the quality or the value of the study itself.

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Applying an age limit ensured some homogeneity, but resulted in two near-misses (Hass &

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Graydon, 2009; Jackson & Martin, 1998). Such limits are necessary but inevitably restrict the

findings.

4.2 Implications
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Given the apparent importance of resilience as a multicomponent construct associated
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with better outcomes for this vulnerable population, focusing on resilience-building and,
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potentially, tolerating associated risks, should be a priority for residential care services. There is

some mixed fledgling evidence with small samples of resilience-focused intervention and
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service design for this settings such as Building Emotion and Affect Regulation (BEAR; Pat-
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Horenczyk et al., 2015), Real Life Heroes (RLH; Kagan et al., 2008; Kagan & Spinazzola, 2013), a

strength-based approach based on social learning (Lietz, 2004, 2007), and a writing based
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intervention to elaborate trauma (WRITE ON; Greenbaum & Javdani, 2017). Whilst Lietz’s

intervention has no reported outcome data and Real Life Heroes has demonstrated benefit in

reducing trauma symptoms only (reflecting its intervention focus), BEAR and WRITE ON have

demonstrated medium effect sizes on resilience, coping and emotional regulation measures.

The mixed outcomes may reflect the need to incorporate more systemic elements into

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resilience-building interventions, and to ensure conceptual clarity. A priori, theory, intervention

and measurement should be aligned, and this requires particular attention when addressing

such a diversified construct as resilience. The findings of this paper provide a basis for

developing further resilience-focused programmes and service design for children and young

people in residential care settings.

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From a policy perspective, the role of significant adults in the child’s world and the

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positive influence they can have on outcomes highlights the need for adequate staffing levels,

high-quality training and ongoing supervision to engage with and build reparative relationships

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with children and young people who, by virtue of their early experiences, may be avoidant or
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destructive in close relationships (Morison, Taylor & Fawns, in prep.). These adults include

residential care staff but also education staff and those working in community organisations to
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ensure a network of support and opportunity for the young person that allows them to develop
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a sense of motivation and vision for their own future. Lastly, as policy increasingly recommends
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support beyond the age of 18, future research should investigate correlates, contributors and

outcomes for resilience in young adults during and after they leave the residential care setting.
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This would also further our understanding of the long-term impacts of resilience-promoting
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practice during childhood and adolescence.

Finally, there were reporting issues in many of the studies included in this review,

suggesting that even when the research methodology was robust, reporting standards had not

been followed. In a field that is inherently heterogeneous in terms of population definition and

resilience conceptualisation and measurement, maintaining consistent research reporting

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standards is one way of facilitating sufficient homogeneity to allow synthesis of findi ngs in

reviews, such that theory and empiricism can progress.

5. Conclusion

The results obtained from this review were found mainly in developed countries, where

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residential care is part of a comprehensive system of alternative care for children and

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adolescents. The main findings suggested that adolescents who have been cared for in

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residential settings are more vulnerable and demonstrated more problems when compared to

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adolescents who have not been in residential care (e.g. adolescents in foster care or kept at

home). Although no single definition of resilience was found, suggesting that resilience can be
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understood and conceptualized from different angles and perspectives, the association with

positive features understood as protective factors, was demonstrated in this review. Among
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them, those aimed at promoting interpersonal relationships (e.g. school engagement and
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significant figures) and development of a future focus and motivation were particularly
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noticeable.
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This review summarised studies on resilience in adolescents within residential settings

and made suggestions for future studies looking at resilience in this specific group. It highlights
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the need for clinicians, policy makers and other professionals to allocate more resources and

time to building the strengths of adolescents in residential care settings to help them achieve

and maintain long term positive outcomes.

5179 words

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Conflicts of Interest

This was an unfunded piece of research and there are no conflicts of interest to declare.

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References

Achenbach, T. M., & Rescorla, L. (2001). ASEBA school-age forms & profiles. Aseba

Burlington. Retrieved from

http://aseba.com/ordering/ASEBA%20Reliability%20and%20Validity-School%20Age.pdf

T
Altshuler, S. J., & Poertner, J. (2002). The Child Health and Illness Profile-Adolescent

IP
Edition: Assessing Well-Being in Group Homes or Institutions. Child Welfare, 81(3), 495–513.

CR
Angel, C. M. (2016). Resilience, post-traumatic stress, and posttraumatic growth:

US
Veterans' and active duty military members' coping trajectories following traumatic event

exposure. Nurse Education Today, 47, 57-60. DOI: 10.1016/j.nedt.2016.04.001

AN
Blaustein, M., & Kinniburgh, K. M. (2010). Treating traumatic stress in children and
M

adolescents: how to foster resilience through attachment, self-regulation, and competency. New
ED

York: Guilford Press.

