Resilience : A clinicians perspective

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Resilience A clinicians perspective

• James Scott
• Child Adolescent Psychiatrist
• Royal Childrens Hospital

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Resilience

• Definition
• The ability to positively adapt in the face of
  adversity
• The ability to cope with both daily and
  unexpected severe stressors

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1997 NSMHWB

• Exposure to trauma elicited from 11 questions of
  traumatic events
• Were you ever involved in a life threatening
  accident?
• Were you ever involved in a fire, flood or other
  natural disaster?

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1997 NSMHWB

• Trauma Exposure
• 4537 (42.6) - No Trauma
• 5725 (53.8) Trauma without PTSD
• 379 (3.6) PTSD

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The Burden of Disease at Various Ages
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Age at Which First Incidence of Disease has an
Impact
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Mean YSR Scores of Adolescents aged 11-16 from 24
countries
N27,306
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Trajectectories of emotional health and well being
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John
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John

• Born to a single mother,
• 2 years old Tantrums, unable to sooth
• Prep Hitting other children, persistently
  disruptive
• Grade 4 Mother unable to cope with behaviours
  Has attended 4 different schools Behaviour
  deteriorating
• Grade 8 Disconnected from peers. Living at home
  but behaviour unmanageable.

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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Jack
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Jack

• Born to a single mother,
• 2 years of age, challenging behaviours at home.
• Prep Ongoing challenging behaviours though
  settles into school work. Responds to praise and
  consequences. Enjoys other children
• Grade 4 Some occasional challenging behaviours
  but largely doing well with peers and school work
• Grade 8 Has made a successful transition to high
  school. Playing sports and doing well
  academically. Good relationship with Mother.

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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Jane
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Jane

• Born to a single mother. Well supported by
  friends and family
• 2 years of age. Affectionate with mother.
  Confident. Able to happily explore
• Prep Fitting in well. No behavioural problems.
• Grade 4 Doing well
• Grade 8 Good network of friends

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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Joan
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Joan

• Single Mother, Well supported
• 2 years old settled. Normal milestones
• Prep Enjoys playing and well behaved
• Grade 4 Some difficulties keeping up with the
  work. Difficulties reading and writing
• Grade 8 Very oppositional Excluded from school
  because of persistent rule breaking behaviours.
  Spends time with older antisocial peers

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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Genes

• Complicated story
• Mendelian Genetics explains very little
• Poly Genic Disorders
• Gene X Environment Effects

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COMT Gene on Chromosome 22
Changes Dopamine Activity
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The COMT Gene

• In community populations, there are differences
  in the COMT gene. This changes the amount of
  Dopamine in the Brain
• 25 have Methionine/ Methionine (Low Dopamine)
• 50 have Valine/ Methionine
• 25 have Valine/ Valine (High Dopamine)

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Adolescent Cannabis, COMT gene and adult Psychosis
Caspi et al., 2005. Biological Psychiatry
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Temperament

• The Smith Family
• Father- Senior Manager
• Mother- Health
• John- Grade 12
• Ron- Grade 8

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The Smith Family

• Ron had disruptive behaviours
• 1 suspension from school
• Parents concerned about exclusion
• Reactive and abusive at school and home
• Parents and school negative towards Ron

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I/V with Rohan

• Pleasant adolescent
• Felt as though he was not liked
• Friends at school
• Showed off to be accepted
• No clear depression, Anxiety or developmental
  problems

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History

• Always difficult from infancy
• Screamed a lot
• Wouldnt settle
• Very rigid and reactive as a toddler
• Some peer difficulties during primary school
• Some financial stressors at home

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Temperament

• The Nature of a child
• Thought to be biologically based
• 5 Dimensions
• Approach (Shy vs Outgoing)
• Rythmicity (Regularity of Biological Functioning)
• Activity/ Reactivity
• Co operation/ Manageability
• Irritability

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Australian Temperament Study(Margaret Prior)

• Infants/ toddlers with easy temperaments are more
  likely to be easy adolescents
• Infants/ toddlers with difficult temperaments
• family problems and maternal distress
• Antisocial behaviours in adolescents
• Depression and Anxiety
• Poor social adjustment

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Interventions

• School took Ron out of circulation
• Parents encouraged
• Rewards for positive behaviour him
• More time spent between Ron and father
• School arranged for G.O. to see Ron
• Parents and school started working together

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Outcome with Ron

• Occasional behavioural problems
• Threat of exclusion resolved
• Feels accepted by teachers
• Not seen as the problem in the family
• Starting to use words to describe his feelings

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Attachment
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Rick

• 13 year old male
• Lives with Maternal Grandparents
• Has been seen since 6 years of age
• Is he autistic?

