Putting resilience and resilience surveys under the microscope

 

“Resilience is a message of hope,” says Debbie Alleyne, a child welfare specialist at the Center for Resilient Children at Devereux Advanced Behavioral Health in Villanova, PA. “It is important for everyone to know that no matter their experience, there is always hope for a positive outcome. Risk does not define destiny.”

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Sounds fantastic. But what exactly does resilience mean?

Resilience generally describes the bounce-back ability of individuals who return to the similar shape, form and condition after misfortune, harm or injury.

But how does resilience work?

Is resilience something one can ingest, like Popeye’s spinach, to become stronger whenever out sized by stress? Can it be put on like Wonder Woman’s bracelets to protect against threat? Can it be given, taken or shared?

Is resilience an internal trait, an external circumstance or some mysterious blend of both?

“There’s always the debate about what’s called state versus trait: Is (resilience) something enduring in a person or is it going to come and go from week to week? The answer is somewhere in the middle,” says Dr. Jonathan R.T. Davidson, emeritus professor of psychiatry at Duke University Medical Center and co-creator, with Dr. Kathryn M. Connor, of the Connor-Davidson Resilience Scale (CD-RISC).

“What we often considered to be enduring characteristics in people can, in fact, change over the course of several weeks in response to some appropriate prompting. So resilience is a bit of both.”

While working together at the Anxiety and Traumatic Stress Program at Duke University in 2003, Connor and Davidson noticed that some people with post-traumatic stress were “able to bounce back better”, he says, which is how they got interested in resilience.

“It was not a concept that people really spoke about in medical practice, that’s for sure,” he says. Up to that point, research on resilience was done mostly by psychologists focused on child development.

Dr. Jonathan R.T. Davidson
Dr. Jonathan R.T. Davidson

It wasn’t looked at much in adults, and there wasn’t what they thought was a good scale to measure it, either. So, they “borrowed various concepts” from the available research, “and incorporated them” into their own to create the CD-RISC scale in 2003.

Since resilience is a word without a universal meaning, I ask Davidson to explain what he means when he uses the word.

“Resilience is the ability to bounce back, pick yourself up from the ground if you’ve been dealt some blows, to be able to cope well or effectively with adverse conditions," he explains. "It certainly includes various properties like being optimistic, having confidence in yourself, or belief in yourself to overcome things, to have the skills you need, social support, ability to find some meaning or purpose in life. Probably one of the most important or critical things of all is something called hardiness,” which is thought to be a mix of commitment, control and challenge.

Resilience: One word, many scales

There is no “gold standard for measurement tools,” was the first conclusion in “A methodological review of resilience measurement scales” published in Health Quality Life Outcomes in 2011. Notable challenges mentioned were “…. the complexity of defining the construct of resilience” and the absence of “an operational definition of resilience.”

Debbie Alleyne
Debbie Alleyne

This remains true in 2017. Not only is the word itself, complex, but the tools vary, too. Some tools are long. Some are short. Some are self-administered and some are not. Some are used with infants and toddlers while others are used with teens and adults. There are resilience surveys, scales and checklists, words often used as though they are “interchangebale,” explains Alleyne, though “they are not identical.”

From a lay person’s perspective, resilience measures appear to fall into one of three categories: research-based, research-informed, and just for fun.

Research-Based Resilience Surveys

These are tools that are evidence-based, validated by science and have specific applications for screening people for resilience. They might have clinical use or be used for research or in educational or professional settings, as well as more broadly, with basic training recruits, athletes focused on peak performance and those in high stress jobs such as first responders. The Deveraux child assessments and the Connor-Davidson scale are examples of this type.

The Connor-Davidson scale has been paired with a 14-question childhood adversity survey to assess the parents of four-month-old babies in a pediatric clinic in Portland, OR. The clinic’s pediatricians find that parents who have low ACE scores and high resilience scores have fewer challenges in parenting than parents with high ACE scores and low resilience scores, and parents who have high ACE scores and high resilience scores fall somewhere in between. A primary care clinic in Pueblo, CO, pairs the Connor-Davidson scale with a 10-question childhood adversity survey to assess the children and their parents.

Dr. Katie Rosanbalm
Dr. Katie Rosanbalm

“DCRC's child assessments are all standardized, strength-based, reliable, valid, normed tools that provide standardized scores that can be used to measure outcomes and/or to drive program design and strategies related to protective factors and social and emotional wellbeing,” says Alleyne.

