Feasibility of an Online Resilience Program for Mothers With Adverse Childhood Experiences

ABSTRACT

Enhancing maternal resilience through targeted interventions has emerged as a promising strategy for preventing the intergenerational transmission of adverse childhood experiences (ACEs). This study aimed to develop and evaluate the feasibility of an online resilience program tailored for mothers with ACEs. The study followed the development and feasibility phases of the Medical Research Council (MRC) framework for developing and evaluating complex interventions. The development phase involved a literature review, application of a theoretical framework, and expert content validation. The program was grounded in Roy's Adaptation Model and structured as an eight‐session, interactive, group‐based online intervention. During the feasibility phase, a pilot study was conducted to assess feasibility, acceptability, and preliminary effectiveness. The pilot study included five mothers with two or more ACEs who were raising preschool‐aged children in South Korea. The study demonstrated high retention (83.3%) and session attendance (97.5%) rates, and participants reported high satisfaction (M ± SD = 9.80 ± 0.45 out of 10). Preliminary findings suggested improvements in resilience and parenting behaviors (both Z = −2.02, p = 0.043). Other outcomes, including self‐rated health, self‐esteem, parenting sense of competence, and mother‐child interaction, showed favorable trends. Based on participant feedback, the program was refined accordingly. This study demonstrates a theory‐driven, evidence‐based intervention approach for mothers with ACEs that may inform practices to prevent intergenerational transmission of adversity.

1. Introduction

Adverse childhood experiences (ACEs) are prevalent across global populations and recognized as significant risk factors for developmental and health challenges throughout the lifespan (Bhutta et al. 2023; Merrick et al. 2019). Traditionally, ACEs referred to traumatic events before age 18, including abuse, neglect, and household dysfunction (Felitti et al. 1998). More recent studies have expanded this concept to include socio‐structural adversities such as community violence, bullying, economic hardship, and social discrimination (Cronholm et al. 2015; Bhutta et al. 2023). ACEs negatively affect brain development and substantially increase the risk of chronic diseases, mental illness, and engagement in health‐risk behaviors in adulthood (Hughes et al. 2017). These findings underscore how ACEs can lead to cascading effects across the lifespan, emphasizing the need for preventive and tailored support.

Mothers with ACEs represent a particularly vulnerable group whose experiences may profoundly shape the next generation (Cooke et al. 2021; Narayan et al. 2021). Mothers who have experienced ACEs are at increased risk for elevated parenting stress and maladaptive parenting behaviors, which adversely affect their children's emotional and behavioral development (Cooke et al. 2021; Lange et al. 2019). Maternal ACEs and parenting behaviors influence parent–child relationships and serve as key pathways for the intergenerational transmission of ACEs (Cooke et al. 2019). Therefore, preventive interventions are essential to break this cycle, with tailored approaches focusing on improving maternal resilience and promoting positive parenting practices (Narayan et al. 2021; Isobel et al. 2019).

Strengthening resilience in mothers with ACEs is recognized as a promising strategy for preventing the intergenerational transmission of adversity (Woods‐Jaeger et al. 2018). Resilience refers to the ability to maintain psychological well‐being and adapt in the face of adversity and stress (Rutter 2012). It serves as a key protective factor that buffers parenting stress and supports positive parenting among mothers with ACEs (Woods‐Jaeger et al. 2018). Resilience is not a fixed trait but a dynamic process of positive adaptation (Luthar and Cicchetti 2000), developing through interactions of risk and protective factors across contexts (Rutter 2012). Resilience‐focused interventions have demonstrated improvements in resilience among individuals with ACEs, including university students and community‐dwelling adults (Cameron et al. 2018; Chandler et al. 2020), suggesting that resilience may be strengthened through structured intervention. Although evidence specific to mothers with ACEs remains scarce, these findings provide a promising starting point for developing and testing resilience interventions in this population.

While an increasing number of studies have examined parenting interventions for mothers with ACEs, existing research has primarily focused on parenting stress, parenting efficacy, and parenting behavior rather than maternal resilience (Cho and Shin 2025; Lyu et al. 2023). A resilience‐enhancement program for mothers in a general community sample demonstrated significant improvements in maternal resilience through a group‐based, emotion regulation–focused intervention (Tobe et al. 2022); however, this study did not specifically target mothers with ACEs. In addition, a recent study by Lowery et al. (2025) reported reductions in parental anxiety and stress alongside improvements in family resilience following a trauma‐informed group‐based intervention for parents with ACEs. Nevertheless, interventions specifically targeting maternal resilience in this population remain scarce, highlighting an important gap in evidence‐based practice aimed at preventing intergenerational transmission.

The preschool period is a critical stage for the development of self‐regulation and socioemotional skills, which are strongly influenced by parenting (Eisenberg et al. 2010). Enhancing resilience and positive parenting in mothers of preschoolers can significantly benefit child development (Lange et al. 2019), underscoring the need for tailored interventions. Given the practical constraints of mothers with young children, online interventions—offering comparable effectiveness and retention to in‐person formats with greater accessibility—present a promising alternative (Corralejo and Domenech Rodríguez 2018). Moreover, group‐based formats may facilitate engagement and learning through shared experiences (Herbell and Bloom 2020; Lawler et al. 2018). To address these gaps, this study aimed to develop an online, interactive, group‐based resilience‐building program tailored for mothers with ACEs raising preschool‐aged children.

Developing complex interventions should be grounded in theoretical frameworks and follow systematic methodologies (Chmitorz et al. 2018; Skivington et al. 2021). This study was guided by the Medical Research Council (MRC) framework, which provides structured steps for developing and evaluating complex interventions (Skivington et al. 2021). In addition, Roy's Adaptation Model (Roy 1970) informed the program's conceptual foundation, emphasizing adaptive responses to stressors across physical, psychological, and social domains. For mothers with ACEs, these domains are particularly relevant, as ACEs can disrupt self‐regulation, self‐identity, parenting roles, and interpersonal relationships (Narayan et al. 2021; Cooke et al. 2021). By integrating these two frameworks, the program was designed to address the adaptive challenges faced by this population.