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Rick

• 6 years old
• Attempts to control the household. Very rigid
• Plays with who ever he meets but play quickly
  becomes destructive
• Will only be cuddled on his terms
• Severe aggression at school. Grandmother has to
  be prepared to collect at any time.
• Excessively active, poor eye contact and delayed
  language Happy if left alone to play .
• Voracious Reader

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Attachment

• Bond between parents and child
• Commences prior to birth
• Develops over years
• Attachment Theory
• Two way process
• Emotional Attunement
• Secure Base from which to explore

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Disorders of Attachment

• Lack of Parental Empathy
• Abuse and Neglect
• Poor Health (Parents or Infant)
• Poor Fit
• Attachment occurs on a spectrum ranging from
  secure to highly disorganised

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Rick

• Parents abused substances
• Severely neglected for first 12 months
• Mother gave Rick into care of Grandmother
• Grandparents had been raising him since
• Doing quite well until school
• Aggression had become more severe at home and
  school

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Rick Interventions

• Calm consistent management at home
• Playful activities
• Affection
• Friends
• Lots of sport
• Encourage education
• School very consistent

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Rick

• Now in Grade 8
• One brief suspension at start of year
• Doing extremely well academically
• Has friends
• Grand mother remains very predictable (Grand
  father becoming more reactive).
• School very strict but Rick likes this.

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Developmental disorders
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Harrison

• 6 years old
• Referred for assessment
• Very active and inattentive
• Annoying behaviours at school
• Parents both professionals
• Mother not working
• Hits younger Sibling

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Harrison

• Seen a child therapist for a year
• Some reduction in tantrums
• Mother managing behaviour more consistently
• Still very challenging at home and school
• Advised of option of trial of medication

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Harrison

• 6 Months later
• Agreed to a trial of medication
• Thrived
• School liaison on one occasion
• No behavioural problems at school
• Much happier at home
• Less sibling conflict
• Now 10 years old. No medication required
• Doing very well

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Harrisons Brother

• Bill
• 3 years old
• Many autistic features
• No Language
• Recommended SEDU
• Progress with Language

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Bill

• Now 8 years old
• Aspergers is very obvious
• Variable course School meetings
• Grade 1 did well
• Grade 2 Trials of medication
• Grade 3 Very few problems. Has a couple of
  friends. Well behaved at home

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Resilience

• Individual Factors
• Family Factors
• Community/ Educational Factors

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Individual Factors

• Intelligence
• Humour
• Social Skills
• Empathy for others
• Innate talent or strength
• Perception of feeling valued
• Positive self concept
• Responsibility

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Family Factors

• Close attachment with at least 1 parental figure
• Attunement to Childs needs
• Good sibling relationships
• Family Harmony

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Community and School Factors

• Positive adult role models
• Good School Experience
• Good social networks
• Opportunities for extra curricular activities
• Consistent supportive environment

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Mental Health Trajectories from Childhood to
Adolescence
Distressed/ Challenging
Emotional / Behavioural Problems
Well Adjusted
5 years
14 years
Age
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Promoting Resilience

• Reduce Risks (e.g. Bullying, drug use)
• Promote Assets in the Child
• Provide Extra Curricular activities
• Vocational education
• Tutoring/ Extra support for children
• Process focused approaches
• Promote positive relationships

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What can schools do?

• Know your children well
• Adequate Learning Support
• Children need friends
• Calm responses to misdemeanors
• Involve Families
• Set expectations for children and families
• Facilitate communication between parents
• Keep Teenagers busy
• Safe ways for adolescents to meet
• Children need to be challenged

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Thank You