Rosanblaum often uses two of the Devereux scales “as screening tools and to assess change over time” in her work which “focuses on the ‘self-regulation’ part of resilience – successfully managing your thoughts, feelings, and behaviors to reach positive goals.”



Research-Informed Resilience Surveys

These are educational, supportive and practical. These are tools and materials used to educate, provide support or guidance and direction. They might have some scientific basis and rely on research, but they are not generally used for assessment or screening. They may share information in checklist fashion or be general surveys that might help identify resilience factors in childhood or current personal strengths, and be used in specific groups such as students or parents. The Deveraux survey for adults falls in this category as does the resilience questionnaire on Got Your ACE Score? on ACEsTooHigh.com.

Just-for-Fun Resilience Surveys

These are informal and perhaps the most popular. They can be found easily online or in magazines. Some may be somewhat based in research or science, such as the resilience quiz online at PBS Kids. Others have a narrow focus only on resilience, such as how fast someone recovers from minor disappointments and huge losses (see "What's Your Emotional Style?).

More detailed descriptions of these and other resilience tools can be found in the ACESConnection.com Resource Center.

What’s so useful about resilience if you’ve got ACEs?

Or a better question is: Since resilience is about “bouncing back” to original shape and form, what might it mean for those without any concept of what to bounce back to, those who have experienced adversity as environment more than event?

For many, toxic stress in childhood was chronic and cumulative. The CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) clearly showed that childhood trauma adversity is quite common, and is linked to the adult onset of chronic disease, mental illness, violence and being a victim of violence.

AACESextended

This extended pyramid builds on original ACE Study

The research, led by Dr. Vincent Felitti (Kaiser) and Dr. Robert Anda (CDC) measured 10 types of childhood adversity that occurred before the age of 18. They are physical (1), verbal (2) and sexual abuse (3); physical (4) and emotional (5) neglect; a family member who has been incarcerated (6), is abusing alcohol or drugs (7), or has a mental illness (8), witnessing a mother being abused (9); and losing a parent to divorce or separation (10). The lowest possible score is 0 and the highest 10. Many other types of childhood adversity exist as well, such as racism, bullying, violence outside the home, being homeless, accidents, natural disasters and major illness or other adversities, but this study focused just on the 10 above. The researchers found that the higher a person’s ACE score, the greater the risk of chronic disease and mental illness. They also found that ACEs contribute to most of our major chronic health, mental health, economic health and social health issues.

Of the 17,000 mostly white, college-educated people with jobs and great health care who participated in the study, 64 percent had an ACE score of 1 or more; 40 percent had 2 or more and 12 percent had an ACE score of 4 or more (i.e., four out of the 10 different types of adversity). Compared with someone who has an ACE score of zero, a person with an ACE score of 4 or more is twice as likely to have heart disease and cancer, seven times more likely to be addicted to alcohol and 12 times more likely to attempt suicide.

But what and how do children and adults fair when ACEs are coupled with resilience factors and how is that measured, determined or quantified?

“A child might have temperamental resilience – just an easygoing optimism, determination, etc. – that is quite protective against adversity,” says Dr. Katie Rosanbalm, a research scholar at the Center for Child and Family Policy at Duke University. “I think it is more common that protective factors such as nurturing relationships with supportive adults will build a child’s resilience – in which case, if you are a statistician, you would consider resilience as the mediator that leads to positive outcomes.”

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I ask: Is resilience is a protective factor in and of itself, or does the presence of protective factors build a child’s resilience?

“Both,” she answers. “I think resilience and other protective factors are mutually supportive and create a positive cycle that builds over time.”

“ACEs are a set of specific risk factors. In the broader view, risk factors are those challenges all children and adults face in life. Without protective factors to buffer the negative effects of risk, there is an increased likelihood of a negative life outcome,” says Alleyne.

There are those of us who recoil from the word resilience. It can be a sensitive subject, both painful and polarizing. Many see resilience as a possible antidote to the avalanche of adversity in the world. However, many trauma survivors, with experiences that are often minimized, marginalized or medicalized, are often frustrated by what seems like excessive funding for or fascination with resilience. It can seem as though resilience and protective factors can get overemphasized while the prevention and treatment of ACEs ends up sidelined – as though human suffering might be optional if it’s served up with enough resilience.

For many, however, resilience is a word that feels hopeful, healthful and healing.

