Building Resilience Siv Fasci, MD FAAP

Developmental-Behavioral Pediatrician Adjunct Clinical Affiliate, Dell Medical School

University of Texas at Austin

Goals 1. Review normal brain development 2. Understand social emotional development in early

childhood and how to reduce its derailment by toxic stress 3. Know the neuroscience behind treatment for toxic stress 4. Learn the factors that contribute to resiliency 5. Learn how to protect and build stronger brain connections

for improved outcomes across the lifespan

Definition - Resiliency • Merriam-Webster:

– the ability to become strong, healthy, or successful again after something bad happens

– Capacity to bounce back from stress, pressure or disturbance

• Oxford dictionary:

– Springing back, rebounding – Capacity to recover quickly from difficulties

Building Resiliency

• Poverty • Caregiver with mental illness

or substance abuse • Neglect • Violence

– Bullying – Abuse – Neighborhood

• Positive emotions • Responsive and attentive

caregivers • Social supportive network of

family/friends • Exercise and sleep • Executive function • Positive parent child

relationship

Risk Factors Protective Factors

Psychosocial Risk Factors • Maternal depression • Parent/community violence • Poverty • Parents with less than H.S. education • Parents with limited literacy • Child lives in a single-parent household • Four or more children live in home • Child has changed school frequently or family has moved more than

twice in 12 months • Parents are unemployed • Child has no prior participation in structured preschool

Resiliency Caveats • People can improve their capacity for

resilience at any time of life • Process (patterns of change) through which a

set of adaptive capacities is linked to positive trajectory of functioning

• Works across different ecological levels: individual, community, organization

Neuroscience • Genetic and environmental factors work together to

shape early brain development • Architecture of a child’s brain is affected by early

experiences • Epigenetics is strongly related to early brain

development • Animal research shows that epigenetic changes can be

long-lasting and passed on to the next generation

Brain Development 1. Increase in brain weight 2. Overproduction/pruning of neurons and synapses (grey

matter) 3. Myelination of axons (increase white matter) 4. Birth and death of neurons occur mostly before birth, but

also later in childhood 5. Experience shapes the brain

– Stress slows down creation of new neurons in the hippocampus – Using parts of the brain helps them grow

Brain Development

Neuroplasticity

Executive Function

• Impulse control • Working memory • Mental flexibility

– Monitor – Adjust – Resist – persevere

Executive Function • Where: Prefrontal cortex • When: Most rapid growth occurs between 3-5

years age AND adolescence/young adulthood • Why: Affects learning, behavior, work and health

– More practice means building stronger brain connections

http://youtu.be/efCq_vHUMqs

Executive Function • Structured play • Caregiver modeling

Developmental functioning is intertwined

• Social • Emotional • Cognitive • Language • Behavior

Social Emotional Development: Birth to 6 months

• What’s expected – Look and responds to

caregivers – Established eye

contact – Social smile – Self calms

• What parents can do – Return baby’s smiles – Pause after talking, babies

take longer to respond; conversations involve taking turns

– Talk to baby a lot, babies understand simple words before they can speak

– Give extra attention (positively reinforce) when baby is able to self calm and stop fussing

Social Emotional Development: 9-12 months

• What’s expected – Discriminates

between familiar people and strangers

– Seek comfort when distressed

– Communicates using gestures and body language

– Understands cause and effect

– Imitates

• What parents can do – Play peek a boo to show

that when you go, you also come back

– Use words to name emotions, “Are you hungry?”. This teach feelings.

– Separation anxiety starts at 8 months but can peak at 18 months. Make good-byes brief, offer transitional object and use concrete time frames. “I’ll be back after your nap”

Social Emotional Development: 18 months

• What’s expected – Simple pretend play – Temper tantrums – Hands things to others

as play – Shows affection to

familiar people – Stranger anxiety/may

cling to caregivers

• What parents can do – Show/model how to take

turns without grabbing – Be good example of how

to cope and acknowledge your toddlers feelings. Instead of saying, “Why are you so upset” try “I see that you’re upset, because it’s Sarah’s turn with the wagon. It will be your turn again soon.”

