Can you think yourself well? Part I – Building resilient children 

How to build resilience in children, adolescents and young adults

introduction

During adversity, as adults we ‘sit’ at a variety of places along a continuum between denial and caving in. At one end of the extreme, we may bury our head in the sand and pretend things haven’t changed or believe we are adapting and evolving, when in fact – like Heraclitus’s metaphor that we can’t step into the same river twice (the water, stones, temperature are ever-moving) – it is everything else that is changing around us. At this extreme, there we are perfectly equipped for a world that no longer exists. At the other end of the continuum, in the face of the same adversity, we might feel overwhelmed or derailed and lose our sense of control over our circumstances. Here, we curl up like a hedgehog or a woodlouse to shut out the world, feeling utterly without options, letting whatever will happen take effect with only the hope that when we uncurl ourselves all will be well.  

Both extremes represent equally psychologically ineffective responses to adversity. Finding the ‘right’ place between themrequires us to grapple with inherent tensions and complexities; accepting some painful realities while ‘keeping the ship anchored’. Some people find this process emotionally exhausting; others find it exhilarating. Still others might find it an affirmative experience – albeit positive or negative, compounding either self-belief and agency (‘I am capable and resilient’) or self-doubt and despondency (‘I’m useless at coping’). Either way, the experience is uniquely linked to our individual physical and psychological make-ups, our life experiences and myriad other psychosocial moderating and mitigating factors.

Most adults will experience some form of mental ill-health over the course of their lives. This might be the result of some significant event (such as a divorce or bereavement) and could be a one-off; or it might be a chronic thread of repeated, similar mental-health episodes or of episodes that morph from one set of symptoms to another (worry to anxiety to negative mood or depression, for example). In other words, it’s more ‘normal’ than not to experience some form of mental ill-health at some point in life. Whether or not these episodes tip us into a more pronounced phase of psychological distress (such as a psychopathology) is in part down to the severity and nature of the triggering event, along with life circumstances and the support network around us – but it is also moderated by our hardiness and then our resilience. In other words, how thick-skinned we are and how we experience stressful events, followed by how we cope with them, bounce back from them and even are able to use them as opportunities for personal growth.

(Interestingly, the absence of mental ill-health is not a definitive predictor of life satisfaction. Longitudinal studies suggest that up to 25% of the relatively small group of people unaffected by mental ill-health nonetheless report some enduring life dissatisfaction.) 

This article is not offered as a mental-health diagnostic tool. The point at which an anxious thought becomes clinical anxiety and warrants medical/psychological intervention is a complex judgement best undertaken in a clinical setting (e.g. by a GP, a Psychologist, a Psychiatrist etc.). The diagnostic criteria used in this process (e.g. DSM-5) are under regular review and are in fact subject to critical debate, though they are publically available. This article focuses on resilience. More specifically, on what we can do during early life to develop resilience as an enduring, lifelong protective mechanism. The aim is, rather than looking at diagnosis and treatment to focus on prevention, to look at ways we can increase the likelihood of being able to bounce back from adversity and even to grow, thrive and prosper as a result of it. In short, to think ourselves well.

What do we mean by ‘mental health’?

Every approach to human science – from physical medicine to psychology – brings with it a different definition of mental health, which makes it hard to find a meaningful, useful singular definition of the term. For the purposes of this article, we think of it as our emotional, psychological and social well-being; something that affects and is affected by how we think, feel and act. It as a concept that allows people to move towards their potential, to cope with life’s stresses, to be economically active and fulfilled and to make meaningful contributions to our communities and other interests. The field of psychiatric rehabilitation offers a person-centred definition that references notions of increasing individuals’ capacity to be fulfilled in the living, working, learning and social spheres of their choosing. Rather like many modern physical health conditions, the notion of successfully living with a given condition is as important as taking steps to prevent it.

