Increasing Resilience: Primary Healthcare Providers’ Opportunities to Promote Protective Factors Before and After Childhood Trauma

Machelle D. Madsen Thompson, PhD; and Bart Klika, PhD, MSW

Lifespan research1,2,3 reveals that although ACEs are common,4 many people are able to move toward recovery and achieve reportedly good functional status.  This resilience does not occur in isolation but is supported by a composite of protective factors that empower a child to return to functional status following ACEs.5 Resilience is observed when a child is immersed in positive influences, such as supportive relationships, and is protected from risk factors across ecological systems, which by definition range from individual characteristics of the child to structures in the environment.6,7 Protective factors are positive qualities located within the cognitive, emotional, environmental, social, and spiritual experience of the child that are associated with resilience and, when combined, facilitate positive outcomes. These modifiable factors work cumulatively to empower and support the child so that she or he may avoid or successfully work through the trauma associated with ACEs.5

Healthcare providers, partnering with supportive family members and mentors close to the child, can play important roles in both preventing ACEs and promoting resilience should ACEs occur.8 Successful prevention of ACEs requires an integrated system of care that includes activities and interventions across disciplines and across the ecological prevention spectrum.9 Primary healthcare providers can initiate universal screening for ACEs with all of their patients.  Screening for ACEs can assist healthcare providers in identifying both patients who may not be experiencing any significant impairment as well as patients who are experiencing health problems related to ACE exposure.  Screening of both children and parents allows healthcare providers to identify patients who may have elevated risk for poor physical and/or psychosocial outcomes.  For these patients, healthcare providers can provide targeted referrals to address the impacts of the ACEs. 

Assessment of ACEs, however, only represents one side of the prevention coin.10 As healthcare providers work to identify and lessen the number and impacts of ACEs, they also should understand the potential sources of protection that can foster resilience for all of their patients.  Identifying the presence or absence of protective factors through universal screening allows healthcare providers to make targeted referrals to facilitate the continued development of such factors. For example, if a child’s parent is diagnosed with a medical illness that limits her ability to support the child, the practitioner could identify and encourage other positive adult mentors in the child’s extended family, school, community, or faith group to provide both practical and emotional support.  In this way, healthcare providers contribute to the “promotion of safe, stable, and nurturing relationships” and well-being for all children and families.11

A review of more than 200 research articles, coupled with narratives of over 350 adults and children,5 demonstrates that several important protective factors are known to help a child who has experienced multiple ACEs.12,13,14 To aid the healthcare practitioner, each protective factor listed below contains references to information, handouts, and real-world implementation for children and families affected by or at risk for ACEs.6,13

Self value: The child’s emotional and behavioral self expressions are positive, accurate, and constructive. Increasing this protective factor focuses on helping a child internally value him or herself enough to keep going and do his or her best despite setbacks, negative consequences, and/or emotions related to ACEs.8,15,16

Self regulation: The child is taught and demonstrates emotional and behavioral self-management that helps him or her resolve difficult situations rather than resort to self-destructive or aggressive behavior.8,17

Hope/future goal setting: The child is encouraged to engage in high and positive expectations, setting attainable goals in relation to his or her life and future outcomes.18

Problem solving: With the child’s goals in mind, the child is supported in his or her ability to find unique solutions to difficult situations.19

Supportive belief structure: The child’s personal beliefs and practices that give encouragement and meaning to life beyond the material or worldly are nurtured.20

Friends: The child learns to create and foster constructive and reciprocal friendships.  A caretaker or mentor facilitates development of positive friendships.21

Family/caretakers: The family, caretakers, and close adult mentors provide stable care for the child. This includes meeting the child’s survival, health, mental health, and emotional needs. Caretakers can be encouraged to place their child’s care as a high priority, become good role models, and set reasonably high expectations in a warm and loving environment.8,22,23,24

Supported academic functioning: The child is supported by caring mentors at school and at home who encourage his or her efforts to work consistently at his or her ability level and to attain educational goals.25,26

Active diversion: The youth is involved in developing and engaging in healthy activities, skills, and groups in the community, school, and/or home.  Adults encourage a balance in activities to avoid over-scheduling or excessive emphasis on competition, creating more stress.8 Activity suggestions from qualitative research participants include helping youth become involved in activities such as sports, music, art, creative writing, religious youth groups, or community/school organizations.5,27,28

Supportive adults and community: The area in which a child lives is a secure place to obtain resources. Practitioners can work with community professionals to refer patients to supportive area resources that meet the child’s needs in areas such as mental and behavioral health, social and emotional development, and disability support.8,29,30,31

Safety/fewer and less severe stressors: The child’s well-being, basic needs, and security are promoted across the spectrum of ecological settings at the individual, relational, school, and community levels.5,32,33,34,35

Resilience, thought of in terms of achievable protective factors, allows a practitioner to recommend real solutions for families affected by ACEs.  Because protective factors work cumulatively, it is imperative to acknowledge that the presence of one or two of the more apparent resilient areas, such as academic achievement, may still necessitate the implementation of resources to improve other, less visible protective factors.  We highly recommend assessing and implementing resources for all children across all protective factors, even with those who are seemingly resilient. A proportion of children might appear to exhibit outward resilience yet continue to mask ACE-related anguish that may contribute to the development of chronic biomedical conditions over time.36

Pediatric medical teams, family practitioners, and other primary care providers who routinely treat children and families can encourage engagement with both (a) formal and professional services that enhance protective factors and (b) resources already available in the child’s natural environment.  Obstetric medical personal and family practitioners can encourage expecting mothers and their partners to begin accessing positive support structures for themselves and the unborn child as prevention tools should the parent have the need to address his or her former ACEs or should future ACEs occur in the child’s life. 