This study aimed to develop and evaluate the feasibility of a theory‐informed, evidence‐based online resilience program for mothers with ACEs by integrating the MRC framework with Roy's Adaptation Model.

2. Methods

2.1. Study Design

This study employed a feasibility study design following a program development. Specifically, this paper reported the development and feasibility phases guided by the MRC framework (Skivington et al. 2021).

2.2. Phase 1: Development

2.2.1. Literature Review: Searching Strategies

A comprehensive literature search was conducted across six databases—PubMed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Central Register of Controlled Trials—using predefined keywords and Boolean operators (Supplement S1). The search targeted peer‐reviewed articles published in English up to December 2025. Studies were included if they met the following criteria: involved adult participants with a history of ACEs; implemented a psychosocial intervention; and reported resilience as an intervention outcome. Eligible study designs included randomized controlled trials, quasi‐experimental studies, mixed‐methods designs, qualitative research, pilot studies, and feasibility trials. Eight studies were selected based on the criteria. We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines (Page et al. 2021). A flow diagram of the selection process is shown in Figure 1.

Figure 1.

PRISMA flow diagram.

The literature review was conducted by both authors. Both authors independently screened titles and abstracts to identify eligible studies and reviewed full texts for inclusion. Data extraction and analysis were independently performed by both authors using a standardized data extraction form. Any discrepancies in study selection, data extraction, or analysis were resolved through discussion until consensus was reached.

2.2.2. Literature Review: The Contents, Delivery, and Results of the Resilience Interventions

The literature review of eight included studies aimed at enhancing resilience in individuals with ACEs is summarized in Tables 1 and 2. The characteristics of the included studies (authors, publication year, country, study design, sample size, participant characteristics, intervention type, intensity, frequency, duration, and providers) are presented in Table 1. Outcome variables, measures of resilience, data collection methods and time points, intervention contents, and study findings are summarized in Table 2.

Table 1.

Characteristics of the included studies.

No	1st Author (year) country	Study design	Sample size	Age	Recruitment	Number of ACEs participants had	Type and strategies of intervention	Duration of intervention	Providers/facilitators
1	Chandler (2015) USA	RCT	N = 28 E:17 C:11	18−24	Community (university)	– Range: 0−8 – M (SD) = 4 (2.4) – No‐ACE (n = 2) – 1 + ACE (n = 26)	Group – Psychoeducation – Mindfulness‐based meditation – Education – Structured writing – Social support with guided peer and facilitator interaction	1 h session 4 sessions 4 weeks Once a week	Two co‐facilitators
2	Scott (2021) USA	RCT	N = 74 E:36 C:38	12−25	Hospital	– 60% have 1+ ACEs – 24% 1 TE – 17% 2 TEs – 19% 3 TEs	Individual – Cognitive behavioral therapy	30−50 min session 4 sessions 8 months bi‐monthly	Trained bachelor's degree non‐clinical staff
3	Lowery (2025) USA	Pilot MM	N = 7	24−44	Community	– ACE count distribution not reported	Group – Trauma‐informed group‐based parenting intervention – Psychoeducation	90 min session 8 sessions 8 weeks Once a week	Two licensed marriage and family therapists, an additional team member served as moderator/notetaker
4	Maurer (2023) Canada	Pilot MM	N = 91	19−51	Community (university)	– Range: 0−9 – M (SD) = 3.12 (2.52) – No‐ACE: 17.6% – 1−4 ACEs: 52.7% – 5+ ACEs: 29.7%	Individual – Mobile application	28 days daily use twice per day	Not applicable
5	Chandler (2020) USA	MM	N = 56 E:40 C:16	18−19	Community (university)	– Range: 0−7 – M (SD) = 1.3 (1.9) – 50% non‐ACEs – 50% 1+ ACEs	Group – Psychoeducation – Relaxation, research, education, writing prompt, reflection	1 h session 10 sessions 5 weeks Twice a week	Not described
6	Cameron (2018) USA	QE One group	N = 59	18−75	Community (mass media)	– Median = 5, Mode = 6 – 85% 2+ ACEs – 54% 4+ ACEs	Group – Psychoeducation – Lecture, workbook, homework, feedback, group discussion	2 h session 12 sessions 12 weeks Once a week	A director and developer of this program
7	Maclsaac (2021) Canada	QE One group	N = 123	16−38	Community (university)	– M (SD) = 2.55 (2.17) – 20.4% no‐ACE – 16.4% 1 ACE – 21.7% 2 ACEs – 12.5% 3 ACEs – 28.9% 4+ ACEs	Individual – Mobile application	2 times a day 4 weeks	Not applicable
8	Mushquash (2021) Canada	Qualitative	N = 30	16−29	Community (university)	– Not described	Individual – Mobile application	2 times a day 4 weeks	Not applicable

Abbreviations: ACEs, adverse childhood experiences; C, control; E, experimental; MM, mixed methods study; QE, quasi‐experimental; RCT, randomized controlled trial; TE, traumatic event.

Table 2.

Outcome variables, measures, contents of intervention, and findings of the included studies.