Cultural influences

The well-established classification of the ways in which we develop resilience (that is, within ourselves, and within our family and community) demonstrate that culture, spirituality, economics, education and physical health all have a direct bearing on how resilient we become. Some of these factors will no doubt be absolute (in the sense that basic subsistence needs are influenced by extreme poverty, malnutrition and so on and will trump the significance of broader and more existential needs, such as a sense of belonging and purpose), but some will be relative. A child’s self-image and his or her perception of their own and others’ hardiness and resilience is as, if not more important than their actual hardiness and resilience no matter how objectively we evaluate those traits. This article is written from the perspective of a democratised, developed economy and culture. And, while it’s important to acknowledge that there are intercultural influences at play in the world’s population and we’re writing with some consideration of the broader psychosocial factors, that’s not our focus.

The stress circuit  

No discussion of resilience would be complete without some reference to our neurobiological structure and functioning. In brief terms, the amygdala (an almond-shaped zone in the base of the brain) has primary responsibility for controlling how we respond to fear. When we perceive danger, the amygdala releases a burst of stress hormones into our blood stream and organs, elevating our blood flow and arousal, and so preparing us for fight or flight. While these temporary bursts of hormone activity are useful (essential for our survival, even), when stress-hormone levels are raised over a prolonged period of time (for example during chronic stress), the brain develops reduced capacity to create new neurons, which in turn leads to changes in brain structure. 

 Furthermore, the amygdala is linked to the brain’s prefrontal cortex – a separate, more rational part responsible for planning, prioritising and taking action. In fight-or-flight scenarios, the amygdala becomes hyperactive and switches off our rational brain so that we don’t waste valuable time thinking through the pros and cons of escaping imminent danger, we just do it. When the danger has passed, the rational brain takes over again and amygdala activity decreases, restoring our ability to think clearly and make rational decisions. Chronically stressed individuals show weakened connectivity between these two key brain areas, thereby reducing the rational brain’s ability to exert control over the amygdala. The brain’s ability to develop and modify its neural circuitry – known as its neuroplasticity – occurs throughout our lives and means we have the potential to adjust our brain functioning in response to stressors and adversity, and therefore improve our emotion regulation.

Future uncertain

We can pretty much bank the likelihood that there is an unknown, volatile and complex world ahead of us – even if some of the timings, subtle interplays and international dynamics lead to quite different permutations of the actual structure of that world. It is likely, for example, that there will be an increase in economic uncertainties and inequalities, continued challenges to family and social systems, and that aging and increasingly medicalised populations and resource scarcity will mean that those breaking into the world of work will continue to face heightened stresses and strains over the decades to come. While we appear to be intent on continuing our path towards this end point, making it hard to prevent the stressors, we can ensure we are fully preparing the next generation with the skills and mindset it needs successfully to navigate its future.

The case for early intervention 

Of the 450 million people suffering mental ill-health around the world today, the vast majority experience mood and anxiety disorders. For most, the clinical beginnings of those disorders lie during early life and they peaked during adolescence. Typically, the earlier the onset, the worse the clinical course over a person’s life, and the more likely there will be additional complications (such as drug and alcohol abuse, risky sexual behaviour, risks of suicide, truancy, and physical health problems). However, younger people are more amenable to change – and we also know that the earlier the intervention, the better the outcome both in terms of primary and co-existing conditions (known as co-morbidities). Once each of us has established rigid patterns of cognition and behaviour, we are far less responsive to new ways of thinking and doing. As Sir Michael Rutter (the ‘father of child psychology’) mused, we choose to vaccinate our children against physical infection to equip them with the tools (in this case antibodies) they need to combat that disease in later life. The same should be true of mental health. 

Thanks in part to advances in neuro-imaging, we are beginning now to understand much more clearly the complex interplay between psychosocial events and biological factors in the development of mental health and resilience. We now understand that events that occur as a foetus and in early life later play a significant part not just in avoiding mental ill-health, but also in building well-being, intellectual engagement and learning agility. Better mental health as a child ripples through improved school attendance and performance, self-efficacy, and our expectations for our life – as well as our actual life success and physical health. Just as chronic illness increases our susceptibility to other illness or negative influence, so wellness has the potential to breed physical, mental, social and emotional success.

