Abstract

Resilience, or the process of adjusting well to risk, relies on constructive collaboration between youths and their social ecologies. Although the literature details the risks of an intellectual disability (ID), there is little explanation of why some young people cope well despite these risks. Accordingly, we report a multiple case study that affords insight into the resilience of 24 adolescents with ID. Using a draw-and-talk methodology, these young people explained their resilience as enabled primarily by supportive social ecologies (which facilitated behavioral and emotional regulation, encouraged mastery, treated them as agentic beings, and offered safe spaces). Adolescents' positive orientation to their life-worlds co-facilitated their resilience. These insights advance effective ways to champion the resilience of young people with ID.

Worldwide, about 15% of the global population—more than a billion people—live with some kind of disability (World Health Organization [WHO] & World Bank, 2011). Disability is associated with diminished health and well-being (Emerson, 2013). Among those challenged by disability, 1.3% of the world's population—around 94,055,000 people—have an intellectual disability (ID; WHO, 2013).

ID is a long-term condition resulting from physical, familial, and/or contextual factors (DSD, DWCPD, & UNICEF, 2012). It commences before the age of 18 and impacts development negatively. Such negative impact relates to ID being characterized by significantly limited intellectual ability, adaptability, and capacity to acquire or apply new skills, all of which impair capability to function independently and optimally. Inadequate social aptitude (e.g., poor communication skills or annoying personal habits), emotional and behavioral disorders, and attention deficit are further limitations associated with ID (Emerson, Baines, Allerton, & Welch, 2011). So too are co-morbid physical disabilities (e.g., cerebral palsy or Fragile X syndrome) and/or physical constraints (e.g., auditory/visual deficits, epilepsy, asthma, atypical physical appearance; WHO & World Bank, 2011). Furthermore, people with ID are often exposed to domestic and community discrimination, violence, and abuse (Emerson, 2013). Thus, living with ID challenges the capacity to cope well with daily living for more reasons that just intellectual deficit. In short, people with ID know compound risks, and the multifaceted, chronic nature of these risks challenges their capacity to do well in life.

However, despite such multiple challenges, some individuals with ID cope well in life and are considered resilient (Murray, 2003). Resilience, or the process of achieving functional outcomes despite compound and/or chronic risk, has been described as “ordinary magic” (Masten, 2001, p. 228) because of its being informed by everyday protective mechanisms that buffer risk. Protection lies in the interaction of personal (e.g., a sense of humor, grit, or agency) and social ecological capacities (e.g., caring families, respectful service providers, quality education, or cultural capital; Bottrell, 2009; Masten, 2014; Munford & Sanders, 2015). The Social Ecology of Resilience Theory (SERT; see Ungar, 2011), which forms the theoretical framework of this article, accentuates the interactive nature of resilience. SERT explains that functional outcomes result when individuals and their social systems collaborate in ways that support positive adjustment to adversity. This includes individuals making use of, and/or negotiating for, assistance that supports functional outcomes, and social ecologies providing, and advocating for, accessible resilience-supporting resources (Ungar, 2015). Such collaboration is optimal when it occurs in contextually relevant ways, given that resilience is a contextually sensitive process (Ungar, Ghazinour, & Richter, 2013).

Although there is much research on resilience processes in general—see, for example, the synthesis by Masten (2014)—research about resilience and youths with disabilities, especially youths with ID, is uncommon (Emerson, 2013; Gilmore, Campbell, Shochet, & Roberts, 2013). The little research that does provide some understanding of what supports resilience in the face of ID, is either quantitative (see Gilmore et al., 2013; Migerode, Maes, Buysse, & Brondeel, 2012), or incidental to studies focused broadly on at-risk youth (see Fourie & Theron, 2012; Hsieh & Donahue, 2010; Murray, 2003; Ungar, 2004). Recent resilience literature urges resilience-focused studies that foreground the contextualized experiences and voices of young people who have personally experienced risk (e.g., Theron, 2015; Wright, Masten, & Narayan, 2013). Such detailed accounts of resilience are essential if social ecologies are to be supported to accept their mandate of co-responsibility for adolescents' resilience (Ungar, 2011, 2013). All of this prompts a qualitative study of the resilience processes of adolescents with ID. Although there are limitations with regard to the generalization of the findings of qualitative studies (Yin, 2014), a rich qualitative study will provide a deeper understanding of why some adolescents with ID adjust well in life. Such insights should enable parents/caregivers, teachers, service providers, and health professionals to better facilitate the optimal development and functioning of adolescents challenged by ID. Thus, the following research question underpins this article: Why do some adolescents with ID, living in a developing context, adjust well to the challenges of ID?

A Brief Review of the Relevant Literature

There are multiple published studies about the coping/well-being of adolescents with ID (e.g., Chen & Shu, 2012; Hutzler & Korsensky, 2010). However, because coping/well-being is not synonymous with resilience (see Rutter, 2012; Ungar, 2012), these studies cannot explain the resilience of adolescents with ID. (Although resilience and coping are related, the coping literature is concerned with individual mitigation of stress, whereas resilience is concerned with the processes [individual and systemic] that account for positive outcomes in the face of adversity [Rutter, 2012]). We could source only six published studies reporting the resilience of adolescents with ID (see Fourie & Theron, 2012; Gilmore, et al., 2013; Hsieh & Donahue, 2010; Migerode et al., 2012; Murray, 2003; Ungar, 2004). These studies offer limited insight into the resilience processes of adolescents with ID for three reasons.

First, four of the six were not exclusively focused on adolescents with ID—ID was included as one of various risks/disabilities that jeopardize the wellbeing of young people. Ungar (2004) included high-risk Canadian youth (e.g., youth marginalized by low socio-economic status, social stigma, inadequate academic performance, as well as ID). The single case study reported by Fourie and Theron (2012) was an American adolescent with fragile X syndrome—ID is sometimes associated with this syndrome. Hsieh and Donahue (2010) and Murray (2003) reviewed the risk and resilience literature relating to youth with a range of high-incidence disabilities (e.g., learning disabilities, ID, speech/language disabilities, or emotional/behavioral disorders).

