Child and Adolescent Social Work Journal (2021) 38:295–308

https://doi.org/10.1007/s10560-020-00674-4

Caregiver Influences on Resilience Development Among Children

with Maltreatment Experience: Practitioner Perspectives
Brieanne Beaujolais1   · Xiafei Wang2 · Karla Shockley McCarthy1 · Rebecca Logue Dillard3 · Fei Pei1 · Susan Yoon1

Published online: 27 May 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Although prior research indicates a link between caregiver characteristics and resilience in maltreated children, the specific
ways in which caregivers influence resilience development remain unclear. This study explored practitioner perspectives
about the influence of caregivers in the development of resilience among children with maltreatment experience. Individual
interviews with 27 practitioners were recorded, transcribed, and analysed. Interview questions included items about practi-
tioner perspectives related to resilience development. Data were analysed using team-based coding. The team developed a
codebook, coded all transcripts, and identified salient themes. Three primary themes emerged from the data, including (a)
caregiver influence, (b) intervention with caregivers (to promote resilience in maltreated children), and (c) caregiver-related
barriers to child resilience. Each theme had two subthemes. Practitioners perceived caregivers to be highly influential on
resilience development among maltreated children. Study outcomes can inform future intervention, prevention, and policy
development aimed at fostering resilience.

Keywords  Caregivers · Child maltreatment · Qualitative research · Resilience

Child maltreatment practitioners and researchers alike seek guide interventions and policies aimed at resilience devel-
to better understand and facilitate resilience development opment for maltreated children. Although prior studies
among children with maltreatment experience. Under- suggest a significant link between caregiver characteris-
standing the factors that promote resilience is essential to tics (e.g., caregiver warmth, caregiver well-being, positive
caregiver–child relationships) and resilience in maltreated
children (Guibord, Bell, Romano, & Rouillard, 2011; Kim-
* Brieanne Beaujolais
Beaujolais.1@osu.edu Spoon, Haskett, Longo, & Nice, 2012; Yoon, 2018), the spe-
cific ways in which caregivers influence (i.e., how) resilience
* Rebecca Logue Dillard
Rebecca.dillard@unlv.edu development remain unclear. Furthermore, despite its poten-
tial importance, little research has incorporated the perspec-
Xiafei Wang
xiwang@syr.edu tive of practitioners to explore the role of caregivers and
caregiving-related factors in resilience development among
Karla Shockley McCarthy
shockleymccarthy.1@osu.edu children with maltreatment experience (Akin et al., 2014).
This paper highlights the potential benefit, value, and impor-
Fei Pei
pei.91@osu.edu tance of understanding and reflecting practitioner views and
perceptions in child maltreatment research. Because of their
Susan Yoon
Yoon.538@osu.edu prolonged engagement with children who have maltreatment
experience, practitioners are well-positioned to provide
1
College of Social Work, The Ohio State University, insight about what they perceive to be the role of caregiv-
Columbus, OH, USA ers in promoting resilience following child maltreatment.
2
School of Social Work, David B. Falk College of Sport Therefore, this study aims to qualitatively explore practition-
and Human Dynamics, Syracuse University, Syracuse, NY, ers’ perspectives about the distinct role of caregivers in the
USA
resilience development among children with maltreatment
3
School of Social Work, Greenspun College of Urban Affairs, experience.
University of Nevada Las Vegas, Las Vegas, NV, USA

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Background & Significance
Child Maltreatment Vulnerability and Outcomes
According to the Centers for Disease Control and Preven-
tion (CDC), child maltreatment is defined as “any act or
series of acts of commission or omission by a parent or
other caregiver that results in harm, potential for harm, or
threat of harm to a child” (Leeb et al., 2008, p. 11). Child
maltreatment is a pervasive public health and human rights
problem contributing to both acute and long-lasting adverse
outcomes. It is estimated that more than 3 million reports
of child maltreatment are made to child protective services
each year (USDHHS, 2019), indicating that child maltreat-
ment is a social concern with a far reach and continuing
impact in the U.S. Victims of child maltreatment are nega-
tively affected in terms of physical, psychological, cogni-
tive, and behavioral development. According to a nationally
representative sample, almost half (47.9%) of the children
aged 2 to 14 involved with the child welfare system exhib-
ited clinically significant emotional or behavioral problems
(Burns et al., 2004). One study from Pennsylvania revealed
that 22% of children in the child welfare system from
birth to age three had at least one developmental problem
(McCrae, Cahalane, & Fusco, 2011). An examination of
youth involved with the juvenile justice and child welfare
systems in the south-eastern region of the U.S. further sug-
gested that over 50% of the youth had conduct problems,
35% had hyperactivity and peer problems, and 25% suffered
from emotional problems (Neely-Barnes & Whitted, 2011).
The pervasive behavioral health problems among maltreated
children can result in sexual risk-taking behaviors, alcohol
and other drug addiction, and delinquency and criminality in
their adolescence and adulthood, exacerbating public health
and safety concerns when those maltreated children do not
receive any intervention (Child Welfare Information Gate-
way [CWIG], 2007).
Given the detrimental effects of child maltreatment,
it is crucial to decipher how maltreated children recover
following the trauma of maltreatment in order to develop
appropriate and effective social work interventions and
policy. After decades of studies dedicated to examining
pathological causes and consequences of child maltreat-
ment, scholars have shifted the research paradigm to focus
on resilience development and facilitation of improved
outcomes following child maltreatment (Cicchetti, 2013).
Resilience Theory and Definition
Masten (2001) defined resilience as positive adaptation and
development in spite of exposure to toxic environments.
13
B. Beaujolais et al.
Though a consensus on the definition of resilience has
not been reached yet, a scoping review on child maltreat-
ment literature (Yoon et al., 2019) found that resilience
was typically conceptualized in one of three ways: (1) an
individual’s intrinsic traits enabling them to bounce back
after experiencing adversity; (2) a successful outcome or
a process of achieving positive functioning following child
maltreatment, such as the absence of clinical symptoms
or mastery of developmental tasks; or (3) an individual’s
capacity to utilize resources to achieve positive outcomes
(see Goldstein & Brooks, 2005; Smith et al., 2017; Ungar
et al., 2013; Williams & Nelson Gardell, 2012). Defini-
tions of resilience appear to be confined to the develop-
mental context of the youth in question (Yoon et al., 2019),
though further research is needed to capture the nuance
of resilience development and display across the lifespan.