No	1st Author (year)	Outcome variables	Measures of resilience Data collection methods and time points	Contents of intervention	Findings
1	Chandler (2015)	Resilience Health behavior Physical and psychological symptoms	Resilience scale Survey Written narratives Pre, post	– Active coping – Building strength – Cognitive flexibility – Social support	– No significant change in resilience and risk behaviors – Increase in physical activity – 3 themes: building strengths, reframing resilience, and creating support connections
2	Scott (2021)	Resilience Hope Benefit‐finding Quality of life Depression & anxiety	Connor−Davidson resilience scale‐10 Survey Electronic medical records Pre, post	– Stress management – Goal setting – Cognitive restructuring – Benefit‐finding	– Increase in resilience among 1 + TE group – Increase in hope and benefit‐finding at the 6‐month – Participants with 1+ ACEs showed greater improvement of benefit finding and hope than participants without ACEs, whereas similar effects in both group for resilience, depression, both generic and cancer specific HRQoL
3	Lowery (2025)	Parental anxiety Parental stress Couple satisfaction Family resilience	Family resilience scale Quantitative Survey Pre, post Qualitative Participant reflections and group discussions Post	– Trauma, neuroscience of parenting – Reflection on parents' own childhood experiences – Nervous system regulation skills – Emotion regulation – Co‐regulation strategies – Relational skill‐building – Peer group support	– Quantitative findings indicated reductions in parental anxiety and stress and improvements in couple satisfaction and family resilience after the intervention. – Qualitative findings indicated increased awareness of intergenerational influences on parenting; improved recognition of emotional and physiological responses; greater self‐reflection and intentional parenting practices; and perceived benefits of the group‐based format in facilitating shared reflection and support
4	Maurer (2023)	Affect regulation Stress responsivity Perceived social support Resilience	Connor–Davidson resilience scale‐10 Quantitative Survey Pre, mid, post Qualitative Interview Post	– Mobile app–based intervention – Affect regulation – Cognitive regulation – Behavioral coping – Mindfulness – Self‐reflection – Social engagement	– No statistically significant change in resilience scores – Decrease in perceived stress and stress responsivity, including PTSD‐related symptoms – Participants with higher ACE exposure showed greater improvements in emotion regulation compared with those with lower ACE exposure – Qualitative themes included: increased emotional awareness and recognition; greater willingness to rely on others and reach out for support; building personal strengths as a new and meaningful experience
5	Chandler (2020)	Resilience Perceived stress Emotional awareness Cohesion	Connor–Davidson resilience scale Quantitative Survey Pre, post Qualitative Expressive writing Oral presentation Post	– Adverse childhood experiences – Neurobiology of stress and coping – Resilience – Strengths‐based education – Cognitive awareness – Self‐leadership – Social support – Internal and external resources	– Increase in resilience and decision‐making – Decrease in perceived stress – Participants with ACEs showed greater improvement in emotional awareness than participants without ACEs – 3 themes: open up and recognition of emotions, count on others and reach out, and building on strengths is a new experience
6	Cameron (2018)	Resilience Emotion suppression Rumination Cognitive reappraisal Mindfulness Self‐efficacy Perceived stress Mood Depressive symptom Quality of life Symptom load Sick days	Ego resilience 89 Survey Pre, post	– Introducing the ACE study – Understanding the physical and mental effects of stress – Overcoming rumination – Calming the threat response – Emotion regulation – Self‐awareness – Reducing anxiety – Self‐soothing – Self‐efficacy – Brain plasticity – Hopefulness – Reframing the difficulties of life – Relational skills, social functioning	– Increase in psychological resilience, emotion regulation skills, mental health (depression, anxiety), quality of life, and physical health problems – Younger adults showed a significantly greater decrease in perceived stress than the older adults
7	MacIsaac (2021)	Resilience Executive functioning Emotion regulation deficits Depression	Connor−Davidson resilience scale–10 Survey Pre, mid, post	– Rate my mood: self‐assessment of mood, emotional awareness – Breathing exercises: emotional self‐regulation, relaxation – Journaling: expressive writing, self‐reflection, emotional processing – Square moves: flow, distraction – Art feature: nonverbal emotional expression, releasing emotions – Circle of trust: social connection – Call for help: social support	– No significant change in resilience and executive functioning – Improvements in emotion regulation. An interaction between ACEs and days of app usage existed for emotion regulation, such that participants with more adversity evidenced a faster rate of change in emotion regulation – Decrease in depression
8	Mushquash (2021)	Not applicable	Not applicable Interview (group & individual) Post	– Rate my mood: self‐assessment of mood, emotional awareness – Breathing exercises: emotional self‐regulation, relaxation – Journaling: expressive writing, self‐reflection, emotional processing – Square moves: flow, distraction – Art feature: nonverbal emotional expression, releasing emotions – Circle of trust: social connection – Call for help: social support	– Increase in self‐awareness to recognize and differentiate their emotions, helpful distraction, and emotional control – Recommendations for app improvement: adding more features, enhancing existing features, enhancing tracking abilities, and providing personalization – App use: M (SD) = 2.11 (0.74), Range 1−5 times a day – Most often: Rate my mood, journal, SquareMoves, most helpful: Rate my mood, journal, breathing – Facilitators of app use: prompts, creating routine, self‐monitoring opportunities, expressive opportunities – Barriers to app use: editing, lack of variety, student lifestyle

Across the reviewed studies, the contents of the resilience‐enhancing interventions for individuals with ACEs included the following: ACEs and their effects (Cameron et al. 2018; Chandler et al. 2015, 2020; Lowery et al. 2025), stress and its psychological and physiological impacts (Cameron et al. 2018; Chandler et al. 2020), and strategies to strengthen emotion recognition and emotion regulation (Cameron et al. 2018; Lowery et al. 2025; MacIsaac et al. 2021; Maurer et al. 2023; Mushquash et al. 2021). Additional intervention components included stress management (Chandler et al. 2020; Scott et al. 2021), active coping (Chandler et al. 2015, 2020; Maurer et al. 2023), cognitive flexibility and cognitive restructuring (Cameron et al. 2018; Chandler et al. 2015, 2020; Lowery et al. 2025; Maurer et al. 2023; Scott et al. 2021), and relational or social components such as peer group engagement, relational skills, and social functioning (Cameron et al. 2018; Chandler et al. 2015, 2020; Lowery et al. 2025; MacIsaac et al. 2021; Maurer et al. 2023; Mushquash et al. 2021; Scott et al. 2021). Some interventions further emphasized strength‐building, goal setting, self‐leadership, and self‐efficacy (Chandler et al. 2015, 2020; Scott et al. 2021), as well as benefit‐finding, hopefulness, and meaning‐making (Scott et al. 2021). Trauma‐informed approaches incorporating neuroscience‐informed parenting education and nervous system regulation skills were also observed (Lowery et al. 2025). Common delivery strategies included reflective writing, deep breathing, and mindfulness‐based meditation (Cameron et al. 2018; Chandler et al. 2015, 2020; MacIsaac et al. 2021; Mushquash et al. 2021). These findings suggest that resilience interventions may exert their effects through multiple psychosocial mechanisms rather than a single outcome indicator.