Second, the two studies that were focused on youth with ID reported quantitative investigations into specific aspects of these adolescents' resilience. Gilmore et al. (2013) profiled the internal (e.g., mastery, reactivity) and external (e.g., school environment, home environment) protective factors of 115 Australian children with ID (mean age, 11.9 years) and compared this with that of 106 peers without ID (mean age, 11.8 years). Migerode et al. (2012) included 111 Flemish adolescents with ID, aged 16 to 24 years (mean age, 19.4 years), and investigated whether resilience and quantity and quality of social support mediated the compound risks that disability holds for quality of life. Accordingly, both these studies offered quantitative descriptions of the protective resources that inform the positive adjustment of youths with ID, rather than a detailed explanation of their resilience processes.

Third, the four empirical studies (Fourie & Theron, 2012; Gilmore et al., 2013; Migerode et al, 2012; Ungar, 2004) report the resilience processes of adolescents living in countries that are members of the Organization for Economic Cooperation and Development (OECD; see http://www.oecd.org/about/membersandpartners/). OECD-member countries are characterized by more developed contexts. Given that resilience is a contextually sensitive process, findings from studies in highly developed contexts cannot be blindly generalized to explain the resilience processes of children in less developed contexts (Masten, 2014; Ungar et al., 2013).

Despite the limitations noted previously, these six studies shed some light on the intrinsic and extrinsic resources and processes that facilitate resilience in adolescents with ID.

Intrinsic protective mechanisms

The resilience literature that is not focused on disability foregrounds the importance of adolescent agency to resilience processes (e.g., Bottrell, 2009; Munford & Sanders, 2015). Similarly, agency informs why adolescents challenged by ID adjust well (Fourie & Theron, 2012). This capacity to take action manifests as an inclination to set goals and to succeed, as well as to use available resources. It is supported by a positive or optimistic temperament, an intrinsic locus of control, self-efficacy, and an aptitude for fun (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Murray, 2003). An optimistic way-of-being encourages supportive others to respond more positively and perceive adolescents with ID as more socially acceptable (Fourie & Theron, 2012; Hsieh & Donahue, 2010). Optimism predicts the degree of success that adolescents with ID experience as adults (Hsieh & Donahue, 2010; Murray, 2003).

Extrinsic protective mechanisms

When the social networks of adolescents are protective, they are unconditionally accepting, and support adolescents with ID toward mastery (Fourie & Theron, 2012). In particular, families, school (including peers), and the community (including the religious community) provide such protective support. For example, authoritative, but loving and supportive, relationships with parents and other adult caregivers afford adolescents with ID a sense of belonging and enhance their self-esteem (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Migerode et al., 2012; Murray, 2003; Ungar, 2004). Such relationships are typically characterized by a structured home environment, constructive activities, and parents/adults who role model appropriate social skills (Fourie & Theron, 2012; Hsieh & Donahue, 2010; Murray, 2003).

In the school context, supportive student-teacher relationships are key (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Murray, 2003). These are characterized by responsive, helpful teachers (e.g., teacher acknowledgement of even small accomplishments, or individualized education, or teachers who role-model appropriate social skills). School-based support of resilience also includes meaningful school-home interaction (e.g., good communication or constructive parent-teacher relationships; Fourie & Theron, 2012; Murray, 2003). Well-designed school-to-work transition planning (Murray, 2003), and opportunity to participate in extra-curricular activity and develop bonds to peers also contribute (Fourie & Theron, 2012; Gilmore et al., 2013).

Community-based resources include sports teams, church groups, and other community organizations, such as support groups (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Murray, 2003). These resources provide access to supportive adults (such as religious leaders). They also make it possible for adolescents with ID to bond with peers who do not necessarily attend the same school. This boosts life skills, (especially acceptance of rules and even sometimes leadership roles) and social skills (Fourie & Theron, 2012).

Method

To answer the research question, we employed an instrumental multiple case study research design (Yin, 2014). Each case constituted an adolescent with ID who evidenced resilience (as explained next). Each case, therefore, shed light on what enabled positive adjustment, despite ID. The collective of these cases facilitated a deeper understanding of resilience processes in adolescents with ID, particularly because the collective reflected multiple youth voices that would ordinarily be marginalized, given their youth and disability (Creswell, 2012). In general, adult researchers sideline the insights of children and adolescents (Kumpulainen, Lipponen, Hilppö, & Mikkola, 2014); this tendency is more pronounced when young people are further disempowered (e.g., because of socioeconomic status or disability).

Informants

Recruitment of primary informants

Following Merriam (2009), we used purposeful sampling to recruit primary informants. To be eligible, informants needed to be adolescents (i.e., young people aged 10-19; see WHO, 2014), formally diagnosed with ID, and considered resilient as defined by an advisory panel (AP; as in prior resilience studies, e.g., Fourie & Theron, 2012). The AP consisted of staff at a school for students with intellectual disability who were accessible to the first author: three management staff, two school therapists, and four teachers. We interacted with the AP to understand what functional outcomes, despite the challenges of ID, could be used to construe resilience. Based on AP consensus, these included not quitting school, acquisition of life skills, appropriate social behavior, acceptance by peers and/or stable friendships, general emotional stability, and participation in extramural activities. Using these criteria, the AP agreed on and nominated 15 adolescent informants to be included in the study. All 15 were invited to participate; 13 accepted the invitation. In order to recruit additional informants, we provided the AP-generated criteria to four gatekeepers at four other schools for students with intellectual disability. They did not adapt the original criteria. Use of these criteria led to the inclusion of 11 additional informants. At that point, following Merriam (2009), data saturation was reached.

In summary, we included 24 primary informants. Probably because all the gatekeepers were school-based, all 24 attended government-funded schools for students with intellectual disability in the Gauteng province (South Africa). These schools were dedicated to students with ID (mild to lower range of the spectrum). Nevertheless, the included cases of resilience despite ID were diverse in terms of race, mother tongue language, and risks additional to that of ID (see Table 1). This diversity supported a richer understanding of resilience in adolescents with ID (Yin, 2014).

Table 1

Demographics of Primary Informants

Demographics of Primary Informants
Demographics of Primary Informants

Secondary informants

Multiple sources of data support richer insight into the cases (Yin, 2014). Therefore, we invited 18 teachers, who at the time of the study had daily interactions with the primary informants, to participate as secondary informants (some teachers interacted with more than one informant). They all accepted the invitation. We chose to invite teachers above parents, given that 11 primary informants had been orphaned or were in care (see Table 1).