Resilience Among Maltreated Children
Strong empirical evidence has shown that although some
maltreated children exhibit compromised capacity to ful-
fill stage-salient milestones of development, a substantial
proportion exhibit resilience—or an ability to function and
perform appropriate developmental tasks—despite experi-
encing adversity (Cicchetti, 2010; Holmes et al., 2015). In
the context of child maltreatment and trauma, studies have
shown that resilience can be amplified by certain factors
(Howell & Miller-Graff, 2014; Luthar & Cicchetti, 2000;
Mota, Costa, & Matos, 2016). Individual attributes that are
associated with positive outcomes and resilience following
child maltreatment include: self-regulation, social compe-
tence skills, personal control, problem-solving skills, moti-
vation, self-esteem, involvement in pro-social activities, and
adaptive functioning (Brownlee et al., 2013; CWIG, 2014;
Shultz et al., 2009). Relational factors associated with miti-
gated risk for negative outcomes include parenting compe-
tence, positive parent–child interactions, positive peer rela-
tionships, religiosity, and the presence of caring adults who
provide consistent support (CWIG, 2014; Holmes et al.,
2018; Mota et al., 2016; Perkins & Jones, 2004; Schultz
et al., 2009; Zimmerman et al., 2013). Several factors at the
community level are also associated with resilience, such as
a positive school environment, safe neighborhoods, social
cohesion, and positive community environments (CWIG,
2014; Perkins & Jones, 2004).
Role of Caregivers
Although parents are commonly the primary caregivers to
their children, it is not always the case that maltreated chil-
dren live permanently with their biological parents. In the
current study, we use the term caregiver to refer to any one
adult or combination of adults with custodial responsibilities
Caregiver Influences on Resilience Development Among Children with Maltreatment Experience:…
for a child. As such, our definition of caregiver is inclusive
of biological parents, adoptive parents, foster families, kin-
ship placements, and other forms of guardianship.
Existing research has identified factors that can foster or
inhibit children’s resilience development from multi-level
systems (e.g., individual characteristics, family, school, and
community environment; Garmezy, 1985; Hartman, Turner,
Daigle, Exum, & Cullen, 2009). The current study specifi-
cally focused on understanding risk and protective factors
related to caregiver influences based on two theoretical
considerations.
First, according to ecological-transactional theory (Cic-
chetti & Lynch, 1993), an individual can be most impacted
by proximal factors from the microsystem, or the family
environment. Therefore, caregivers are positioned to play an
essential role in fostering or hampering resilience develop-
ment for maltreated children. Second, given that attachment
theory postulates a tremendous influence of an attachment
relationship with caregivers on a person’s lifelong develop-
ment (Bowlby, 1988), it is suggested that the presence of a
supportive caregiver is one of the more important factors
defining the outcomes of maltreated children (Houshyar,
Gold, & DeVries, 2013). Therefore, understanding car-
egivers’ roles in resilience development is necessary to the
expanding resilience research, and is also essential for pro-
viding effective intervention for children experiencing mal-
treatment. As detailed below, the extant literature indicates
that caregivers can positively or negatively influence mal-
treated children’s resilience development primarily through:
(1) parenting behavior, (2) caregiver–child relationship, and
(3) caregivers’ own well-being and employment.
Parenting Behavior
Research has suggested that parental warmth and sensitivity
(Haskett et al., 2008; Herrenkohl et al., 1995; Kim-Spoon
et al., 2012; Lind et al., 2018; Ward & Haskett, 2008), paren-
tal monitoring (Wall & Kohl, 2007), and parental support
(Heller et al., 1999; Lynskey & Fergusson, 1997; Everson
et al., 1991; Spaccarelli & Kim, 1995) are important protec-
tive factors, while harsh parenting (Ward & Haskett, 2008),
parental overprotectiveness and authoritarianism (Lind
et al., 2018), and less perceived parental support (Lauterbach
& Armour, 2016) were risk factors threatening maltreated
children’s resilience. For example, the study conducted by
Kim-Spoon et al. (2012) on 95 physically abused children
found that positive parenting—which is characterized by
positive affect, responsiveness, less hostility, and more
structure—could ameliorate the negative effects of mala-
daptive self-regulation caused by physical abuse, which in
turn could decrease the level of externalizing symptoma-
tology of maltreated children. Similarly, Lind et al. (2018)
found that parental warmth was associated with greater
297
psychiatric resilience whereas overprotectiveness was asso-
ciated with decreased resilience. Ward and Haskett (2008)
found that physically abused children who were classified in
the socially well-adjusted group (i.e., exhibiting more pro-
social behavior and less aggression) had parents who showed
more parental sensitivity and less harsh parenting practices
than parents of children in the social difficulties group.
In addition to warmth and sensitivity, caregivers’ monitor-
ing also contributes to promoting maltreated children’s resil-
ience. Parental sensitivity has been found to reduce the risk
of youth substance use, as suggested by a study conducted
on 1179 maltreated children (Wall & Kohl, 2007). Finally, a
body of research on sexual abuse survivors strongly argued
the role of non-offending parent support after disclosure in
promoting resilience development (Bick et al., 2014; Ever-
son et al., 1991; Spaccarelli & Kim, 1995). Based on 120
mother–child dyads, Bick et al. (2014) found that mother’s
belief in the child’s disclosure and parent–child discussion
of the abuse incident can lower sexual abuse survivors’ risk
of substance use and trauma symptoms. Additionally, based
on the outcomes of 1423 childhood sexual abuse survivors,
Lind et al. (2018) suggested parental overprotectiveness and
authoritarianism were associated with lower resilience to
stressful life events in adulthood.
Caregiver–Child Relationship
Studies adopting an interaction perspective identified car-
egiver–child relationship as an important factor associated
with resilience. For example, children with maltreatment
experiences whose mothers were more affectionate and
supportive and less hostile and controlling exhibited higher
functioning and resilience (Herrenkohl et al., 1994; Herren-
kohl et al., 1995). In another longitudinal study of 206 mal-
treated children, results indicated that a secure mother–child
relationship can reduce children’s internalizing and external-
izing symptomatology and promote resilience development
through its impact on child self-esteem (Kim & Cicchetti,
2004). Similarly, a study on 122 adolescent child welfare
participants conducted by Guibord et al. (2011) found that
the perceived quality of the youth–caregiver relationship
could protect youth from experiencing mental health dif-
ficulties (i.e., depression and substance use). These findings
align with previous studies indicating that maltreated chil-
dren with less positive perceptions about their mothers, com-
pared to those with more positive perceptions of their moth-
ers, exhibited higher levels of externalizing and internalizing
symptomatology (Toth & Cicchetti, 1996; Toth et al., 2002),
which correspond to diminished development of resilience.
