In Review

Resilience Following Child Maltreatment:

A Review of Protective Factors

Tracie O Afifi, PhD1; Harriet L MacMillan, MD2

Objective: Child maltreatment is linked with numerous adverse outcomes that can continue throughout the
lifespan. However, variability of impairment has been noted following child maltreatment, making it seem
that some people are more resilient. Our review includes a brief discussion of how resilience is measured
in child maltreatment research; a summary of the evidence for protective factors associated with resilience
based on those studies of highest quality; a discussion of how knowledge of protective factors can be
applied to promote resilience among people exposed to child maltreatment; and finally, directions for future
research.

Method: The databases MEDLINE and PsycINFO were searched for relevant citations up to July 2010 to
identify key studies and evidence syntheses.

Results: Although comparability across studies is limited, family-level factors of stable family environment
and supportive relationships appear to be consistently linked with resilience across studies. There was also
evidence for some individual-level factors, such as personality traits, although proxies of intellect were not
as strongly related to resilience following child maltreatment.

Conclusions: Findings from resilience research needs to be applied to determine effective strategies and
specific interventions to promote resilience and foster well-being among maltreated children.

Can J Psychiatry. 2011;56(5):266–272.

Clinical Implications
• Knowledge about protective factors associated with resilience following exposure to child
maltreatment can assist clinicians in developing individual treatment plans for patients.
• Such information is important in developing the theoretical basis for interventions aimed at
promoting resilience following child maltreatment, but such programs and strategies cannot
assume to be protective—evaluation is still required.
Limitations
• Most studies have focused on child maltreatment generally, or one subtype of maltreatment without
considering that the association between exposure and resilience may vary depending on the
subtype.
• Sex- and gender-based analyses need to be included in considering the link between protective
factors resilience following exposure to child maltreatment.

Key Words: child maltreatment, resilience, protective factors

C hild maltreatment is a major public health problem,

associated with impairment in childhood, adolescence,
and extending throughout the lifespan. Specifically, child
maltreatment includes physical abuse, sexual abuse,
emotional abuse, neglect, and exposure to IPV. It is
estimated that every year millions of children are abused
and neglected worldwide.1 Being maltreated as a child can
have devastating consequences that create a significant
burden of suffering. Child maltreatment contributes to
mortality and morbidity and, in particular, is linked to poor
academic performance,2 mental health problems,2–5 physical
health problems,2,6 aggression,2 crime,2 violence,2,7 suicidal
behaviour,8 and decreased quality of life.2,9 Collectively,
this literature indicates that child maltreatment is associated
with impairment involving multiple domains of competence
and health, including physical, behavioural, emotional,
cognitive, and social functioning. Fortunately, not all
maltreated children experience negative consequences
related to this childhood adversity, making it seem that
some children are more resilient