Contextualization

In South Africa, the context of the study being reported on in this article, the people who are intellectually disabled constitute 2.3% of South Africans living with disability, equaling around 62,146 individuals (SSA, 2013). This includes 24,601 adolescents whose primary impairment is ID (DSD et al., 2012). Following a diagnosis of ID by a psychologist, South African students are mostly placed in a government-funded school for students with intellectual disability (that is, not a mainstream school). These schools offer special services that are considered to the advantage of students with special learning needs (SA Department of Education [DoE], 2008). These schools include smaller classes (12-18 students), needs-aligned teaching and services, and individuated/differentiated progress assessments.

School-based support teams cater to the needs of students. They comprise teachers, occupational therapists, speech therapists, and psychologists, and identify and remediate psychological, speech, motor, and behavioral problems individually as well as in groups (Landsberg, 2009). These schools also offer organized extramural activities (sport and cultural) at levels commensurate with student ability. Senior students are included in a school-to-work program, where they are exposed to the work environment at participating local businesses for up to 3 days a week.

Ethical Aspects

The study received ethical clearance from the authors' institutional review board, participating schools, and the relevant Department of Education. Informed consent was obtained from the parents/legal caregivers of primary informants. The secondary informants also provided informed consent.

We were sensitive to the vulnerability of primary informants, and committed to avoiding research-related physical and psychological harm (Ginsberg & Mertens, 2009). The first author has taught adolescents with ID for 18 years. She was, therefore, particularly aware that new/strange situations cause them discomfort. This shaped the process of gaining consent and research activities: the first author engaged with all the primary informants twice, and with 13 primary informants a third time to do member checking.

The first interaction facilitated a gentle introduction of the research and opportunity for informants and the first author to become a little more familiar with one another. To make sure that the adolescents understood what participation entailed, she slowly read the letter of information, as well as consent form, with them. Even though these documents used primary-school-level language, she also provided a simple paraphrase about the aim, method, duration, and potential benefits and risks of the study, as well as informants' rights (e.g., to refuse participation, to withdraw at any stage, to stop the process if they felt tired/anxious). She confirmed informants' language of preference and the availability of a translator (no one asked to make use of her).

In the second session, the first author continued to purposefully facilitate participants' comfort. She repeatedly communicated that the contents—not the quality—of their drawings were of value. She only provided stationery with which informants would already be familiar. No time limits were imposed and informants completed their drawing without rushing. In addition, the first author played soothing background music (i.e., Baroque music). She respectfully acknowledged the primary informants' artistic ownership of their drawings, and offered them the choice of keeping their drawings (in which case a photograph of the drawing would have been taken). However, all participants expressed pride/joy at giving their drawings to the first author to use in her “learning” about why they did in well in life. During member checking, they were excited upon seeing their drawings in a “book” (i.e., a preliminary research report). Each primary informant received a snack, soft drink and a color scan of their drawing as a token of appreciation.

We respected the primary and secondary informants' right to anonymity in that no informant's identity was revealed at any stage of the research (Ginsberg & Mertens, 2009). All informants were invited to choose pseudonyms. They were identified by their chosen pseudonyms throughout.

Data Collection Strategies and Process

Each primary informant engaged in a draw-and-talk methodology (Guillemin & Westall, 2008). Draw-and-talk is a visual method which invites participants to share their insights into a particular phenomenon by representing it through a drawing and then, afterwards, explaining the drawing in their own words (Mitchell, Theron, Stuart, Smith, & Campbell, 2011). It supports social research on contentious issues (e.g., HIV & Aids), human behavior, and/or abstract phenomena (e.g., resilience), without prioritizing literacy skills (Guillemin & Westall, 2008). Draw-and-talk was, therefore, well suited for use with the primary informants given their limited literacy skills. Furthermore, draw-and-talk is known to decrease the power imbalance between researchers and informants, partly because informants have the freedom to choose how to visually represent social issues—in this case, that which the adolescent with ID experiences as contributing to his/her resilience (Guillemin & Drew, 2010).

The first author met with each primary informant individually for 30 to 50 min in his or her familiar school environment. She provided each informant with a blank A4 sheet of paper, a grey pencil, and twistable crayons (that did not need sharpening), and asked: “What has helped you to do well in life at times when you felt that life was difficult? Please draw what helped you to do well.” Because ID is associated with limited expressive skills and anxiety (Emerson et al., 2011), the drawing was followed by a simple, informal conversation. This was to ensure that we attached the right meaning to the drawing (Guillemin & Drew, 2010). All conversations were recorded (with the explicit consent of informants) and transcribed verbatim.

The secondary informants completed an open-ended questionnaire. It invited written responses to the following: “(1) Please describe circumstances that put this adolescent at risk” and “(2) In your opinion, what is helping this adolescent to do well in life?” In their responses, secondary informants drew on relevant school documents (e.g., case files, class records), as needed. As necessary, we used telephonic follow-up interviews to obtain deeper information from the secondary informants.

Data Analysis

Within-case analyses

Data generation and data analyses occurred concurrently. In other words, once an informant had generated a drawing and explanation, and his or her teacher had completed the questionnaire, these were first analyzed before we proceeded to the next case. Following Creswell (2012), we used inductive content analysis to systematically make meaning of the visual and narrative data. We started by open-coding the visual and narrative data (transcript and completed questionnaire). This open-coding was constantly directed by the research question: “Why do adolescents with ID adjust well to the risks and limitations of ID?” This meant that we labeled the drawn content and words, phrases, and segments in the transcripts/questionnaires that provided reasons for a specific adolescent's adjustment. In other words, the data (and not the extant literature) drove the coding process.

Next, we listed the emerged open codes and grouped similar ones to form a new axial code. We recorded the inclusion and exclusion criteria for each axial code (see Creswell, 2014). The axial codes constituted case-specific preliminary answers to the research question. To support the credibility of the process of analysis, we constantly returned to the drawings, transcripts, and completed questionnaires to consider whether we had missed anything (see Merriam, 2009).

All of the previous actions were done independently by each author, as well as independent peer coder. By means of consensus meetings (Saldana, 2009), these codes were compared. In instances where codes differed, we re-visited the data and debated, until consensus was reached. In this way, we increased the trustworthiness of the process of analysis (see Creswell, 2014).