A stable home environment may be critical to resilience
development in children with maltreatment experience. In
their longitudinal study of 212 adolescents, Herrenkohl
et al. (2003) found that, for adolescents with maltreatment
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298
experiences, living in an unstable family environment with
frequent placement disruptions increased the risk for later
deviance (e.g., criminal behavior, substance use, truancy,
etc.) in adolescence. Frequent disruptions in caregiving in
early childhood have been shown to contribute to emotional
insecurity and to affect emotional growth and behavior
throughout childhood (Cicchetti & Tucker, 1994). Results
from another longitudinal study indicated that caregiver sta-
bility was associated with positive behavioral adjustment
for kids between the ages of 6 to 14 who had been placed in
early foster care (Proctor et al., 2010). A stable home envi-
ronment that offers safety and consistency may enable these
children to develop a secure attachment with their caregiver
(Fanshel, Finch, & Grundy, 1990), which may be important
for resilient development. Similarly, a stable home environ-
ment minimizes the disruptions in school and neighborhood
placement, disruptions which can contribute to challenges in
psychosocial development (Herrenkohl et al., 2003).
Caregiver Well‑Being and Employment
There is also a link between caregiver well-being and
maltreated children’s resilience development. Depressive
symptoms among caregivers have been extensively iden-
tified as a risk factor for maltreated children’s behavioral
health problems; studies have also demonstrated the inverse,
whereby the absence of caregiver depression serves as a
protective factor for maltreated children (Heneghan et al.,
2013; Tabone et al., 2010; Dubowitz et al., 2016). Like-
wise, caregiver’s substance abuse problems tend to result in
maltreated children’s compromised resilience (Jaffee et al.,
2007) in realms such as social-emotional concerns (Fusco
& Cahalane, 2013) and worsening behavior problems in the
developmental trajectories of child maltreatment survivors
(Tabone et al., 2010). Other researchers have defined car-
egiver well-being as the absence of parental substance-use
problems, depression, and other mental health problems,
finding that caregiver well-being was associated with a lower
likelihood of clinically significant levels of child aggres-
sion (Holmes et al., 2015) and externalizing symptomology
(Yoon, 2018). Finally, though it may not be directly related
to well-being, caregiver employment status has been sug-
gested as a protective factor for child resilience. Based on
a study of  68 female adults who experienced childhood
domestic violence, Anderson and Bang (2012) found par-
ticipants who had mothers with full-time steady employment
were more resilient than the counterparts with mothers who
were not working or who worked inconsistently.
Gaps in the Literature
To date, most studies examining caregiver influences adopt
a quantitative approach. Though larger quantitative inquiries
13
B. Beaujolais et al.
can help to identify and disentangle factors relevant to the
development of resilience, such studies have failed to elu-
cidate the process of how caregivers influence maltreated
children’s resilience development (e.g., Haskett et al., 2008;
Herrenkohl et al., 2003). Meanwhile, existing studies in this
area predominantly rely on self-reported data from caregiv-
ers regarding parenting and child outcomes (e.g., Kim-
Spoon et al., 2012; Kitzas & Grobler, 2005), which may
skew results because of shared method variance or social
desirability bias. The current study makes a significant con-
tribution by qualitatively exploring practitioner perspectives
about the role of caregivers in the development of resil-
ience in children following experiences of maltreatment.
By approaching the gap qualitatively and drawing from the
perspective of direct service practitioners, the study can also
contribute to caregiver-involved intervention development
to cultivate resilience development for maltreated children.
Methods
This study applied a cross-sectional, qualitative design. The
following research question guided this study: “What are
practitioner perspectives regarding the role of caregivers
in the development of resilience following child maltreat-
ment?” Data were collected using in-depth individual inter-
views with practitioners who had expertise in the area of
child maltreatment.
A purposive sampling strategy was used to recruit and
enroll participants in the study. The target sample included
practitioners from two agencies that serve victims of child
maltreatment in an urban Midwestern city in the U.S. One
agency was a children’s advocacy and behavioral health
center based in a pediatric hospital, and the other was a
non-profit foster care agency. To be eligible for participa-
tion, the practitioners needed to have experience directly
serving maltreated children. Several recruitment strategies
were used to identify and enroll participants. First, agency
staff received emails with details about the study, including
information about what participation entailed. Second, sen-
ior management personnel at each agency verbally shared
information with their staff. Third, the principal investiga-
tor attended staff meetings at each agency and presented
information about the study while also distributing a sign-up
sheet. Last, participants were invited to share information
about enrolling in the study with eligible colleagues.
Data Collection Procedures
Data were collected through semi-structured individual
interviews facilitated by one of four trained researchers. The
interviews—which were conducted in private spaces at the
participants’ places of employment—lasted between 30 and
Caregiver Influences on Resilience Development Among Children with Maltreatment Experience:…
60 min, with the average time being about 40 min. The inter-
views were guided by an interview schedule developed by
the researchers in consultation with an external child welfare
expert. The interview questions encouraged participants to
share their perspectives based on their experiences related
to resilience in maltreated children. The interview schedule
was structured to elicit examples of how maltreated children
have shown resilience, practitioners’ definitions of resil-
ience, and factors that practitioners identified as promotive
or inhibitory to resilience development. To avoid biasing the
perspectives of practitioners, a uniform definition of resil-
ience was not provided to them during the interview; rather,
as part of the interview, they were asked to provide their own
definition of resilience based on their practice experience
with maltreated children, and the interviewer then relied on
the practitioner’s definition to elicit information regarding
the role of caregivers in promoting or hindering resilient
functioning. Sample interview questions included, “How
have you seen your clients showing resilience?”; “What
differences are there between kids who are resilient versus
those who are not resilient? What makes the difference?”;
“What factors do you believe inhibit resilience?”; “What
factors do you believe increase and promote resilience?”;
and “Are there approaches that you or your agency have used
with maltreated children that you feel have been helpful to
promote resilience?”.
Demographic information from each participant was also
collected at the beginning of each interview to provide per-
sonal information about each participant’s age, gender, race/
ethnicity, as well as professional details such as their role in
the agency, length of employment, familiarity with the cur-
rent resilience literature, and the populations served. Before
the start of each interview, researchers obtained informed
consent from the participant. Interviews were audio-recorded
and conducted in private spaces at the participants’ agencies.