PT

Bonanno, G. A., Romero, S. A., & Klein, S. I. (2015). The Temporal Elements of

Psychological Resilience: An Integrative Framework for the Study of Individuals, Families, and
CE

Communities. Psychological Inquiry, 26(2), 139-169. DOI: 10.1080/1047840X.2015.992677

AC

Born, M., Chevalier, V., & Humblet, I. (1997). Resilience, desistance and delinquent

career of adolescent offenders. Journal of Adolescence, 20(6), 679–694.

https://doi.org/10.1006/jado.1997.0119

Borum, R. (2006). Manual for the Structured Assessment of Violence Risk in Youth

(SAVRY). Retrieved from https://works.bepress.com/randy_borum/2/

24
 ACCEPTED MANUSCRIPT

Brendtro, L., & Larson. S. (2006). The resilience revolution. Bloomington, IN: National

Educational Service.

Butler, L. S., & Francis, E. (2014). Resiliency Differences Between Youth in Community-

Based and Residential Treatment Programs: An Exploratory Analysis. In L. S. Butler & E. Francis

(Eds.), Resilience Interventions for Youth in Diverse Populations (pp. 259–277). Springer.

T
IP
Retrieved from http://link.springer.com/chapter/10.1007/978-1-4939-0542-3_12

CR
California Healthy Kids Survey. (2003). California Healthy Kids Survey – Helping schools

US
build positive environments for student success. Retrieved May 1, 2017, from

http://chks.wested.org/
AN
Chia, M., & Lee, M. (2015). Relationship between quality of life and resilience among
M

sport-active Singaporean youth. Physical Education of Students, 19(2), 29–36.

ED

https://doi.org/10.15561/20755279.2015.0205

Chmitorz, A., Kunzler, A., Helmreich, I., Tüscher, O., Kalisch, R., Kubiak, T., Wessa, M.,&
PT

Lieb, K. (2018). Intervention studies to foster resilience – A systematic review and proposal for a
CE

resilience framework in future intervention studies. Clinical Psychology Review, 59, 78-100.

https://doi.org/10.1016/j.cpr.2017.11.002.
AC

Collin-Vézina, D., Coleman, K., Milne, L., Sell, J., & Daigneault, I. (2011). Trauma

Experiences, Maltreatment-Related Impairments, and Resilience Among Child Welfare Youth in

Residential Care. International Journal of Mental Health and Addiction, 9(5), 577–589.

https://doi.org/10.1007/s11469-011-9323-8

25
 ACCEPTED MANUSCRIPT

Critical Appraisal Skills Programs (CAPS). CASP Appraisal Checklists. Retrievable at

https://casp-uk.net/casp-tools-checklists/

Culhane, S. E., & Taussig, H. N. (2009). The structure of problem behavior in a sample of

maltreated youths. Social Work Research, 33(2), 70-78. https://doi.org/10.1093/swr/33.2.70

T
Davidson-Arad, B., & Navaro-Bitton, I. (2015). Resilience among adolescents in foster

IP
care. Children and Youth Services Review, 59, 63–70.

CR
https://doi.org/10.1016/j.childyouth.2015.09.023

US
Dimigen, G., Del Priore, C., Butler, S., Evans, S., Ferguson, L., & Swan, M. (1999).

Psychiatric disorder among children at time of entering local authority care: questionnaire
AN
survey. BMJ, 319(7211), 675–675. https://doi.org/10.1136/bmj.319.7211.675
M

Drapeau, S., Saint-Jacques, M.-C., Lépine, R., Bégin, G., & Bernard, M. (2007). Processes
ED

that contribute to resilience among youth in foster care. Journal of Adolescence, 30(6), 977–999.

https://doi.org/10.1016/j.adolescence.2007.01.005
PT

Duke, T., Farruggia, S. P., & Germo, G. R. (2017). “I don't know where I would be right
CE

now if it wasn't for them”: Emancipated foster care youth and their important non-parental
AC

adults. Children and Youth Services Review, 76, 65-73.

https://doi.org/10.1016/j.childyouth.2017.02.015.

Ehlert, U. (2013). Enduring psychobiological effects of childhood adversity.