Cross-case analysis

After completion of the first three in-case analyses, we commenced cross-case analyses. We grouped similar axial codes and critically considered the codes that could not be grouped. As each new set of axial codes from a within-case analysis was added to the across-case analysis, we re-visited and refined the patterns emerging from clustered axial codes. In this way, we began to determine emerging themes and subthemes (see Merriam, 2009). As we approached the end of the cross-case analysis process, the process became increasingly deductive. The extant (albeit limited) literature on resilience in adolescents with ID and SERT (Ungar, 2011) increasingly informed the way we clustered axial codes and conceptualized themes and subthemes.

Trustworthiness

Following Creswell (2012, 2014), we confirmed the findings with 13 of the adolescent informants (i.e., we conducted member checking). The first author explained the findings to them in very simple language, and asked how well this explanation summarized what they had drawn and explained. This process indicated participant consensus that the information had been interpreted and represented correctly. Because of this consensus, the remaining 11 participants were not included in member checking. We also arranged peer debriefing sessions, in which very experienced educators of adolescents with ID were invited to review the findings. They considered the findings to be credible and accurate, as well as helpful to their interaction with adolescents with ID.

Findings

Essentially, the resilience processes of adolescents with ID can be reported as two, interrelated themes: (1) their being embedded in a supportive social ecology, (2) as cooperative members of this ecology (see Figure 1). In what follows, we detail this interactive, multifacetted process.

Figure 1.

Summary of the resilience processes supporting adolescents with ID.

Figure 1.

Summary of the resilience processes supporting adolescents with ID.

A Supportive Social Ecology

The social network that adolescents with ID had access to was typically comprised of parents, caregivers, siblings, and teachers, as well as community-based organizations that welcomed them (e.g., church or school). This network supported them to regulate their behavior and emotions, encouraged them toward mastery, respected their capacity for agency, and offered safe developmental spaces.

Social ecology facilitates regulatory support

In making opportunities for learning and meaningful activity available, social ecologies supported adolescents with ID to regulate their behavior and emotions.

Opportunity to learn values and life-lessons. Observing religious activities (such as praying and reading the Bible) regulated adolescents' anxieties about all they could not cope with and gave them hope. This was largely related to their faith-based activities emphasizing peace, hopefulness, and tolerant acceptance of hardship. Roxy, for example, portrayed this hope in her drawing of a Bible in her hands, against a brightly colored rainbow (see Figure 2). Roxy explained: “God tells me every day I don't have to worry about what will happen in my life.”

Figure 2.

Roxy's drawing of faith-inspired hope.

Figure 2.

Roxy's drawing of faith-inspired hope.

Others referred to how these values (reinforced by opportunities to engage in religious activity) supported positive emotion and even success. In Chrissie's words: “It [reading the Bible] makes me happy again when I'm sad.” Natalie said: “I go to church. . . . It makes me feel good.” Similar happiness was experienced by Tshabalala who said: “I feel so happy because I can talk to God.” The Rock explained:

In the church they tell me you must do your best. You must not do the bad stuff. . . . You must always listen to your mother and your father. . . . You must also respect them because things you want to go well.

Relaxed conversations with parents, caregivers, siblings, and teachers about, amongst others, school engagement, diligence, socially appropriate behavior, and how to overcome problems also supported adolescents to regulate their behavior. Sometimes, the support was more directive, but still useful. Princess, for example, told how she had learnt socially appropriate behavior from her mother: “Sometimes, my sister and I fight, then my mother says we must not fight. Then, we must always forgive each other. . . . Then we forgive each other.”

Parents, caregivers, and teachers were directive about peer relationships when they were concerned that these might increase the vulnerability of adolescents with ID. Superhot Boy, for example, drew his home and explained that his parents' advice to walk away from troubled relationships regulated his choices:

Suppose if I got the wrong buddies. Then my mother and father will say those are the wrong buddies, leave them. Then I say, I don't want to leave them because I like my buddies [laughs slightly]. Yes, but then I leave them. Then I listen to what my mother and father are saying ... what they are saying is the right stuff. Because, they have already come through the things that have been happening. What buddies do to you.

Opportunity to be constructively occupied. Positive peer interactions, time spent in nature, and/or music and dancing took adolescents' minds off their difficulties and so facilitated adjustment. This calmed and comforted them, and shifted their focus. For example, Superhot Boy explained: “Then I will just dance that I forget. Because dancing also takes away the angriness.”

Some adolescents indicated that they were able to reduce, and even avoid, negative peer pressure by engaging in activities that occupied their attention (e.g., crafts, drawing, cleaning house, and watching TV). Lady, for example, explained:

I don't like the friends at home because they are going to . . . tell me something else that I do not want. Like if they are going there to their boyfriends, let's go and party. . . . I don't want to do things like that. . . . Mm, I stay at home. I have the knitting needles, I knit there at home.

Social ecology encourages mastery

The social ecology made it easier for adolescents to master their daily challenges, particularly those associated with ID, by offering two particular supports:

Encouragement to be invested in special schooling. Encouragement from parents/caregivers, siblings, and friends helped adolescents accept that going to a special school, and being committed to this schooling, would make it possible to master their many daily challenges. Such support was ongoing, and included regular enquiries about how adolescents with ID were progressing at school. Queen, for instance, explained how scared she was of being maligned and ostracized when she learned that she had to attend a school for students with disabilities. Her social ecology helped her master this fear:

When they said I must come to this school . . . I didn't want to come here. Then my father said, this school is right for me, I must come here because I am going to learn many things here. . . . Now, when I got here, then I saw, he's right. Then, he asked me every day, every Friday . . . how are things at school? I told him well, yes. I thought the friends of mine they would laugh at me. I thought this school was the mad school. Then my father he said, no it's not the mad school, it's the school of the “slow learner”. . . . When I came, then I saw the stuff was right. . . . They [friends] did not say anything. They said no it's right, is right school that. They said I mustn't be ashamed of my school.

Unconditional acceptance. Adolescents' willingness to try new activities was strengthened when they knew that their parents/caregivers, siblings, and friends accepted them unconditionally. For example, in Rambo's drawing of his smiling family, the word “lief” (meaning love) written next to each of them, and the crosses above their heads (symbols of kisses), depicted the belonging and love that he experienced within his family (see Figure 3). This made him less afraid to fail.

Figure 3.

Rambo's loving family.

Figure 3.

Rambo's loving family.