With respect to intervention delivery, resilience‐enhancing programs varied in format. Identified strategies included group‐based (four studies) and individual‐based (four studies) formats, psychoeducational approaches (four studies), mobile application‐based interventions (three studies), and cognitive behavioral therapy–informed programs (one study). Common delivery methods included lectures, structured reflective writing and journaling, breathing and mindfulness‐based practices, and facilitated group discussions. Overall, these studies suggest that resilience interventions for individuals with ACEs tend to emphasize strengthening adaptive regulatory processes and coping capacities, with variable evidence regarding improvements in resilience scores.

Based on the findings of the literature review, resilience interventions are commonly defined as psychosocial programs designed to strengthen individuals' capacity to adapt to stress and adversity by enhancing emotional, cognitive, behavioral, and relational regulatory processes (Cameron et al. 2018; Chandler et al. 2015, 2020; MacIsaac et al. 2021; Maurer et al. 2023). Prior studies have reported improvements in specific psychosocial outcomes (Cameron et al. 2018; Chandler et al. 2020; Lowery et al. 2025; MacIsaac et al. 2021; Maurer et al. 2023; Scott et al. 2021). For example, improvements in emotion regulation have been observed in several studies (Cameron et al. 2018; MacIsaac et al. 2021; Maurer et al. 2023), and reductions in perceived stress have also been reported (Cameron et al. 2018; Chandler et al. 2020; Maurer et al. 2023). However, findings regarding changes in overall resilience scores have been mixed, with some studies reporting significant improvements (Cameron et al. 2018; Chandler et al. 2020; Lowery et al. 2025) and others finding no significant change (Chandler et al. 2015; MacIsaac et al. 2021; Maurer et al. 2023). Notably, participants with higher ACE exposure consistently demonstrated greater improvements in emotion regulation compared to those with lower exposure (MacIsaac et al. 2021; Maurer et al. 2023), suggesting that individuals with higher ACEs may be especially responsive to resilience‐focused interventions.

2.2.3. Theory Application

The program was developed based on Roy's Adaptation Model (Roy 1970), which conceptualizes individuals as biopsychosocial adaptive systems responding to environmental stimuli through coping mechanisms across four adaptive modes: physiological, self‐concept, role function, and interdependence. Within this framework, resilience was conceptualized as a coping mechanism facilitating adaptive functioning and serving as a precursor to adaptation (Zautra and Reich 2011). The model guided how enhancing resilience may strengthen mothers' adaptive capacities and promote positive parenting outcomes.

Figure 2 presents the conceptual framework. ACEs were defined as residual stimuli, depression as contextual stimuli, and parenting stress as focal stimuli. Previous research has documented that mothers with ACEs experience elevated parenting stress (Lange et al. 2019) and depression (Dosanjh et al. 2023). The program aimed to strengthen coping mechanisms to buffer these effects on maternal functioning.

Figure 2.

Conceptual framework of this study.

Coping mechanisms were operationalized into two subsystems: the regulator (self‐care) and the cognator (self‐regulation, positivity, social connection, and parenting knowledge). The online resilience program was designed to strengthen these mechanisms, which align with protective factors of resilience and adaptive functioning identified in prior research (Harper Browne 2016; Luthar and Cicchetti 2000; Pahwa and Khan 2022). Program outcomes corresponded to Roy's four adaptive modes: self‐rated health (physiological), self‐esteem (self‐concept), parenting sense of competence (role function), and mother‐child interaction (interdependence). Adaptive behaviors, the ultimate outcome of Roy's Adaptation Model, were operationalized as positive parenting behaviors.

Each component of Roy's Adaptation Model was systematically linked to specific program sessions (Table 3). Session 2 addressed awareness of ACEs and their intergenerational effects. Sessions 1 and 3–6 targeted coping mechanisms through resilience‐building, emotion regulation, cognitive reframing, positivity, and self‐care. Sessions 7–8 addressed role function and interdependence through parenting education, child‐led play, and strategies for children's emotion regulation. Feedback was integrated through reflective sharing and workbook activities in a secure online chatroom.

Table 3.

The content of the online resilience program.

Session time	Topic	Content	Learning activities	Learning methods	Theory
1. 1 h	Introduction Understanding resilience	– Introduction of the online resilience program – Meaning, components, and importance of resilience – The body's responses to stressful situations – Meaning and importance of neuroplasticity	N/A	Lecture Group discussion	– Coping mechanism: Resilience – Feedback
2. 1 h	Understanding adverse childhood experiences	– Concept and types of adverse childhood experiences – Its impact on brain development and health – Its impact on parenting – Ways to counteract its negative effects	N/A	Lecture Group discussion	– Residual stimuli: Adverse childhood experiences – Feedback
3. 1 h	How to regulate emotions	– Meaning and importance of emotional regulation – Emotional regulation techniques: flexible thinking, emotion journaling, deep breathing, STOP method, mindfulness meditation	Reflective writing for an emotional journal	Lecture Group discussion	– Coping mechanism: Resilience (Self‐regulation) – Feedback
4. 1 h	How to regulate thoughts	– Meaning and importance of thought regulation – Thought regulation techniques: converting automatic negative thoughts into healthy core beliefs, identifying thinking errors, and replacing them with rational thinking	Reflective writing for cognitive restructuring	Lecture Group discussion	– Coping mechanism: Resilience (Self‐regulation) – Feedback
5. 1 h	How to enhance positivity	– Concept and source of happiness – Meaning and importance of positivity – Ways to enhance positivity: finding my strengths and gratitude journaling	Reflective writing for gratitude journal	Lecture Group discussion	– Coping mechanism: Resilience (Positivity) – Feedback
6. 1 h	How to enhance self‐care	– Meaning and importance of self‐care – Ways to enhance self‐care – Importance of small success and self‐efficacy – How to set goals and plans	Setting goals and plans for self‐care	Lecture Group discussion	– Coping mechanism: Resilience (Self‐care) – Feedback
7. 1 h	Parenting–Part 1: Understanding preschool‐aged children	– Becoming a resilient mom – Ways to enhance your child's resilience: understanding the developmental features of preschoolers	N/A	Lecture Group discussion	– Coping mechanism: Resilience (Social connection, knowledge of parenting and child development) – Feedback
8. 1 h	Parenting–part 2: Raising children to be resilient	– Ways to develop self‐regulation skills among children – Meaning, importance, and application of routines and rituals – Child‐led play techniques	N/A	Lecture Group discussion	– Coping mechanism: Resilience (Social connection, knowledge of parenting and child development) – Feedback

