Traub & Boynton-Jarrett (2017). Modifiable resilience factors to childhood adversity for clinical pediatric practice.” – Article summary

Early childhood adversity is common (i.e. 48% - 60%). Early life trauma impacts the developmental trajectory of children and health outcomes over the life course. No experiences with maltreatment and a non-depressed primary caregiver are associated with resilience. Adult health outcomes are influenced by the cumulative incidence of adverse life experiences. Differences in risk are influenced by chronicity (1), severity (2), contextual factors (3) an type of childhood traumas (4).

Resilience refers to good mental and physical health despite early adverse life events. This means that it includes a ability to withstand, adapt to and recover from adversities. It may buffer a child from adversity by reducing the impact of trauma (1), reducing negative chain reactions stemming from trauma (2) and it may enable opportunities for recovery (3).

Resilience results from the interplay between a child’s genetics (1), temperament (2), knowledge and skills (3), past experiences (4), social supports (5), cultural resources (6) and societal resources (7). High self-esteem (1), internal locus of control (2), external attributions of blame (3), optimism (4), determination in the face of adversity (5), cognitive flexibility (6), reappraisal ability (7), social competence (8) and the ability to face fears (9) are resilience factors.

There are five modifiable resilience factors:

1. Positive appraisal style and executive function skills (i.e. individual)
   A positive appraisal style refers to optimism and confidence in one’s ability to manage adversity. This is modifiable via experience and explicit CBT. Executive function is modifiable through educational approaches on narrow executive functions, computer training programmes on broad executive functions, aerobic exercise and mindfulness training. Executive function especially promotes resilience when it comes to cognitive flexibility and inhibitory control.
2. Parenting (i.e. family)
   Responsive parenting and good parental relationships foster resilience. Positive parenting could normalize HPA-axis activity (i.e. cortisol level).
3. Maternal mental health (i.e. family)
   This is associated with risk for trauma and less sensitive parenting. Screening for, identifying and treating it could foster resilience and prevent trauma. Depressed mothers are less responsive and use more punitive disciplinary measures. A history of adverse life experiences for the mothers leads to more difficulties in modulating their own stress response and teaching coping to their children.
    A mother’s self-efficacy regarding parenting also promotes resilience.
4. Self-care skills and household routines (i.e. family)
   Adverse life events are associated with poor sleep, nutrition and exercise habits. Teaching self-care skills and using consistent routines and caregiving at home could promote resilience.
5. Trauma understanding (i.e. individual and family)
   Children with trauma rarely speak of it and often do not understand the relationship between their experiences and how they feel and act. Educating children and families about traumas could promote resilience through trauma-focused interventions.

Paediatric primary care could enhance resilience to childhood adversity. Barriers to the identification and treatment of trauma in paediatrics include a perceived lack of time (1), lack of training (2), lack of reimbursement (3) and a reluctance to experience the discomfort of discussing trauma and parenting with the children in the room (4). There are ten recommendations for promoting modifiable resilience factors in a paediatric clinical setting:

1. Train all paediatric clinical staff in the principles of trauma-informed care.
2. Screen paediatric patients for adverse life experiences (1), resilience (2), maternal psychopathology and adverse life experiences (3), family functional capacity (4) and family violence (5).
3. Employ non-physicians to conduct psychosocial screening and offer education to families about healthy development (1), trauma impacts and recovery (2), self-care skills and mental health treatment (3), age-appropriate risk reduction (4) and parenting (5).
4. Create a medical home for children with adverse life experiences which emphasize strong relationships with families, regular care providers and individualized care.
5. Integrate behavioural health care into the paediatric office.
6. Offer group-based parenting education and support while emphasizing the importance of the parental role in enabling trauma recovery and resilience (1), responsive parenting (2) and the establishment of consistent routines at home (3).
7. Offer peer-based group education and anticipatory guidance to children and families with multiple adverse life experiences about trauma and self-care to foster resilience and increase social support.
8. Customize paediatric health care to the need of the family while considering the broad-reaching effects of trauma on a wide range of outcomes.
9. Familiarize paediatric staff with resources in the community and make individualized referrals for children and their families (i.e. treat the whole family using adjunct services).
10. Be conscious of barriers to engagement facing families of children with adverse life events (e.g. negative perception of mental health services; family stress; lack of social support for receiving behavioural health services).