Pergamon S0277-9536(96)00110-4 Soc. Sci. Med. Vol. 43, No. 5, pp. 621-635, 1996 Copyright �� 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00 SECTION D CHILD DEVELOPMENT: VULNERABILITY A N D RESILIENCE P A T R I C E L. E N G L E I, SARAH CASTLE 2 and P U R N I M A M E N O N 3 ~Department of Psychology, Cal Poly, San Luis Obispo CA, U.S.A., -'Population Studies and Training Center, Brown University, Providence RI, U.S.A. and ~International Food Policy Research Institute, Washington DC, U.S.A. Alrstraet--Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of children's psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of children's development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a child's psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding) family dynamics and types of family forms (e.g. child fostering and non-traditional families) and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children? Copyright �� 1996 Elsevier Science Ltd Keywords---child development, vulnerability, resilience, malnutrition, violence toward children VULNERABILITY AND RISK Risk factors are individual or environmental hazards that increase children's vulnerability to negative developmental outcomes [2]. These risk factors come into play when "the interaction between the child and the environment produces stresses which result in new limitations or difficulties, new threats to homeostasis and to integration, new obstacles to learning, increased difficulties in mastering anxiety, or negative expectancies" [3]. Ecological theory suggests that there are several levels of interaction that are important to distinguish in understanding risk factors [4]. The first is between the child and his/her immediate family, and the second is between the various social systems in the child's environment that give meaning and significance to the child's experience, such as schools or community events. This level becomes increasingly significant as a child passes into the school-aged years. A third level of social system is represented by the larger forces, such as government, cultural values, or legal systems, which define the climate of the child's environment. The emergence of the study of resilience in the last two decades represents a novel approach to the understanding of how children develop when confronted with difficult circumstances. Many re- searchers focus on risk factors and the etiology of problems in children and youth such as alcohol and drug abuse, psychopathology, delinquency, early childbearing and violent behavior [5]. This research has documented a "pathology of disadvantage" [6]. Risks include individual-level characteristics such as intrauterine growth retardation, low birth weight, cocaine exposure in utero, or physical disability household-level factors such as family poverty and marital disruption and community-level factors such as living in a high-crime neighborhood, going to an inadequate school, or living in a community that has suffered from political violence. Although the analyses of risk initially examined these factors as static events, eventually more sophisticated analyses suggested that risk was a process, and that, for example, the total number of risk factors a child was exposed to, or the length of time of risk exposure, was more important than a single severe exposure [7]. More recently, it has been noted that in spite of difficult circumstances (risks), some children manage to grow and apparently prosper, whereas others in similar situations seem to follow the path originally described by vulnerability research. Even if half of the 621

622 Patrice L. Engle et al. children raised by a teen mother become teen mothers themselves, the others do not, and important lessons can be learned from examining the group who managed to overcome the risk [8]. How can these variations in life trajectories be explained? Researchers such as Werner [9], Rutter [10] and Garmezy [11] have begun to investigate why some children manage to come through situations of multiple risks apparently unscathed by the experi- ence. Thus, the focus of investigation changes from those who have problems to those who have succeeded in some way. This approach has advantages not only for understanding processes that might lead to interven- tions, but also to assist helpers who are working with individuals in high-risk situations. These helpers may, through expecting negative outcomes, unwittingly become part of the problem. This approach may also help the individual in a high-risk situation understand that a negative outcome is not inevitable. An adolescent having her first child, and deciding to keep it, may need to understand that not all who are in her situation will have negative life trajectories. The response of the individual to risk has been described in terms of vulnerability and resilience. Vulnerability has been defined as the individual's predisposition "to develop varied forms of psycho- pathology or behavioral ineffectiveness" or "suscepti- bility to negative developmental outcomes that can occur under high-risk conditions" [6]. This suscepti- bility has been attributed in part to genetic or temperamental factors [10]. On the other hand, resilience is the opposite: it is the individual's predisposition to resist the potential negative consequences of the risk and develop adequately. Individual characteristics such as locus of control, intelligence, or ego development might serve a protective function for children raised in risky circumstances [12, 13]. For example, Luthar [12] examined the relation of stress and competence among adolescents in the U.S. facing risks of inner-city violence and poverty. Adolescents under high stress who managed to be rated as assertive and responsible (competent) by peers and teachers, and therefore "resilient", had a greater sense of control over their environments than teens in a high-stress environment who were rated as less competent. Rutter [14] also suggested that resilient children differed on individual characteristics such as sense of self-efficacy and well-developed social problem-solv- ing skills. Factors in the environment may also ameliorate or diminish the potential