During the interviews, the researchers took written notes to
record their observations, such as participant’s non-verbal
expressions, mannerisms, or body language. As compensa-
tion for their time, study participants received a $25 gift card
to a local retail or grocery store. Interviews were conducted
over three months from November 2018 to January 2019.
Data Analysis
Coding and Thematic Analysis
All data were de-identified prior to analysis, and the inter-
views were transcribed verbatim by an independent profes-
sional transcription agency. ATLAS.ti, version 8 (ATLAS.
ti scientific software development GmbH, 2018) research
software was used to assist with the coding and analysis
of the qualitative data. Data analysis was conducted using
team-based coding and analysis (Guest & MacQueen, 2007).
299
During the first step of the analysis, the researchers reviewed
all of the data by reading each of the transcripts. Next, each
of the four researchers individually coded the lengthiest
transcript by identifying significant statements and apply-
ing descriptive codes to those significant statements. After
coding this single transcript, all of the individual codes from
each researcher were compiled, and researchers convened
to compare, discuss, and consolidate codes (MacQueen
et al., 2007). At the same meeting, the principal investiga-
tor reviewed the codes to verify that they were linked to the
data (Lincoln & Guba, 1985). A codebook was constructed
from these codes and included code names, definitions, and
examples. Researchers then coded an additional transcript
using the codebook, and reconvened to ensure consistency in
code application and to ensure that any issues with applying
the codebook could be resolved (MacQueen et al., 2007).
Next, the remaining transcripts were coded such that each
transcript was coded separately by two researchers. Files
were then merged in order to calculate percent agreement
and inter-rater reliability. The inter-coder percent agreement
rate was 91.8%. Krippendorff’s alpha coefficient, which is
considered to be the standard for determining inter-rater
reliability (Hayes & Krippendorff, 2007), was above the
acceptable limit of 0.667 (Krippendorff, 2018). Krippen-
dorff cu-alpha coefficients ranged from 0.443 to 0.985, with
an average of 0.706.
After the coding process was complete, the team met to
review the coded text and to identify and discuss the emer-
gent themes. Themes were determined based on their sali-
ence and support from the data. Discussions continued until
researchers reached a consensus about the major themes,
the subthemes, and their corresponding definitions. Poign-
ant, illustrative verbatim statements were extricated from the
coded transcripts to maintain the breadth of the perspectives
and to authentically illustrate the study results.
Strategies to Promote Rigor
To minimize subjective bias of the researchers and to foster
the credibility of the results, various strategies were applied
throughout this study. Single researcher bias was reduced
through a triangulated approach. Having multiple research-
ers involved in data analyses provided a more extensive
understanding of the phenomenon by incorporating diverse
perspectives while also minimizing selective, individual
perceptions (Carter et al., 2014; Patton, 1999). Peer consul-
tation and debriefing was provided by a professional who
was familiar with the research and held a neutral perspec-
tive about this specific study and phenomenon (Creswell
& Miller, 2000). Moreover, the credibility of the findings
was improved by having an expert qualitative researcher
serve as a peer reviewer, examine the study data and find-
ings, and critically consider the researchers’ methods and
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300
interpretations. Maintenance of an audit trail (Rodgers &
Cowles, 1993) that included documentation of decision mak-
ing processes and rationales was kept during the entire data
collection and analyses of this study. The audit trail also
contained field notes and reflexive memos written by the
researchers.
Results
A total of 27 practitioners participated in the study. These 27
practitioners included medical and behavioral health practi-
tioners affiliated with a children’s advocacy center (n = 22)
and practitioners who work at a community-based child
and family foster care agency (n = 5). A majority (92.6%)
of the participants were female. A majority identified as
White (81.5%), while 14.8% identified as African Ameri-
can and 3.7% identified as Hispanic. The average length
of employment at their current agency was 5.5 years. All
participants worked directly with children who had expe-
rienced maltreatment. The types of maltreatment that their
clients experienced varied. According to the practitioners,
their clients had primarily experienced some form of sexual
abuse (85.2%) and/or physical abuse (85.2%). Other forms
of maltreatment included experiences of neglect (70.4%),
emotional abuse (66.7%), and other forms of abuse such
as exposure to domestic violence (10%). Practitioners also
reported that many of the maltreated children they worked
with suffered poly-victimization, or exposure to multiple
forms of maltreatment.
Three primary themes emerged from the data. These three
themes include (a) caregiver influence, (b) intervention with
caregivers (to promote resilience among maltreated chil-
dren), and (c) caregiver-related barriers to child resilience.
Caregiver influence described the specific characteristics
of caregivers and behaviors of caregivers that practition-
ers perceived to be promotive of resilience development in
maltreated children. The caregiver influence theme had two
subthemes: environmental stability and supportive behavior
from caregivers. Intervention with caregivers also had two
subthemes. The first subtheme was educating and empow-
ering caregivers, and the second was a systems approach
to intervention. Practitioners also discussed two significant
barriers that they found to be particularly problematic to the
development of resilience in maltreated children. One bar-
rier included caregivers who were not engaged in or who did
not follow-through on treatment. The other barrier included
cases in which the perpetrator was also a caregiver.
Illustrative quotes from participants are used to present
the results of the study. In most instances, false starts and
fillers (e.g., um, like, etc.) have been removed from the
quotes. Participant numbers are attached to each quote in
13
B. Beaujolais et al.
order to demonstrate the representation of a breadth of
voices among the participants.
Caregiver Influence
Participants overwhelmingly perceived that there were
specific efforts and behaviors of the caregivers that helped
to foster resilience in children with maltreatment experi-
ence. When asked about what they perceived to be the most
important factor in promoting resilience following child mal-
treatment, many practitioners responded by describing the
role of caregivers. Participant 16 was one of the practitioners
who identified caregivers as the most influential factor in
resilience development following child maltreatment:
Having a supportive caregiver that believes them....
And that, even above therapy, having a relationship
with someone that believes them and supports them
is more foundational to their healing and them being
okay, long term, than anything else.
This practitioner perceived that, more than any other fac-
tor—whether it be an intervention or an innate quality in
the child—caregivers were the most influential factor in
promoting resilience among children following maltreat-
ment experiences. Furthermore, practitioners indicated
that the strongest and most prominent ways that caregivers
could influence the development of resilience was through
providing (a) environmental stability and (b) a supportive
environment.