Research indicates that resilient people operate transformationally when they’re faced with stressful circumstances. They analyse the problem, formulate possible solutions to it and carry out those solutions confidently. In contrast, people with low resilience operate regressively. They wish the problem would just go away and detach themselves from it. Resilient adults show far fewer activated physiological stress responses (measured through blood pressure, heart rate and so on)

Nurturing secure attachment  

A child’s interactions with and experiences of his or her family and family environment shape a sense of attachment and psychological safety that is pivotal in the development of resilience. From the 1950s onwards, work by Ainsworth Bowlby et aldemonstrated this importance, and while it was not without methodological limitations and certain cultural and psychosocial constraints, it remains fundamentally relevant. Indeed, neuro-imaging developments lend weight to many of these early claims.

The nature of an infant’s attachment to his or her primary caregivers has a significant impact on how he or she will grow up to navigate stressful situations and also how willing he or she will become to undertake new learning experiences. Furthermore, this same relationship sets us up with ideas about how relationships ‘work’ and therefore how we should be in relationship with others. What happens in this early phase of life is not binding nor irreversible (for example, most adolescents who have experienced developmental trauma during early childhood are able to ‘catch-up’ when relocated to a supportive, loving environment), but the links between a secure early upbringing and mental health – for better or worse – are significant.

According to Bowlby et al when an infant is frightened, distressed or vulnerable, he or she will seek comfort from their primary attachment figures (for the sake of simplicity, we will refer to them as ‘parents’, but of course that can be any primary care-giver or stable and reliable group of caregivers).

If a parent is physically and psychologically available and attuned, he or she facilitates an infant’s return to play, learning, exploration and so on. This is an important recursive relationship: the parent needs to be able to disentangle their own worries from the infant’s. When the infant is not in an activated attachment state (that is, feeling distressed), he or she should be free and encouraged safely to play, learn and explore (to build independence). In this way, the child feeds off the parent’s confidence that the environment/activity is a safe one in which to learn and grow. This parent-led emotional regulation leads into co-regulation (I feel safe alongside you), en route to auto-regulation (I feel safe by myself).

This secure attachment cycle requires the parent to be secure in their own attachment style (that is, able to distinguish between their own angsts without projecting them onto the child). The parent needs to have the skills to attune (empathically to acknowledge and understand), to be psychologically available (to notice and acknowledge, and also to be patient, calm, timely and so on) and to have good reflexive capacity and cognitive flexibility (to consider different possibilities and conclusions, without narrowly or rigidly sticking to one line of reasoning). 

As you might expect, insecure and unavailable parent styles aid and abet insecure patterns of behaviour in a child. Children can grow up to be avoidant (doubting the trustworthiness of a relationship, leading to a general reluctance to invest in relationships, preferring to trust the self and avoid closeness), ambivalent-resistant (stormy and inconsistent push-me, pull-me relationships) and demonstrate ‘disorganised’ (chaotic) attachment styles, the latter putting the individual at markedly heightened risk for mental ill-health later in life.  

So, a parent who reacts dismissively, anxiously or aggressively because of their own relationship trauma and/or stressors (substance use, stress, anxiety, depression and so on), who lacks reflective capacity and who is unable to contain an infant’s anxieties is at risk of hindering both the child’s ability to learn how to deal with anxiety and fright, and their more general ability to regulate their emotions. The result is to inhibit the development of the pre-frontal cortex and in turn inhibit the child’s ability to grow up to explore the world with maturity and confidence.

Key to a secure attachment is the carefully managed elastic band of psychological safety that the relationship between infant and parent fosters. The 1970s’ book Even Eagles Need a Push expounds that part of a parent’s role is to nudge a child towards ‘safe uncertainty’. The book draws parallels with the life of eagles: the parent eagle literally nudges the eaglet out of the nest, over the cliff edge, in order for the natural flying instinct to kick in. Mostly, the strategy works out well!

Given that 75% of adult mental-health problems begin before the age of 18, attachment seems like a good place to start!

Building a positive environment

A parent’s positive communication style with non-judgemental listening and a child’s perception that his or her parent is trustworthy appear to be key interactions that contribute to childhood well-being, including a child’s ability to develop pro-social values and manage stressful situations. For example, adolescents who have grown up with open family communication on sexual issues are less likely to indulge in high-risk sexual behaviours. Young people who report good communication with their parents have higher overall life satisfaction and report fewer physical or psychological complaints. For example, girls who find it easy to talk to their fathers report higher life satisfaction and a more positive body image than comparable peers.

