Of the 15 measures reviewed by this group, six were classified as Well-established assessment instruments that broaden understanding and one as a Well-established instrument that guides treatment. Of the three stress measures, only the CHS and CUS (Kanner et al., 1987
) is Well-established, and it broadens understanding. In research with the CHS and CUS, hassles and uplifts have been found to correlate in the expected direction with children's adjustment. Both subscales are available in the original journal publication.
Of the 12 coping measures, six met criteria for Well-established. These included the A-Cope, CSI, PCQ, PRI, WCCL, and the CAMPIS/CAMPIS-R (). There were also some very promising scales, such as the RISCS, that would have met the criteria for Well-established except that all investigations have involved one or more of the original authors of the measure. Having multiple investigative teams use the scales in published research is a requirement for the Well-established designation. Each of the coping scales has been used in correlational research. In addition, the A-COPE, PCQ, PRI, RISCS, BAADS, and CAMPIS/CAMPIS-R have been shown to be sensitive as dependent variables for measuring changes in treatment research. Others scales also have the potential for measuring change in intervention research.
The measures of coping appeared to hold the greatest potential for guiding the design of treatment interventions. When using the Stress and Coping workgroup criteria, the CAMPIS/CAMPIS-R was the only scale thus far that has been shown to directly inform the design of treatment interventions. The connections between assessment research using the CAMPIS and treatment design have been described by the authors (Blount et al., 2000a
; Blount, Piira, & Cohen, 2003
), and may serve as one possible prototype for helping guide this area. Although not systematically addressed by this subgroup, the reviewers noted that several other scales that were reviewed have the potential to indirectly inform the design of treatment interventions. For example, research with these inventories may specify the types of constructs that need to be changed rather than specific behaviors that should be trained in order to produce a desirable outcome. However, we did not find explicit, direct linkages for the other inventories in which assessment research directly informed the design of treatment interventions.
Limitations of this review should be noted. The first broad issue to be considered involves the selection of measures. The survey that was initially mailed to the membership, although intended to be comprehensive, almost surely excluded some stress and coping scales. Scales that were more likely to be left out were the ones that were most recently developed. Further, the newer scales that were included in the survey were less likely to become part of the review because they were less likely to be endorsed as having been used by as many people. Few endorsements could reflect the short duration since they had been published rather than any lack of strong psychometric properties or potential for high clinical utility. In addition, the survey of the membership was conducted in 2003 and, although it may have accurately represented the research activities and clinical practice of the responders at that time, some additional scales might be used today. Finally, the responses of the 87 subscribers to the Division 54 listserv who completed the surveys may not accurately reflect the use of particular coping and stress measures by the field as a whole. The second broad issue relates to the criteria that were used by the Evidence-based Assessment Task Force and those that were unique to the Stress and Coping Workgroup. In contrast to prior efforts to determine evidence-based treatments, determining assessment instruments that should be considered as evidence-based is a much more complicated task. This complexity arises in large part because there are multiple kinds of validity that an assessment instrument could display (Cohen et al., in press). Further, an instrument might be valid for one purpose, but not for another. For the SPP-ATF, one global categorization was made for each scale, as being Promising, Approaching well-established, or Well-established. It is possible that future assessment task forces might apply these criteria individually to the different types of validity.
To help guide future research, and in particular to help facilitate a closer and more explicit connection between stress and coping assessment research and the design of treatment interventions, we suggest the following considerations and guidelines:
- Assessment of stress may indicate that something needs to be changed, and may even indicate what that something is, but rarely indicates how to change it. High levels of stress in a person's life is generally associated with undesirable outcomes. This is true whether stress is viewed as an accumulation of aversive external events or counterproductive means of dealing with those events. The treatment implications of high stress are negative, in the sense that there should be a reduction or removal of external stressors or a cessation of reacting in counterproductive ways to life's challenges. This information can be very valuable, but it may not be sufficient. It can be very difficult to simply cease doing something, even if that something is counterproductive. It is difficult to turn from something without having a desirable alternative place to go.