Rambo considered his family as integral to his resilience: “My family. My mother and my father. I love them very much. They love me very, very much. They are very strong for me.” Rambo's teacher described them as “tight-knit” and reported that his parents were “very closely involved in his school and extramural activities.” She also mentioned that Rambo had a “very wide field of interest.” This field of interest included being part of the church band—an activity that she believed he mastered because his family accepted him unconditionally, looked past his disability, believed he could learn to play a musical instrument, and then supported his being part of the church band.

Social ecology promotes agency

Although the social ecology sometimes supported adolescents to regulate their behavior by being directive, significant adults (parents, teachers) also nurtured agency that potentiated positive outcomes. Again, this was facilitated in two particular ways.

Respecting adolescents' dreams. Many adolescents with ID reported dreams of a meaningful future as part of what supported their resilience, including being a sports star, artist, and pilot. They also reported more immediate dreams—achieving at sporting events, and/or eisteddfods—and how their schools provided resources (like sports coaches) to support these dreams. Even though the chances of realizing these dreams were probably slim, their teachers and parents did not discourage them. Their siblings and peers were less supportive, but adult support compensated.

Spiderman, for example, drew a picture of the airplane that he hoped to be able to fly one day when he joined the army (see Figure 4). He also reported wanting to dance in the school concert and eisteddfod. School staff supported him to realize this dream; his teacher reported: “Although his brothers laughed at him, he still danced in the concert and took part in the eisteddfod.”

Figure 4.

Spiderman's dream of piloting a jet.

Figure 4.

Spiderman's dream of piloting a jet.

Enabling constructive choices. In the course of drawing and explaining what supported their resilience, adolescents included opportunity to select a preferred extra-mural activity and to stipulate the extent of their involvement in these activities. Exercising this choice generally facilitated an opportunity for friendships with peers who made similar choices and forged strong bonds. Soccer-man, for example, emphasized the importance of school friends and interacting with them in sporting activities (see Figure 5).

Figure 5.

Soccer-man and his school-friend.

Figure 5.

Soccer-man and his school-friend.

Implicit in such choice, was access to prosocial activities that would support avoidance of anti-social activities and peers. The Rock, for example, chose to participate in school-facilitated sport. His drawing depicted the different types of sports from which he could choose (see Figure 6). He also indicated, with boards next to the gate, what he believed was wrong to engage in, namely, substance abuse and violence. He explained: “My whole must be fit. And, must be strong. . . . I like sports. If you are playing sports you must not smoke and drink and hold the gun and knife.” The Rock's teacher confirmed social ecological support of his choices: “The Rock performs well in sports. . . . He is motivated, and he can rely on his parents' support - particularly his father is involved in his life.”

Figure 6.

The Rock's choice of sport fields with signs prohibiting alcohol, cigarettes, and weapons.

Figure 6.

The Rock's choice of sport fields with signs prohibiting alcohol, cigarettes, and weapons.

Social ecology provides safe spaces

Adolescents with ID appreciated places where they could develop safely and feel secure in their relationship with others. The following four spaces were emphasized.

ID-friendly children's homes. The primary informants included adolescents whose parents had both died (for example, Roxy) or whose parents/single parent could not look after them properly (for example, Nike, Samantha, and Natalie). The latter was sometimes associated with physical disability, which required extra precautionary measures and equipment (for example, Chrissie). In their experience, the children's homes that they lived in were good places to be.

In her conversation about her drawing of her smiling grandmother, Natalie, for example, mentioned that the “aunties” at the children's home helped her be strong in life. She was, however, not able to explain this further. Her teacher explained Natalie's circumstances as follows:

Natalie is in the children's home due to the fact that she and her younger brother were molested by their stepfather. . . . The fact that she was removed from her molester helped Natalie to do well in life. . . . She receives a lot of support both from the teachers at school and her housemothers at the children's home.

For Roxy too, her residence in the children's home gave her the opportunity to enjoy the support of a housemother. She described this supportive relationship: “Auntie [name] from [name] Children's Home . . . always helps me to get things right, and when I do something wrong, she tells me no it's wrong to do that, because she is training me and . . . preparing the road ahead for me.”

Nurturing boarding facilities. Five primary informants used their schools' boarding facilities. For them, these were safe spaces filled with staff who cared about them and provided for their daily needs. Tsabalala, for example, explained that, as a boarder: “I feel so happy . . . and I'm always clean, because they look after me.” Superman reported: “I enjoy it. It's so nice. . . . Some of the housemothers are so kind.”

Routine-respecting homes. Seven of the primary informants who lived at home commented that routine at home helped order their lives and give them structure. Christiano, for example, credited his grandmother for his resilience. Part of what she did was provide him with a structured home-routine:

My Granny. . . . She makes me eat every day. . . . Then she make me sleep. . . . And then I go play. . . . She help me to sweep and things like that. . . . And pick up this mess in the house. . . . And under the beds we sweep. . . . And the sitting room.

Similarly, Princess drew her parents (see Figure 7) and emphasized that her mother's firmness assisted her to cope with challenges. In being strict, her mother provided a predictable home life.

Figure 7.

Having a strict mother made home-life predictable for Princess.

Figure 7.

Having a strict mother made home-life predictable for Princess.

Positive Orientation of Adolescents With ID to Their Life-Worlds

Although the social ecology was prioritized in the informants' responses, adolescents with ID cooperated and showed positive orientation to their life-worlds. Such positive orientation included an appreciative stance and a cheerful disposition.

An appreciative stance

Adolescents with ID valued themselves. They were aware of their strengths (e.g., persevering, being respectful) and were able to endorse their preferences (e.g., being busy at home) and dislikes (e.g., negative peers). Rambo for, example, was appreciative of his own company: “I like being quiet and sitting on my own, watching the children and what they are doing and chilling.”

Adolescents with ID also valued their life-worlds. They expressed appreciation for reliable support networks (families, religious communities, schools), unconditional friendships, and safe spaces in which to reside, learn, and participate in organized activities. For instance, when Queen drew her father (see Figure 8) she expressed gratitude for his motivating presence in her life.

Figure 8.

Queen's drawing of the father she values.

Figure 8.

Queen's drawing of the father she values.

