Children experience stressful events throughout their lives and the formation of coping skills to manage these events is part of normal development. The ability of a child to recover after experiencing something difficult is the result of resilience. It is important to recognize that building resilience is a process that is multi-dimensional and influenced by a variety of social, environmental, and cultural factors. Helping children to learn and practice skills that build resilience can help them manage major life events and adapt to difficult circumstances throughout their life course.
Recent studies have shown that around one in four adults report having experienced at least one adverse childhood event (ACE). Stress from ACEs can create changes in brain development that can, in turn, affect social relationships and general functioning. Mental health diagnoses that have been associated with ACEs include depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorders, and disruptive behavioral disorders. Research in the field of resilience has identified key factors that place children at greater risk for experiencing adversity and subsequent issues with physical health and mental health. Many ACEs are related to negative social determinants of health (SDOH)- conditions that can lead to poor education, employment, and quality of life outcomes in addition to health issues on the individual level. Outcomes for children who experience ACEs can be improved through positive childhood experiences (PCEs) and protective factors that strengthen connections and assist them in managing adversity.
Conditions or Events that Expose Children to Adversity
- Global Health Crises/Pandemic
- Chronic Illness
- Poverty/Economic Instability
- Food Insecurity
- Poor Attachment
- Domestic Violence
- Abuse and Neglect
Protective Factors for Managing Childhood Adversity
- Healthy Attachment
- Stable Housing
- Food Security
- Access to Healthcare
- Parental Employment
- Early Intervention
- Community Involvement
- Intrinsic Motivation/Achievement Oriented
- Neural Plasticity
- Self-Advocacy Skills
- Problem Solving Skills
- PCEs include secure attachments with family and nonparent adults, enjoyment of community traditions, support and a sense of belonging with friends.
How Healthcare Providers Can Promote Resilience
While healthcare providers may not be able to significantly affect the degree to which patients experience negative SDOH, recognition of these factors can inform relationship building and clinical recommendations. Leveraging strengths and promoting protective factors can assist children in overcoming adversity, acquiring healthy stress management habits, and reducing the risk of long-term effects.
Primary care practitioners and other healthcare providers play an important role in early identification of risk factors and offering appropriate biopsychosocial interventions to promote resilience and mitigate the long-term consequences of adversity. Interventions should target multiple systems, focusing on the child, their families, their schools, and relationships in their communities.
Screening and Assessment
Strengths: By understanding patient and family strengths, healthcare providers can select effective strategies to promote resilience. Screening tools such as the Strengths and Difficulties Questionnaire (SDQ) can be integrated into other aspects of social history-gathering to identify protective prosocial behaviors (strengths) that can be leveraged. (See here for additional languages)
Adverse Childhood Experiences (ACEs): The ACE categories may provide an evidence-based framework for understanding a child’s exposure to various types of trauma. Abuse and neglect across five domains (verbal/emotional abuse, physical maltreatment, sexual abuse, physical neglect, and emotional neglect) and family system dysfunction across five domains (parental divorce/separation, domestic violence, mental illness, incarceration, and substance use) are associated with long-term health problems in adulthood. Since ACEs are often generational experiences, information may be gathered from parents of young children as well. Early intervention can mitigate the negative consequences of ACEs.
Screen for Related Behavioral Health Conditions: Children and adolescents who endure adversity or are in situations with many risk factors present need to be routinely screened for mental health, substance use, and disruptive behavioral disorders. This screening may take the form of an interview, where the primary care physician asks questions about mood, behavior, and substance use. Direct conversations about these topics may be difficult for many children and adolescents, so the use of self-report assessments/questionnaires may be helpful in gleaning additional data. Self-report measures that could be used include the Beck Depression Inventory (BDI), Screen for Child Anxiety Related Emotional Disorders (SCARED), and Patient Health Questionnaire (PHQ).
Promoting Resilience in Young Children and Families:
Positive Parenting and Family Resources
Family support and resilience have been associated with greater adult health outcomes despite experiencing ACEs in childhood. Parents can help mitigate the effects of ACEs through modeling coping skills and assisting children in building positive social connections with peers and in the community.
A great tool for fostering resilience in the home is Positive Parenting. Positive Parenting focuses on building independence by understanding children’s individual needs and addressing challenges with empathy and respect.
Create Safe Environments
Children are better able to build resilience when they feel safe, and it is important for PCPs to check in regularly on the physical and emotional safety of their youngest patients. These check-ins may include conversations about healthy boundaries, the differences between good touches and bad touches, and a child’s ability to identify and label their emotions. Encouraging children to exert control over their bodies and their minds can help promote safety and build resilience.
Model Healthy Habits
It is important for parents to model healthy coping skills when dealing with stress and adversity. Healthcare professionals can help parents by having conversations with them about the importance of regularly engaging in self-care. When parents take care of their own needs, they are better equipped to meet the needs of their children. Parents may teach their children deep breathing skills, relaxing yoga poses, or even the benefits of taking time out to regroup from a difficult situation.
