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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Nurs Scholarsh. Author manuscript; available in PMC 2010 July 15.
Published in final edited form as:
PMCID: PMC2904627
NIHMSID: NIHMS189666

Conceptualization and Measurement of Coping During Adolescence: A Review of the Literature

Carolyn Garcia, RN, PhD, MPH, Assistant Professor1

Abstract

Purpose

The purpose of this review was to examine the conceptualization and measurement of coping in adolescent research.

Design

A review of the literature published and abstracted in four scientific databases was undertaken between July 2008 and June 2009 with the following key words: adolescent(s), cope/coping, stress(ors), and adaptation/psychological.

Methods

A total of 367 articles were initially identified, and review of published abstracts yielded 104 empirical articles to retrieve and examine more closely for inclusion. Criteria for inclusion in the review were that the study (a) measured coping, (b) presented original data, (c) primarily targeted adolescent participants, (d) was reported in English, and (e) was published between 1998 and June 2009. Fifty-nine subsequent articles were organized using a matrix approach that facilitated cross-study comparisons of purpose, sample, and dependent variables.

Findings

Fewer than half of the studies reviewed included a specific statement defining coping. Instead, many authors described coping in the context of stress response by identifying particular types or ways of coping or naming specific coping strategies used. The theoretical frameworks guiding examination of coping varied across studies. A range of measures, congruent with adolescent developmental processes, were used to assess adolescent coping. A wide range of stress-related risks or conditions were examined, including psychological stressors such as eating disorders, suicidal ideation, and depression; physical stressors such as chronic illness, HIV infection, sports participation, violence, or sexual abuse; familial stressors such as domestic violence or interparental conflict; social stressors such as romantic relationships or difficulties in settings such as school, prison, or a homeless shelter; and societal stressors such as discrimination.

Conclusions

Coping is an important construct in understanding how adolescents react to the extensive stressors and adjustments they experience. Coping is a complex construct yet worthy of examination because it can be a critical point of intervention in the health trajectory of adolescents and young people. Research is needed to advance the conceptualization and measurement of adolescent coping such that interpretation of findings across studies is enhanced. In this way, future research, including interventions targeting coping, will work synergistically to advance the science and adolescent well-being.

Clinical Relevance

Nursing and other healthcare providers working with adolescents understand the need for interventions that promote use of healthy coping strategies and minimize unhealthy coping. Findings from this study demonstrate the state of coping conceptualization and measurement in adolescent research and indicate a need for research that will advance the science and improve the usefulness of adolescent coping data.

Keywords: Coping, adolescent, measurement, literature review, instrument

Suicide is a leading cause of death for adolescents, surpassed in occurrence only by unintentional injuries and homicide (National Center for Health Statistics [NCHS], 2009). Depression is a leading risk factor for suicidal ideation and attempts, and approximately 20% of all adolescents will suffer from depression before reaching young adulthood (10% to 15% of adolescents in the United States are estimated to be depressed at any given time). Complex factors contribute to adolescents experiencing depressive symptoms, including developmental stressors (e.g., peer relationships, school accomplishments, physical and emotional changes) and environmental and contextual stressors (e.g., poverty, crime, family separation, discrimination). How adolescents cope, or respond, to these stressors influences their well-being. Some adolescents “cope” and demonstrate resilience in response to overwhelming negative stressors; other adolescents need very little “stress” to plunge into a depressive episode.

Adolescent coping and its relationship with health-risk behaviors has been researched extensively, demonstrating consistent risks when an adolescent lacks adequate coping abilities, including psychological distress and suicidal attempts, smoking/substance use, and high-risk sexual behaviors (Rew, 2005). Growing attention toward adolescent coping is in part the result of increasing awareness of risk and protective factors that can be intervened on to enhance the well-being of adolescents. If an adolescent's coping skills can be improved, it is feasible that she or he may perceive and react to stressors in a different manner yielding more positive health outcomes. This article provides a review of adolescent coping conceptualization and measurement with recommendations to advance adolescent coping science and knowledge.