266 W La Revue canadienne de psychiatrie, vol 56, no 5, mai 2011


In the previous In Review article, Dr Helen Herrman
and colleagues10 summarized the variations in definition
and conceptualization of resilience generally, as well as
methodological and theoretical considerations. In the
overall field of resilience, standardized and operational
definitions of resilience do not exist. As outlined by
Dr Herrman and colleagues,10 much of the early resilience
research focused on childhood adversities, such as exposure
to child abuse and neglect. Even within the specific area
of resilience research focusing on child maltreatment, the
definitions and conceptual frameworks differ. For example,
some studies define resilience as high functioning, whereas
others consider it to be the absence of poor functioning.11
People with a history of child maltreatment may be
considered resilient in one area of functioning, but fail to
meet criteria for resilience in other areas of functioning.12,13
Resilience is not static; it may vary over time and across
developmental phases—a person’s resilience status can
change from resilience to nonresilience and vice versa.
A growing literature has focused on enhancing our
understanding of resilience among people with a history of
child maltreatment through the examination of protective
factors that are linked to resilience.14–17 Focusing on
protective factors can provide insight into how to promote
resilience and overall health and well-being among
maltreated children. Further, it can inform the development
of interventions aimed at reducing impairment following
exposure to child maltreatment.
The objective of this current review is to examine the
protective factors related to resilience following child
maltreatment. To achieve this goal we will: briefly discuss
how resilience is measured in child maltreatment research;
provide a summary of the evidence for protective factors
related to resilience among children, adolescents, and adults
following child maltreatment based on the studies of highest
methodologic quality; consider the clinical application of
such knowledge; and, discuss directions for future research
in this area.
This review extends the current literature in several
important ways. First, a large number of studies have been
published in the area of resilience and child maltreatment
in the past several years; we include literature identified
through searches up to and including July 2010. Second, this
review includes all major categories of child maltreatment
as listed above. Finally, although, much of the literature in
this area has focused on children and adolescents, several
studies have addressed these issues in adults. We examine
these issues across the lifespan.
Abbreviations
EEG electroencephalogram
IPV intimate partner violence
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Resilience Following Child Maltreatment: A Review of Protective Factors
Resilience and Child Maltreatment
Walsh et al11 provide a comprehensive overview of how
resilience has been defined and measured, specifically
in child maltreatment research. Briefly, the authors note
that resilience among maltreated children is present when
children show a normal range of competence across
several domains of functioning. Developmental domains
of functioning commonly include behavioural competence
(for example, patterns of behaviours toward others),
emotional competence (for example, mental health), social
competence (for example, peer relationships), and academic
achievement (for example, school performance).11
In studies involving child and adolescent samples,
resilience is frequently measured using normative levels of
internalizing and externalizing symptoms and competent
age-appropriate functioning across several developmental
domains. Studies involving adult samples tend to use
fewer resilience criteria, which often include absence of
psychopathology, psychological well-being, self-esteem,
and social functioning. It should be noted that self-report
resilience questionnaires measuring concepts such as
adaptability have been developed, but these scales are
not commonly used in child maltreatment studies. Using
multiple indicators to determine resilience is a widely
accepted practice because, as previously mentioned, a person
may show competence in one domain, but not in another.12,13
In studies of people exposed to child maltreatment where
only one outcome is measured, a person may be considered
resilient simply in the absence of one disorder. While this
type of investigation is informative, a single outcome is
not adequate when considering overall resilience following
maltreatment.
Although resilience is more accurately captured using
multiple rather than single indicators, a challenge of
measuring resilience with this approach is the substantial
variability in specific measures included and selection of
their cut-off points.11,14 Importantly, variation in definitions
and threshold affects the proportion of children considered
resilient,11,18 and makes comparisons across studies difficult.
Despite these measurement differences, the use of several
indicators of competence and functioning to measure
resilience results in a more comprehensive assessment of
those who have effectively adapted following exposure
to child maltreatment and also has important implications
for prevention of subsequent impairment. Consistent with
Walsh et al,11 only studies using more than one subcategory
within a domain of functioning to assess resilience will be
included in this review.
Search Strategy and Selection Criteria
Although we did not do a formal systematic review, our
search strategies were designed to identify original research
articles and reviews that evaluated protective factors
related to resilience following child maltreatment. The
databases MEDLINE and PsycINFO were searched for
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In Review
relevant citations up to July 2010 to identify key studies
and evidence syntheses. Terms used to search databases
included resilience, resilient, and resiliency, with child
abuse, child maltreatment, physical abuse, sexual abuse,
emotional abuse, neglect, exposure to intimate partner
violence, and exposure to domestic violence. References
from retrieved articles were reviewed for additional relevant
citations. We focused on higher levels of evidence, to
review studies that met the following criteria: they assessed
more than one domain of functioning (cognitive–academic,
emotional, social, physical, or behavioural) or more than
one subcategory within a domain (for example, internalizing