By implementing multifaceted real world strategies, programs, and resources,37 primary healthcare providers can help maximize the protective factors in children and adolescents across multiple levels of prevention and treatment.  Across the lifespan, these children and adolescents then become more likely to demonstrate the positive effects of resilience, growing up in a life less encumbered by major psychological and stress-induced physical health problems, enhanced by positive long-term relationships, and connected to society through successful careers and positive parenting despite ACEs.38

References

1.  Garmezy N. Stress-resistant children: The search for protective factors. In Stevenson JE (ed). Recent research in developmental psychopathology. (pp 213-33). Oxford: Pergamon Press; 1985.

2.  Rutter M. Psychosocial resilience and protective mechanisms. Am J Orthopsychiat. 1987;57(3):316-31.

3.  Werner EE, Smith RS. Journeys from Childhood to Midlife: Risk, Resilience and Recovery. Ithaca, NY: Cornell University Press; 2001.

4.  DePanfilis D. Child Neglect: A Guide for Prevention, Assessment and Intervention. Office on Child Abuse and Neglect. Chapter 4: Risk and Protective Factors. Children’s Bureau; 2006.

5. Madsen Thompson, MD. Trauma Resilience Scale for Children: Validation of Protective Factors Associated with Positive Adaptation Following Violence [dissertation]. Tallahassee, FL: Florida State University; 2010.

6. Bronfenbrenner, U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.

7. World Health Organization, Violence Prevention Alliance. The Ecological Framework.

8. Ginsburg KR with Jablow MM. Building Resilience in Children and Teens: Giving Your Child Roots and Wings. Elk Grove Village, IL: American Academy of Pediatrics; 2006.

9.  Whitaker DJ, Lutzker JR, and Shelley GA. Child maltreatment prevention priorities at the Centers for Disease Control and Prevention. Child Maltreatment. 2005:10(3):245-259.

10. Find Youth Info. Positive Youth Development. 2012.

11.  Centers for Disease Control and Prevention. Preventing Child Maltreatment Through the Promotion of Safe, Stable, and Nurturing Relationships Between Children and Caregivers. National Center for Injury Prevention and Control.

12.  Department of Health and Human Services Administration on Children, Youth and Families. 2013 Resource Guide. Preventing Child Maltreatment and Promoting Well-Being: A Network for Action. 2013.

13.  Pinheiro PS. World report on violence against children. United Nations Secretary-General’s Study on Violence Against Children. 2006. 

14.  Youngblade LM, Theokas C, Schulenberg J, et al. Risk and promotive factors in families, schools, and communities: a contextual model of positive youth development in adolescence. Pediatrics. 2007;119 Suppl 1:S47-53.

15.  American Academy of Pediatrics. Helping Your Child Develop a Healthy Sense of Self Esteem. 2012.

16.  American Academy of Pediatrics. Ages & Stages. Ways to Build Your Teenager’s Self-Esteem. 2011.

17.  American Psychological Association. What You Need to Know About Willpower:  The Psychological Science of Self-Control. Strengthening Self-Control. 2013.

18.  Seginer R. Future orientation in times of threat and challenge: how resilient adolescents construct their future. Int J Behav Dev. 2008;32(4):272-282.

19.  Shure MB. Preventing Violence the Problem-Solving Way. Juvenile Justice Bulletin. Office of Juvenile Justice & Delinquency Prevention. 1999.

20.  Kim S and Esquivel GB. Adolescent spirituality and resilience: theory, research, and educational practices. Psychol Schools. 2011;48(7):755-65.

21.  American Psychological Association. Seek the Right Kind of Social Support. 2013.

22.  Chamberlain L. Partnering with Parents: Pathways to Prevention in the Pediatric Setting. ACEs: Healing and Health AVA/NHCVA Next Steps.  Section 10. 2014.

23.  American Psychological Association. Parents and Caregivers are Essential to Children’s Healthy Development. 2013.

24.  American Psychological Association. Communication Tips for Parents. 2013.

25.  American Psychological Association. Resilience Guide for Parents and Teachers. 2013.

26.  Centers for Disease Control and Prevention. School Connectedness: Strategies for Increasing Protective Factors Among Youth. 2009.

27.  Centers for Disease Control and Prevention. Making Physical Activity a Part of a Child’s Life. 2011.

28. Find Youth Info. Program Directory Search. [Search evidence-based rated youth programs by Risk and/or Protective Factors].

29. Psychology Today. Find a Therapist.

30. Find Youth Info. Map My Community. [Interactive search by zip code for local youth programs receiving federal funds].

31. Ability First. Serving Children and Adults with Special Needs.

32.  American Academy of Pediatrics.  How Pediatricians Can Advocate for Children’s Safety in Their Communities.  

33. Feeding America. Food Bank Locator. 2014.

34. U.S. Department of Housing and Urban Development. HUD Approved Housing Counseling Agencies [by state].

35.  American Academy of Pediatrics. Keeping Children Safe: Preventing Gun Violence. 2013.

36. Anda R, Felitti VJ, Corwin DL. Adverse Childhood Experiences and Long-Term Health. ACEs: Informing Best Practice, AVA/NHCVA, Section 1. 2014.

37.  US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration: Center for Mental Health Services. Promotions and Prevention in Mental Health: Strengthening Parenting and Enhancing Child Resilience. 2007.

38.  Leadbeater BJ, Schellenbach CJ, Maton KI, and Dodgen DW. Research and policy for building strengths:  Processes and contexts of individual, family, and community development. In Maton KI, Schellenbach CJ, Leadbeater BJ, and Solarz AL (Eds.). Investing in Children, Youth, and Families: Strengths-Based Research and Policy. Washington, DC: American Psychological Association, 2004.

© 2015 by Academy on Violence and Abuse