Environmental Stability
Most participants reported that providing a stable home
environment for maltreated children was a significant factor
in promoting resilience following child maltreatment experi-
ences. Practitioners conceptualized environmental stability
as an environment that offered consistency, predictability,
and safety. When asked about factors that contribute to resil-
ience, Participant 4 responded, “…when they have perma-
nency of some kind, whatever that might look like, whether
it’s reunification, whether it’s adoption, whether it’s inde-
pendent living, you know.” Similarly, Participant 6 stated:
It depends upon….if they have been bounced around
from different houses or living arrangements, or not.
So stability, consistency, predictability—those things
I think are very important for kids and their well-
being—in their ability to be able to cope.
Both of these participants illustrated that having a transient
home environment or having to move from location to loca-
tion can have a detrimental effect on the child and their
ability to develop resilience, whereas, conversely, having a
Caregiver Influences on Resilience Development Among Children with Maltreatment Experience:…
stable and permanent home environment offers consistency
for the child which is promotive of resilience.
Practitioners defined a stable environment as one that
offered predictability for the child. For example, Participant
27 stated, “So creating kind of a safe space for their kid
where the kid feels like they can talk to them about prob-
lems, kind of come to them with how they’re feeling—and
know that caregiver’s going to respond.” In this example,
predictability involved the child being able to expect a con-
sistent response from their caregiver. Another participant
provided this example:
A child, that perhaps is in a new placement—so
whether it’s foster care or maybe next of kin—... they
start seeing that level of consistency throughout the
weeks, throughout the months, at some point, it’s
just—it’s amazing. It’s refreshing to just see that one
day, out of the blue, it might be like, “Oh, I don’t need
to hide food anymore in my room. I don’t need to
worry about the electricity being shut down or turned
off, or, I don’t need to worry about being evicted, or…
do we need to, you know, leave this place where we’re
at?” Being able to smile. (Participant 19).
In this example, consistency and predictability went hand
and hand—when the child was consistently getting their
needs met by their caregiver, they could begin to predict
that their needs would continue being met. This predictabil-
ity alleviated fear and anxiety associated with a pattern of
unmet basic needs.
Another aspect of environmental stability included safety
in the home. Participant 24 explained, “A caregiver that’s
not supportive and that happens to be your mom—and let’s
say your dad was a sexual abuse perpetrator—well, there’s
an increased risk simply because you maybe don’t really
have that physical protection.” In this example, the unsafe
environment, specifically the exposure to the perpetrator of
maltreatment, was a factor that inhibited the development of
resilience because the child was vulnerable to—and likely
lived in constant fear of—repeat victimization. Participant
17 also discussed the influence of a safe environment on
resilient functioning:
I think that if kids are able to be in a healthy environ-
ment or a safe environment—once they are, then I’ve
seen kind of a sense of like feeling stronger for having
gone through really difficult situations, and feeling like
they want to help others or kind of having more com-
passion. Yeah, just kinda feeling like they can accom-
plish things or they can get through difficult things
because of what they’ve experienced before.
This practitioner describes the impact that the presence of
a safe environment had on their clients—feeling safe facil-
itated feelings of strength and being capable of enduring
301
difficult and challenging experiences in the future. A safe
environment allows the maltreated child to focus beyond sur-
vival of and protection from maltreatment, and instead divert
their energy toward healing, empowerment, and personal
development, all of which were described by practitioners
as features of resilience.
Supportive Behavior
The second subtheme under caregiver influence considered
the supportive behavior of caregivers that directly or indi-
rectly affected the resilience development in kids. Practi-
tioners identified that supportive behavior included putting
the child’s needs first, believing the child, verbalizing their
belief, and accessing needed resources—including treatment
for themselves as the caregiver if necessary.
Practitioners described the importance of caregivers
prioritizing the needs of the child as a factor in promoting
resilience in children with maltreatment experience. Par-
ticipant 9 stated, “You know, why did you live with three
sex offenders in a row that sexually abused your children?
Why did you choose to just totally disregard their safety?
Why did you choose your parent, or your spouse, over your
child?” In this example, the practitioner explains how some
caregivers’ refusal to put the kid’s need for safety above
their own priorities exposed kids to further risk of harm.
This further risk of polyvictimization created obstacles to
developing resilience.
Most practitioners identified the importance of caregivers
believing their child when the child disclosed their experi-
ence of maltreatment. For example, Participant 10 stated, “I
will say supportive caregivers and caregivers that believe
their children and are protective of their children, I think
those kids have better outcomes.” Another practitioner fur-
ther elaborated:
It’s helpful for a caregiver who can tolerate listening
to what their child has to say related to their trauma.
So not necessarily just at the time... at that initial dis-
closure, but as maybe more information comes out, as
kids are moving through treatment and maybe they’re
having an increase in symptoms, because we’re start-
ing to talk more about the trauma. So, a caregiver
who’s able to kind of tolerate maybe hearing some of
those things and being able to manage their own reac-
tions to it. (Participant 25).
These practitioners illuminate the importance of caregiver
response to the disclosure, and especially the importance
of believing their child when they report their experiences
with maltreatment. Though it was important to believe their
child at the time of initial disclosure, maltreated children
may continue to develop and display behavioral issues as
the trauma continues to be divulged over time. Therefore,
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302
it was also vital—in order to promote the child’s resilience
and better outcomes—that the belief was sustained over time
as more information about the maltreatment and the child’s
experiences was revealed.
Though the caregiver needed to believe their child, it was
also critical that the caregiver reported their belief verbally.
Participant 25 explained, “So I think that the main—the
most important piece is just believing their child’s disclo-
sure of maltreatment whatever it might be and being able
to verbalize that, and let the child know that.” Similarly,
Participant 10 stated, “Examples of supportive caregivers
would be caregivers who are, first, verbalizing their support
to children. ‘I believe you.’” Participant 7 gave the follow-
ing example:
So if you have a parent that says, “What happened to
you is a bad thing, it’s not an acceptable thing, and
we’re gonna get through this together, and we’re going
to, um, know that that bad thing doesn’t define you.” I
think that kids can do really well.
The first two practitioners emphasize the importance of
the child hearing verbally from their caregiver that the car-
egiver believed them. The third practitioner illustrates the
importance of the caregiver’s verbal expression of belief,
and even further, validating for the child that the experience
was unacceptable and bad. Kids who heard verbally from
their caregiver that they believed their child reportedly had
better outcomes related to resilience.