negative effects of the risks [12, 15]. For example, Werner and Smith [16], in their longitudinal study of children who grew up with poverty and families experiencing discord and instability, found that those who developed into healthy adults had experienced a close relationship with at least one caregiver who provided unrestricted positive attention. Presence of some form of significant support by a valued person appears quite consistently as a protective factor. Some literature has used the term "invincible" or "invulnerable" interchangeably with resilience to describe these apparently successful children [17, 18]. However, this term suggests that there has been no cost to the child of the exposure to risk, as if the child were unscathed by the risk factors. Some work has suggested that children labeled as "resilient", who appeared healthy or competent despite experiences of risk, were using internalizing strategies to cope with risk, and these children were more likely to experience anxiety or depression [12, 19, 20]. Much more attention has been paid to individual- level and family-level factors than protective factors at the community level such as schools, health clinics, workplaces for young people, or community groups, although it is the latter that may be more amenable to intervention. Also, the causality of the relations is not unidirectional, even in longitudinal studies. What are the factors that result in a child having a higher sense of control? The individual's locus of control is probably determined in part by factors outside the child, such as type of neighborhood the child lives in, but also by the patterns of interaction that have developed around the child as a function of the child's characteristics. More careful attention needs to be paid to the multiple causal links. From the research on risks to children growing up in poverty one can identify various stages in the research process. Four separate stages can be identified these are described in Fig. 1. First, the risk factor is identified and established as a cause for concern. For example, recent evidence suggests that prenatal exposure to cocaine is a risk factor for children's later development [21, 22]. The second stage is an analysis of the causes and consequences of the risk, such as the assessment of the stage or extent of exposure to cocaine that might have negative effects on brain development. Stage 3 emerges when it is recognized that not all children respond in the same way to the same threat, and that not all are equally negatively impacted. In the example of studying the risks of cocaine exposure, researchers might recognize that some children exposed to cocaine in utero seem to function well, and they would look for possible protective factors. This stage has been reached with problems that have been the subject of intensive research for quite a while, such as the risk of poverty for adolescent competence. Finally, the application of research on protective factors should be incorporated into intervention programs that begin to capitalize on the research on protective factors. In the cocaine example, treatment programs for the families of cocaine abusers would use these protective factors to design an appropriate intervention. At each stage, there should be attention given to the three levels of analysis--the individual, the immediate environment of the family, and the larger

Child development community and institutions--for an exploration of risk factors and protective factors. NUTRITIONAL RISKS One of the major risks facing children, particularly in developing countries, is malnutrition. About 3% of children worldwide are severely malnourished [23], and 1990 studies show that 34% of children under 5 in developing countries suffer from mild to moderate malnutrition or are underweight [23]. In South Asia, fully 60% of children are undernourished. Other nutritional deficiencies with functional consequences are iron deficiency and iodine deficiency. Stage I research Numerous studies have identified the risks of malnutrition for children's development. Many years ago the linkage of severe protein-energy malnutrition with later cognitive deficits was identified [24-26]. To the list of risk factors have been added iodine deficiencies, associated with cretinism, hearing loss 623 and, in adults, loss of work potential [27, 28] and iron deficiencies and anemia, associated with lower levels of cognitive development in numerous studies [29, 30]. Currently, investigations are underway to understand the risks associated with other micronu- trients such as zinc deficiencies and riboflavin deficiencies. Stage 2 research: understanding the risks Much has been learned about the causes and consequences of protein-energy malnutrition, iodine and iron deficiencies for cognitive development. Research includes the effects of insults at various time periods, and severity or dose-response effects, and some of the mechanisms through which malnutrition may function as a risk factor. However, relatively few studies have looked for protective factors (Stage 3) or interventions (Stage 4). Research informed by the search for positive deviants [31] is a slightly different approach to the identification of protective factors (Stage 3). STAGE 1 ) efinition of the risk factor: oes the factor increase risk? onsequences of the risk? STAGE 2 ) nalysis of the risk factor: onditions of risk? Severity, timing of risk. ffect on child's development? tiology of the risk? ode of operation of the risk? ~ ' - STAGE 3 Recognition of resilience: - Are there children that respond differently to the risk factor? - Characteristics of these children? - Conditions under which effects of risk are lessened? - Are there children that recover from exposure to risk better? x._ j / f ~ STAGE 4 Research and Planning for Interventions and recovery: - Conditions under which children may be protected from risk? - Do resilient children show any negative effects? - What interventions could encourage resilience at all levels (individual, family, community)? - What interventions at a broader level could enhance protective conditions? j Fig. 1. Stages in the definition and analysis of risk.