Researchers such as Rosanbalm remain enthusiastic about resilience research. She views resilience as “a crucial strength that we can build on!” in children or adults. Rosanbalm says. “Or, alternately, that we can seek to enhance if we know some aspect of resilience is lacking. In measuring resilience, we seek to learn where a certain person is at the moment, and how we might best help that person to develop new skills and supports so that they can become MORE resilient. The assessment is simply a tool that teaches us about areas for growth and how best to promote change.”

Others see resilience tools as simple ways to measure the effectiveness of particular approaches such as yoga, meditation, medication, therapy or stress management.

Plus, as Rosanbalm explains: “Resilience is a multi-factor construct – so measuring resilience could be about measuring self-regulation, or motivation, or attitudes, etc., etc.”ares9

For her, the key is in being specific: “It is important to think about what EXACTLY you want to be measuring when you pick a tool.”

When it comes to people and how tools are used, context matters. However, it is impossible to tell how culturally-sensitive or trauma-informed any specific tool is and how much this matters to those who create and use resilience tools.

Alleyne, who works with families, reminds me that “an effective assessment not only offers a means of measuring desired behaviors, but also can serve to foster effective communication among all adults who know and care for the child.”

Resilience as a conversation, not just a score

Dr. Mark Rains, a clinical psychologist with three decades plus experience, has a private practice in Farmington, Maine,  where he also participates in the Maine Resilience Building Network (MRBN). MRBN was founded in 2012 with the mission of increasing awareness about ACEs and resilience. He consults about traumatic stress as part of the leadership team of the Pediatric Integrated Care Collaborative (PICC), PICC's work involves many ways of "protecting children from exposure to traumatic stress, supporting and soothing them so that their experience of stress is not so traumatic, and promoting family strengths and child resilience," he writes. PICC is funded by the Substance Abuse Mental Health Service Administration and based at John Hopkins University within the National Child Traumatic Stress Network.

PICC Resources, 2016 Trauma-Informed Integrated Care for Families and Children

The PICC framework seems to go beyond traditional efforts to prevent abuse, neglect and dysfunction - great, but not always possible - and includes a robust, cross-sector response to traumatic stress, when it occurs. An integrated team of family, community members and primary care and mental health providers work with families.

“Part of what we look at is a trauma history, but also family and community protective factors and children’s resilience expectations and how those overlap," says Rains.

PICC uses "a wide variety of tools for identifying stress exposure," which includes ACE questionnaires developed by the Center for Youth Wellness, called the ACE-Q, the Safe Environments for Every Kid (SEEK) model and the Survey of Well-Being of Young Children (SWYC).

"There are at least four ways to look at a stress history: surveillance, questions, screening, and in in-depth assessment of experiences and effects," notes Rains.

Surveillance is basically "being informed about the possibility that problems in health and behavior may relate back to unresolved stress," and the way a provider remains tuned in, he explains. "It's like the lifeguard watching the whole beach, prepared to take a closer look if someone might be having trouble."

Questions are "helpful in opening conversations about stresses and coping," he says. Specifically, the three structured ones created by a team in PICC's Learning Collaborative and used at the University of New Mexico's Children's Health Center, which are as follows:

  1. Did your family or child experience any major stressful events since we met last?
  2. How much are these events still bothering you and/or your child?
  3. Despite these concerns, what have been good things that have happened in the past few months for your child?

Screening provides “a more formal way to gather information" he says. He uses the ACE questionnaire, "which is gaining in popularity as a screening tool" although it was not originally designed for this purpose. While it, and other tools are "enlightening about trauma exposure," he says, they "fail to take into account how a person experienced adversity and whether this led to trauma effects."

Dr. Mark Rains
Dr. Mark Rains

Getting the ACE score alone allows someone to share a number, and the categories of adversity experienced, without needing to say which ones. This, he says, can "begin a conversation about health and coping," without the "stigma of documenting trauma" the "need for a mandated report" or even "overwhelming the training of service providers prepared to discuss stress and health, but not specific traumas or PTSD."



In-Depth Assessment of Experiences and Effects

Once Rains knows a person's ACE score, he asks follow-up questions that allow him to understand how ACEs have been experienced by a person. He does not assume that all ACEs are a problem for people in the present. In fact, he proposes "summing the number of adversity categories that still bother a person and reflecting on how protective factors, life changes, and resilience contribute." His goal is move the conversation from "impairment to strengths," because someone with an ACE score of 6 might only be bothered by three of the ACEs. The difference between these numbers “is kind of a measure of resilience” and one he believes worthy of exploration.