Research has shown that children who engage in routines experience more stability and greater feelings of control. Healthcare professionals should discuss the importance of routine with their young patients and their caregivers as a mechanism to help them build resilience.
Young children who develop a healthy attachment with their caregiver are better able to confront challenges in life. Providers can talk with both the child and their caregiver about ways in which they can increase attachment (spending time together, engaging in child-led play, ensuring basic needs—food and safety—are being met). Research shows that playing with a child for just ten minutes per day can significantly improve the parent-child relationship and help them develop resilience. During these play sessions, it is important to let the child lead the play and to follow their lead.
Healthy risk-taking behavior can also help to build resilience in children. Allowing children to try new things and step outside of their comfort zone, when very little potential for harm exists, can help them learn to trust themselves in situations that are not familiar to them. It may be good to encourage them to try a new slide at the park, write their name from memory, or say hello to a new friend.
Consistent Behavior Support
It can be difficult to know the most appropriate way to correct a child who makes a poor choice. When children can appreciate the link between their actions and negative consequences, they are less likely to repeat the behavior. It is important for parents to normalize making mistakes and help children identify what they can learn from the situation. Embracing mistakes and learning from them can increase a child’s willingness to try new things. The structure associated with clear expectations and consequences can help a child to feel safe and experience a sense of control in their environment. This structure may be more difficult for children who have experienced trauma or have cognitive limitations that affect their ability to use problem-solving skills to fully understand the link between their behavior and consequences. Parents and care providers should discuss if imposing negative consequences is appropriate for a specific child or if a positive behavior plan would be more beneficial to helping them identify what they are feeling and appropriate ways to express themselves before imposing consequences.
Foster Emotional Intelligence
Helping children to identify and label their emotions can allow them to put words to their feelings. By adding words to their feelings, they are better able to understand and communicate what they need. Parents can also work on teaching their children how to solve problems. Rather than giving a child the answer, it can be helpful to ask questions that can assist them working through the problem themselves. This allows the child to begin building the skills that they need to cope with difficult situations.
Promoting Resilience in Adolescents and Teenagers:
Positive Peer Relationships
PCPs may assess social support by asking both youth and caregivers about peer relationships inside and outside of school and level of engagement in social activities. Encouraging a child to evaluate their friendships and spend time with the people who make them feel good and want to be the best version of themselves can also help to promote resilience.
Adult Role Models and Mentors
In addition to peer relationships, having an adult that youth feel comfortable reaching out to when things become difficult can assist with managing adversity. Parents and caregivers can encourage youth to develop emotionally meaningful relationships with the important adults in their lives (parents, grandparents, aunts/uncles/cousins, teachers, etc.). Adults should check-in regularly with youth to talk about what is going well and any struggles that they may be experiencing.
It is important for parents to celebrate independent thinking and help youth foster a healthy sense of self. PCPs can help parents and youth by having conversations about normalizing mistakes, taking responsibility for one’s actions, accepting consequences, and suggesting coping tools and strategies that may be helpful. Youth should be empowered to try new experiences and learn how to set boundaries for themselves. Important conversations about sexual consent, substance use, and balancing demands can help adolescents to feel more at ease when they encounter difficult situations. When talking to adolescents instead of asking, “have you ever…,” healthcare providers may get a better response by asking, “how often do you…?” This normalizes the topic of conversation and helps adolescents to feel more comfortable with answering in an honest manner.
Helping youth to realize their passions and purpose in life can help to promote resiliency. This can occur through goal setting and conversations about the future. Youth who regularly set goals often feel they have more control over their lives. Encouraging youth to set goals can help enhance their self-esteem and establish future direction. Healthcare professionals can have conversations with their adolescent and teenage patients about how to set and reach realistic goals,
Discuss Mental Health
Self-respect and self-compassion serve as protective factors against stress and trauma. Strategies for practicing self-compassion, like engaging in mindfulness and making a conscious effort to have a positive mindset, can promote resilience. Talking with youth and their caregivers about how and where they can practice self-compassion in their lives can assist them in shifting mindsets. It is important to help youth understand that it is “okay not to be okay.” It may be a good idea to ask about three strategies that they use to cope when things become stressful. If they are unable to identify any coping skills, it will be important to have a conversation about various coping skills that they could try (ex. deep breathing, journaling, yoga, etc.).
Feelings of loneliness put teenagers at a greater risk of experiencing depression, anxiety, and suicide while the presence of a strong support network (of both peers and adults) can help to mitigate these problems. PCPs can ask youth who they seek out (both adults and peers) when they find themselves in difficult situations. It may also be helpful to refer youth with limited social connectedness for counseling to further assess their support system and ways in which they can increase it. Youth should be encouraged to spend time with their friends and limit the amount of time that they are spending on social media and other technology. Research has shown that the more time teenagers spend online, the more likely they are to experience depression and anxiety, low self-esteem, and loneliness.
