The topic of resilience has lately received a lot of attention on Twitter. We hear that kids have resilience when it comes to bouncing back from Covid lockdowns, or that we need to 'build' their resilience, which typically means that someone well-meaning wants them to make less of a fuss when they are put under pressure. 

So, what exactly is resilience, and how do we 'build' it? 

Seminal research carried out by Felitti & Anda in 1998 (1) linked adult health conditions such as heart disease and cancer with 'Adverse Childhood Experiences' (ACEs). The concept was discovered by chance: Dr Vincent Felitti, a physician with the Department of Preventive Medicine in San Diego, was trying to understand why more than half of the participants in his obesity clinic were dropping out each year, even when they were doing well. He began interviewing them initially to get an idea of how much they had weighed at specific points in their lives, and it transpired that most of his participants had been sexually abused as children (2). Felitti then met Dr Robert Anda, a medical epidemiologist at the Centers for Disease Control and Prevention who had been researching the effects of depression and hopelessness on coronary heart disease (2). They then carried out a mega-study by adding a set of trauma-related questions to a medical evaluation form filled out by thousands of people every year and initially had over 17000 participants agree to take part. They found a direct link between childhood trauma and adult onset of chronic disease and mental illness. These traumas included neglect, abuse, and family dysfunction, such as a parent in prison. 

The CDC-Kaiser Permanente Adverse Childhood Experiences Study measures ten different types of childhood trauma (3). According to Bellis et al. (4), approximately half of all people in England were exposed to at least one adversity during childhood, and 9% were exposed to four or more ACEs. Analysis of multiple studies (5, 6, 8, 9) indicates that ACEs can create a vicious cycle – they affect multiple generations, as one parent's health problems (caused by ACEs) impacts the care of their children, and so on (9). It has also been found that people with more ACEs have a greater chance of being economically disadvantaged which makes it challenging to provide a safe, nurturing environment (9), and are less likely to want to rely on others due to their experiences (8). And the ultimate Catch 22 situation: ACEs can increase the likelihood of child health conditions but having a health condition also increases the chances of a child suffering ACEs (5). 

This was a wonderful opportunity for individuals who enjoy quantitative data: assess everyone's ACE score and then determine who needs the greatest help. Unfortunately, in practice, this strategy does not work. Someone with four or more ACEs may be OK, but someone with only one ACE could be struggling mentally or experiencing serious health consequences. This is partly because the ACE measure does not account for all sorts of trauma, such as racism, bullying, witnessing a sibling being abused, losing a caregiver, homelessness, surviving a serious accident, and so on. But there's another aspect at work here: resiliency factors (3). 

Much further research has been carried out since the 1998 study, particularly those looking at mitigating factors, which have found that 'resiliency' can reduce ACEs' adverse health effects.  Long-term health can be enhanced by encouraging resiliency increasing factors, also known as 'counter ACEs' or Positive Childhood Experiences (PCEs) (10, 11). These include being treated fairly, social support and a protective community, having a predictable home routine, having access to a trusted adult, and having a role model to look up to were independently linked to better outcomes (5, 6, 7, 10). 

This is how we 'build' resilient children. Rather than leaving them to cope with their experiences on their own and then applauding their resilience, we can encourage the factors listed above. We can be trusted role models, we can help support families in our community, and we can break the cycle. We can build resilience. 

References
1.    Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. American Journal of Preventive Medicine. 1998;14(4):245-258. 

2.    Stevens J. The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic [Internet]. ACEs Too High. 2012 [cited 5 November 2021]. Available from: https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/ 

3.    What ACEs/PCEs do you have? [Internet]. ACEs Too High. 2021 [cited 5 November 2021]. Available from: https://acestoohigh.com/got-your-ace-score/ 

4.    Bellis M, Hughes K, Leckenby N, Perkins C, Lowey H. National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine. 2014;12(1). 

5.    Bellis M, Hughes K, Ford K, Hardcastle K, Sharp C, Wood S et al. Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance. BMC Public Health. 2018;18(1). 

6.    Daniel R, Ring K, Husbands T, Marshall H, Wang J, Shah A et al. Resilience in the Setting of Adverse Childhood Experiences: A Cross-Sectional Study. Clinical Pediatrics. 2020;59(14):1296-1300. 

7.    Sciaraffa M, Zeanah P, Zeanah C. Understanding and Promoting Resilience in the Context of Adverse Childhood Experiences. Early Childhood Education Journal. 2017;46(3):343-353. 

8.    Leung D, Chan A, Ho G. Resilience of Emerging Adults After Adverse Childhood Experiences: A Qualitative Systematic Review. Trauma, Violence, & Abuse. 2020;152483802093386. 

9.    Woods-Jaeger B, Cho B, Sexton C, Slagel L, Goggin K. Promoting Resilience: Breaking the Intergenerational Cycle of Adverse Childhood Experiences. Health Education & Behavior. 2018;45(5):772-780. 

10.  Talt V. Ways to Counter the Effects of Adverse Childhood Experiences [Internet]. Psychology Today. 2019 [cited 5 November 2021]. Available from: https://www.psychologytoday.com/gb/blog/pulling-through/201910/ways-counter-the-effects-adverse-childhood-experiences 

11.  Crandall A, Miller J, Cheung A, Novilla L, Glade R, Novilla M et al. ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child Abuse & Neglect. 2019;96:104089.