Practitioners perceived that another way that caregivers
supported their kids—perhaps indirectly—was by having
their own support system. The support system could be
informal support provided through social support systems,
as this practitioner explained:
Caregivers who have their own supports, like adult
supports, so that if their child is sharing things with
them and they’re able to hold it together in that
moment for their child, that they’ve got somewhere
where they can kind of decompress, and be able to talk
about how it’s really affecting them. So having their
own supports I think is very important. (Participant
25).
Alternatively, caregivers may need more formal support such
as that provided through counseling services, as Participant
21 described:
A lot of the caregivers don’t understand trauma... They
don’t get it and don’t really know what to expect... And
then [some] need therapy for themselves because some
of them were involved in intimate partner violence or
whatnot.
Formal support for caregivers was identified as being helpful
in most cases—whether caregivers needed psychoeducation
13
B. Beaujolais et al.
to feel equipped to support the child or whether they needed
their own treatment to address their personal experiences of
trauma. Participant 7 summarized the importance of a sup-
port system for caregivers: “I really think that what we see
is kids do well when their parent does well.”
Intervention with Caregivers (To Promote Resilience
Among Maltreated Children)
Practitioners identified the critical importance of interven-
tions as a way for caregivers to help promote resilience in
maltreated children. This intervention included (a) educat-
ing and empowering caregivers, and (b) using a systems
approach to interventions and treatment.
Educating and Empowering Caregivers
Practitioners described the education and empowerment of
caregivers as including several components. One aspect of
education and empowerment included teaching caregivers
to validate the child’s feelings. For example, Participant 18
explained:
Being able to build up validation in the caregiver—so
being able to get the caregiver to validate the child’s
feelings and thoughts as well as their experience or
getting the caregiver to understand the abuse and
maybe why the child is reacting that way.
Participant 11 explained the utility of validating the child’s
behaviors for the caregiver: “Just upfront knowledge for the
caregiver and for the child because a lot of the times, kids
don’t even realize that some of their behaviors are due to
the maltreatment that they’ve received.” As this practitioner
explains, sharing knowledge with both the caregivers and the
kids helped to normalize and validate their realities, which
in turn helped to promote resilience. Overall, practitioners
found it helpful to contextualize the child’s reactions in order
to encourage caregivers to validate their child’s feelings.
Another component of educating and empowering car-
egivers was teaching about or helping caregivers with behav-
ior management for the child. One practitioner described
the importance of using behavior management strategies in
order to establish predictability and trust:
We try to teach consistency and predictability as far
as, like, punishment and reward, so they know what
to expect. Whereas whatever happened before, they
didn’t know what to expect. It may or may not have
been consistent—may have been unpredictable...
And so, if you say something, you’re gonna do some-
thing, then you should do it. You know, don’t make
threats that you don’t plan to keep. If you’re gonna
Caregiver Influences on Resilience Development Among Children with Maltreatment Experience:…
give the reward, then give the reward... So that they
learn to build that trust in you. (Participant 4).
In this example, teaching caregivers to implement behavior
management strategies such as rewarding positive behavior
or punishing negative behaviors was used to help establish
a sense of predictability, stability, and trust—all factors
identified by practitioners as essential factors promoting
resilience.
Modeling behavior—particularly behavioral responses
to trauma—was also identified by practitioners as an ele-
ment of educating and empowering caregivers through
intervention with caregivers. One practitioner explained:
And because I think that also helps increase resil-
iency for the child if they can look and see that car-
egiver that is trying to make it through. And whether
that’s them accessing their own treatment or just
being able to talk about how they’re coping I think
is a win–win. (Participant 22).
Another practitioner further elaborated:
Gettin’ back into a regular routine is good, but I
think parents just wanna shut it down—like, imme-
diately—and so I think psycho-ed[ucation] for par-
ents... and just really increasing their motivation
to be available to their kids to talk about it so the
secrecy piece to everything dissipates. (Participant
8).
These statements exemplify the practitioners’ perception
that caregivers’ ability to model responses to trauma—
skills learned through intervention—promoted resilience
development among maltreated children. When parents
were able to be accessible to their child, rather than shut-
ting down and trying to ignore the maltreatment experi-
ences, the children received messages about appropriate
behavioral responses.
Educating and empowering caregivers often included
teaching caregivers that they likely needed to adapt their
parenting to better support a traumatized child and pro-
mote resilience following child maltreatment. Participant 2
explained, “You can’t parent a traumatized child the same
way you would parent a child who hasn’t, because you’re
gonna have to do different things.” Many of the practitioners
implemented specific types of therapy such as Parent–Child
Interaction Therapy (PCIT) to promote adapted parenting
styles. For example, Participant 25 described:
[PCIT] is heavily led—really eventually led—by the
caregiver. And again... helping the caregiver learn
skills through play to be able to then have a better
attunement and relationship with their child to help,
then, kind of decrease those behavioral type of symp-
toms that you might be seeing.
303
As this practitioner explains, the new strategies learned
through PCIT promote an improved relationship between
the caregiver and child, which in turn decreases the negative
symptomology associated with maltreatment.
Systems Approach
Practitioners described that, in order to promote resilience
following child maltreatment, optimal intervention with car-
egivers required a systems approach to treatment. Most prac-
titioners found family involvement to be optimal, and they
tried to include the whole family in treatment or case man-
agement when possible. The extent of family involvement
depended on what was most appropriate for the situation:
We definitely include the family or the caregivers... I’m
trained in a couple different family type approaches, so
depending on what the kid needs, you know, that may
be more the focus than the—trauma narrative and stuff.
At least until we get through whatever we need to get
through. (Participant 4).
In a systems approach, practitioners also included fami-
lies by conducting environmental assessments to determine
family needs and to remove obstacles to accessing treatment.
Participant 10 elaborates: “I think these families need some
comprehensive case management, above and beyond their
therapy recommendations, just to assist with some of those
daily living tasks. To [mitigate] some of those barriers so
that the trauma treatment can be successful.” Participant 12
further explains:
One of the things that we do in our programs is... an
environmental assessment—to look in the home envi-
ronment to see not only about sleep safety for kiddos—
but also... does the family have a stroller? Does the
family have books in the home?... Is the home what
we’d consider safe, based on several factors?