2.2.4. Content Validation of the Intervention Program

The expert panel consisted of seven members: two pediatric nursing professors, one psychiatric nursing professor, one psychiatrist, two online parent education experts, and one resilience‐enhancing intervention expert. Experts evaluated program content and teaching‐learning methods using a four‐point content validity index (CVI; Polit et al. 2007), ranging from one (“not appropriate at all”) to four (“very appropriate”).

Content validity was established with an item‐level CVI of 0.99 (range: 0.86–1.00), scale‐level CVI/universal agreement (S‐CVI/UA) of 0.96, and scale‐level CVI/average (S‐CVI/Ave) of 0.99, all exceeding recommended thresholds (Polit et al. 2007: I‐CVI > 0.78; S‐CVI/UA > 0.80; S‐CVI/Ave > 0.90). Based on expert feedback, the program was refined: group size was set at six participants, discussion guidelines were added, participant preferences for camera use were incorporated, and lecture materials were streamlined with facilitator scripts to enhance readability. The finalized program content is presented in Table 3.

2.3. Phase 2: Feasibility

2.3.1. Study Design

The pilot study used a single‐group pretest–posttest design to evaluate the program's feasibility, acceptability, and preliminary effectiveness with six mothers with ACEs. Feasibility was assessed based on recruitment, retention, and attendance rates. Acceptability was evaluated through satisfaction scores and qualitative feedback. Preliminary effectiveness was examined by comparing pre‐ and post‐intervention scores.

2.3.2. Study Participants

Inclusion criteria were as follows: mothers with a history of at least two ACEs, based on evidence that ACEs commonly co‐occur and that cumulative exposure is more strongly associated with adverse outcomes than single events (Hughes et al. 2017); currently raising a child aged 3–6 years, and able to participate in an online program and complete online surveys. The 3–6 age range was selected for developmental and methodological reasons. The preschool period represents a critical stage for children's socioemotional and self‐regulatory development, during which parental behaviors play a central role (Eisenberg et al. 2010). Methodologically, this range ensured sample homogeneity and facilitated peer support by enabling mothers at similar developmental stages to more easily share experiences and apply program content to comparable parenting contexts.

Exclusion criteria included individuals currently receiving treatment or medication for mental illness, those receiving other mental health or parenting support services, and those raising a child with a severe chronic illness or disability. Participants were considered dropouts if they withdrew, missed two or more sessions, or failed to complete both pre‐ and posttests.

2.3.3. Sample Size

For this pilot study, six participants were initially enrolled to evaluate the feasibility and acceptability of the program. One participant withdrew after the first session for personal reasons; thus, five participants (n = 5) completed the pilot program and were included in the final analysis. To provide a preliminary reference for a future evaluation phase within the MRC framework, the sample size for the subsequent study was estimated using RMASS (Repeated Measures Analysis Sample Size; Bhaumik et al. 2008). Assuming equal allocation to two groups, three repeated measures, a two‐tailed test, 80% power, a significance level of 0.05, a correlation of 0.5 among repeated measures, and an anticipated attrition rate of 30%, the required sample size was estimated to be approximately 56 participants. This estimate should be interpreted as indicative only, as feasibility studies are not intended to determine definitive sample size requirements.

2.3.4. Recruitment

Participants were recruited through a notice posted on the bulletin board of the largest online parenting community in South Korea. The notice included a program application form and a screening questionnaire based on eligibility criteria. Applicants were contacted by phone to confirm eligibility, including having at least two ACEs, and to receive detailed information about the pilot study. A total of 12 individuals applied. Four did not respond to follow‐up contact despite multiple attempts, and two declined participation due to personal circumstances. The remaining six applicants met the eligibility criteria and provided informed consent to participate. All screening and selection procedures were conducted in accordance with the approved protocol, and no applicants were selectively excluded by the researchers.

2.3.5. Study Variables and Measures

The study variables and measures used to evaluate the preliminary effectiveness of the intervention are described below. Detailed information for each instrument—including subdomains, number of items, scoring, and reliability, is provided in Supplement S2. All instruments used in this study were previously translated, culturally adapted, and validated in Korean populations, with acceptable reliability and validity reported in prior studies.

ACEs: ACEs were assessed using the Adverse Childhood Experiences International Questionnaire (ACE‐IQ), developed by the World Health Organization (2012) and adapted into Korean by Ryu et al. (2017). The ACE‐IQ extends the original 10‐item ACE measure by including contextual adversities such as peer bullying, community violence, and economic hardship (Cronholm et al. 2015, cited in Nichol et al. 2025). In this study, ACEs were defined as exposure before age 18 to one or more forms of emotional, physical, or sexual abuse; emotional or physical neglect; or household dysfunction including parental divorce, domestic violence, household economic hardship, substance abuse, mental illness, or incarceration of a household member, as well as peer bullying, community violence, or collective violence. Each ACE category was scored as one point (range = 0–14), with higher scores indicating greater cumulative exposure. Participants with an ACE‐IQ score of ≥ 2 were eligible for inclusion, consistent with prior evidence linking cumulative ACE exposure to increased psychosocial risk (Hughes et al. 2017).