and externalizing symptoms)11,13; they examined several
indicators of resilience concurrently rather than considered
several resilience outcomes individually; and, they
were quantitative, with a cross-sectional or longitudinal
research design. A wide range of samples were included:
community, convenience, court, child protective services,
clinical, treatment seeking, and at-risk people. Only a few
qualitative studies have been conducted in this area and
were not included in our review; implications of important
findings from these studies are discussed below. A total of
27 articles were included in the review and are summarized
in online eTable 1.
Protective Factors
To improve our understanding about how to promote
resilience following child maltreatment, it is necessary to
study factors that may protect a person from impairment
associated with being maltreated. Research on protective
factors examine traits that contribute to resilience and
those mechanisms that facilitate resilience.19 A protective
factor may influence, modify, ameliorate, or alter how a
person responds to the adversity that places them at risk
for maladaptive outcomes.20 Although most of the child
maltreatment research has focused on negative outcomes
associated with maltreatment, a growing literature has
investigated protective factors related to resilience. These
factors can be divided into those at the individual, familial,
and community level.
Individual-, Family-, and Community-level
Protective Factors Related to Resilience
Individual-level protective factors are personal character-
istics, traits, and resources, such as personality traits,
intellect, self-efficacy, coping, appraisal of maltreatment,
and life satisfaction. Family-level protective factors include
resources and supportive relationships, such as family
coherence, stable caregiving, parental relationships, and
spousal support. Protective factors at the community level
include peer relationships, nonfamily member relationships,
nonfamily member social support, and religion, among
others. The following section summarizes the evidence for
links between protective factors and resilience following
child maltreatment, based on longitudinal and cross-
sectional research studies.
268
Longitudinal Studies Extending From Childhood
and Adolescence Into Early Adulthood
The ideal study design for investigating protective factors
associated with resilience following child maltreatment
is longitudinal, with prospective data collection over
multiple time points, from childhood into adulthood, with
a community sample. The following studies have several of
these characteristics.
Hyman and Williams21 investigated protective factors
related to resilience in a sample of sexually abused girls
interviewed in childhood and later in adulthood. Predictors
of resilience in this sample included a stable family, less
severe sexual abuse experiences, no history of juvenile
arrests, graduation from high school, and no history of sexual
re-victimization in adulthood. In another study of sexually
abused girls, social connections, life satisfaction, and
adaptive coping were related to resilience during a 1-year
period in adulthood.22 In a community sample of abused and
nonabused people, Collishaw et al23 examined the relation
between several individual-, familial-, and community-
level protective factors; resilience was defined as absence
of adult mental health disorders and suicidal ideation and
(or) attempts during a 30-year period.23 Forty-five percent
of people who were abused met study criteria for resilience.
Low neuroticism, no history of adolescent mental health
disorders, perceived good parental care, normal adolescent
peer relationships, stable adult relationship history, and good
adult friendships were associated with resilience. DuMont
et al24 used a longitudinal study design to examine whether
sociodemographic characteristics, cognitive ability, stable
living situation, neighbourhood advantage, and supportive
partner relationships were associated with resilience
measured using multiple domains of successful functioning.24
The significant findings related to resilience in adolescence
included gender (girls) and having stable living situation
and in adulthood included gender (women) and having a
supportive partner relationship. Interestingly, 50% of abused
and neglected people who were resilient in adolescence
remained resilient in young adulthood; the majority of
those who were not resilient in adolescence remained not
resilient in adulthood (89%), with only 11% moving from the
nonresilient to resilient category in adulthood.
Longitudinal Studies Within Childhood and
Adolescence
Several longitudinal studies that included individual-
and family-level protective factors have been conducted
within childhood and adolescence. The type of protective
factors most consistently related to resilience following
maltreatment in these studies was at the family level,
including supportive caregivers and stable caregiving
environments. Herrenkohl et al25 studied high-functioning
children who had been abused or neglected and identified
the stable presence of at least one caregiver in childhood
as a protective factor related to resilience.25 In a sample
of 147 sexually abused boys and girls, being satisfied
with emotional support from caregivers at the time of
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discovery of abuse was related to better teacher- and parent-
rated adjustment 1 year later.26 Similarly, in a sample of
86 sexually abused girls aged 11 to 17 years, less conflict
with mothers and being trusting of others, in addition to
empowerment, adaptive coping strategies, and less drug
use were related to stable resilience during a 5-month
period.27 In a community-based study of boys and girls,
less unilateral parental decision making was protective
against externalizing outcomes among abused children,
while lower stress in childhood and adolescence and higher
hostile attributional bias were considered protective against
internalizing outcomes.28 Collectively, the results of these
studies suggested that ensuring that the child feels supported
in a stable caring family environment may help to promote
adaptive functioning following child maltreatment.
At the individual level, longitudinal studies have found
some evidence for personality traits (ego resilience and
ego overcontrol),29,30 positive self-esteem,29 easy child
temperament,31 and daily living skills (personal, domestic,
and community adaptive functioning skills)32 as protective
factors related to resilience following maltreatment. Simply