In practice, he is likely to engage in a “resilience conversation” instead of obtaining a resilience score. This might surprise people, because in 2006 Rains worked with pediatricians, psychologists, and health advocates from Southern Kennebec Healthy Start in Augusta, Maine, to develop a popular research-informed resilience questionnaire. They created it to provide some balance for the ACE questionnaire, which focuses only on trauma. Today, he has misgivings about his involvement, "apologizing for potential misrepresentation of a list of resilience conversation items he had helped compile that may have been construed as a Resilience Questionnaire, as if it yielded a 'Resilience Score," as "there is no validity data to support that to offset an ACE Score."

He worries that a score alone (whether for ACEs or resilience) may mislead people as much or more than it is helpful.  He questions whether knowing one’s ACE score alone is helpful for individuals because “we are making it sound like it means more than it really is. Like a person with an ACE score of 6 is different than a person with an ACE score with a 4,” he says. There’s a difference between what’s statistically significant, “which we write papers about" and what’s clinically significant, "which is more of what it means for the actual person.”

This is important, he says: “If I come out of trauma feeling unsafe, feeling shamed or unloved, expect to be helpless or not capable or can’t make sense out of things… then I probably stay stressed.”

He emphasized that "multiple ACEs may contribute to such expectations, especially if they include abuse or neglect from caregivers. Chronic stress and unhealthy attempts to manage it may actually be what lead to the negative outcomes, rather than simply the number of ACEs."

Rains said the the term "toxic stress” has becoming popular" but that it would be more accurate to say, "chronically unsoothed stress" instead.

Rains cites the work of Drs. Jack P. Shonkoff and Andrew S. Garner, two pediatricians who defined toxic stress as “the third and most dangerous form of stress response,” in an article entitled, The Lifelong Effects of Early Childhood Adversity and Toxic Stress, published in the journal Pediatrics in 2012. “Toxic stress,” they wrote, “can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship.”

“Take two children who experience the same stress," Rains explains. "One of them might have a parent who’s
able to help their response system get back to normal and the other might remain stressed without the support system to help them feel safe again. That chronic stress may lead to toxic effects."

He explains how toxic effects can damage children: “A trauma stress response gets activated. Typically, we deal with the trauma and it passes. Stress goes back to normal. Cortisol goes up and down. We’re OK. Part of resilience for a child is being in a relationship that can protect them, preventing stress from happening or soothing it. If that doesn't happen and the stress response remains active... if stress doesn't get soothed, there can be toxic effects, in brain, endocrine, immune, emotional, and behavioral systems," he writes.

Being overwhelmed by stress, he explains, and not being soothed, is what robs people of one or more of these four expectations -- that one is safe, capable, lovable and that life makes sense. Finding a way to get back these expectations is what “getting your resilience back” means in a practical sense.

Rains does not rely on scores alone (ACE or resilience), though he acknowledges screenings help identify children and families who might need support and possible intervention.

Instead, he favors an approach that explores how safe, lovable, capable and meaningful a person feels. The specific resilience tools being considered by PICC "for application within the integrated care for early childhood stress program," he says, are as follows:


Putting resilience into practice

Dr. Emmy Werner had a research project in Hawaii where she studied nearly 700 people over 40 years – all the babies born on the island of Kauai in 1955 -- from infancy through adolescence and adulthood. “They could look at what kind of characteristics in childhood made a difference in whether people had problems later on,” says Rains.

Werner found that one-third of the high-risk children grew into adults who were caring and successful. One of the main reasons, says Rains, “is that having a secure, supportive relationship in early childhood is one of best predictors of whether you’d be resilient later in childhood and into adulthood. If you had at least one relationship where people were able to do that soothing, protecting…or help you build strength, if you had at least that one relationship at least that could protect you from many other stress exposures.”

Quote by Stephen Porges Body Language Exhibit, Mobiu

He adds: “It wasn’t how many of those relationships you had, it’s not the kind of thing that added up, as much as if you had just one." That one "could be protective. Two would be better. But it’s not like six relationships is six times better than one. If you had one or two, then that was good; if you didn’t have any then that could be a risk. So that’s where having a secure relationship early on helped you be resilient later.”

“It basically takes one good relationship” he says, that “teaches you from experience that you are safe-lovable-capable-meaningful."