Depression: Depression was measured using the Center of Epidemiologic Studies Depression Scale, 10‐item version (CES‐D‐10), developed by Kohout et al. (1993) and translated into Korean by Cho and Kim (1993).

Parenting stress: Parenting stress was assessed using the Korean Parenting Stress Index, 4th Edition–Short Form (K‐PSI‐4‐SF), originally developed by Abidin (1983) and validated in Korean by Chung et al. (2019).

Resilience: Resilience was measured using the Korean version of the Connor‐Davidson Resilience Scale (K‐CD‐RISC‐25), developed by Connor and Davidson (2003) and validated by Baek et al. (2010).

Self‐rated health: Self‐rated health was assessed using a single item from the National Health and Nutrition Examination Survey in South Korea: “How would you rate your health in general?”

Self‐esteem: Self‐esteem was measured using the Rosenberg Self‐Esteem Scale (RSES), originally developed by Rosenberg (1965) and translated into Korean by Bae et al. (2014).

Parenting sense of competence: Parenting sense of competence was assessed using the Korean version of the Parenting Sense of Competence Scale (K‐PSOC), originally developed by Gibaud‐Wallston and Wandersman (1978) and translated by Shin and Chung (1998).

Mother‐child interaction: Mother‐child interaction was measured using the Mother–Preschool Child Interaction Scale (MPIS), developed by Park and Bang (2013).

Parenting behaviors: Parenting behaviors were measured using the Maternal Behavior Research Instrument (MBRI), originally developed by Schaefer (1959), adapted into Korean by Lee (1983), and later modified by Sang (1992).

General characteristics: General characteristics included age, employment status, educational level, religion, area of residence, monthly household income, number of family members, number and age of children, spouse's age, marital status, cohabitation status, primary caregiver, and average childcare time on weekdays and weekends.

Marital satisfaction: Marital satisfaction was assessed using the Korean version of the Couple Satisfaction Index (K‐CSI 4), originally developed by Funk and Rogge (2007), and validated by Kim et al. (2022).

Spouse's parenting involvement: Spouse's parenting involvement was measured using a four‐item scale on spouse's involvement in parenting, originally developed by Hong (1995) and later adapted for use in the Korean Child Panel Study.

Feasibility and acceptability: Feasibility and acceptability were evaluated using three indicators: retention rate, session attendance rate, and participants' program satisfaction. Retention rate was defined as the proportion of enrolled participants who completed the program. Session attendance rate was defined as the proportion of scheduled sessions attended among completers. Program satisfaction was assessed using both quantitative and qualitative methods. The quantitative evaluation used a 20‐item questionnaire developed by the authors for this study. The questionnaire measured perceived effectiveness in enhancing resilience and parenting, as well as satisfaction with each session's content, delivery methods, scheduling, and overall experience. The qualitative assessment, conducted through open‐ended questions, explored participants' experiences regarding program content, delivery methods, scheduling, and suggestions for improvement.

2.3.6. Data Collection

Online surveys were administered before and after the intervention. Participants completed questionnaires independently via a web‐based platform to minimize researcher influence. The pretest assessed general characteristics, marital satisfaction, spouse's parenting involvement, ACEs, depression, parenting stress, resilience, self‐rated health, self‐esteem, parenting sense of competence, mother‐child interaction, and parenting behaviors. The posttest assessed resilience, self‐rated health, self‐esteem, parenting sense of competence, mother‐child interaction, parenting behaviors, and program satisfaction. Participant feedback informed program refinement. Marital satisfaction, spouse's parenting involvement, ACEs, depression, and parenting stress were assessed only at baseline as contextual variables.

2.3.7. Data Analysis

All analyses were conducted using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize participant characteristics and the distributions of study variables. Feasibility was assessed through recruitment, retention, and session attendance rates. Acceptability was evaluated using descriptive statistics for satisfaction scores and qualitative feedback. Preliminary effectiveness was examined by comparing pre‐ and post‐intervention scores using the Wilcoxon signed‐rank test.

2.3.8. Implementation of the Pilot Program

The pilot program was implemented over 4 weeks (June 3–28, 2024) and consisted of eight 1 h sessions delivered twice weekly via Zoom, aligning with moderate‐intensity interventions (Kunzler et al. 2020). Sessions were facilitated by the principal investigator, a registered nurse trained in trauma counseling and resilience, and incorporated lectures, group discussions, and reflective writing using a workbook. Sessions were delivered sequentially to promote resilience and positive parenting: Session 1 (resilience, neuroplasticity), Session 2 (ACEs, intergenerational transmission), Session 3 (emotion regulation), Session 4 (cognitive reframing), Session 5 (positivity, strengths, gratitude), Session 6 (self‐care, goal setting), Session 7 (child‐led play, positive reinforcement), and Session 8 (children's emotion regulation, routines). Each session concluded with a shared reflection to facilitate integration. Between sessions, participants completed daily workbook activities (emotion diaries, cognitive reframing, gratitude journaling, self‐care planning) and received brief feedback. To ensure privacy, participants used self‐selected pseudonyms and could keep cameras off or use avatars during sessions. A secure KakaoTalk chatroom, accessible only with researcher‐issued access codes, was used for announcements, peer interaction, and reflection sharing.

2.4. Ethical Considerations

The study was approved by the Institutional Review Board of Yonsei University Health System (IRB no. 4‐2023‐0355) and adhered to the Declaration of Helsinki. Written informed consent was obtained from all participants. Given the sensitivity of discussing ACEs, participants were informed of potential emotional distress and reminded that participation was voluntary with no penalty for withdrawal. Contact information for local mental health services (National Center for Mental Health and National Trauma Center) was provided to ensure access to professional support if needed. Participants who completed both assessments and attended all sessions received a mobile gift voucher (KRW 60,000, approximately USD 42) as compensation.