Overview of Adolescent Development

Adolescent development has been described extensively in numerous theories that are well beyond the scope of this article to summarize in their entirety. However, an overview of this second decade in life is necessary to provide context for why understanding of adolescent stress and coping is important and distinct from adult stress and coping. Adolescence is marked by growth on many levels; holistically, one can appreciate the intertwined development of an adolescent in physical, psychological, social, and spiritual domains (Rew, 2005). The rate at which an adolescent develops in these domains varies, and development in one domain does not imply parallel development in another. In this way, adolescents reflect unique developmental patterns that can be generally categorized into predictable patterns of change. For example, the pubertal development of boys and girls occurs in a relatively sequential manner within a range of time such that there are “early” or “late” developers but very few who have not developed most physical changes by a certain age.

Psychologically, adolescence is a decade of cognitive and moral development. Piaget's theoretical work identified four cognitive developmental phases, namely, sensorimotor, preoperational, concrete operational, and formal operational. He also outlined the three processes an adolescent undertakes to reach a new phase (i.e., assimilation, accommodation, and equilibration; Piaget & Inhelder, 1969). According to Piaget, a preadolescent, at 12 years of age, is capable of the fourth stage, and therefore most adolescents will reach adult-like thinking in their adolescent years. Critical thinking and information processing develop during adolescence, with older adolescents demonstrating greater abilities to remember (short- and long-term memory) and to reason (deductively and inductively). Adolescent moral development has been conceptualized in three phases (i.e., preconventional morality, conventional morality, and postconventional morality) by Kohlberg (1978). Gilligan (1993) advanced understanding by exploring observed gender differences in how boys and girls approach moral dilemmas, demonstrating that generally, boys seek direct resolution and girls will avoid conflict to maintain a relationship (Rew, 2005). These differences are likely to be reflected in how boys and girls cope with stressors.

Socially, adolescence has been characterized by Erikson (1968) as the developmental period in which “identity” is the primary psychosocial crisis. Indeed, as adolescents migrate toward peer relationships and begin to separate from their parents, their perspectives are broadened and they are faced with the task to form their own identity. Identity development is critical to how the adolescent perceives not only self but also social interaction and the future and is “conferred or constructed” (Marcia, 1980; Rew, 2005, p. 112). A healthy identity is one that is constructed by the adolescent (rather than conferred by others onto the adolescent), as she or he formulates opinions as simple as whom to spend time with and as complex as what to believe (Rew).

Adolescent spiritual development has been explored theoretically despite lacking a consistent definition of what “spiritual” comprises. It is acknowledged that spiritual development should not be overlooked and is integral to holistic adolescent development, as evidenced in the growing research addressing spirituality and newly developed models to explain adolescent spiritual development (e.g., Cole's Model of Spiritual Development; Fowler's Stages of Faith Consciousness Theory; Rew, 2005). For example, Fowler (1991) proposed seven stages of faith consciousness, two of which can occur during adolescence because formal thinking and identity formation are occurring. These stages include synthetic-conventional faith and individuative-reflective faith, the latter occurring after one has a “coherent sense of self-identity” (Rew, p. 68). In these stages, the adolescent establishes a set of beliefs, in the context of identity formation, and then is able to reevaluate the beliefs in order to more clearly explicate those beliefs she or he adheres to.

The complexity of adolescent development, and the variability in which this development occurs, makes obvious the challenges inherent in specifying what stress and coping are for adolescents, and how they should be measured in research. Similar to the spectrums of development, adolescent stress and coping concepts reflect a range of behaviors, experiences, triggers, and actions. And as with theories of development, theories of stress and coping have been developed, refined, and challenged as the field, and understanding, advances.

Stress and Coping Theoretical Development

Lazarus and Folkman (1984) used the term coping to describe the “cognitive and behavioral efforts” a person employs to manage stress, generally categorized as emotion focused or problem focused coping. Not an individual trait, coping is instead conceptualized by Lazarus and Folkman as a process (Rew, 2005). Stress and coping models such as Lazarus' (1990) transactional stress-coping process and Moos' (2002) model of context, coping, and adaptation (transactional model), and the theoretical work of Carver and colleagues (Carver, 1997; Carver, Scheier, & Weintraub, 1989) and Frydenberg and Lewis (1990) have advanced the science regarding stress, coping, and the measurement of these constructs. These theorists have built upon the original work of Selye (1978), who proposed the term stress to explain responses being observed in the general adaptation syndrome, a syndrome identified as an “initial alarm reaction followed by a state of adaptation … called the stage of resistance” (Rew, 2005, p. 136). Selye was also the first to identify a “stressor,” or cause of subsequent stress. A healthy response to stress resulted in adaptation, according to Selye, whereas an unhealthy or resistant response would lead to exhaustion.