- Focus on coping assessment research for treatment implications. The goal of coping assessment should be to find effective, malleable behaviors, and strategies that reduce adverse reactions to stressful life events. This is true whether the event is chronic, such as having a medical disorder, or acute, such as receiving a painful injection. In the best of cases, greater proficiency in using these strategies might not only lead to a reduction of adverse outcomes, but might actually promote a sense of mastery for patients and others who may be enlisted to assist them. In contrast to the negative therapeutic implications of the assessment of stress (e.g., take something away), as noted earlier, the therapeutic implications of discovering effective, trainable coping strategies are positive, in the sense that they can be taught and added to the individual's repertoire. By turning to the use of effective coping strategies to promote personal growth and satisfaction, patients necessarily will have to turn from the excessive use of ineffective, and perhaps habitual, unproductive ways of being.
- To the extent possible, coping assessment research should focus on discrete behaviors as well as on constructs. Constructs are part of theory development and testing, and they allow for an easier conceptualization of how broad categories of variables relate to each other and to outcomes of interests. In contrast to more amorphous constructs, individual assessment scale items may reflect particular, discrete behaviors that can be trained. Those individual overt or cognitive behaviors that are associated with beneficial outcomes can be taught to increase their occurrence. Behaviors associated with adverse outcomes can be targeted for reduction, probably by training an incompatible and beneficial behavior to replace it.
Constructs and behaviors can be reframed in terms of risk and resiliency research as marker variables and functional variables (Kazdin et al., 1997
). Constructs can be thought of as markers that direct researchers’ attention to examine the components of the construct that may be functional; that is, helpful or detrimental in relation to a particular outcome of interest. These individual behaviors are potentially trainable, whereas constructs tend to be more abstract and difficult to operationalize in training programs. Including relevant, malleable, individual behavioral items in the design of coping scales helps facilitate the potential linkage between assessment and treatment. This may also mean a rethinking of how to present the results of correlational research, with attention to behavioral items that are helpful, as well as to constructs.
A greater attention to individual coping scale items that are indicative of modifiable behaviors increases the likelihood of correlational research on coping yielding direct implications, as opposed to general recommendations, for the design of therapeutic programs. The implication, simply put, is that the patient is to do more of this particular coping behavior when faced with a particular stressor. Greater reliance on constructs rather than particular behavioral items lessens the explicitness of the connection between coping assessment research and the design of treatment interventions. With this said, the lack of an explicit connection does not mean that prior coping research has not been valuable for designing treatment interventions. Indeed, construct-oriented coping assessment research suggests many valuable, but often general, implications for treatment design. Construct-oriented assessment research necessarily means that treatment designers must extrapolate, correctly or not, from the findings of correlational research if particular coping strategies are to be trained.
- Coping assessment research should consider important contextual variables that facilitate the performance of effective coping behaviors. Simply knowing how to perform a coping behavior does not assure that behavior will be used when needed. Identification and assessment of malleable contextual variables that encourage or discourage the performance of effective coping behaviors is essential to help assure generalization from the times, when coping behaviors are taught to the times when their performance is needed. For children, the behaviors of parents, medical professionals, siblings, teachers, peers, and even the presence of environmental stimuli might provide important cues that either increase or decrease the likelihood of coping occurring when needed. For example, in assessment and coping skills training research with children in acute painful situations, prompts from parents or medical staff (Blount et al., 1989, 2003; Chambers et al., 2002) or the use of potent environmental prompts (Cohen et al., 1997) are often necessary to facilitate children engaging in effective coping during the painful events. In fact, one study showed that children's coping behaviors during painful medical treatments rarely occurred except when repeatedly prompted (Blount et al., 1989).
It is also well-established that the effectiveness of coping behaviors varies depending on a multitude of factors, including the characteristics of the stressor. For example, different coping behaviors seem to be useful for coping with acute versus long term stressors. Even within acute painful medical stressors, effective coping seems to vary for different phases of the medical procedure, such as before versus during painful injections (Blount, Sturges, & Powers, 1990
). As stressors differ on important domains, different coping behaviors would be required. Generally, we advocate that researchers focus on stressor-specific coping assessment, with attention to both effective coping behaviors and their match to the unique characteristics of the stressors.