3. Results

3.1. Participant Characteristics

General characteristics are presented in Table 4. The mean age was 36.00 ± 3.39 years, and participants reported an average of 8.00 ± 2.19 ACEs. All participants reported experiences of emotional neglect, witnessing domestic violence, and economic hardship.

Table 4.

General characteristics in the pilot study (N = 5).

Variable	Mean ± SD or n (%)
Participant characteristics
Age (years)	36.00 ± 3.39
Employment status
Unemployed (homemaker)	3 (60.0)
Employed	2 (40.0)
Educational level
High school or associate degree	2 (40.0)
Bachelor's or graduate degree	3 (60.0)
Religion
No religion	2 (40.0)
Has religion	3 (60.0)
Area of residence
Metropolitan area	2 (40.0)
Non‐metropolitan area	3 (60.0)
Monthly household income (10,000 KRW)	520.00 ± 284.17
Number of family members	3.40 ± 0.55
Spouse characteristics
Marital status: Married	5 (100.0)
Cohabitation status	5 (100.0)
Age of spouse (years)	36.80 ± 4.66
Couple satisfaction (range: 4‐25)	14.80 ± 5.81
Child characteristics
Number of children	1.40 ± 0.55
Age of first child (year)	4.80 ± 1.10
Age of second child (year)	1.00 ± 0.0
Primary caregiver: Mother	5 (100.0)
Weekday childcare time (hours)	10.00 ± 7.84
Weekend childcare time (hours)	17.40 ± 6.15
Paternal involvement in parenting (range: 4‐20)	15.60 ± 2.70
Adverse childhood experiences	8.00 ± 2.19
Abusea
Emotional abuse	3 (60.0)
Physical abuse	3 (60.0)
Sexual abuse	1 (20.0)
Neglecta
Emotional neglect	5 (100.0)
Physical neglect	1 (20.0)
Household dysfunctiona
Witnessing domestic violence	5 (100.0)
Mental illness	4 (80.0)
Substance abuse	3 (60.0)
Incarceration	0 (0.0)
Divorce, separation, or bereavement	4 (80.0)
Economic hardship	5 (100.0)
Exposure to community violencea
Bullying or peer rejection	3 (60.0)
Community violence	1 (20.0)
Collective violence	2 (40.0)

^a Multiple response.

3.2. Feasibility and Acceptability of the Program

Of six enrolled participants, five completed the program (83.3% retention). One withdrew after Session 1 for personal reasons. Among completers, session attendance was 97.5%. Only one session was missed by one participant due to a personal appointment.

Participant satisfaction with the pilot program is summarized in Table 5. The overall satisfaction score was 9.80 ± 0.45 out of 10. High ratings were observed for perceived improvements in resilience (9.20 ± 0.84) and parenting (9.40 ± 0.55), as well as for each session's content and delivery methods. All completers provided complete pre‐ and post‐surveys, and no technical issues were reported during online session delivery or survey completion.

Table 5.

Satisfaction with the pilot program (N = 5).

Item	Mean ± SD (range: 1−10)
How much do you think this program has helped improve your resilience?	9.20 ± 0.84
How much do you think this program has helped with your parenting?	9.40 ± 0.55
How helpful do you think each session has been to you?
Session 1: Understanding resilience	8.80 ± 0.45
Session 2: Understanding adverse childhood experiences	9.40 ± 0.55
Session 3: How to regulate emotions	9.40 ± 0.89
Session 4: How to regulate thoughts	9.20 ± 1.30
Session 5: How to enhance positivity	9.20 ± 1.30
Session 6: How to enhance self‐care	9.40 ± 0.89
Session 7: Parenting—part 1: Understanding preschool‐aged children	9.40 ± 0.89
Session 8: Parenting—part 2: Raising children to be resilient	9.20 ± 0.84
How much do you think each teaching method has been helpful to you?
Lecture	9.40 ± 0.55
Group discussion	8.80 ± 1.10
Workbook	8.80 ± 1.10
Were the delivery method and operation of the program appropriate?
Total program duration (4 weeks)	9.40 ± 0.89
Total number of sessions (8 sessions)	9.00 ± 1.22
Session frequency (twice a week)	9.60 ± 0.55
Duration per session (1 h)	9.00 ± 1.00
Delivery method (online)	9.80 ± 0.45
How likely are you to recommend this program to others?	10.00 ± 0.0
Overall, are you satisfied with the program based on your responses?	9.80 ± 0.45
Comments on the pilot program (N = 5)
What was particularly good or impressive?
− “The workbook helped me reflect, plan, and practice self‐care consistently.” − “Writing an emotion journaling helped me understand myself and regulate my emotions more effectively.” − “I appreciated the group discussions, especially with others raising children of similar ages.” − “The anonymous, non‐video format made it easier for me to share honestly and comfortably.” − “The online format made it easier to adjust my schedule than offline.” − “How you overcame your own stress‐related health issues was inspired and motivated to me.”
What needs to improve about the program?
− “It would be helpful if you could give us a heads‐up or let us know in advance when there will be discussions during the program. Some people may need more time to think and prepare.” − “It would be helpful to review the previous session and share reflections from the week.”

Participants provided positive feedback on program content, delivery format, and perceived usefulness. Key themes from participant responses included appreciation for: (a) structured reflective writings using workbook including emotion journaling that facilitated self‐awareness and emotion regulation, (b) peer support through group discussions with mothers raising similarly‐aged children, (c) anonymous, non‐video format enabling comfortable and honest sharing, (d) online delivery format's scheduling flexibility, and (e) the researcher's personal experience sharing as inspiring and motivating.

Suggestions for improvement primarily related to program structure rather than content. Participants recommended providing advance notice for discussion topics to allow adequate preparation time and incorporating brief reviews of previous sessions to reinforce learning and reflection. These suggestions were incorporated into the refined program.