stated, ego overcontrol is master over impulses and ego
resilience is the ability to modify ego control in response to
situations. Ego overcontrol and ego resilience characterize a
person as having control and being resourceful and flexible,
which may help maltreated children become adaptive
and highly functioning.33,34 Intelligence as a potential
individual-level protective factor related to resilience
following child maltreatment has also been studied, but
has yielded inconsistent and somewhat weak findings in
longitudinal research. For example, of the 23 abused and
neglected people identified in the study by Herrenkohl et
al25 as highly functioning in childhood, 14 were attending
or had graduated from high school later in adolescence
and all had an average or above average IQ.25 However,
in 2 longitudinal child samples, intelligence as measured
using tests of receptive vocabulary was not a predictor of
resilience in maltreated children.29,31 Interestingly, in another
study of resilience, having a greater commitment to school
was a consistent predictor of less violence, delinquency, and
status offences until the age of 18 years, both in physically
abused and in nonabused children.35
Cross-sectional Studies Involving Child and
Adolescent Samples
Similar to the findings of longitudinal studies, supportive
family relationships and family environments were
identified consistently as protective factors for resilience
following child maltreatment exposure in cross-sectional
investigations. More specifically, a warm and supporting
relationship with a nonoffending parent,36 better parenting
performance,37 and family coherence38 were linked with
resilience following such exposure. Likewise, in a sample
of children exposed to IPV, warm and effective parenting
along with less maternal depression distinguished those
children who were resilient from those with severe problems
and children who were struggling.39 Findings from a study
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Resilience Following Child Maltreatment: A Review of Protective Factors
involving an adolescent child welfare sample indicated that
relatedness to a caregiver and social skills, but not academic
variables, were important latent components of resilience.40
Of note, not all studies have found evidence for a link
between family support and resilience. One study, which
involved a sample of sexually abused girls in foster care,
did not find evidence for an association between family
support and resilience.41 However, the authors aptly
concluded that the nonexistence of this relationship may
be because this was a foster care sample. Peer influences,
certainty of school plans, and positive future orientation
were related to resilience, suggesting that adolescent girls
in care may rely more on support outside of the family.41
Likewise, another study found a positive association with
another type of nonfamily member support—relationships
with camp counsellors—and resilience.42
Cicchetti and colleagues (Cicchetti et al,33 Flores et al,42
Cicchetti and Rogosch,43 Curtis and Cicchetti,44 and Kim
and Cicchetti45) have made several important contributions
to our knowledge of individual-level protective factors
related to resilience; their findings have been mainly based
on cross-sectional data comparisons of maltreated and
nonmaltreated children from low-income families attending
summer camp.33,42–45 These studies are informative because
data were collected from multiple sources, including the
child, peers, school records, and camp counsellors. Results
consistently showed that the personality dimensions of
ego resilience and ego overcontrol were associated with
resilience among maltreated children.33,42,43 Positive self-
esteem is another individual-level protective factor that has
been associated with resilience in cross-sectional studies
from Cicchetti’s group.33
Cross-sectional Studies Involving Adult Samples
A small number of cross-sectional studies involving adult
samples have explored factors associated with resilience
among people with child maltreatment histories. Several
individual-level protective factors associated with resilience
across these studies have been identified, including:
internal locus of control or personal control,46–48 optimism
about the future,46 less self-destruction,47 less self-blame,47
and less trauma-related beliefs (self-blame, betrayal, and
powerlessness).49 At the family level, less family stress has
been associated with greater resilience.47 In addition, in a
sample of mothers with a history of sexual abuse, spousal
support was related to resilience.50 In one study involving
a representative community sample of men and women,
emotional and instrumental support were not found to be
related to resilience in this study.48
Discussion
Owing to wide variation in study designs and samples, it
is difficult to compare findings across studies of protective
factors associated with resilience following exposure to
child maltreatment. However, the family-level factors of
stable family environment and supportive relationships
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In Review
appear to show a consistent association with resilience
across studies. The research to date supports an observation
by Egeland et al51 made almost 2 decades ago: “the
capacity for resilience develops over time in the context of
environmental support.”p 518
There was also evidence for some individual-level factors,
such as personality traits, although proxies of intellect
were not as strongly related to resilience following child
maltreatment. This was consistent with findings from
a study involving an adolescent child welfare sample:
relatedness to a caregiver and social skills, but not academic
variables, were important latent components of resilience.40
Clearly one important goal of future research should be
to determine ways that these findings can be applied in
developing specific interventions to reduce impairment
associated with exposure to child maltreatment; that is,
to promote resilience. It is equally important to consider
the current clinical implications of these findings for our
patients—children, adolescents, and adults—presenting
with a history of exposure to maltreatment. Knowledge
of protective factors associated with resilience can assist
clinicians in taking a history to identify those factors
specific to an individual patient that might assist him or
her in coping with exposure to maltreatment. Some factors
are amenable to change—for example, involvement of
supportive family members, whereas this is much more