Positive Parenting and Family Resilience
Positive parenting for adolescents and teens includes things like showing respect for teens’ opinions and concerns, showing confidence in teens’ ability to solve problems, encouraging open communication about challenges and concerns, showing interest in achievements and extracurricular activities.
Olivia is a 14-year-old female with no past medical history who presented to the PCP's office for her yearly well-child check. Her mom reports that she sometimes complains of a low mood and worries a lot about her friend group. She is spending a lot of time in her room on her phone, and it is difficult to get her to interact with family members. Olivia’s parents divorced six months ago, and she has become quieter since the family was forced to move to a new home. She is not talking to her parents, preferring to text with her friends. Olivia also started at a new school. She is usually a straight A student but this quarter she earned a C in two classes and her average grade is now a B. She denies feeling depressed, but she admits to being anxious sometimes when it comes to keeping her friends happy. She also denies difficulty with focusing or concentrating. When interviewed alone, Olivia reports that she identifies as a female, is sexually attracted to males only, and has never had sex. She has tried vaping nicotine in the past month, but denies alcohol, marijuana, and other illicit drugs. She denies abuse, trauma, purposeful self-harm, and suicidal ideation. A PHQ-9 administered at the beginning of her visit showed a score of 4.
The PCP counsels Olivia about the dangers of vaping and use of nicotine before she brings her mom back into the room. Once her mom returns, the doctor talks about positive things that they can do to improve resilience when life gets stressful. She explains the importance of establishing clear parental standards for behavior and improving their parent-child connection. She recommends that Olivia has time limits set on her electronic usage, and that she engages in positive time with both her mom and dad. The PCP also notes the importance of positive peer interactions and empowers the patient to set healthy boundaries with her current friends. She recommends that the patient spends time in clubs or activities (whatever the family can manage) to help minimize isolation. The PCP scheduled a follow up in six weeks to check mood and progress on goals.
Upon follow up, Olivia’s mom reports that she is doing much better. She is required to be out of her room and interact with her family for at least one hour every day. Her mom has been taking her on walks in the evening and feels that they have “reconnected.” Olivia is also spending more time with her dad, and this seems to be going well. She has joined an art club and has connected with two more friends with similar interests. Her grades are back up and she has not seemed sad or depressed. When interviewed alone, Olivia denies further nicotine use. She says that it is “annoying” to have to be out of her room but does like spending time with her parents one-on-one. She also enjoys school now that she has more friends and is thinking about joining the drama club. Her PHQ-9 score was 0 at this visit.
Primary Care Management Strategies
Regular follow up with patients is important as many are at an elevated risk of experiencing significant stress or trauma. At follow-up visits, it may be helpful to repeat previously completed assessments to track symptoms and monitor progress. It may also be helpful to have a direct conversation with patients and their families about their stressors and the ways in which they are coping with them. This will allow providers an opportunity to discuss healthy coping strategies, potential needs, and assist in making biopsychosocial recommendations. Clinicians may also support the progress of their patients by regularly coordinating care with outside providers and obtaining collateral information. This can help improve adherence to treatment recommendations made by those providers.
Patients not meeting their developmental milestones or those who have experienced a traumatic event should be referred to for early intervention services.
Early Intervention Resources for Providers
- Bold Beginning!
- Help Me Grow
- Incredible Years
- Medicaid Department of Jobs and Family Services Child Protective Services Mentorship Programs (ex. Big Brothers/Big Sisters)
Educational Resources for Families
- Resilience Guide for Parents and Teachers
- Resilience in Children: Strategies to Strengthen Your Kids
- How to Build Resilience in Kids
- Resilience for Teens: Got Bounce?
- ACEs Aware website:
- Video: Nadine Burke Harris TED Talk, How childhood trauma affects health across a lifetime
- American Academy of Child & Adolescent Psychiatry
- Anxiety and Depression Association of America
- Center for Disease Control
- Incredible Years
- National Alliance on Mental Illness (NAMI)
- National Institute of Mental Health- PTSD
- And Traumatic Events
- National Institute of Mental Health (NIMH)-Understanding Resilience
- Ohio Chapter American Academy of Pediatrics
- Parent Child Interaction Therapy
- Substance Abuse and Mental Health Services Administration
What is the link between a person’s Adverse Childhood Experience (ACE) score and physical health?
The greater a person’s ACE score, the more likely they are to experience long-term health complications like heart disease, stroke, cancer, and diabetes (Felitti et. Al., 1998).
My patient does not experience food insecurity or poverty. Are they still at risk for adversity?
Absolutely. No one is immune from adversity, and it is important to always assess the many factors that may put them at risk.
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