Similarly, Roxy told that her mother had left them when she was 8-years old. A year before she participated in this research her father (her primary caregiver) died after a long illness. She was placed in a children's home. What stood out for her in all of this was helpful others and she valued this: “Even when there is dark tunnel . . . and difficult things in your life, there's always a hand or two that will help . . . so that's what makes me strong to know there's somebody on who I can rely on.” Roxy's teacher confirmed this grateful stance and how it supported Roxy to make the most of resources offered to her: “She cooperated daily, and with great amazement and self-discipline, caught up the deficit. She is currently the strongest in her group”.

A cheerful disposition

“Happy,” “like,” “love,” and “nice” were words that were often used by the adolescents with ID. Their use of bright colors, and cheerful symbols (e.g., smiling faces, flowers, butterflies, and hearts) in their drawings further reflected their cheerfulness. For instance, Flora drew hearts and flowers (see Figure 9). Her cheerfulness was palpable in her explanation. “I like plantings. . . . I draw some flowers. . . . There's some hearts. . . . I love it. . . . It's beautiful.” Flora's teacher described her as “Very friendly . . . very happy”.

Figure 9.

Flora's cheerful drawing of the things that inspire her.

Figure 9.

Flora's cheerful drawing of the things that inspire her.

Discussion

In answer to why some adolescents with ID adjusted well to the risks and limitations of ID, collaboration between individuals (in this case, the adolescents with ID) and a supportive social system was central. Although adolescents' positive adjustment to ID was a collaborative endeavor, the social system seemed to dominate the partnership. The “preponderance of the data” (Merriam, 1989, p. 763) pointed to a supportive social ecology as instrumental to the resilience of the adolescents with ID (see Figure 1). Much less data pointed to the adolescents as facilitators of their resilience. Ungar (2013) is unequivocal in this regard. He maintains that social ecologies are more responsible for the facilitation of resilience processes, than youths themselves. In instances of disability, adolescents are probably more reliant on a supportive social ecology, and so it places an even greater responsibility on the social ecology.

Despite the dominance of the social ecology in adolescents' positive adjustment to the challenges of ID, this suggests no order of resilience processes. It is unclear whether a supportive social ecology preceded adolescents' appreciation, or vice-versa. It is possible that a positive, appreciative orientation prompted the adolescents with ID to reach out to resources in their social ecology that would buffer them against the risks and limitations of ID. It is also possible that membership of a supportive social ecology encouraged such orientation in the first place. It is, however, equally possible that adolescents' positive orientation stimulated the social ecology to be supportive of them. The order is unimportant. Of importance is that the previous processes are interwoven, and probably reinforcing. As illustrated in Figure 1, being resilient in the presence of ID, with all of its associated challenges, requires the existence of a social ecology that supports the adolescent absolutely and, at the same time, an adolescent who is positively inclined toward this supportive community.

The detail of the previous collaboration, or the actions that the adolescents and their social ecologies engaged in, overlaps somewhat with the extant literature relating to resilience and adolescents with ID, living in developed contexts: Fourie and Theron (2012), Hsieh and Donahue (2010), as well as Murray (2003), reported the resilience-supporting value of varied opportunities to develop self-regulation. Social ecological facilitation of mastery in the form of championing special education opportunities and/or accepting adolescents with ID unconditionally was also previously noted (Fourie & Theron, 2012; Hsieh & Donahue, 2010; Migerode et al., 2012; Murray, 2003; Ungar, 2004). Safe spaces too are not new to accounts of resilience in adolescents with ID (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Migerode et al., 2012; Murray, 2003). The same applies to the resilience-supporting value of adolescents with ID being positively oriented to their life-worlds (Fourie & Theron, 2012; Gilmore et al., 2013; Hsieh & Donahue, 2010; Migerode et al., 2012; Murray, 2003).

These overlaps are important because they indicate that despite probable differences in the majority-world (less developed) social, cultural, and physical ecologies of adolescents with ID who participated in the current study, and those who participated in the previous minority-world studies, the mechanisms that support resilience appear to be shared. This is reminiscent of Masten's (2001) “ordinary magic” explanation, or the fact that adjusting well is informed, universally, by commonly occurring resources and processes. Such overlap reinforces the centrality of social ecologies—across developing and developed contexts (see Masten, 2014)—to the resilience of adolescents with ID. Accordingly, social ecologies (developed and developing) might well want to use the overlaps as starting points for promoting positive adjustment in adolescents with ID. To this end, social ecologies would do well to facilitate regulatory support, champion mastery, offer safe spaces, and support adolescents with ID to develop an appreciative, cheerful stance.

The results introduce three previously unreported pathways of resilience for adolescents with ID. The resilience literature does not explicitly associate agency (via opportunities for socially appropriate choices or dreams for the future) with resilience in adolescents with ID. Murray (2003) recommends that social ecologies should promote agency in youths with disability by encouraging these youths to plan toward a constructive postschool life, but there is no evidence (as in the current study) of agency being intertwined with opportunities to dream of achievement and/or a meaningful future. Likewise, stereotypical understandings of adolescents with ID imply that they are disinclined to make socially appropriate choices (Harper, Webb, & Rayner, 2013). In the resilience literature, there is also no reference to children's homes and/or school-boarding facilities constituting safe spaces for adolescents with ID. The literature is more likely to report the latter as putting youths with ID at increased risk (Kozma, Mansell, & Beadle-Brown, 2009). The value of these novel pathways lies in how they challenge stereotypical bias against the agency of youths with ID, as well as categorical understandings of which social ecological services benefit youths with ID (for example, children's homes facilitating protection for some adolescents with ID). In doing so they align with the broader resilience literature which foregrounds youth agency and meaningful social ecological services as important leverage points for championing the resilience of young people made vulnerable (Bottrell, 2009; Munford & Sanders, 2015; Theron, 2015).

Significantly, the findings prompt questions about the increasing emphasis on inclusive education for youths with disabilities, including ID, when inclusion is understood as being synonymous with mainstreaming (Rogers, 2013). Participating adolescents with ID flagged their everyday social ecology, including their special school and the supportive attachments to peers and teachers in that exclusive world, as supportive of their resilience. If these adolescents with ID are, therefore, that happy in their exclusive environment, would inclusion in a mainstream environment be optimal? What influence would the removal of adolescents with ID from their school environment, where they experience supportive attachments to their peers and teachers, to an inclusive school environment have on the adolescent with ID's health and well-being?