These communication channels are particularly important given the significant neurological development that happens during puberty. The surge in brain development around this time in particular relates to areas of the brain that deal with social relationships, risk-taking and emotional control. This perhaps helps to explain why 14- to 17-year-olds are particularly susceptible to risky behaviours and peer influence. The dynamic interaction between body changes, changing identity and changing social groups gives rise both to great potential and to significant risk.

Setting boundaries

During later childhood, attachment security relies upon parents setting boundaries that regulate a teenager’s degree of autonomy. Interestingly, besides the perhaps more obvious at-risk teenage groups, scientists have now identified the youth of affluent parents as particularly at risk – with these parents’ lax repercussions on discovering substance use as one specific cause for concern. Levels of teens’ symptoms (rule breaking, and anxious–depressed and somatic symptoms) have been found to correlate strongly with the teens’ relationships with their mothers rather than with their fathers (albeit with a potential skew in role divisions). Zero-tolerance regarding teens’ rule breaking, remaining vigilant about children’s activities outside school, engaging in talks and workshops for families in distress and holding support groups (particularly for mothers) appear to be important interventions. Consistently criticising a child or teen has, perhaps unsurprisingly, relatively strong associations with mental ill-health, while patterns of acrimony are highly destructive. 

Inoculating against stress (or ‘steeling’)

We’ve learned that, paradoxically, early exposure to stressful conditions enables children to develop greater resilience and hardiness. Recent studies investigating the neurological impact on infant monkeys when separated from their parents reveals a clear link between exposure to stress and an accelerated ability to build resilience and regulate emotions. Brief, intermittent separations simulating naturally occurring, albeit stressful conditions promote enduring trait-like transformations in multiple domains of adaptive functioning. Not only does this process serve to reduce anxiety in the long term, but it also increases goal-orientated behaviour, curiosity and intellectual engagement, all with cascading effects that promote further positive adaptations. 

Dosage is key however. In line with Rutter’s analogy, we need to expose young people to low doses of challenge (micro-stressors) in safe and supported environments, in order to strengthen ‘immunity’ to stress later in life. Challenging but not overwhelmingly stressful experiences have these positive effects. In this so called ‘window of tolerance’ hyper- and hypo-arousal wrap around either end of a resting calm state. At its extreme, hyper-arousal features restlessness, anxiety, anger, panic and startle; while hypo-arousal features depression, flatness, numbness, lethargy and disconnectedness. Of course, there’s much subjectivity involved when we try to pinpoint the perfect dosage of challenge, but we can reasonably conclude that attachment in the form of dynamic, recursive relationships will enlarge this window of tolerance and so increase the potential benefits of stress inoculation.

Studies of early work experiences also show that early challenge has beneficial effect. Children and young adults who undertake work during their early years tend to experience a temporary deterioration in mood, self-efficacy and self-esteem, but there is a clear, longer term pay back. In the face of work stressors in the first four years of paid employment after school, the very same group show significantly more resilience than those who had no early work experience at all. 

Support programmes targeting stress inoculation have focused on three related beliefs concerning the interaction between self and world: commitment, control and challenge. People who have a strong sense of commitment expect to be able to make whatever they are doing seem interesting and worthwhile through their resourcefulness (instead of feeling bored and empty). Those with a strong sense of control believe that they can influence the direction and outcome of what is going on around them through their own efforts (as opposed to feeling like the victims of circumstance). Finally, those who have a high sense of challenge believe that their lives are most fulfilled when they are developing through learning from experience (rather than wishing for easy comfort and security).  

The minority group (the 17%-ers) who go through life without experiencing any psychopathology owe their mental health in part to an advantageous personality style and lack of family history of disorder, not simply to childhood socioeconomic privilege, superior physical health, or high intelligence. Social support, sociability, greater self-control and positive outlook (while all linked to personality traits), and to some extent hard-wired genetics, environmental factors (such as role-modelling and encouragement at home, with friends and at school) all play a significant role in shaping personality during these critical, formative years.  

