Resilience is a dynamicprocess involving aninteraction between risk andprotective factors that act tomodify the effects of anadverse life event.1
—Professor Sir Michael Rutter
EMOTIONAL
and
behavioural disorders
are the mo
st com
mon
chronic disorders
treated in primary care. Up to
30% of children presenting to
their GP will fall into this cate
gory.
GPs and mental health
workers know some people do
well despite adversity in their
lives, while others don
t. For
example, it is known that
between 20% and 44% of
people who experienced sexual
abuse in their childhood have
no negative outcomes in adult
hood.
2
In the 1970s, mental health
care providers shifted their
focus away from thinking
about problems and deficits.
Instead, they began to con
sider the strengths and com
petencies that helped their
patients through times of
adversity. The hope was that
identifying these factors
would lead to a better under
standing of both normal and
abnormal development. These
resilience factors might also
provide useful preventive
strategies and inform social
policy. There is always the
hope, of course, that promot
ing resilience might protect
children from the effects of
inevitable adversity.
The quote at the beginning
of this article gives a defini
tion of what is meant by
resilience. It should be noted
that resilience is a dynamic
process that is changeable and
ongoing, and is not a trait or
something inherent in some
one
s personality. It can
t be
easily measured because it is
really an inference drawn
from two constructs: risk
exposure and positive adap
tation.
3
Avoiding a negative out
come in the face of adversity
might be dependent on con
stitutional as well as envi
ronmental factors. Risk of
adversity and resilience are
not all-or-nothing phenom
ena, so exposure to a risk
might affect only one area of
a child
s functioning and the
effects may be time-limited.
2
Therefore, when assessing
the effects of adversity it is
important to think about the
different areas of a particular
individual
s functioning, as
well as looking at these areas
across time. For example,
family functioning may be
affected more than school or
social functioning and these
effects may be already
resolving by the time the
child is brought to the GP
s
attention.
Factors that promoteresilience
Some of the individual
resilience factors that are
known to be protective against
adversity include a child
s cog
nitive ability, including a
normal IQ, capacity to pay
attention, problem-solving
ability and capacity for
men
talising
(thinking about their
own and others
mental
states). A sense of self-worth,
competence and confidence
are also protective against
adversity.
Temperament determines
the effect of these elements,
with more adaptable and
sociable children tending to do
better than others. Genetic fac
tors are also increasingly
recognised as important as
links between genetic vulnera
bility and environmental fac
tors are discovered. Children
who have good impulse con
trol and who are able to regu
late their own emotions also
do better, as do those with a
positive outlook on life.
4
Relationship factors of
importance include parenting
quality, children
s close rela
tionships with competent
adults and connections to
peers with
sociable behaviour
during their adolescence. This
comes down to children feel
ing connected to others and
to their community.
5
Social services and support
and community networks are
some of the factors that are
important in resilience. These
include good schools and
after-school clubs, and reli
gious organisations that chil
dren and families may belong
to.
6
The overall quality of a
child
s neighbourhood also has
an influence
safe neigh
bourhoods with a sense of col
lective supervision of children,
with good facilities and high-
quality health care, are protec
tive and promote resilience.
Parenting theories
There are several useful theo
ries of parenting that can help
when assessing parenting qual
ity and educating parents to
promote resilience in their chil
dren. These parenting theories
can also help GPs understand
the nature of child behaviour
problems that present in their
practice and to arrange an
informed intervention and
referral if necessary.
Social learning theory
This proposes that parental
behaviour and relationship
quality are linked to a child
s
behaviour through reinforce
ment. An example would be
a child with an aggressive
behaviour problem whose par
ents respond to them in a neg
ative or coercive manner. The
child amplifies their own
aggressive behaviour, which is
again matched by the parents
behaviour in a vicious cycle.
The child
s behaviour persists
until the parents give up,
which only reinforces the
child
s aggression. In time, the
parents (and others) come to
expect aggressive behaviour
from the child, which adds fur
ther reinforcement.
Programs that attempt to
deal with such cycles often
emphasise the role of conflict
and the need for consistent
management. So-called positive
parenting programs attempt to
promote the child
s positive
behaviours and shift the focus
away from the negatives.
7
Attachment theory
This examines the child
s emo
tional tie to their parent or
caregiver. In this theory chil
dren are thought to be biolog
ically wired to seek safety and
protection from a caregiver.
Predictable care-giving by a
sensitive parent allows the
child to develop a sense of
security over time. In other
words, this is a didactic
process where child and parent
each affect the other
s behav
iour. In the longer term, this
shapes a child
s expectations
of relationships in general.
Although secure attachment
is not synonymous with a lack
of psychopathology, the most
severe form of attachment
problems
disorganised
attachment
is linked with
psychopathology and can
identify parents and children
in need of intervention.