Finally, with the exception of their special schools, children's homes, and school-based residence facilities, the adolescents with ID emphasized the informally supportive nature of their social ecology. There is an increasing tendency in the resilience literature to report formal services (for example, mental health services and health care) as a significant social ecological support of youths' resilience processes (see, for example, Liebenberg & Ungar, 2014), also when youths are challenged by ID and other disabilities (Fourie & Theron, 2012). The emphasis on informal social ecological supports (that is, supportive relationships with caregivers, siblings, and peers, as well as sporting, cultural, and religious activities) cautions against assumptions of the universal utility of formal services as a pathway to resilience for adolescents with ID. This caution should be heightened in contexts (such as South Africa) where there is acute disparity in access to services, particularly in marginalized groups (such as people with disabilities) and historically disadvantaged groups (for example, black South Africans; Patel, 2012).

Conclusion

The focus of this study (that is, the resilience process of adolescents with ID) inadvertently presented challenges that imposed limitations on the study and how its results are transferred. The cognitive and expressive-language-related limitations associated with ID made it difficult for these adolescents to explain/verbalize their lived experiences of what supports their resilience. The fact that we compensated for this through a visual method did facilitate rich data, but we are aware that the narrative parts are limited. The data are also biased toward adolescents with ID who are in an exclusive school setting, that is, a special school for learners with ID. Thus, further studies are needed to explore whether or not the understanding of resilience that flows from this study also applies to adolescents with ID in mainstream schools or (as in the South African situation) to those who are excluded from education systems (DSD et al., 2012). Additionally, it is possible that the AP might not have nominated adolescents who were atypically resilient (Ungar, 2011). For example, young people who were quietly competent (see Theron, 2015) might not have come to the AP's attention.

Despite these limitations, the findings that emerged from this study provide important clues about how best to promote the health and wellbeing of adolescents challenged by ID. Most salient, perhaps, is that in the interests of championing resilience, social ecologies have a duty to provide both formal and informal supports to adolescents with ID. In the course of doing so, they would do well to remember that resilient adolescents with ID have capacity for agency and dreams.