difficult for other factors—for example, personality traits.
Given the paucity of effective interventions to prevent
impairment following exposure to child maltreatment,
it is important for the clinician to identify factors that
potentially promote resilience as part of any treatment
plan. For example, determining the stability of the family
situation should be included in the overall assessment of
a child and family following his or her exposure to one or
more types of child maltreatment. Graham-Bermann et al39
emphasize that interventions for children exposed to IPV
(although this extends to all types of child maltreatment)
should be “tailored to the specific needs of the child” rather
than assuming “a one-size-fits-all approach.”p 659
Although we are highlighting the relevance to clinicians
of knowledge about protective factors associated with
resilience following maltreatment, it is important to keep
the limitations of this information in perspective. Although
it provides some theoretical basis on which to formulate
a treatment plan, such information is not a substitute for
theoretically based interventions evaluated in controlled
trials regarding their effectiveness in promoting resilience.
Too often there is the assumption that information about
increasing protective (and lowering risk) factors translates
into definitive evidence for the effectiveness of an
intervention; such programs or strategies need to undergo
appropriate evaluation.
In moving toward development of specific interventions
based on our knowledge of protective factors, it is useful to
270
review some of the research gaps in the existing literature.
First, many studies only investigate child maltreatment
broadly defined without examining the potential differential
relations between subtypes of maltreatment and resilience.
Although some studies have investigated individual
subtypes of child maltreatment, mainly physical and sexual
abuse, other forms of child maltreatment, such as neglect and
exposure to IPV, need to be more thoroughly investigated.
As well, as many children are exposed to more than one
type of child maltreatment,9 it is necessary to understand
how co-occurring types of maltreatment relate to resilience.
Second, more detailed analysis of the association between
protective factors and resilience needs to be conducted
separately among boys and girls and men and women. Most
studies either use a combined sample or only included girls
or women. Only a few studies have compared sex or gender
differences to investigate if sex or gender is a protective
factor or if the relation between protective factors and
resilience varies according to sex or gender. For example, in
a longitudinal study investigating resilience following child
maltreatment, but not protective factors, women, compared
with men, were more likely to meet criteria for resilience.13
In another longitudinal sample, females were more likely to
be resilient in adolescence and early adulthood.24 We need
greater availability of datasets that would provide sufficient
statistical power to conduct more detailed sex- and gender-
based analyses.
Third, only a few studies have investigated the important
relation between potential biological and genetic protective
factors related to resilience following child maltreatment.
One study examined emotion regulation and hemispheric
EEG asymmetry in relation to resilience and found
significant biological differences in EEG asymmetry across
central cortical regions distinguishing between maltreated
and nonmaltreated children.44 In addition, Cicchetti and
Rogosch43 investigated resilience in relation to stress-
responsive adrenal steroid hormones and personality
constructs and found that hormones and personality were
able to predict resilience in maltreated and nonmaltreated
low-income children. Additional research examining
biological and genetic protective factors is necessary,
including the use of twin study and molecular genetics
designs to investigate the resilience outcomes.
Fourth, although some longitudinal studies24,25,27,29 have
investigated changes in resilience over time, further
research should be conducted to understand resilience
trajectories. The most informative study designs will be
those that measure the co-occurrence and interaction of
multiple protective factors in relation to resilience, and how
the course of such resilience and its relations with protective
factors change over time.
Finally, many individual- and family-level protective
factors have been studied, but there has been less focus
on community-level variables. It is important to identify
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understudied protective factors at the individual, family,
and community levels and include them in future research.
Qualitative research would serve as an excellent method
to identify new protective factors that could be included in
future quantitative studies.
Conclusion
High competence and functioning following child
maltreatment are indicators of resilience. Studying
protective factors related to resilience following child
maltreatment allows for a more in-depth investigation of the
context in which resilience can be established. Stable family
environment and supportive relationships were identified as
2 family-level factors that have been linked consistently
to more adaptive functioning. Findings from this area of
research need to be applied to determine effective strategies
and specific interventions to promote resilience and foster
well-being among maltreated children.
Acknowledgements
Our research was supported by funds from the Canadian
Institutes of Health Research Institute of Gender and Health
and Institute of Neurosciences, Mental Health and Addictions
awarded to PreVAiL (Centre for Research Development in
Gender, Mental Health and Violence across the Lifespan).
The Canadian Psychiatric Association proudly supports the
In Review series by providing an honorarium to the authors.
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Manuscript received September 2010 and accepted October 2010.
1
Assistant Professor, Departments of Community Health Sciences,
Psychiatry, and Family Social Sciences, University of Manitoba,
Winnipeg, Manitoba.
2
Professor, Departments of Psychiatry and Behavioural Neurosciences,
and of Pediatrics, McMaster University, Hamilton, Ontario.
Address for correspondence: Dr T O Afifi, Department of Community
Health Sciences, Faculty of Medicine, University of Manitoba, S113
Medical Services Building, 750 Bannatyne Avenue, Winnipeg, MB
R3E 0W3; T_Afifi@umanitoba.ca