Understanding the impact of social media  

Some studies show a positive association between social media usage and improvements in subjective well-being, while others show that frequent use of social media may be associated with declines in subjective well‐being and life satisfaction, and an increase in depressive symptoms. For the former, new routes to connectedness with others, including modes that enable teens to use different tactics to manage social anxieties, have a broadly beneficial impact. However, this doesn’t hold true for everyone. Social media usage has contributed to elevated anxiety and depression that is driven significantly by a fear of missing out (FOMO). Individuals who are prone to despondency or negativity (or who are experiencing those emotions at a particular time), those with some form of elevated anxiety and those with some form of insecure attachment history appear to be most at risk.  Interestingly, the nature of the risk appears to lie less in the social media platforms themselves, and more in how individuals interact with these platforms. Put another way, higher risk individuals behave differently on social media than lower risk individuals. For example, higher risk individuals are more inclined to compare themselves to others more critically, to share risky behaviour and to post negative content. There is likely to be a greater disparity between offline and online portrayal and they are more likely to ruminate on their perceived inferiority.  

We still have much to explore in terms of the relationship between social-media usage and attachment style and self-esteem, but FOMO is clearly emerging as a significant contributory factor to mental ill-health.

Developing skills & traits  

Actively encouraging young children to develop resilience through fostering commitment, control and challenge are all useful parenting, schooling and extra-curricular practices. In training to improve hardiness, we explore cognitive, emotional and action responses to stressful experiences in order to find coping techniques and improve a person’s ability to view stressful events in a broader perspective. In this way, things don’t seem so terrible after all. Furthermore, we encourage people to take decisive, rather than evasive actions. If these efforts fail, we shift the emphasis to learning to accept the events as unchangeable, without bitterness or self-pity, to give some solace that it’s possible to learn the skills and habits to see beyond stressful events. Optimism, cognitive reappraisal (reframing negative thoughts more positively), access to and use of social support, humour, altruism/generosity, mindfulness, and a strong sense of belief and purpose all show strong positive relationships with positive mood, self-esteem and, crucially, resilience.

However, children need to know where to turn. School-based programmes, typically targeting more general aspects of depression and anxiety, appear to have small beneficial effects in the short and longer-term, with depression-related material seemingly being better delivered by ‘external experts’ than teachers. However, the effects appear to be small, so the benefits of delivering this way, above and beyond standard PSHE content, remain unclear. 

Various evidence-based protocols (such as Youth Aware of Mental Health, or YAM, and the Mental Health and High School Curriculum Guide), offering a mixture of psycho-educational content, practical guidance and competency building, are available to young people. Content is often geared to one discrete topic (like anxiety or depression) and yet the evidence shows that in many cases it is rare for an individual to get only a single, pure diagnosis throughout their lifetime. While it’s important that we treat any conditions that a patient presents with, broader preventative work can help to build more enduring platforms for good lifespan mental health.

Conclusion 

• Over the course of life, most of us will experience some form of mental-health episode – this is normal.

• Resilience is a skill or capability that offers some form of protection against the intensity, severity and frequency of mental-health episodes and also enables us to better cope with stress.

• We can build the bedrock of a secure, resilient adult through promoting positive attachment experiences in a child’s early years.

• Like with vaccination, stress inoculation shows clearly that safe exposure (from a secure attachment base) to stressful situations builds resilience; and benevolent hardship encourages resilience and intellectual engagement and curiosity.

• Resilience is a learnable skillset, and so is being a psychologically available parent, who is attuned, cognitively flexible, well-boundaried and able to make fine judgements about the ‘dosage’ of stress exposure that maintains an optimal ‘window of tolerance’.

• Family relationships have clear potential for risk and/or protection.

• School-based ‘generic’ programmes linked to resilience and mood disorders (anxiety and depression) have some positive effects for some, but more customised psycho-educational interventions achieve better outcomes.

• Screen usage and social media more generally seem to create different effects for different children and the more useful question is more nuanced around how a given child is interacting with their device/platform than simply whether or not they are.

• Physical and mental health show strong associations – movement, exercise and activity are well-evidenced risk-prevention strategies.

• Left unresolved, early years mental-health episodes become more entrenched, attract additional, new mental health conditions and increase the risk of picking up a wide range of concurrent psycho-social risks. Early intervention is key.