In adolescent stress and coping research, specifically, there are stressors that coincide with this developmental stage. For example, stressors associated with identity development, a process involving growing independence from parent figures while establishing stronger associations with peer groups. Numerous factors influence the extent to which this and the other developmental milestones present stress for an adolescent, including intrapersonal and environmental factors.

Bronfenbrenner's (1979) ecological model demonstrates the complex and numerous sources of potential stress or security in the life adolescents, influences that may be protective or harmful. Family, school, and peers are examples of microsystem level factors that present direct influences, while macrosystem level factors (e.g., societal values, economic circumstances) are distal influences. These external forces are particularly recognized in Moos' (2002) model of context, coping, and adaptation in adolescence, in that Moos emphasizes the necessity of understanding them (e.g., family, social context) in order to realize how an adolescent adapts and subsequently copes. One can see how an adolescent's appraisal of a stressor involves both subtle and obvious factors that contribute to how an adolescent acts, or copes, with the stressor. It becomes clear, as well, that assessment of one's coping, resources, and responses is complex and challenging. However, with gained insights about adolescent coping, interventions such as school- or clinic-based programs can be structured to strategically reinforce environmental factors that promote healthy coping. This is an ideal but challenged scenario, given the complexity of the existing science specific to coping conceptualization and measurement.

State of the Science: Relevant Reviews of Coping Measurement

Over 15 years ago, Parker and Endler (1992) conducted a critical review of coping assessment and concluded that the empirical weaknesses in coping assessment significantly challenged and limited the applicability and relevance of coping data. In 2001, Compas, Connor-Smith, Saltzman, Thomsen, and Wadsworth completed a critical review of coping with specific attention to the coping of children and adolescents. Similar to Parker and Endler, Compas et al. concluded that a gap continues to exist between the acknowledged need for identifying ways individuals cope or subtypes of coping behaviors and the development of measures that can distinguish these subtypes for children and adolescents. More recently, Skinner, Edge, Altman, and Sherwood (2003) completed an evaluation of 100 coping assessment tools used with young people and adults. They identified over 400 ways of coping that were measured in these tools, demonstrating the breadth and depth of coping measurement and the resultant challenges in interpreting, generalizing, and acting on coping data. And in 2007, Nicholls and Polman conducted a systematic review of the coping literature on sports and athletes. The review confirmed a variety of coping strategies were used, as well as age and sex differences in coping. None of these existing reviews specifically focuses on measurement of coping in adolescent research, nor do they address the relevance of coping measurement for vulnerable subgroups of adolescents such as those who are not fluent in the primary language of a country or region.

Therefore, the main goals of this review were to summarize how coping is being conceptualized and measured in adolescent research and to synthesize coping measurement in adolescent research published in the past decade. Findings from this review will contribute useful insights for both observational and intervention research. Whether observing coping over time during adolescence, developing interventions to influence coping behaviors, or evaluating interventions aimed at modifying coping behaviors, researchers will benefit from clarity regarding the conceptualization and measurement of coping in adolescent health research.

Methods

Search Strategy

This search was conducted between July 2008 and June 2009. The main search strategy employed four scientific databases: Medline, CINAHL, HAPI, and PyschInfo. The key words used, purposefully broad, included adolescent(s), cope/coping, stress(ors), and adaptation/psychological (as alternative wording for stress in some of the databases). Reference lists of identified articles were also examined in order to identify relevant work that may not have surfaced in the database search. Finally, published reviews addressing adolescent coping and coping measurement were examined to identify additional relevant publications.

Inclusion Criteria

A total of 371 articles were initially identified using the search strategy outlined above. Review of published abstracts yielded 108 empirical articles to retrieve and examine more closely for inclusion. Criteria for inclusion in the review were that the study (a) measured coping, (b) presented original data, (c) primarily targeted adolescent participants between the ages of 12 and 18 years, (d) was reported in English, and (e) was published between 1998 and June 2009. Purposefully, articles describing research outside the United States were included if the above criteria were met. These criteria resulted in 58 articles included in the review (Table 1).