References

References
Bottrell
,
D.
(
2009
).
Understanding “marginal” perspectives: Towards a social theory of resilience
.
Qualitative Social Work
,
8
(
3
),
321
329
. doi:
Chen
,
C. H.
,
&
Shu
,
B. C.
(
2012
).
The process of perceiving stigmatization: Perspectives from Taiwanese young people with intellectual disability
.
Journal of Applied Research in Intellectual Disabilities
,
25
(
3
),
240
251
. doi:
Creswell
,
J. W.
(
2012
).
Educational research: Planning, conducting and evaluating quantitative and qualitative research (4th ed.)
.
Boston, MA
:
Pearson Education
.
Creswell
,
J. W.
(
2014
).
Research design: International student edition. Qualitative, quantitative, and mixed methods approaches (4th ed.)
.
Thousand Oaks, CA
:
Sage
.
DSD, DWCPD, & UNICEF
. (
2012
).
Children with disabilities in South Africa: A situation analysis: 2001-2011
.
Pretoria, SA
:
Department of Social Development/Department of Women, Children and People with Disabilities/UNICEF
.
Emerson
,
E.
(
2013
).
Commentary: Childhood exposure to environmental adversity and the well-being of people with intellectual disabilities
.
Journal of Intellectual Disability Research
,
57
(
7
),
589
600
. doi:
Emerson
,
E.
,
Baines
,
S.
,
Allerton
,
A.
,
&
Welch
,
V.
(
2011
).
Health inequalities & people with learning disabilities in the UK: 2011
.
Fourie
,
C. L.
,
&
Theron
,
L. C.
(
2012
).
Resilience in the face of Fragile X syndrome
.
Qualitative Health Research
,
20
(
10
),
1
14
. doi:
Gilmore
,
L.
,
Campbell
,
M.
,
Shochet
,
I.
,
&
Roberts
,
C.
(
2013
).
Resiliency profiles of children with intellectual disability and their typically developing peers
.
Psychology in the Schools
,
50
(
10
),
1032
1043
. doi:
Ginsberg
,
P. E.
,
&
Mertens
,
D. M.
(
2009
).
Frontiers in social research: Fertile ground for evolution
.
In
D. M.
Mertens
&
P. E.
Ginsberg
(
Eds.
),
The handbook of social research ethics
(pp
.
580
613)
.
Thousand Oaks, CA
:
Sage
.
Guillemin
,
M.
,
&
Drew
,
S.
(
2010
).
Questions of process informant-generated visual methodologies
.
Visual Studies
,
25
(
2
),
175
188
. doi:
Guillemin
,
M.
,
&
Westall
,
C. A.
(
2008
).
Gaining insight into women's knowing of postnatal depression using drawings
.
In
P.
Liamputtong
&
J.
Rumbold
(
Eds.
),
Knowing differently: Arts-based and collaborative research methods
(pp
.
121
139)
.
New York, NY
:
Nova Science Publishers
.
Harper
,
S. K.
,
Webb
,
T. L.
,
&
Rayner
,
K.
(
2013
).
The effectiveness of mindfulness-based interventions for supporting people with intellectual disabilities: A narrative review
.
Behavior Modification
,
37
(
3
),
431
453
. doi:
Hsieh
,
W-Y.
,
&
Donahue
,
M. L.
(
2010
).
Risk and resilience frameworks in understanding special education
.
International Encyclopedia of Education
(3rd ed., pp. 840–844).
Hutzler
,
Y.
,
&
Korsensky
,
O.
(
2010
).
Motivational correlates of physical activity in persons with an intellectual disability: A systematic literature review
.
Journal of Intellectual Disability Research
,
54
(
9
),
767
786
. doi:
Kozma
,
A.
,
Mansell
,
J.
,
&
Beadle-Brown
,
J.
(
2009
).
Outcomes in different residential settings for people with intellectual disability: A systematic review
.
Journal Information
,
114
(
3
),
193
222
. doi:
Kumpulainen
,
K.
,
Lipponen
,
L.
,
Hilppö
,
J.
,
&
Mikkola
,
A.
(
2014
).
Building on the positive in children's lives: A co-participatory study on the social construction of children's sense of agency
.
Early Child Development and Care
,
184
(
2
),
211
229
. doi:
Landsberg
,
E.
(
2009
).
Learning support
.
In
E.
Landsberg
(
Ed.
),
Addressing barriers to learning: A South African perspective
(pp
.
380
404)
.
Pretoria, SA
:
Van Schaik
.
Liebenberg
,
L.
,
&
Ungar
,
M.
(
2014
).
A comparison of service use among youth involved with juvenile justice and mental health
.
Children and Youth Services Review
,
39
,
117
122
. doi:
Masten
,
A. S.
(
2001
).
Ordinary magic: Resilience processes in development
.
American Journal of Psychology
,
56
(
3
),
227
238
. doi:
Masten
,
A. S.
(
2014
).
Global perspectives on resilience in children and youth
.
Child Development
,
85
(
1
),
6
20
. doi:
Merriam
,
S. B.
(
1989
).
The structure of simple reminiscence
.
The Gerontologist
,
29
(
6
),
761
767
.
Merriam
,
S. B.
(
2009
).
Qualitative research: A guide to design and implementation
.
San Francisco, CA
:
Jossey-Bass
.
Migerode
,
F.
,
Maes
,
B.
,
Buysse
,
A.
,
&
Brondeel
,
R.
(
2012
).
Quality of life in adolescents with a disability and their parents: The mediating role of social support and resilience
.
Journal of Developmental and Physical Disabilities
,
24
(
5
),
487
503
. doi:
Mitchell
,
C.
,
Theron
,
L. C.
,
Stuart
,
J.
,
Smith
,
A.
,
&
Campbell
,
Z.
(
2011
).
Drawings as research method
.
In
L. C.
Theron
,
C.
Mitchell
,
A.
Smith
,
&
J.
Stuart
(
Eds.
),
Picturing research: Drawings as visual methodology
(pp
.
19
36)
.
Rotterdam, NL
:
Sense
.
Munford
,
R.
,
&
Sanders
,
J.
(
2015
).
Young people's search for agency: Making sense of their experiences and taking control
.
Qualitative Social Work: Research and Practice
,
14
(
5
),
616
633
. doi:
Murray
,
C.
(
2003
).
Risk factors, protective factors, vulnerability and resilience. A framework for understanding and supporting the adult transitions of youth with high-incidence disabilities
.
Remedial and Special Education
,
24
(
10
),
16
26
. doi:
Patel
,
L.
(
2012
).
Poverty, gender and social protection: Child support grants in Soweto, South Africa
.
Journal of Policy Practice
,
11
(
1-2
),
106
120
. doi:
Rogers
,
C.
(
2013
).
Inclusive education and intellectual disability: A sociological engagement with Martha Nussbaum
.
International Journal of Inclusive Education
,
17
(
9
),
988
1002
. doi:
Rutter
,
M.
(
2012
).
Resilience: Causal pathways and social ecology
.
In
M.
Ungar
(
Ed.
),
The social ecology of resilience
(pp
.
33
42)
.
New York, NY
:
Springer
.
Saldana
,
J.
(
2009
).
The coding manual for qualitative researchers
.
London, UK
:
Sage
.
South Africa. Department of Education (DoE)
. (
2008
).
Strategic plan 2008-2012 and operational plans 2008-2009
.
South Africa. Statistics South Africa (SSA)
. (
2013
).
General household survey 2012
.
Theron
,
L. C.
(
2015
).
Towards a culturally- and contextually-sensitive understanding of resilience: Privileging the voices of black, South African young people
.
Journal of Adolescent Research
. Advance online publication. doi:
Ungar
,
M.
(
2004
).
The importance of parents and other caregivers to the resilience of high-risk adolescents
.
Family Process
,
43
(
1
),
23
41
. doi:
Ungar
,
M.
(
2011
).
The social ecology of resilience: Addressing contextual and cultural ambiguity of a nascent construct
.
American Orthopsychiatric Association
,
81
(
1
),
1
17
. doi:
Ungar
,
M.
(
2012
).
The social ecology of resilience: A handbook of theory and practice
.
New York, NY
:
Springer
.
Ungar
,
M.
(
2013
).
Resilience, trauma, context, and culture
.
Trauma, Violence, & Abuse
,
14
(
3
),
255
266
. doi:
Ungar
,
M.
(
2015
).
Practitioner Review: Diagnosing childhood resilience–a systemic approach to the diagnosis of adaptation in adverse social and physical ecologies
.
Journal of Child Psychology and Psychiatry
,
56
(
1
),
4
17
. doi:
Ungar
,
M.
,
Ghazinour
,
M.
,
&
Richter
,
J.
(
2013
).
Annual research review: What is resilience within the social ecology of human development?
Journal of Child Psychology and Psychiatry
,
54
(
4
),
348
366
. doi:
World Health Organization
. (
2013
).
WHO methods and data sources for global burden of disease estimates 2000-2011
.
Geneva
:
Department of Health Statistics and Information Systems, WHO
.
World Health Organization
. (
2014
).
Maternal, newborn, child and adolescent health: Adolescent development
.
Geneva
:
Department of Health Statistics and Information Systems, WHO
.
World Health Organization & World Bank
. (
2011
).
World report on disability
.
Geneva
:
World Health Organization
.
Wright
,
M. O.
,
Masten
,
A. S.
,
&
Narayan
,
A. J.
(
2013
).
Resilience processes in development: Four waves of research on positive adaptation in the context of adversity
.
In
S.
Goldstein
&
R. B.
Brooks
(
Eds.
),
Handbook of resilience in children
(pp
.
15
37)
.
New York, NY
:
Springer Science and Business Media
.
Yin
,
R. K.
(
2014
).
Case study research: Design and methods (5th ed.)
.
Thousand Oaks, CA
:
Sage
.

Author notes

The findings reported in this article were orally presented at the 20th Annual Psychology Congress, September 16-19, 2014, at the Inkosi Albert Luthuli International Convention Centre, Durban, KwaZulu-Natal, South Africa. The authors are grateful to conference attendees for their insightful comments which supported tweaking of findings.

Competing Interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The findings reported in this article were orally presented at the 20th Annual Psychology Congress, September 16-19, 2014, at the Inkosi Albert Luthuli International Convention Centre, Durban, KwaZulu-Natal, South Africa. The authors are grateful to conference attendees for their insightful comments which supported tweaking of findings.

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The research reported in this article was partially supported by a National Research Foundation South Africa, Incentive Funding Grant: IFR2011041100058

The research was approved by the IRB of North-West University.