Résumé : La résilience après la maltraitance dans l’enfance : une revue des

facteurs protecteurs
Objectif : La maltraitance des enfants est liée à de nombreux résultats indésirables qui
peuvent persister toute la vie. Cependant, la variabilité de la déficience a été notée à la suite
de la maltraitance des enfants, et il semble que certaines personnes sont plus résilientes.
Notre revue comporte une brève discussion de la manière dont la résilience est mesurée
dans la recherche sur la maltraitance des enfants; un résumé des données probantes sur
les facteurs protecteurs associés à la résilience d’après les études de qualité supérieure;
une discussion de la façon d’appliquer les connaissances sur les facteurs protecteurs à la
promotion de la résilience auprès des personnes exposées à la maltraitance dans l’enfance; et
enfin, des directions pour la future recherche.

Méthode : Des recherches de citations pertinentes ont été effectuées dans les bases de
données MEDLINE et PsycINFO jusqu’à juillet 2010 afin de repérer les études clés et les
synthèses de données probantes.

Résultats : Bien que la comparabilité entre études soit limitée, les facteurs de niveau familial
d’un environnement familial stable et de relations de soutien semblent être uniformément liés à
la résilience dans les études. Il y avait aussi des données probantes sur les facteurs de niveau
individuel, comme les traits de personnalité, même si les indicateurs de l’intellect n’étaient pas
aussi fortement liés à la résilience à la suite de maltraitance dans l’enfance.

Conclusions : Les résultats de la recherche sur la résilience doivent être appliqués pour
déterminer les stratégies efficaces et les interventions spécifiques visant à promouvoir la
résilience et à favoriser le bien-être chez les enfants maltraités.

272 W La Revue canadienne de psychiatrie, vol 56, no 5, mai 2011