Psychoneuroendocrinology, 38(9), 1850-1857. https://doi.org/10.1016/j.psyneuen.2013.06.007

26
 ACCEPTED MANUSCRIPT

Ford, T., Vostanis, P., Meltzer, H., & Goodman, R. (2007). Psychiatric disorder among

British children looked after by local authorities: comparison with children living in private

households. The British Journal of Psychiatry, 190(4), 319–325.

https://doi.org/10.1192/bjp.bp.106.025023

Gartland, D., Bond, L., Olsson, C. A., Buzwell, S., & Sawyer, S. M. (2011). Development of

T
IP
a multi-dimensional measure of resilience in adolescents: the Adolescent Resilience

CR
Questionnaire. BMC Medical Research Methodology, 11(1). https://doi.org/10.1186/1471-

2288-11-134

US
Gearing, R. E., Brewer, K. B., Elkins, J., Ibrahim, R. W., MacKenzie, M. J., & Schwalbe, C. S.
AN
J. (2015). Prevalence and Correlates of Depression, Posttraumatic Stress Disorder, and

Suicidality in Jordanian Youth in Institutional Care. The Journal of Nervous and Mental Disease,
M

203(3), 175–181. Doi: 10.1097/NMD.0000000000000267

ED

Georgas, D. D., Paraskevopoulos, I. N., Bezevegis, I. G., & Giannitsas, N. D. (1997). Greek
PT

WISC-III: Wechsler intelligence scale for children. Athens: Ellinika Grammata.

CE

Go, M., Chu, C. M., Barlas, J., & Chng, G. S. (2017). The role of strengths in anger and

conduct problems in maltreated adolescents. Child Abuse & Neglect, 67, 22–31.
AC

https://doi.org/10.1016/j.chiabu.2017.01.028

Greenbaum, C. A., & Javdani, S. (2017). Expressive writing intervention promotes

resilience among juvenile justice-involved youth. Children and Youth Services Review, 73, 220–

229. https://doi.org/10.1016/j.childyouth.2016.11.034

27
 ACCEPTED MANUSCRIPT

Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., … for

the GRADE Working Group. (2008). GRADE: an emerging consensus on rating quality of

evidence and strength of recommendations. BMJ, 336(7650), 924–926.

https://doi.org/10.1136/bmj.39489.470347.AD

Hass, M., & Graydon, K. (2009). Sources of resiliency among successful foster youth.

T
IP
Children and Youth Services Review, 31(4), 457–463.

CR
https://doi.org/10.1016/j.childyouth.2008.10.001

US
Hoge, E.A., Austin, E.D., & Pollack, M.H. (2007). Resilience: Research evidence and

conceptual considerations for posttraumatic stress disorder. Depression and Anxiety, 24(2),
AN
139-152. DOI: 10.1002/da.20175
M

Jackson, S., & Martin, P. Y. (1998). Surviving the care system: education and resilience.
ED

Journal of Adolescence, 21(5), 569–583. https://doi.org/10.1006/jado.1998.0178

Jones, R., Everson-Hock, E. S., Papaioannou, D., Guillaume, L., Goyder, E., Chilcott, J., …
PT

Swann, C. (2011). Factors associated with outcomes for looked-after children and young people:
CE

a correlates review of the literature: Looked-after children and young people: factors and

outcomes. Child: Care, Health and Development, 37(5), 613–622.

AC

https://doi.org/10.1111/j.1365-2214.2011.01226.x

Jozefiak, T., Kayed, N. S., Rimehaug, T., Wormdal, A. K., Brubakk, A. M., & Wichstrøm, L.

(2016). Prevalence and comorbidity of mental disorders among adolescents living in residential

youth care. European Child & Adolescent Psychiatry, 25(1), 33–47.

https://doi.org/10.1007/s00787-015-0700-x

28
 ACCEPTED MANUSCRIPT

Kagan, R., Douglas, A. N., Hornik, J., & Kratz, S. L. (2008). Real Life Heroes Pilot Study:

Evaluation of a Treatment Model for Children with Traumatic Stress. Journal of Child &

Adolescent Trauma, 1(1), 5–22. https://doi.org/10.1080/19361520801929845

Kagan, R., & Spinazzola, J. (2013). Real Life Heroes in Residential Treatment:

Implementation of an Integrated Model of Trauma and Resiliency-Focused Treatment for

T
IP
Children and Adolescents with Complex PTSD. Journal of Family Violence, 28(7), 705–715.

CR
https://doi.org/10.1007/s10896-013-9537-6

US
Kalisch, R., Baker, D., Basten, U., Boks, M., Bonanno, P., Brummelman, G. A.,…Kleim, B.

(2017). The resilience framework as a strategy to combat stress -related disorders. Nature
AN
Human Behaviour, 1(11), 784-790. DOI: 10.1038/s41562-017-0200-8
M

Kaplan, H. B. (2005). Understanding the Concept of Resilience. In S. Goldstein & R. B.