Table 1
Articles Reviewed: Purpose, Sample, Dependent Variables, and Coping Results

Organization

Articles were organized using a matrix approach (Garrard, 2007) that facilitated cross-study examination of purpose, sample, and dependent variables (see Table 1). Specifically, Table 1 provides an overview of the articles reviewed so that at a glance, the reader understands why the original study was conducted, why coping was measured (was it a primary study focus), who participated in the study (age, sex), and what the main study findings were, specific to coping. Although this review is not focused on study results, providing the results facilitates additional reflection on specific coping measures, which might be useful to a researcher undecided about which adolescent coping measure to use. Additionally, to support the aim of the review to summarize the state of coping measurement and conceptualization, the matrix identified coping definitions, measures used, and theories used (Table 2). Instrument details, including number of items and coefficient reliability data are also provided in Table 2, as a resource to those specifically exploring use of coping measures.

Table 2
Coping Measurement: Instrument Details, Coping Definitions, and Use of Theory

Findings

Coping Conceptualization … the What

Definition versus description

Fewer than half of the studies reviewed included a specific statement defining coping (n=22; 38%). For example, Yi, Smith and Vitaliano (2005) defined coping as follows: “Coping involves cognitive and behavioral measures designed to master, tolerate, or reduce external and internal demands and conflicts” (p. 258). de Anda and colleagues (de Anda 1998; de Anda et al. 1997) defined coping simply as those strategies that are used to deal with stress, or stressors. Thirteen of the articles referenced Lazarus and Folkman when defining or describing coping (22%).

Rather than providing a definition of coping, many authors described coping in the context of stress response by identifying particular types or ways of coping or naming specific coping strategies used (n=20; 34%). Ways of coping have been defined by Skinner et al. (2003) as “the basic categories used to classify how people cope” (p. 216) such as problem-solving or help-seeking. These mechanisms vary across individuals and influence not only the coping response to an acute stressor but also the longitudinal health and well-being of the individual. Among the studies describing rather than defining coping, 10 (50%) defined coping by highlighting ways of coping such as avoidant or active coping strategies and the subsequent outcomes when adolescents employed one type of strategy rather than the other. For example, Puskar, Sereika, and Tusaie-Mumford (2003) state,

Although coping is a process, and there is no “right or wrong” manner of coping, adolescents who used more approach and problem solving than avoidance strategies and who appraised the stressor to be a challenge were more often associated with an adaptive outcome. (p. 72)

Many utilized the popular dichotomy for ways of coping, namely problem-focused or emotion-focused coping strategies (Li, DiGiuseppe, & Froh, 2006; Meijer, Sinnema, Bijstra, Mellenbergh, & Wolters, 2002; Vaughn & Roesch, 2003). For example, Vaughn and Roesch provide this description of coping in reviewing existing literature: “Some coping strategies (e.g. problem-focused) have been associated with positive outcomes such as higher levels of self-esteem and resiliency, whereas other coping strategies (e.g. denial) have been associated with negative outcomes such as alcohol abuse, depression and delinquency” (p. 672). Sixteen articles (28%) did not include either a description or definition of coping.

The existing literature is silent with respect to how coping conceptualization or definition might change with varying adolescent developmental stages. This could, in part, be due to general recognition that adolescent coping, as conceptualized and defined, remains broad enough to encompass the various stages of development adolescents' experience.

The theoretical frameworks guiding examination of coping varied across studies. Among those who identified the study's theoretical conceptualizations (n=43; 73%), most described a stress and coping theoretical foundation, citing Lazarus and Folkman, Moos, and Frydenberg and Lewis. Others employed theories of development (e.g., Loevinger's model of ego development) or self-regulation, and models such as the cognitive-behavioral model.

Coping Measurement … the How

Study designs

Eight articles reported findings from intervention studies (14%), while the remaining articles were based on descriptive studies (86%; see Table 1). Of the intervention studies, four assessed the effects of a cognitive-behavioral therapy intervention on coping and the remaining four described other intervention strategies designed to improve coping skills such as school-based stress management programs. Fifty-five (93%) of the studies employed a cross-sectional design (eight of these had pre-post measurement); five were longitudinal, including 3-year and 10-year follow-up studies.