3.3. Preliminary Outcomes

Preliminary analyses showed significant improvements in resilience and positive parenting attitudes (both Z = –2.02, p = 0.043; Table 6). Self‐rated health, self‐esteem, parenting sense of competence, and mother‐child interaction increased but did not reach statistical significance. No meaningful change was observed in negative parenting attitudes. Raincloud plots illustrating the distributions of pre‐ and post‐intervention scores for all variables are provided in Supplement S3.

Table 6.

Preliminary outcomes of the pilot program (N = 5).

Variable	Range	Pretest	Posttest	Z	p
		Median (IQR)	Median (IQR)
Resilience	0−100	35.0 (19.0–65.0)	55.0 (52.0–71.0)	−2.02	0.043
Self‐rated health	1−5	3.0 (2.0–3.0)	3.0 (3.0–3.5)	−1.73	0.083
Self‐esteem	10−40	20.0 (19.0–29.0)	30.0 (26.0–30.0)	−1.76	0.078
Parenting sense of competence	16−90	49.0 (28.5–61.0)	55.0 (46.5–62.0)	−1.48	0.138
Mother−child interaction	34−170	119.0 (96.5–145.0)	130.0 (122.0–149.0)	−1.75	0.080
Maternal behavior
Positive attitude	24−120	78.0 (66.0–95.0)	93.0 (88.5–101.5)	−2.02	0.043
Negative attitude	24−120	76.0 (70.0–87.5)	73.0 (72.0–88.5)	−0.41	0.684

Note: Wilcoxon signed‐rank test.

4. Discussion

This study developed a theory‐informed, online resilience program for mothers with ACEs and evaluated its feasibility and acceptability through a pilot study. The program was feasible, with high recruitment, retention, and attendance rates, and acceptable, with high satisfaction and positive feedback. Exploratory improvements in resilience and positive parenting attitude were observed.

4.1. Feasibility and Acceptability of the Program

The high retention and attendance rates align with research showing that structured group interventions are acceptable to parents with trauma histories when delivered in supportive, flexible formats (Lawler et al. 2018; Lyu et al. 2023). Online delivery likely enhanced feasibility by reducing logistical barriers such as childcare and scheduling constraints (Corralejo and Domenech Rodríguez 2018).

Participant feedback highlighted the value of reflective writing, emotion‐focused activities, and structured discussions—core elements identified in prior ACE‐focused interventions (Cameron et al. 2018; Chandler et al. 2015, 2020; MacIsaac et al. 2021). The anonymous, non‐video format appeared to facilitate engagement and comfort, consistent with findings that safety and psychological containment are critical when working with parents with trauma histories (Herbell and Bloom 2020).

Taken together, the observed feasibility and acceptability indicators correspond to several core domains of implementability—particularly acceptability, feasibility, and usability—outlined in recent implementation science syntheses (Klaic et al. 2022).

4.2. Preliminary Outcomes

Preliminary findings suggested improvements in resilience and positive parenting attitudes. Similar short‐term improvements have been reported in prior resilience interventions with young adults and college students (Chandler et al. 2015, 2020); however, these findings should be interpreted with caution given the very small sample size in the present study and the potential influence of chance. Therefore, these findings should be considered preliminary and hypothesis‐generating rather than confirmatory.

However, systematic reviews and meta‐analyses have emphasized that the certainty of evidence supporting resilience interventions remains limited. For example, a systematic review of psychological interventions to foster resilience concluded that there is very low certainty evidence that resilience training may improve resilience and psychological outcomes, and that effects are often small and short‐lived (Kunzler et al. 2020). Similarly, broader reviews of resilience interventions have highlighted heterogeneity in intervention content, intensity, and outcome measurement, complicating definitive conclusions regarding effectiveness (Chmitorz et al. 2018; Blessin et al. 2022).

In parenting contexts, evidence remains particularly limited. Group interventions for parents with ACEs show promise but are characterized by heterogeneity and methodological constraints, with few focusing on maternal resilience (Lyu et al. 2023). The present findings should be interpreted as preliminary signals warranting further investigation rather than evidence of effectiveness.

4.3. Strengths and Limitations

A key strength of this study is the integration of a theoretical model—Roy's Adaptation Model (Roy 1970)—with its research design, which guided the program's structure and content across emotional, cognitive, and behavioral domains. This addresses a gap identified in systematic reviews, noting limited theoretical grounding in resilience interventions (Chmitorz et al. 2018).

This study has several limitations. First, the small sample size without a control group renders the findings preliminary and non‐generalizable. Second, self‐selected participants and self‐reported measures likely introduced selection and response biases. Third, the principal investigator's triple role in intervention delivery, data collection, and analysis likely introduced researcher bias. Accordingly, the findings should be interpreted as exploratory.

4.4. Future Research

This study addressed the development and feasibility phases of the MRC framework, providing a foundation for progression to the evaluation phase. The observed feasibility and acceptability support further evaluation of the intervention. Future research should build on these findings to refine intervention components and study procedures within the MRC framework. In addition, the optimal duration and intensity of the intervention should be examined to determine the therapeutic dose required to achieve sustained improvements in resilience and parenting behaviors among mothers with ACEs.

5. Conclusions

This study developed a theory‐driven online resilience program for mothers with ACEs. The findings suggest the intervention is acceptable and feasible for this population. This work contributes to the literature on resilience enhancement among mothers with ACEs and offers a structured framework to inform future intervention research.

Author Contributions

Hyeseon Yun: conceptualization, methodology, investigation, data curation, formal analysis, visualization, writing – original draft, project administration, funding acquisition. Eun Kyoung Choi: conceptualization, methodology, investigation, formal analysis, writing – review and editing, resources, supervision.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File 1: Literature search strategy.

Supporting File 2: Study variables and measures.

Supporting File 3: Raincloud plots for all variables.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.