ED

Brooks (Eds.), Handbook of Resilience in Children (pp. 39–47). Boston, MA: Springer US.

https://doi.org/10.1007/0-306-48572-9_3
PT

Leve, L. D., Harold, G. T., Chamberlain, P., Landsverk, J. A., Fisher, P. A., & Vostanis, P.
CE

(2012). Practitioner Review: Children in foster care - vulnerabilities and evidence-based

interventions that promote resilience processes: Children in foster care: interventions

AC

promoting resilience. Journal of Child Psychology and Psychiatry, 53(12), 1197–1211.

https://doi.org/10.1111/j.1469-7610.2012.02594.x

Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gotzsche, P. C., & Ioannidis, J. P.

(2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies

29
 ACCEPTED MANUSCRIPT

that evaluate health care interventions: explanation and elaboration. PLoS Med, 6(7), e1000100,

https://doi.org/10.1371/journal.pmed.1000100

Lietz, C. A. (2004). Resiliency Based Social Learning: A Strengths Based Approach.

Residential Treatment For Children & Youth, 22(2), 21–36.

https://doi.org/10.1300/J007v22n02_02

T
IP
Lietz, C. (2007). Strengths-Based Group Practice: Three Case Studies. Social Work With

CR
Groups, 30(2), 73–87. https://doi.org/10.1300/J009v30n02_07

US
Liu, D., Tan, M. Y. L., Lim, A. Y.-Y., Chu, C. M., Tan, L. J., & Quah, S. H. (2014). Profiles of

needs of children in out-of-home care in Singapore: School performance, behavioral and

AN
emotional needs as well as risk behaviors. Children and Youth Services Review, 44, 225–232.
M

https://doi.org/10.1016/j.childyouth.2014.06.019
ED

Lodewijks, H. P. B., de Ruiter, C., & Doreleijers, T. A. H. (2010). The Impact of Protective

Factors in Desistance From Violent Reoffending: A Study in Three Samples of Adolescent

PT

Offenders. Journal of Interpersonal Violence, 25(3), 568–587.

CE

https://doi.org/10.1177/0886260509334403
AC

Lyons, J. S. (2009). Communimetrics: A communication theory of measurement in human

service settings. New York: Springer.

Lyons, J. S., Weiner, D. A., & Lyons, M. B. (2004). Measurement as communication in

outcomes management: The child and adolescent needs and strengths (CANS). In M. E. Maruish

(Ed.), The Use of Psychological Testing for Treatment Planning and Outcomes Assessment.

30
 ACCEPTED MANUSCRIPT

Volume 2: Instruments for Children and Adolescents (pp. 461- 476). Retrieved from

https://books.google.co.uk/books?hl=en&lr=&id=nDvtKj0CIlYC&oi=fnd&pg=PA461&dq=Measur

ement+as+communication+in+outcomes+management:+The+child+and+adolescent+needs +an

d+strengths+(CANS).+&ots=xruwzt5YCx&sig=2gpMx9dCl3k96gE-eAj0AD3Bu6Q

Lyubomirsky, S., & Lepper, H. (1999). A measure of subjective happiness: Preliminary

T
IP
reliability and construct validation. Social Indicators Research, 46, 137-155.

CR
https://doi.org/10.1023/A:1006824100041

US
Malindi, M. J., & Machenjedze, N. (2012). The Role of School Engagement in

Strengthening Resilience among Male Street Children. South African Journal of Psychology,
AN
42(1), 71–81. https://doi.org/10.1177/008124631204200108
M

Masten, A. S., Hubbard, J., Gest, S. D., Tellegen, A., Garmezy, N., & Ramirez, M. (1999).
ED

Adversity, resources and resilience: pathways to competence from childhood to late

adolescence. Development and Psychopathology, 11(1), 143-169.

PT

Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American

CE

Psychologist, 56(3), 227–238. https://doi.org/10.1037/0003-066X.56.3.227

AC

Maurović, I., Krisanic, V., & Klasic, P. (2015). From risk to happiness: the resilience of

adolescents in residential care. Kriminologija & Socijalna Integracija, 22(2), 25.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group (2009). Preferred

Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med,

6(7): e1000097. https://doi.org/10.1371/journal.pmed.1000097

31
 ACCEPTED MANUSCRIPT

Morison, A., Taylor, E.P., & Fawns, K. (in prep). Psychosocial outcomes of staff training in

residential childcare: A systematic review.