- It may be beneficial for coping assessment measures to be multidimensional. We will use the CAMPIS as a basis for discussion. This scale includes behaviors indicative of coping, distress, and other child behaviors, as well as a host of behaviors that may be performed by parents and/or medical staff that influence the child. These behaviors may be performed before, during, or after different medical procedures. The inclusion of these various dimensions within one inventory has facilitated investigations and analyses to discover those parent, staff, and child behaviors that are helpful and those that are detrimental during different phases of the medical procedure. If the CAMPIS was unidimensional, measuring only coping behaviors, it would be less likely that researchers who use it would assemble the necessary additional measures to assess all of the other relevant dimensions. We believe that there is a place in research for more labor-intensive measures, and in practice for the abbreviated usage of only several highly relevant codes, or for more easily used rating inventories or brief paper and pencil measures that assess the same constructs.
- Coping assessment researchers should more explicitly describe how assessment results inform treatment design. It is possible that there are more direct assessment-treatment linkages in the extant research than were identified by this group. Discovering these linkages is easier when the developers of the inventories and others who use them specifically describe how correlational results and other findings from research with any given inventory directly inform the design of treatment interventions. Such descriptions may also serve to help other scale developers attend to this aspect of clinical utility when designing the scales.
- Use the results from coping assessment studies to conduct treatment research. As has been noted elsewhere (Blount et al., 2000a,b) and as elaborated on subsequently, the rates of treatment research compared to other types of research, particularly correlational research, has remained too low over the last decade and a half. If coping assessment is to be shown to have direct clinical utility, researchers must take the next step and use the data from correlational research to design treatment interventions. Experimental treatment-outcome studies of this type would provide a stringent test of the validity of findings from correlational research. This research would also demonstrate the assessment-treatment design linkages that we so strongly advocate in this article.
In conclusion, as we noted at the beginning of this review, the assessment of stress and coping is essentially the assessment of risk and resiliency factors, respectively. The identification of these risk and resiliency factors through assessment research is primarily useful to the extent that those factors can be manipulated to promote better biopsychosocial outcomes (Blount et al., 2000a
; Kazdin et al., 1997
). It has been observed over the years (Blount et al., 1991
; Compas et al., 2001
) that the study of coping is well-developed, in terms of theory and that the assessment of coping has the potential to yield tremendous practical and clinical implications for the development of effective treatment interventions in multiple areas of pediatric psychology. However, as is true of assessment in other areas of psychology (Frick, 2000
) that potential is yet to be fully realized. Only one coping scale was rated as having demonstrated direct implications for the design of effective treatment interventions. Others have clear potential and may have indirectly informed the design of interventions. However, the explicitness of the linkage was not as clear.
Michael Roberts noted (1992
; Roberts, McNeal, Randall, & Roberts, 1996
) that a disproportionate 78% of research published in the Journal of Pediatric Psychology (JPP)
is explicative, or correlational, in nature. This explicative research involves the use of assessment instruments with the purpose of enhancing understanding and developing theory. That is a noble goal and necessary for any field. However, Roberts also found that only about 10% of research published in the JPP
during his surveys involved treatment- outcome research. To him and to us this seems too little. The editors following Roberts each made significant efforts to increase the publication of treatment-outcome research in JPP
, but the percentage of published treatment research remained the same or decreased during those subsequent 5-year editorship periods. La Greca (1997
) reported that there was a similar percentage of treatment studies published (11% or 26 treatment studies/236 total publications) during her editorship. Kazak indicated in 2002 that the percentage of treatment studies published decreased to 4.7% (14 treatment studies, including three case studies/292 total articles). Finally, although these data are preliminary and based on a shorter time span the prior editors’ reports, during an 18-month period of Ronald Brown's editorship (personal communication, November 11, 2006), only 4.67% of manuscripts that were submitted
online involved treatment-outcome research. With a rejection rate of 80–90% for JPP
, the percentage of articles published from that total could be lower. There are multiple reasons for the apparently low and decreasing rate of treatment-outcome research in JPP
other than the design of coping assessment inventories. However, coping instruments that yield direct implications for the design of treatment interventions at least equip researchers to take the next step and use that information.
We have described elsewhere (Blount et al., 2000a
) some ways in which the assessment of coping and stress can be better designed and utilized to attain its potential for changing the low ratio of explicative or correlational research to treatment research. This effort will be enhanced by application of the paradigm for studying risk and resilience factors, as described by Kazdin et al. (1997
), as well as by some of the recommendations provided earlier. Further, we hope that the special criteria adopted by the Coping and Stress subgroup will encourage this endeavor. With these criteria, there is an explicit expectation that coping assessment measures should be useful for designing treatment interventions, as well as for broadening understanding.
Conflict of interest. None declared.