7
To
give an example of how
attachment relationships can
result in problems, a child with
behaviour problems may have
had a parent who only
responded if emotions were
very high or dramatic. This
child learns very quickly that
to get noticed, emotions must
be presented very loudly and
dramatically. So when feeling
anxious, insecure or even just
tired, the child seeks attention
from the parent at a high level
of emotional arousal. This can
become generalised to rela
tionships outside the family so
that even minor episodes of
frustration or anxiety result in
major behavioural or emo
tional outbursts.
Parenting-style theory
A third parenting theory
addresses style of parenting,
typically characterising par
enting across two dimensions:
warmth and control. Optimal
parenting in this theory is
described as
authoritative
and comprises high levels of
both warmth and control.
This style of parenting is
linked to the best outcomes
for children. Parenting that is
high in control and low in
warmth is labelled as
author
itarian
; that which is low in
control and high in warmth is
permissive
; and that which
is low in both control and
warmth is
neglectful
7
This model can be useful
when considering what might
need to be changed in a family
to help a particular child. For
example, it is not uncommon
to find differences between
parents in their management
of the children
s behaviour,
such as a permissive mother
and an authoritarian father.
In such circumstances, chil
dren can be anxious, test
limits or play one parent
against the other. Helping the
mother to increase control
and the father to increase
warmth might reduce conflict
between the parents and help
manage the child
s behaviour.
Effects of parenting style
There are recognised links
between aggression and delin
quency in children and harsh,
coercive or punitive parenting
with a lack of warmth, inef
fectual control and a lack of
monitoring of children by their
parents. Similarly, there are
links between parenting style
and depression and anxiety in
children.
Academic achievement is
also linked to a child
s rela
tionship with their parents:
parents who are attuned to a
child
s abilities provide a sup
portive environment for the
child to learn. A good exam
ple of this is the recognised
link between parents reading
to their children and a child
s
developing reading ability.
Parents also shape their
child
s aspirations and moti
vation by role modelling and
through their expectations of
the child.
GP intervention
So what can a GP do to pro
mote resilience in children
attending their practice? Very
simple interventions can be
helpful, for example, provid
ing educational material in the
waiting room such as infor
mation pamphlets on normal
child development and posters
on parenting courses. Suggest
ing participation in commu
nity organisations for parents
or children can enhance social
connectedness. Empowering
young people by including
them in decisions that affect
them promotes their resilience.
Encouraging parents to talk
about emotions and relation
ships with their children and
to take an interest in their chil
dren
s activities and friendships
help in the development of
trusting relationships into ado
lescence and improves parents
abilities to supervise their chil
dren. At-risk patients can be
identified by GPs, such as
teenage parents, single parents,
families in conflict and sub
stance-abusing parents who all
might benefit from referral to
a parenting program or inves
tigation of other available sup
ports. Public and private
mental health services can pro
vide more specialised assess
ment and management when
indicated, and non-govern
ment organisations also pro
vide counselling and support
services.
All of us are exposed to
adverse events some time
during our lives. Promoting
resilience in children and
teenagers is one way in
which we can practise true
prevention.
Dr Bowden is director oftraining, child and adolescentpsychiatry, NSW Institute ofPsychiatry; senior staffspecialist child and adolescentpsychiatrist, Children’s Hospitalat Westmead; clinical lecturer,departments of psychologicalmedicine and child health,Western Clinical School,University of Sydney, NSW.
References
1. Rutter M. Resilience in the
face of adversity: protective
factors and resistance to
psychiatric disorder.
BritishJournal of Psychiatry
1985;
147:598-610.
2. Caffo E, et al. Child abuse
and neglect: a mental health
perspective. In: Garralda ME
and Flament M (Eds).
Workingwith Children and Adolescents
Aronson
Maryland
, 2006.
pp 95-128.
3. Kim-Cohen J. Resilience and
developmental psychopathology.
Child and Adolescent PsychiatricClinics of North America
2007;
16:271-83.
4. Friedman RJ, Chase-Lansdale
PL. Chronic adversities. In:
Rutter M and Taylor E (Eds).
Child and Adolescent Psychiatry
4
th
edn. Blackwell,
Oxford
2002. pp 261-76.
5. Stewart D, Sun J. How can we
build resilience in primary school
aged children? The importance
of social support from adults and
peers in family, school and
community settings.
Asia-PacificJournal of Public Health
2004;
16(Supp):S37-S41.
6. WHO. Prevention of Mental
Disorders: Effective Interventions
and Policy Options Summary
Report. WHO,
Geneva
, 2004.
7. O
Connor TG, Scott SBC.
Promoting children
s adjustment:
parenting research from the
perspective of risk and
protection. In: Garralda ME and
Flament M (Eds).
Working withChildren and Adolescents.
Aronson
Maryland
, 2006.
pp 67-94.
Online resources
www.reachout.com.au
www.embracethefutureorg.au/resiliency
www.auseinet.com/resources/gp/index.php
www.parc.net.au
www.resilnet.uiuc.edu