Mota, C. P., & Matos, P. M. (2015). Does sibling relationship matter to self-concept and

resilience in adolescents under residential care? Children and Youth Services Review, 56, 97–106.

https://doi.org/10.1016/j.childyouth.2015.06.017

T
IP
Nourian, M., Mohammadi Shahbolaghi, F., Nourozi Tabrizi, K., Rassouli, M., & Biglarrian,

CR
A. (2016). The lived experiences of resilience in Iranian adolescents living in residential care

US
facilities: A hermeneutic phenomenological study. International Journal of Qualitative Studies

on Health and Well-Being, 11(1), 30485. https://doi.org/10.3402/qhw.v11.30485

AN
Novotný, J. S., & Křeménková, L. (2016). The Relationship Between Resilience and
M

Academic Performance at Youth Placed at Risk. Vztah Mezi Resiliencí a Školním Výkonem U
ED

Dospívajících, Vyrůstajících v Rizikovém Prostredí, 60(6), 553–566.

Pat-Horenczyk, R., Shi, C. S. W., Schramm-Yavin, S., Bar-Halpern, M., & Tan, L. J. (2015).
PT

Building Emotion and Affect Regulation (BEAR): Preliminary Evidence from an Open Trial in
CE

Children’s Residential Group Homes in Singapore. Child & Youth Care Forum, 44(2), 175–190.

https://doi.org/10.1007/s10566-014-9276-8
AC

Pienaar, A., Swanepoel, Z., van Rensburg, H., & Heunis, C. (2011). A qualitative

exploration of resilience in pre-adolescent AIDS orphans living in a residential care facility.

SAHARA-J: Journal of Social Aspects of HIV/AIDS, 8(3), 128–137.

https://doi.org/10.1080/17290376.2011.9724995

32
 ACCEPTED MANUSCRIPT

Prince-Embury, S. (2006, 2007). Resiliency Scales for Children and Adolescents–A profile

of Personal Strengths (RSCA). San Antonio, TX: Pearson Education.

Prince-Embury, S. (2008). The Resiliency Scales for Children and Adolescents,

Psychological Symptoms, and Clinical Status in Adolescents. Canadian Journal of School

Psychology, 23(1), 41–56. https://doi.org/10.1177/0829573508316592

T
IP
Quisenberry, C. M., & Foltz, R. (2013). Resilient Youth in Residential Care. Residential

CR
Treatment For Children & Youth, 30(4), 280–293.

https://doi.org/10.1080/0886571X.2013.852448

US
Scottish Intercollegiate Guidelines Network (2001). SIGN 50: a guideline developers'
AN
handbook. Edinburgh: SIGN.
M

Sesma Jr., A., Mannes, M., & Scales, P. C. (2013). Positive Adaptation, Resilience and the
ED

Developmental Assets Framework. In S. Goldstein & R. B. Brooks (Eds.), Handbook of Resilience

in Children (pp. 427–442). Springer US. https://doi.org/10.1007/978-1-4614-3661-4_25

PT

Sim, F., Li, D., & Chu, C. M. (2016). The moderating effect between strengths and
CE

placement on children’s needs in out-of-home care: A follow-up study. Children and Youth
AC

Services Review, 60, 101–108. https://doi.org/10.1016/j.childyouth.2015.11.012

Southwick, S. M., Bonanno, G. A., Masten, A. S., Panter-Brick, C., & Yehuda, R. (2014).

Resilience definitions, theory, and challenges: Interdisciplinary perspectives. European journal

of psychotraumatology, 5(1), 25338. DOI: 10.3402/ejpt.v5.25338

33
 ACCEPTED MANUSCRIPT

Starfield, B., Riley, A., Ensminger, M., Green, B., Ryan, S., Kim-Harris, S., … Vogel, K.

(1994). Manual for the Child Health and Illness Profile-Adolescent Edition (CHIP-AETM).

Baltimore, MD: The Johns Hopkins University.

Target, M., Fonagy, P., & Shmueli-Goetz, Y. (2003). Attachment representations in

school-age children: The development of the Child Attachment Interview (CAI). Journal of Child

T
IP
Psychotherapy, 29, 171–186. DOI: 10.1080/0075417031000138433

CR
Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to

US
bounce back from negative emotional experiences. Journal of personality and social psychology,

86(2), 320. https://dx.doi.org/10.1037%2F0022-3514.86.2.320

AN
The University of Nottingham. (n.d.). Appraisal of cross -sectional studies. Retrieved May
M

1, 2017, from https://www.nottingham.ac.uk/cevm/evidence-synthesis/assessing-

ED

quality/appraisal-of-cross-sectional-studies.aspx

The World Factbook — Central Intelligence Agency. (n.d.). Retrieved May 1, 2017, from
PT

https://www.cia.gov/library/publications/the-world-factbook/index.html
CE

Ungar, M., Liebenberg, L., Boothroyd, R., Kwong, W. M., Lee, T. Y., Leblanc, J., et al.
AC

(2008). The study of youth resilience across cultures: lessons from a pilot study of measurement

development. Research in Human Development, 5, 166–180.

https://doi.org/10.1080/15427600802274019

34
 ACCEPTED MANUSCRIPT

Ungar, M., & Liebenberg, L. (2011). Assessing Resilience Across Cultures Using Mixed

Methods: Construction of the Child and Youth Resilience Measure. Journal of Mixed Methods

Research, 5(2), 126–149. https://doi.org/10.1177/1558689811400607

United Nations. (2010). Guidelines for the Alternative Care of Children. Resolution

adopted by the General Assembly [on the report of the Third Committee (A/64/434)] 64/142.