Coping measures

A range of measures were used among the studies to assess adolescent coping, as conceptualized by the researcher (e.g. available coping strategies versus actual coping behaviors). These are summarized in Table 2. Instruments most commonly used include the Adolescent Coping Orientation for Problem Strategies Questionnaire (A-COPE), the Adolescent Coping Scale (ACS), the Coping Response Inventory (CRI), the Stress and Coping Questionnaire for Children (SCQ-C), and the Ways of Coping Checklist (WOCC). Reliability coefficients of internal consistency were reported for most, but not all, measures for the samples studied. These measures each uniquely assess coping, yet all of them reflect theoretically sound and congruent conceptualizations of adolescent coping. Many of the measures are theoretically congruent with Lazarus and Folkman's theory of cognitive appraisal and coping, including A-COPE, ACS, WOCC, and the Jalowiec Coping Scale (JCS; Rew, 2005). Many measures include a wide range of ways in which an adolescent might cope, and the assessment/categorization of whether the coping is healthy or unhealthy is, in part, based on knowledge of adolescent growth and development.

Measurement modalities

Most studies relied on retrospective, self-report data collection using a survey instrument (n=43; 73%). Four utilized computer-assisted technology to administer a survey, typically in the participant's home, which included questions regarding coping. Two studies included parent data collection via survey and interview. Six studies employed a qualitative, face-to-face interview format; these were distinct from four studies that included diagnostic interviewing and did not specifically indicate coping had been assessed. Additional measurement of coping included data collected from observation (three studies) and participant-completed diaries (two studies).

Coping Study Context … the Why and Who

Study purposes

A high proportion of the articles reviewed indicated that a primary reason for conducting the research was to examine adolescent coping strategies or behaviors (n=52; 88%). Five articles reported on the measurement properties of a particular coping measure. The remaining studies measured coping as a secondary outcome, a moderator or a mediator.

A wide range of stress-related risks or conditions were examined in these studies, representing many of the ecological systems represented in Bronfenbrenner's model. These included psychological stressors such as eating disorders, suicidal ideation, and depression; physical stressors such as chronic illness, HIV infection, sports participation, violence, or sexual abuse; familial stressors such as domestic violence or interparental conflict; social stressors such as romantic relationships or difficulties in settings such as school, prison, or a homeless shelter; and societal stressors such as racial discrimination. A few used a strength-based approach to examine coping as it relates to adaptive functioning, resilience, and emotional well-being.

Adolescent samples

Although 41 articles included males and females, only 6 highlighted differences in coping strategies by sex of the participants. Female-only studies (n=11; 19%) occurred more often than male-only (n=5). Of the male-only studies, one was a case study of an adolescent male golfer, another two focused on athletes, the sample of the third were incarcerated males, and the fourth focused on adolescent males with eating disorders. Only one study reported on differences by where the adolescents resided, in rural or urban settings, and three highlighted differences in coping strategies by ethnicity and acculturation.

What the Data Mean

Herein lay the challenges with synthesizing coping research among adolescents. Indeed, independently the studies provide data that are informative and contribute to our understanding of the adolescents represented in the particular investigations. However, when examining data across studies, the differential measures of coping make synthesis extremely challenging. For example, coping outcomes were reported in many of the descriptive studies by using the terms from the selected study measures, which limits meaningful interpretations across the studies unless one has the time needed to manually synthesize different terms/similar concepts (e.g., terminology such as avoidance, problem-focused, ruminative, self-blame, approach, seeking social support, engagement, disengagement, emotion-based, negative, thriving, and despairing).

Recommendations for Measurement of Adolescent Coping

The most consistent feature of the measurement of coping in adolescent health research is how inconsistent it has been, including lack of uniformity in choice of measures to assess how adolescents cope with stressful situations. While research over the past two decades has solidified the importance of healthy coping strategies in stress response, substantial progress has yet to be made in consistently using coping measures that are meaningful, representative, and interpretable across studies.

Advances in the science regarding adolescent coping will be enhanced as researchers consistently use measures that have been developed specifically for adolescents which have reliable and valid measurement properties. Rather than developing new measures, researchers might benefit from time committed to modifying and adapting those that already exist. For example, if a particular subscale does not demonstrate adequate reliability with a particular group of adolescents, the researcher might explore adapting the instrument (e.g., cultural expectations may preclude certain coping behaviors that are measured in a tool created using a different cultural group/adolescent population). In addition, nursing researchers might consider identifying coping measures that are congruent with leading coping theories broadly, and nursing coping theories specifically (e.g., Roy's adaptation model; Yeh, 2003). Also, researchers using standardized adolescent coping measures might consider additional open-ended queries of perceived stressors and actual coping strategies identified by the adolescents. These data will offer insights about how adolescents in a specific location, context, and time frame are coping with common stressors, and will clarify the extent to which their preferred coping strategies are represented in the quantitative coping measures.