Taken together, these practitioners explain the importance
of removing obstacles to treatment and barriers to resilience
development. In order to remove these barriers, the practi-
tioners found it necessary to consider ecological issues of
the family home environment that are beyond the treatment
needed for the trauma.
Practitioners described that supporting the emotional
needs of both the child and the caregiver simultaneously
was critical in the process of promoting resilience following
child maltreatment. For example, Participant 10 reported,
“Caregivers are almost always hysterical messes. I don’t
mean that in a disparaging way, but they’re usually really
struggling with the kid’s disclosure.” This practitioner
explains how the child maltreatment not only affects the
child, but, oftentimes, it immensely affects the caregivers
13

304
as well. Participant 8 also illustrates the impact of maltreat-
ment on caregivers and the importance of supporting them:
If we encounter a family where a parent is just really
struggling to acknowledge what has happened or just
emotionally just devastated and having trouble func-
tioning themselves, we’re really trying to focus on get-
ting them the support that they need—with the under-
standing that the better place they are in, the better
place their kid is gonna be in. So I think really focusing
on parental mental health has been something we’ve
done that is effective.
This practitioner emphasizes the importance of supporting
caregivers, not just for the caregiver’s benefit, but also for
the child’s—when the caregiver is able to manage their men-
tal health, the child has better resilience outcomes.
Practitioners also perceived that, within the systems
approach, treatment was a team effort that involved the
therapist, client, and family. Participant 25 illustrates how
treatment involved effort from everyone—the therapist, car-
egiver, and client:
[The] mom was actively engaged in treatment. She
would come in, I would provide education to her and
how she could be helpful to him. It really opened up
their communication a lot, and so it ended up that he
was able to progress through treatment and talk about
the abuse that happened... He also did a lot more com-
municating... with mom and dad at home about his
feelings and being able to talk through things instead
of having behavioral issues.
As this practitioner illustrates, positive outcomes in the child
were a product of everyone’s effort to establish open lines
of communication among everyone involved in treatment.
Another practitioner further explicates the importance of
team effort:
Even if we don’t have the parent in here participating...
they’re at least aware that we’ve done something and
can reference it. So most younger kids, like, [we teach]
red flag/green flag touches. So, we might... involve the
parent [to] take it home and put it on your fridge. You
know, and that was a green flag touch, you know, and
getting the kids to also do those things and—um, ver-
sus, oh, this is only something you learn in here. And
it’s only something where I talk about in here. You
know, making it part of daily life, so... it’s getting the
parent to do things at home. (Participant 5).
This practitioner explains how team effort and engagement
in treatment may vary across families. In this example,
the practitioner explained how although the level of direct
caregiver involvement in treatment varied, the caregiver
must be encouraged to stay involved with what their child
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B. Beaujolais et al.
was learning in order to reinforce treatment strategies out-
side of the therapeutic setting. This level of involvement
was still helpful in contributing to the child’s resilience
development.
Caregiver‑Related Barriers to Child Resilience
Practitioners identified two caregiver-related barriers or
challenges that interfered with resilience development
among maltreated children. One obstacle related to the dif-
ferent levels of caregiver engagement and follow-through
with their child’s treatment. Lack of caregiver engagement
and follow-through was noted as being caused by the fam-
ily’s limited access to treatment, or emotional resistance
from the caregiver/s based on their own trauma or trau-
matic experiences. For example, some families had finan-
cial barriers to accessing treatment, as this practitioner
explained: “Because if the barrier to them getting treat-
ment is transportation, those basic need things need to
be addressed. They don’t have reliable transportation, so
they can’t get to and from appointments.” Other times, the
barrier related to the caregiver’s denial of a need for treat-
ment. Participant 7 explained, “Because a lot of parents
are kind of trying to take the approach of, ‘There’s nothing
wrong with my kid. This bad thing happened, and we just
need to move on’.” Later, Participant 7 further explained
that some caregivers experience their own stressors as a
result of the maltreatment their child experienced: “If you
have a parent that, because their child experienced some-
thing, experiences their own trauma as a result of it; I
think they’re far less likely to do well getting through it.”
The participants also found that the challenge presented
when the caregiver and the perpetrator are the same per-
son can create a significant barrier to the resilience of a
maltreated child. Although this was not necessarily deter-
ministic of eliminating that relationship, it often made it
more difficult to do interventions with the family and to
foster healing and resilience. For example, one practitioner
described the challenge of continued exposure to maltreat-
ment in the home:
Well, I mean we’re talking about maltreatment...
obviously [it] is a huge [obstacle] if that can’t be
removed from their life. Yeah, that would absolutely
stunt the—because they’re trying to develop resil-
ience as it’s happening, but if it continues, and it’s
chronic, then the resilience doesn’t actually have a
chance to affect any change. (Participant 23).
This practitioner explains how the continued presence
of the perpetrator, particularly when the maltreatment is
chronic, prevents the child from developing resilience.
Caregiver Influences on Resilience Development Among Children with Maltreatment Experience:…
Discussion
The current study extends the existing knowledge about
resilience development among children with maltreatment
experience by examining practitioner perspectives about
the specific traits and behaviors of caregivers that posi-
tively or negatively impact a child’s resilience develop-
ment after maltreatment. While previous studies about the
influence of caregivers on child resilience development
use self-reported measures from parents or kids, the pre-
sent study makes a unique contribution to the literature by
examining the perspective of practitioners on this topic.
Similarly, while previous studies have focused on specific
aspects of parenting using quantitative measures (e.g.,
parenting styles, positive vs. negative parenting, etc.), the
current study widens the scope to consider the broader
influence of caregivers that affect resilience development.
Using qualitative interviews with practitioners who work
with maltreated children, this study examined the role of
caregivers on resilience and interventions among mal-
treated children.
Practitioners indicated that there were specific parent-
ing behaviors that affected maltreated children’s resilience
development. Maintaining a stable home environment—
one that offered consistency, predictability, and safety—
was a significant factor in promoting resilience. This result
aligns closely with previous quantitative research about
the role of stable home environments on child and youth
outcomes in which unstable home environments contribute
to diminished resilience outcomes (see Cicchetti & Tucker,
1994; Fanshel et al., 1990; Herrenkohl et al., 2003; Proc-
tor et al., 2010). Given that these previous studies relied
on self-reported measures from parents and kids, which
are prone to respondent bias, this finding from the current
study is significant because it both confirms and bolsters
the previous research indicating the importance of a stable
environment in helping to promote resilience.