T
IP
Retrieved on 2nd April, 2018 from:

CR
https://www.unicef.org/protection/alternative_care_Guidelines -English.pdf

US
Vorria, P., Ntouma, M., & Rutter, M. (2015). Vulnerability and resilience after early

institutional care: The Greek Metera study. Development and Psychopathology, 27(3), 859–866.
AN
https://doi.org/10.1017/S0954579415000243
M

Vorria, P., Papaligoura, Z., Sarafidou, J., Kopakaki, M., Dunn, J., Van IJzendoorn, M. H., &
ED

Kontopoulou, A. (2006). The development of adopted children after institutional care: a follow-

up study. Journal of Child Psychology and Psychiatry, 47(12), 1246-1253.

PT

https://doi.org/10.1111/j.1469-7610.2006.01666.x
CE

Wagnild, G., & Young, H. (1993). Development and psychometric. Journal of Nursing

Measurement, 1(2), 165–178.

AC

Wright, M. O. D., Masten, A. S., & Narayan, A. J. (2013). Resilience processes in

development: Four waves of research on positive adaptation in the context of adversity. In S

Goldstein & R. Brooks (Eds.), Handbook of resilience in children (pp. 15-37). Springer, Boston,

MA.

35
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Figure 1: PRISMA flowchart detailing study selection

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Figure 2: Resilience in Residential Care

Impacts on
Resilience Concept Correlates Outcomes
Resilience

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Definition: Ability to Positive Internal

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resist/adjust Attributes: Self- Wellbeing: Happiness |
Frequency of efficacy | Problem-
to/overcome Positive adaptation |
adversity | Positive
abusive/neglectful solving ability | Psychological
Developmental

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experiences
attitude | Ability to Positive ID | Self- functioning
outcomes: Basic skills |
bounce-back | reliance | Self- Restoration of
Respond or perform protection | childhood | Healthy
Gender Future Vision:
in a positive way | Resilience skills development

US
Capacity enabling Achievement
aspiration/motivati |educational
Interpersonal Skills:
healthy competence|
development | Age on | Goal-setting | Relatedness
Essentialadaptation
Positive Qualities: Purpose in life| Sharedness | Pro-social
Positive Internal
AN
Construct/process | Parental factors: Optimism behavior
Complex | Multi- Attributes: Self-
acceptance | evaluation | Self-
dimensional | rejection | control A Moral Compass:
Context-based | protection | Self-
Morality | Social
reliance | Coping
M

Internal and external values | Spirituality

resources | External School engagement strategies | Problem-
realities/supports | solving ability | Mastery
Self-Regulation:
Support networks |
ED

Significant others Self-Regulation: Emotion regulation |

Interpersonal (e.g. care staff) Reactivity
Self-regulation | Future focus: Future
problem-solving Emotional
skills | Dynamic and Length of time as orientation |
management Achievement aspiration
PT

developmental | infant in residential

Multifinal and care | Spirituality |
equifinal Optimism
CE
AC

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Table 1. Study Characteristics and Description of Results

Study design, Sample

Main Findings
Author, Year, time-points, Characteristics: Resilience
(compared to control,
Location definition of N, Age, Gender Measure
where relevant)
resilience (m=male)

T
IP
Altshuler & Randomised n=63 (Control: CHIP-AE High resilience

CR
Poertner Controlled normed ref (problem-solving skills)

(2002) U. S. A. (general youth group n = 867): (t = 2.12, p ≤ 0.05),

US
population) Cross- 12 - 19 yrs, M
AN home safety and health

sectional =16; (T = 3.60, p < .01).; Low

m = 4 5(71%), family involvement (t = -

M

3.75, p ≤ 0.01); Similar

ED

Physical activity (T =

0.10, ns)
PT

Butler & Longitudinal (5 N = 232 RSCA Higher reactivity [t (230)

CE

Francis (2014) years) Controlled enrolled in 5 = −5.34, p < .0005] and

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U. S. A. Cohort (clinical programs 9 – 19 vulnerability [t (231) =

residential v. non- yrs, median = −2.96, p = .004];

clinical 14; residential Otherwise similar

commmunity treatment: n =

services) 64, m=45 (70%),

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median = 15

yrs; community

based program:

n = 168, median

age = 14, m =

T
IP
99 (59%)