Finally, the breadth of research addressing adolescent coping demonstrates the importance of this concept as a point of understanding and intervention. Beyond the scope of this literature review there are much data that, if published in peer-reviewed journals, will contribute to advancing understanding about adolescent coping and measurement. For example, in the past 10 years, over 100 dissertations have been completed that focus on aspects of adolescent stress and coping (e.g., Finkelstein, 2005; Fisher, 2006; Toliver Powell, 2008). Some of these scholars have summarized their work in peer-reviewed journal articles (e.g., Finkelstein, Kubzansky, Capitman, & Goodman, 2007, yet many more should be encouraged to present and publish their research via mechanisms that will promote scholarly critique and thought, beyond the successful completion of a dissertation.

Recommendation for studies validating coping measures with diverse adolescent populations

Additional efforts are needed to ensure that the ways in which coping is measured are meaningful and valid for adolescents at various developmental stages as well as for those from a broad range of cultural backgrounds. Continued examination of theoretical development, content validity, and language appropriateness will facilitate advancement in understanding coping processes for diverse adolescents. It is promising that over half of the identified studies involved adolescents from a range of countries (e.g., Australia, England, Netherlands, Spain, Uganda) and languages beyond English. Growing awareness of the health and social disparities experienced by ethnic minority youth necessitates examination of and intervention toward building protective factors, including healthy coping. Advancement in culturally and linguistically relevant coping measures will encourage researchers not only to describe coping among these youth but also to conduct interventions that seek to promote healthier coping behaviors.

Recommendation for longitudinal studies examining coping trajectories over time

Likewise, longitudinal studies that examine patterns of change and continuity in coping processes over time will advance our understanding and measurement of adolescent coping. Existing studies, the majority of which are cross-sectional or include information from two points in time, do not adequately capture the variability in coping behaviors with time, experience, and social context. Longitudinal studies will assist in refining coping measurement as trends can be observed within and across participants over several points in time.

Recommendation for intervention studies examining coping as a primary outcome

The lack of intervention studies promoting health coping processes among adolescents is problematic given concerning mental health trends and the potential for healthy coping to positively influence mental health status. Despite recognizing the importance of coping, researchers may be hesitant to measure healthy coping because of measurement incongruity aforementioned in this review. However, thoughtfully designed intervention studies that take into account challenges in studying coping are reasonable and needed to advance the state of the science respective to adolescent coping processes. Importantly, longitudinal intervention studies that include measures of coping are needed. Such research will aid the understanding of how coping impacts other health outcomes and can be impacted by changes in other factors.

Coping processes have been recognized as critical protective or risk factors for adolescents (Li et al., 2006; Lubell & Vetter, 2006; Zimmer-Gembeck & Skinner, 2008). Because coping is a process linked to many health outcomes of interest, such as depression, sexual risk taking, or substance use, it is a commonly measured mediator or moderator of other relationships (Franko, Thompson, Affenito, Barton, & Striegel-Moore, 2008; Rodrigues & Kitzmann, 2007). While data gained from these mediator/moderator analyses are important and useful, studies that conceptualize and measure coping as an independent or dependent variable are needed to advance the field. As the measurement of coping becomes more sophisticated, so might our efforts to intervene in ways that build adolescents' protective coping behaviors.

Conclusions

Coping is an important construct in understanding how adolescents react to the stressors and adjustments they experience in their lives. Coping is a complex construct yet worthy of examination because it is a critical point of intervention in the health trajectory of adolescents and young people. Research is needed that contributes to clarity in how coping processes are conceptualized and measured. With these advances, intervention studies that target adolescent coping processes will generate valuable, actionable findings.

Clinical Resources

Acknowledgments

Thank you to the following individuals who assisted in compiling the articles reviewed: Christie Martin, Eve Shapiro, and Jessie Kemmick Pintor. Thank you to my colleague, Dr. Renee Sieving, for thoughtful editing of manuscript drafts. Effort on this review was supported by a Building Interdisciplinary Research Careers in Women's Health Grant administered by the Deborah E. Powell Center for Women's Health at the University of Minnesota, Grant K12HD055887 from the National Institutes of Child Health and Human Development. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institute of Child Health and Human Development, or the National Institutes of Health.

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