A unique contribution of this study is the finding related
to supportive behaviors from caregivers as a promotive
factor for resilience development among maltreated chil-
dren. This result extends knowledge about the importance
of parental warmth and support. While prior empirical
research concludes that parental warmth, sensitivity, and
support are important factors associated with resilience
development (Haskett et  al., 2008; Heller et  al., 1999;
Herrenkohl et al., 1995; Kim-Spoon et al., 2012; Lind
et al., 2018; Lynskey & Fergusson, 1997; Spaccarelli &
Kim, 1995; Ward & Haskett, 2008), the current study fur-
ther distills specific caregiver behaviors associated with
warmth, sensitivity, and support (i.e., prioritizing needs
of the child, believing child disclosures, verbalizing
belief, and establishing/engaging support systems) that
305
practitioners perceive to be most important in promoting
resilience from a therapeutic orientation. Additionally,
whereas the aforementioned literature focuses on parents
specifically, the current study considers the role of car-
egivers more broadly.
Notably, practitioners found it most effective to take a
systems approach to treatment, such that family involvement
was optimal during treatment. The helpfulness of a sys-
tems approach to treatment is consistent with theories that
highlight the importance of family systems and the role of
families and caregivers on child development. For example,
Family Systems Theory (Bowen, 1978), Socio-Ecological
Theory (Bronfenbrenner, 1989), and Ecological-Transac-
tional Theory (Cicchetti & Lynch, 1993) all suggest that
family systems and caregivers have a critical effect on child
development, and findings from the current study suggest
that this effect may be especially crucial to engage following
maltreatment experiences of a child.
Practitioners described how living with a caregiver who
is also a perpetrator creates a significant barrier to resilience
development. The exposure to continued maltreatment pre-
vents the child from developing features of resilience that
can affect positive change. An added challenge of having a
caregiver in the home who is the perpetrator of maltreatment
is the knowledge that the other caregiver failed to interrupt
the maltreatment. Children’s resilience development may
be further inhibited when caregivers who are not the per-
petrator of maltreatment do nothing to prevent their child’s
exposure to the other caregiver who was the perpetrator of
maltreatment.
Implications for Social Work Practice & Policy
Findings from this study have important implications for
social work practice in particular. Given that practitioners
emphasized the importance of intervening with caregivers to
help them develop additional skills and behaviors that were
critical components of promoting resilience development,
social work interventions focusing on resilience develop-
ment following child maltreatment should include elements
designed to empower and educate caregivers to validate
the child’s feelings and experiences, manage their behav-
ior, model appropriate behavior (particularly as it relates
to trauma response), and adapt their parenting. Moreover,
these strategies should be implemented early in the treat-
ment stages in order to emphasize the importance of family
involvement and to promote family engagement.
Interventions designed to foster resilience in children
with maltreatment experience may consider incorporating
a systems approach to treatment. While a systems approach
is not a new concept to social work practice and is lauded
as an optimal treatment modality, it can be challenging to
implement. However, results from this study indicate that
13

306
there is a significant need for more training and develop-
ment in order for practitioners to effectively implement a
systems approach and to successfully engage and integrate
caregivers into the treatment. Corresponding to this need is
also the need for improved structural and systematic support
for implementation.
In adopting a systems approach to treatment, practition-
ers should be intentional about including all relevant car-
egivers, and not just family members. Even if caregiving
is temporary (e.g., foster placement), these caregivers will
likely benefit from inclusion in treatment efforts designed
to educate and empower caregivers to develop important
resilience-promotive behaviors, such as prioritizing needs of
the child, believing child disclosures, verbalizing belief, and
establishing/engaging support systems. Additionally, social
work practice should include assessment of these behaviors
to determine the extent to which caregivers are developing
or engaging in these behaviors.
Given the importance of caregiver engagement in treat-
ment, social work practice and policy development should
seek to minimize barriers to resilience development—
namely, follow-through with treatment and access to
resources. Social work practice should continue to develop
novel ways to help caregivers gain access to much needed
resources, such as transportation or other needs identified
through environmental assessments. Engaging caregiv-
ers early in the treatment process may also help improve
treatment compliance and follow-through. Clinical train-
ing policies could incorporate a resilience perspective into
child welfare treatment and permanency planning so that the
strengths of maltreated families and the resilience inherent to
caregivers and households is engaged in treatment and can
be mobilized to encourage thriving and normalcy following
maltreatment.
Limitations & Strengths
There are several limitations to the current study. As with all
qualitative research, results from the study are not generaliz-
able to all practitioners who work with maltreated children.
The results presented in this study can be attributed to a
limited sample of practitioners from a large city in a single
county in a Midwestern state. The voices of practitioners
from other geographic regions are missing and may provide
alternate perspectives. Similarly, the sample from this study
included a self-selected group of practitioners who work
with maltreated children. Other professionals who interact
with and may contribute to resilience development among
maltreated children, such as teachers, law enforcement, reli-
gious leaders, and other professionals are not represented in
the sample.
13
B. Beaujolais et al.
Despite these limitations, this study has notable strengths.
Practitioners who work with maltreated children have a
significant role in implementing interventions to promote
resilience development, and yet, their perspectives about
the role of caregivers in resilience development among
maltreated children have been missing from the field. By
eliciting and synthesizing their perspectives, this study
makes a significant and unique contribution to the field of
resilience research. An additional strength is the implemen-
tation of strategies designed to enhance rigor in qualitative
research. Researchers strictly adhered to strategies that have
been shown to enhance the trustworthiness of qualitative
research results.
Conclusion
Though research related to resilience development has gar-
nered increased attention in the child maltreatment literature,
the specific role of caregivers and their impact on resilience
development among maltreated children is largely unknown.
The current study begins to address this gap by exploring the
perspectives of practitioners about caregiver influences on
resilience development among children with maltreatment
experience. Findings from this study provide a significant
contribution to the literature by illuminating the specific
ways in which caregivers affect resilience development. It is
the authors’ hope that these study results can help to inform
future intervention, prevention, and policy development
aimed at promoting resilience development and improving
outcomes for children with maltreatment experience.
Compliance with Ethical Standards 
Conflict of interest  Authors of this paper have no conflicts of inter-
est—neither financial nor non-financial—to disclose.
Ethical Approval  The authors adhered to principles of ethical and
professional conduct when implementing this study. The institutional
review board at [removed for review] approved the research protocol
and all activities for this research study that involved human partici-
pants. All participants provided informed consent prior to engaging
in the research.
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