CR
Collin-Vézina Cross-sectional, N=53 from six CYRM Lower individual (F(4,

et al. (2011) quasi- residential care 49).=3.93, p<0.01;,

US
Canada experimental, units: 14 – 17 relational (F(4,
AN
exploratary yrs, M =15.5; m 49).=5.43, p<0.001), and

= 29 (55%), community (F(4,

M

49).=4.69, p<0.01)
ED

resilience features
PT

associated with multiple

forms of trauma
CE

Davidson- Cross-sectional N=286, 13-17 RYDM Girls showed greater

AC

Arad & yrs, M=15 yrs: resilience: general

Navaro-Bitton maltreated resilience (F(2.276) =

(2015) Israel from foster 5.832, p = .05); internal

care: n = 63, M resilience (F(2.276) =

age= 15.5, SD = 5.832, p = .05); external

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1.55; residential resilience (F(2.276) =

n = 71, M age= 9.205, p = .01).

15.22, SD =

1.79;

community care

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(n = 52, M age =

15.2, SD = 1.69.

CR
Go, Meng Cross-sectional N=130 CANS Resilience significant

US
Chu, Barlas, & adolescents predictor in anger
AN
Chng, (2017) from 11 control problem (ß =

Singapore Voluntary −1.14, SE = 0.31, OR =

M

Children’s 0.32) and conduct

ED

Homes (VCHs) problem (ß = −0.89, SE =

PT

(Age NR) 0.32, OR = 0.41);

m=46.8% Educational support

CE

also significant predictor

AC

(ß = −0.81, SE = 0.41,

OR = 0.45).

Malindi & Qualitative (Case N = 17 male focus group School engagement

Machenjedze, report); street children transcribed strengthened resilience

(2012) exploratory focus living in interview by promoting pro-social

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South Africa groups shelters; 11-17 change, future

yrs. orientation,

opportunities for

support, learning of

basic skills and

T
IP
restoration of

childhood.

CR
Maurović, I., Cross- sectional N = 118 youths LMLES Everyday stress and all

US
Križanić, V., & placed in protective mechanisms
ESAR
AN
Klasić, P. community (e.g. individual
PMARQ
(2015) residential resources, caring
M

Croatia SHS
home, Mage = relationships with staff
ED

16.47, SD = and friends) but not

PT

1.21; m= 74% , f caring relationships with

= 26% family members were

CE

correlated (r = .32- .44,

AC

p < .05) with the level of

self-reported happiness.

Number of life events

and everyday stressors

predicted self-reported

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happiness, accounting

for 5.9% of the variance.

Once protective factors

were included, they

explained 15.6% of the

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happiness levels.

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Mota & Cross-sectional N=246 in RS Resilience partially

Matos (2015) institutions, 12- mediated the

US
Portugal 18 yrs, median association between
AN
= 14.87, m = quality of sibling

114 (46.3%). relationship and self-

M

concept (ß=.226),
ED

reducing the direct

PT

effect from ß=.37 to

ß=.13 (all p<.001).

CE

Nourian et al. Qualitative; N=8 in Persian Themes included: going

AC

(2016) Iran hermeneutic; governmental version of RS through life’s hardships,

phenomenological residential care aspiring for

facilities, 13-17 achievement,

yrs, m=5 selfprotection, self

reliance, and spirituality

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Novotný & Cross-sectional N=467 from 35 CYRM, RSCA, Resilience accounted

Křeménková, children’s YSR 24% of variance in

(2016) Czech homes: academic performance

Republic residential care (Adj. R2 = .23, F = 12.09,

(Romany): p < .001, considering

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IP
n=95, M age = the following predictors:

CR
15.76, SD = CYRM Context:

1.58; residential Education, Relationships

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care with caregivers,

(Caucasian): Psychological care,

AN
n=182, M age = Physical care and RSCA
M

16.49, SD = Emotional Reactivity,)

ED

1.62; control: and Length of stay

n=190, M
PT

age=17.08, SD =
CE

1.02
AC

Pat- Case-series; pilot N = 73 from 5 Bespoke Increase in emotion

Horenczyk et intervention; residential measure regulation, (p < 0.001,

al. (2015) mixed-method group homes: Cohen’s d = 0.437) and

Singapore 7-13 yrs, M = positive coping (p =

10.53, m=33 0.003, Cohen’s d =

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(45%) 0.389), sig. decrease in

general distress (p =

0.036, Cohen’s d =

0.266).