Social Emotional Development: 2 years

• What’s expected – Copies adults/older

children – Increasing

independence and defiance

– Parallel play, but starting to include peers

– Gets excited when with other children

• What parents can do – Look for opportunities

to reinforce good behavior

– Give lots of positive comments

– Involve toddler in meal routines and family outings to give her a sense of being part of family and community

Social Emotional Development: 3 years

• What’s expected – Spontaneously shows

affection for friends – Takes turns in games – Shows concern – Separates easily from

parents – Dresses/undresses self – Gets upset with major

changes in routine

• What parents can do – Monitor what social

behavior the child is exposed to on TV/movies. What are interactions like at home?

– Let your toddler gain mastery and have some control, within limits, e.g. give choices and chores to build competence and self-confidence

Social Emotional Development • Learning continues through adulthood

– Executive function, emotional regulation, social competency

• Individual variability (temperament) • Positive stress can build resiliency • Teaching social emotional skills (modeling,

practice, reinforce) buffer against toxic stress

Symptoms of Toxic Stress • Social emotional difficulties

– Dev delay – Behavior problems – Learning problems

• Somatic complaints – Headache, stomachache, polyuria

Screening Tools • Brigance Parent Child Interaction Scale

– http://www.pedstest.com/Portals/0/TheBook/BPCISinEnglish.pdf

• Pediatric Symptom Checklist – http://www.brightfutures.org/mentalhealth/pdf/p

rofessionals/ped_sympton_chklst.pdf

Anticipatory Guidance

Parenting

Purposeful

Positive

Progressive

Protective

Playful

Personal

Healthy Mothers, Healthy Baby • Teach parents to be

responsive and attentive to a child’s cues

• Emphasize play, conversation, and modeling

• Quality of parent child interaction is directly related to lifelong outcome

Facetime “Serve and return builds foundation for development of emotional and cognitive skills. If returns don’t come or are unreliable, the infant/child’s development becomes derailed”

• Engage your baby each day • Pay close attention to his likes/dislikes • Respond to her cries with your face, a soothing voice,

gentle stroking, rocking • Reply to her vocalizations enthusiastically without

interrupting or looking away https://www.youtube.com/watch?feature=player_embedded&v=m_5u8-QSh6A

Baby Buffer Prescription http://babybuffer.org/

• For your baby – Make lots of eye contact with

your baby – Play and share enjoyment with

him/her – Respond to your baby’s

attempt to be social (when he smiles, coos or looks at you)

– Talk to you baby…a lot! Be sure to wait and give him a turn to respond to you

– Try to get your baby to imitate you and play social baby games (peek a boo)

• For you – Sharing positive emotions

(e.g. smiling, laughing, soft talking and gentle touch) with your baby will make you feel better and his/her brain stronger.

– Life can be stressful and its not always easy to be in a cheerful mood. If you’re feeling sad or hopeless, call your doctor as soon as possible to discuss how your feeling.

Resiliency Factors • Competence • Confidence • Connection • Character • Contribution • Coping • Control

Bad news:

• Toxic stress can cause long lasting brain damage to executive functioning across generations and result in poor health outcomes

Good news: • Brain plasticity • Environment (external factors) changes brain architecture • Executive function skills can be trained

Take Home • Resiliency can be learned! • Resiliency is about quality relationships

– Well being of moms – Play – Face time

• Brain architecture is experience dependent and synaptic plasticity can be lifelong

• Health outcomes are directly related to development social emotional skills and biologically based.

Resources • For professionals: AAP Tools and Resources

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Medical-Home-for-Children-and-Adolescents-Exposed-to-Violence/Pages/Resources.aspx

• For kids: – http://www2.aap.org/connectedkids/samples/expectrespect.ht

m – http://www.loveisrespect.org

• For parents: http://www2.aap.org/stress/buildresTOC.htm