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Author ORCID Identifier
Date Available
7-2-2026
Year of Publication
2026
Document Type
Doctoral Dissertation
Degree Name
Doctor of Public Health (DrPH)
College
Public Health
Department/School/Program
Health Services Research
Faculty
Min-Woong Sohn
Faculty
Amanda Ellis
Abstract
Adverse childhood experiences (ACEs), which refer to exposure to traumatic life events before age 18, and instability in caregiving experiences contribute to poor physical, mental, behavioral, and developmental health outcomes for both children and adults. Previous research shows that these experiences can have negative effects both in the short term and throughout a person’s life. However, children’s strengths, which are the internal and external assets that support their development, can help protect against the impact of ACEs. Effective parenting, positive social support, and self-regulation skills are essential factors that build resilience, helping individuals adapt to challenges that may affect their well-being and development. In this study, I used a hierarchy of needs framework, well known in the context of children’s development, to understand the needs of children who have experienced ACEs or have been removed from their families. At the same time, by examining their strengths within the same framework, I emphasized the importance of building resilience to handle adversity and promoting recovery. As children grow and gain experience, their needs and strengths may change, impacting their development.
Therefore, to fully understand children who have experienced ACEs while they are in or are out-of-home care (OHC), I conducted three studies from a strength-based perspective, focusing on children’s assets to promote their resilience rather than their deficits and problems.
Study 1 identifies the unmet needs of caregivers at the time of child reunification and examines whether these needs are associated with the likelihood and timing of re-entry into OHC within one year. This study examines the association between various caregiver factors and the risk of children re-entering the system. Identifying caregivers’ needs helps prevent re-entry and promote stability by addressing children’s safety and psychological needs.
Study 2 explores the impact of cumulative ACEs and positive childhood experiences (PCEs) on mood challenges in youth within OHC. It also examines how the impacts of ACEs and PCEs vary across demographic groups. PCEs refer to children’s experiences of safe, stable, and nurturing relationships and environments that address their psychological needs.
Study 3 examines the role of spiritual/religious strength in influencing the behavioral and emotional health of children who have experienced multiple ACEs. A higher level of spirituality or religiosity is identified as a protective factor associated with resilient functioning, which can help mitigate the long-term mental health impacts of ACEs and support self-fulfillment needs.
The results of this study offer valuable insights into the role of strengths as children’s assets in recovery from traumatic experiences and into possible interventions that capitalize on children's strengths after adversity. Through the use of real-world populations of children and families currently in the child welfare service delivery system, my results are generalizable to all children in the child welfare system and can be used for designing and/or improving systems of care for them. By supporting caregivers and fostering positive relationship experiences within child welfare systems, interventions can be designed to enhance the social ecologies of children and promote their development.
Digital Object Identifier (DOI)
https://doi.org/10.13023/etd.2026.325
Archival?
Archival
Recommended Citation
Shin, Hyeeun K., "Understanding Resilience in Children in Out-of-Home Care: Using Person-Centered Health Services Research" (2026). Theses and Dissertations--Health Services Research (HSR). 3.
https://uknowledge.uky.edu/hsr_etds/3
Figure 2.1 log-log survival curve for each of the caregiver factors
Supplemental Figure 3.1 ACE and PCE by Demographics.docx (509 kB)
Figure 3.1 ACE and PCE by Demographics
Supplemental Figure 4.1 Impact of ACE Counts on Behavioral and Emotional Needs, Modified by SRS.docx (399 kB)
Figure 4.1 Impact of ACE Counts on Behavioral and Emotional Needs, Modified by SRS
Supplemental Table 2.1 Cox Proportional Hazards Model with PCA.xlsx (24 kB)
Table 2.1 Cox Proportional Hazards Model with PCA
Supplemental Table 3.1 Post hoc power analysis.docx (16 kB)
Table 3.1 Post hoc power analysis
Supplemental Table 3.2 Main & Sensitivity analysis results with full sample.xlsx (25 kB)
Table 3.2 Main & Sensitivity analysis results with full sample
Supplemental Table 3.3 Analysis results with samples stratified by age, sex, and race.xlsx (27 kB)
Table 3.3 Analysis results with samples stratified by age, sex, and race
Supplemental Table 4.1 Categories mapping, Similarities of ACEs indicators.xlsx (21 kB)
Table 4.1 Categories mapping, Similarities of ACEs indicators
Supplemental Table 4.2 A model with joint effect between Demographics and SRS on 12 BENs.xlsx (34 kB)
Table 4.2 A model with joint effect between Demographics and SRS on 12 BENs
Supplemental Table 4.3 Logistic Regression Analyses Predicting 12 Behavioral and Emotional Health Outcomes From SpiritualReligious Strength, Multiple ACEs, D.xlsx (17 kB)
Table 4.3 Logistic Regression Analyses Predicting 12 Behavioral and Emotional Health Outcomes From Spiritual Religious Strength, Multiple ACEs, D
Supplemental Table 4.4 The prevalence of ACEs, SRS, and BENs, respectively, for participants in 4 or more ACEs group and overall.docx (17 kB)
Table 4.4 The prevalence of ACEs, SRS, and BENs, respectively, for participants in 4 or more ACEs group and overall
