What is Resilience and How do we Promote it?

Moira Szilagyi, MD, PhD, FAAP

President-elect, American Academy of Pediatrics

Professor of Pediatrics, UCLA

Division Chief, Developmental Behavioral Pediatrics

Disclosure

• I do not have any relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

• Did publish a book: Forkey H, Griffin J, Szilagyi M. Childhood Trauma and Resilience: A Practical Guide. AAP Publications.

Outline and Learning Objectives

• Define resilience and the factors that help us recognize it

• Describe the importance of the attachment relationship in the development of child resilience

• Identify the 5Rs that we can use in pediatric practice to promote resilience

A Short History of Resilience Research

• Research began after WWII–Norman Garmezy: American soldier

–Emmy Werner: experienced bombing as a child

–Michael Rutter: evacuated overseas as a child to escape London Blitz

• 1970s-2000 or so• Focus on understanding variability of outcomes in response

to adversity• Shift began from a disease-oriented framework to a life-

course development approach: comprehensive, developmental and dynamic health-oriented approach

WHAT IS RESILIENCE?

ResilienceDefinition (courtesy of Anne Masten, PhD)

Dynamic process of positive adaptation to or in spite of significant adversities; can be applied to a child, family, system or community, or ecosystem.

Developmental and DynamicDependent upon interaction of our genes with our environment; Changes over time depending on our circumstancesComplex

Masten, A.

Child Develop.2014;85: 6-20.

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What matters?

• Exposure to risk and dose

• Promotive and Protective Factors—the short list• Caring family, sensitive caregiving• Close relationships, emotional security, belonging• Skilled parenting• Agency, mastery, coping• Executive function skills• Self-regulation skills• Hope, faith or optimism• Meaning making, life has meaning• Routines and rituals (family)• Effective schools• Effective communities• Effective cultures

What matters?

• Exposure to risk and dose• Promotive and Protective Factors—the short list

• Caring family, sensitive caregiving• Close relationships, emotional security, belonging• Skilled parenting• Agency, mastery, coping• Executive function skills• Self-regulation skills• Hope, faith or optimism• Meaning making, life has meaning• Routines and rituals (family)• Effective schools• Effective communities

Effective cultures

Culture Infuses every aspect of this shortlist. Culture is the Umbrella under which families function, socialize children, have expectations of child behavior, what is valued and how experiences are perceived, interpreted, and integrated

THREADS: The Universal Resiliency Factors of Childhood and Adolescence

• Thinking and learning brain• Hope • Regulation or self control• Efficacy (self-efficacy)• Attachment (secure)• Developmental skill mastery• Social connectedness

New Conceptualization of Resilience

• Based on neurobiology of affiliation

• Resilience is not defined by adaptation to adversity

• But is embedded in the typical parent-child relationship• The mature parental brain nurtures and shapes the infant brain

• Three components of this resilience by affiliation system: • Oxytocin

• Subcortical brain structures primed by oxytocin for affiliation

• Biobehavioral synchrony: coordination of biological and behavioral signals between social partners (infant and caregiver)

Feldman, R. World Psychiatry. 2020;19:132-150.

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Resilience: Ordinary Magic

For children, the pathways to resilience develop in:

The give and take of safe, stable and nurturing relationships that are continuous over time (attachment)

Masten, A. Child Develop.2014;85: 6-20.

Resilience: Ordinary Magic

And it develops in the growth that occurs through play, exploration and exposure to a variety of normal activities and resources

The remarkable power of the ordinary in human development..

Attachment RelationshipServes Vital Functions for the Child

• Protection – provides a secure base to safely explore the world and relationships;

• Sense of self - see self interpreted and reflected back by attachment figure.

• Self in relation to others- foundation of social learning, understanding ourselves as a person in relation with others;

• Emotional regulation – soothing by parent dampens stress response, restoring a feeling of security –; over two decades the parent models and co-regulates as we integrate these skills

• Executive function –similarly, initially provided by and then modeled and co-managed by caregiver until we eventually integrate into self

• Developmental mastery– of age-salient tasks

• Self-efficacy –sense of control over our environments and future

Bowlby J. Attachment and loss. Volume 1. Basic Books. Perseus Books Group. NY. 1969.Feldman R. Biobehavioral synchrony: a model for integrating biological and microsocial behavioral processes etc. Parenting. 2012; 12:154-164.