Pienaar et al. Qualitative; multi- N = 8 HIV- N/A Resilience fostered

T
IP
(2011) South perspective infected or - through: external

CR
Africa analysis; affected stressors and

qualitative; orphans in a challenges, external

US
exploratory residential care supports, inner
AN
facility , 9-13 strengths,interpersonal

yrs, m:f ratio NR and problem-solving

M

skills.
ED

Quisenberry Cross-sectional N = 42 from 5 ARQ, CoC, Correlation between

PT

& Foltz (2013) residential ACEs resiliency and positive

U. S. A. treatment youth development (r

CE

centres, 13– = .734, p < .01); Internal

AC

18yrs, M=16, m Resiliency sub-scale had

= 27 the strongest

correlation (r = .55, p

< .01).

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Sim, Li, & Chu Cohort N=285 in out- CANS After controlling for

(2016) Sub- (longitudinal 1 yr) of-home care: (strength covariates, higher

sample of Liu 5-17 yrs, domain) baseline strengths

et al., 2014; M=9.53,m = (factors enhancing

Singapore 145 (49.1%): resilience) predicted

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IP
Non-kinship lower baseline life

CR
foster home: functioning (LF) needs

n=153(54%); (ß =-.39), school needs

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residential (ß =-.045, both p > .001)

group homes n and behavioural and

AN
= 132(46%); emotional needs (ß =-
M

.017, p < .05), regardless

ED

of placement settings.
PT

At 1yr FU,

baseline strengths
CE

predicted higher LF
AC

needs only in residential

care, reflected in

placement x strength

interaction effect (ß

= .14, p < .05).

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Vorria, Cross-sectional; N=52 living in a CAI Greek No significant

Ntouma, & FU Greek WISC-III + differences.

Rutter (2015) residential baby teacher

Follow-up center, adopted report of

from Vorria at 20 months school

T
IP
et al., 2006 (M) In adoptive performance

Greece

CR
group, m = 27, f

= 25, Mage =

US
13.1, SD = 0.5 in

comparison
AN
group, n = 36, m
M

= 18, f = 18,
ED

Mage = 13, SD =

0.5.
PT

Legend:
CE

ARQ = Adolescent Resiliency Questionnaire (Gartland et al., 2011); ACEs= The Adverse
AC

Childhood Experiences Questionnaire (Gartland et al., 2011); BEAR = Building Emotion and

Affect Regulation; CAI: Child Attachment Interview (Target, Fonagy, & Shmueli-Goetz, 2003);

CANS = Child and Adolescent Needs and Strengths CANS (Lyons, 2009: Singapore adaptation

from Sim et al., 2016); CHIP-AE = Child Health and Illness Profile—Adolescent Edition (CHIP-AE)

(Starfield et al., 1994); CoC = Circle of Courage (Brendtro & Larson, 2006); CYRM = The Child and

Youth Resilience Measure (CYRM) (Ungar et al., 2008) (Ungar & Liebengerg, 2011); ESAR = The
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Everyday Stress Among Adolescents in Residential Care; f = female; FH = Foster Homes; FU =

follow-up; G = group; LMLES = The List of Major Life Events/Stressors; M = Mean; m = male; NR

= not reported; MAS = Mastery Profile Scale; N/A = Not Applicable; PMARQ = The Protective

Mechanisms among Adolescents in Residential Care Questionnaire; RYDM = Resilience was

assessed using the Resilience and Youth Development Module-(RYDM); REA = Reactivity Profile

T
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Scale; REL = Relatedness Profile Scale; RI = Resource Index; RS = Resilience Scale (Wagnild and

Young 1993; Portuguese adaptation); RSCA = Resiliency Scales for Children and Adolescents

CR
(Prince-Embury, 2006, 2007); Greek WISC-III Wechsler Intelligence Scale for Children ( Georgas,

US
Paraskevopoulos, Bezevegis, & Giannitsas, 1997); SD = Standard Deviation; SHS = The Subjective

Happiness Scale (Lyubomirsky & Lepper, 1999); VCH = Voluntary Children’s Homes; VI =
AN
Vulnerability Index; YSR = Youth Self Report (Achenbach, Rescorla, 2001); SE = Self-esteem
M
ED
PT
CE
AC

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T
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CR
US
AN
M
ED
PT
CE
AC

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Highlights

Adolescents in residential care settings present more problems compared to their peers
living in non-residential settings.
Despite the lack of a single definition, resilience was consistently associated with
protective factors in youths in residential settings.
Among the factors used to operationalise resilience, interpersonal relationships and the
development of a future focus and motivation were noticeable.

T
These findings suggested the need for researchers, clinicians, and policy makers, to

IP
allocate more resources for the promotion of strengths in youth in residential care.

CR
US
AN
M
ED
PT
CE
AC

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