What was also interesting about the Kauai study was that most of the teens who were troubled during adolescence had recovered to become successful in their 30s and 40s, due to the availability of adult high school, trade school and community colleges, joining the military or becoming involved in a religion, or marrying a stable person or having a stable job. Nevertheless, even the people who Werner described as “resilient” developed a high rate of stress-related health problems by their 30s, indicating that although a secure, supportive relationship helped them achieve their goals, their childhood adversity may still have left its mark on their health.

Rains notes that the “findings about protective factors in early childhood and resilience” come not only from the Kauai Longitudinal Study,” but also from the Minnesota Longitudinal Study of Risk and Adaptation. Both emphasize “the importance of an early secure attachment relationship, as well as ongoing support and opportunities to repair early attachment difficulties.”

>Margaret Bellafiore, Body Language Exhibit at Mobius

In other words, the impacts of trauma, toxic stress and resilience are all relevant to adults. To build resilience in adults, Rosanbalm believes two other “R” words are crucial to children: relationships and regulation. Rosanbalm works on “building trauma-informed schools – positive climates where WHOLE kids are nurtured, not just drilled with times tables” and works with caregivers as well “to teach people (kids in my case) the coping skills and social-emotional skills that they need to really experience their feelings, yet not be overwhelmed and controlled by them.”

She says if caregivers learn “how to build the warm, nurturing relationships AND how to create the structure and skill-building to support child regulation, I think these two together go a long way to building resilient kids with positive outcomes.”

In other words, resilience is relational but need come only from relatives or family members, though it might, but also within the wider community in which a child lives.

Alleyne agrees. In fact, she insists: “Protective factors and resilience can be nurtured in all children no matter their risk or ACEs” and that “no child or adult is without hope for healing”.

 

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Andres or Dr. Sciolla: 

Thank you for this in-depth comment. Though this piece was long it could have been even longer. There is SO MUCH to consider. I've not read the study you mentioned yet and couldn't speak to gene variations or if or how they might impact outcomes or ways that those with toxic stress effects, high ACEs, PTSD symptoms express symptoms so differently (in terms of social mobility, physical health, emotional issues, work or school or destructive choices). I share this concern:

However: I share this concern:

"I'm afraid that an emphasis on resilience as a quality of individuals to the exclusion of resilience as a quality of communities and social groups may unduly burden socially disadvantaged or stigmatized individuals and communities, especially if they have been historically so."

I'd not thought of it as much in terms of also being an issue in thinking about how toxic stress is defined and soothed. Thank you. for pointing that out.

"A society or a community that satisfies basic needs for safety, jobs, housing, healthcare and other services among its citizens will arguably see fewer children affected by toxic stress."

So very yes to this! I appreciate your comment. 

Cissy

 

Excellent summary, Christine, thank you for the posting! Two additional angles that in my opinion qualify somehow the conceptualizations of resilience you discuss are 1) gene x environment interactions and 2) the social and structural determinants of resilience. 

Research into naturally occurring variations in certain genes that are expressed in the brain show that some of us, just because of mere chance, inherit variations that make us either particularly vulnerable or particularly resilient to childhood adversity. Take, for example, violating the rights of others or antisocial behavior. We know that the higher the ACE scores the higher the odds for someone to display such behavior. But we also know that not all children exposed to similar ACEs grow up to display those behavioral traits (some may call them resilient). In their study published in the journal Development and Psychopathology in 2012  Dante Cicchetti and colleagues were able to show that specific variations in brain-active genes conferred low-income abused children (half were girls; 67% were African American) a certain degree of protection for developing antisocial behaviors. We can only guess, but it would be safe to assume that those genetic variations will be more common among those children who will grow up to attend college and less so among children who end up in jail, prison or worse.

The growing traction of conceptualizing health as socially and structurally determined, and developing interventions at those levels to improve health, will hopefully lead to a similar conceptualization of resilience. I'm afraid that an emphasis on resilience as a quality of individuals to the exclusion of resilience as a quality of communities and social groups may unduly burden socially disadvantaged or stigmatized individuals and communities, especially if they have been historically so. The same caveat is valid for the definition of toxic stress in childhood. We know that structural and socioeconomic inequities play a role in the number of adults who would be available to a child to soothe and nurture her whenever she experiences stress. Moreover, those adults need support and resources, too. A society or a community that satisfies basic needs for safety, jobs, housing, healthcare and other services among its citizens will arguably see fewer children affected by toxic stress.

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