The Role of Culture• Intersection of culture and

– Health– Attachment– Trauma

• Each culture has its own approaches to welcoming a new child and promoting resilience

• The meaning assigned to experiences is provided by one’s cultural group(s)

Toolbox of skills to grow/repair each of the frayed THREADS

AAP.org/PATTeR

SEAMS: Sewing the Threads together to Create Resilience

Safety and security – physical and psychological

Availability – predictable and compassionate

Emotional container

Mind in mind

Engagement

• Safety

• Engagement• Greeting • Ask about concerns (their agenda)• Empathy, validating concerns• Attuned attentive empathic reflective listening, • Motivational Interviewing (MI)

• Alliance: what will work in their family and culture

• Mind in mind

• Strengths based

The 5 Rs

Reassurance of safetyReading the childRoutinesRegulation (co-regulation)Relationship Building

Reassurance: Caregivers Model Calm BehaviorCreate Zone of Safety and Calm for Child

Emotional Container

Reading the Child: Understanding

Behaviors

EmotionsThoughts

“You have to study your childTo understand your child.”Grandmother of Adiah Spinks-Franklin, MD

Routines turn down stress responses, promote regulation

Regulation: Identification, understanding and modulation of feelingsRULER

• Recognize feeling

• Understand feeling

• Label feeling

• Express

• Regulate

Marc Brackett, PhD. Permission to Feel. 2019.

Brackett, M. Permission to Feel. 2019

The Language of Emotions: Building Emotional Vocabulary

Caregiver modulate own

emotions

So can help child to name emotions

So child can learn to modulate

emotions

Regulation: Calming the Stress Response

Sesame Street in Communities

Adolescents and Self-regulation • Self-regulation skills still developing

• Trauma hijacks the thinking and learning brain and self-regulation along with it

• Rely on co-regulation from others

• Learning coping skills• Self-monitoring

• Self-calming

Regulation: Self-monitoring

• Monitoring: What is the first thing they notice when they begin to get upset (or whatever the emotion is-–use teen’s language)?• Thoughts• Emotions• Body sensations

• Coping: • Can they sometimes calm or distract themselves when this happens? If so, how?• Who do they talk with when they start to feel upset?

• Make a plan: able to identify, have strategies to manage. Write them down including who they can reach out to.

• Safety

Relationship Building

Collaborative Problem Solving

Minor problems: Ignore

Safety Issues: Always respond

All the rest: Collaborate and Compromise• Attuned listening to each other• Each offers solutions• Compromise solution to try• Contract• Modification over time

Greene R. Collaborative Problem Solving

Native American: Circle of Courage

Brokenleg M, Bredtro L. Reclaiming Youth at Risk. (1990)

Adolescent Development

Identity formationSelf-efficacy or competenceRelationships outside the familyIndependence

Advocacy

• Schools

• Childcare

• Early childhood education

• Housing

• Poverty

• Nutrition

• Health Insurance

• Policy

“Educate, Advocate, Agitate.”~Stacy Abrams

“Practice Radical Pediatrics.”~Jasmine Zapata, MD, MPH.

ResourcesFor more information on this subject, see the following:

A: National Child Traumatic Stress Network: Parenting the Traumatized Child (https//:NCTSN.org/)

B: Harvard Center for the Developing Child (https://developingchild.harvard.edu/)

C. Sesame Street in Communities (https://sesamestreetincommunities.org/)

D. American Academy of Pediatrics PATTeR website: aap.org/PATTER

E. Garner A, Yogman M, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, SECTION ON DEVELOPMENTAL

AND BEHAVIORAL PEDIATRICS, COUNCIL ON EARLY CHILDHOOD. Preventing Childhood Toxic Stress: Partnering With Families and

Communities to Promote Relational Health. Pediatrics. 2021;148(2):e2021052582

F. James Duffee, MD, MPH, FAAP, Moira Szilagyi, MD, PhD, FAAP, Heather Forkey, MD, FAAP, Erin T. Kelly, MD, FAAP, FACP, Council on

Community Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health. Policy Statement: Trauma-Informed Care in Child Health Systems. Pediatrics. 2021;148(2):e2021052579

G. Heather Forkey, MD, FAAP1, Moira Szilagyi, MD, PhD, FAAP1, Erin Kelly, MD, FAAP, FACP2 , James Duffee, MD, MPH, FAAP2 . Council on

Foster Care, Adoption and Kinship Care1, Council on Community Pediatrics2, Council on Child Abuse and Neglect and Committee on

Psychosocial Aspects of Child and Family Health> Clinical Report: Trauma-Informed Care. Pediatrics. 2021;148(2):e2021052580

Suggested Reading

• Garner, A. S. and J. P. Shonkoff (2012). "Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health." Pediatrics 129.

• Masten, A. S. (2001). "Ordinary magic. Resilience processes in development." Am Psychol 56(3): 227-238.

• National Child Traumatic Stress Network. "Complex Trauma." http://www.nctsn.org/trauma-types/complex-trauma.

• National Child Traumatic Stress Network ."Resource Parent Curriculum." http://learn.nctsn.org/mod/page/view.php?id=8691.

• National Child Traumatic Stress Network . "Traumatic stress: Resources for Professionals." http://www.nctsn.org/resources/audiences/for-professionals.

• Shonkoff, J. P. and A. S. Garner (2012). "The lifelong effects of early childhood adversity and toxic stress." Pediatrics 129(1): e232-246.

Parents : Magicians of Ordinary Magic

1. Focus on attachment relationships as context of building or rebuilding child and family resilience

2. Use continuity of care to build caregiver knowledge and skills over time