Dianna Hutto Douglas, DNS APRN CNS

Susan Rick, DNS APRN CNS

LSUHSC

The Science of Resilience: Evidence to Intervention

Evidence–Based Nursing PracticeEvidence-based nursing practice solves problems encountered by nurses by carrying out five steps:

Formulating a well-built questionIdentifying articles in other evidence-based resources that answer the question Critically assessing the evidence to assess its validityApplying the evidenceRe-evaluating the application of evidence and areas for improvement (University of Minnesota, 2008)

Resilience“Resilient Functioning, the attainment of unexpected competence despite significant adversity is among the most intriguing and adaptive

phenomena of human development” (Cicchetti & Blender, 2006).

The Science of ResilienceThe first influences on resilience to be explored through research were psychological traits and social relationships In early investigations children who did well despite extreme adversity findings included:

Connections to caring and competent adults• The ability to form supportive social attachments

Cognitive and self-regulation skillsPositive views of selfMotivation to be accepted in the environment

(Harvard Mental Health Letter, December, 2006)

The Emerging Science of Resilience

Neurobiological FactorsThe role of certain neurotransmitters, neuropeptides, and hormones have been shown to be significantly altered by stress (Charney, 2004)

Genetic FactorsThere is some evidence that specific genetic factors may contribute to the presence or absence of resilience in negative or stressful situations

(Caspi, et al. , 2002, 2003)

The Emerging Science of Resilience

Neural plasticity is viewed as a dynamic nervous system process that orchestrates nearly constant neurochemical, structural and functional central nervous system (CNS) alterations in response to experience (Cicchetti & Blender, 2006)

Adversity is thought by some to exert a damaging effect on neural substrates. Mechanisms of neural plasticity may promote recovery. Resilient individuals may then be classified as those who have increased neural plasticity (Cicchetti & Blender, 2006)

Multiple-Level-AnalysisThe biology of resilience is only part of what should be an all-encompassing systems approach which must take into account all levels of analysis from cellular to cultural (Cicchetti & Blender, 2006)

Examination of resilience should include psychological and biological processes at varying developmental periods (Charney, 2004)

Areas of the Brain Indicated in Resilience Research

Effects of Stress on Brain StructurePreclinical studies indicate brain regions particularly vulnerable to early stressful experiences have one or more of the following features:• A protracted postnatal development• A high density of glucocorticoid receptors• Some degree of postnatal neurogenisis

(Teicher, et al. , 2003)

DefinitionsAllostasis – the adaptive physiologic response to acute stress in which the internal milieu varies to meet perceived and anticipated demand (Sterling & Eyer, 1988)

Allostastic Load - is the burden born by a brain and body adapting to challenges both physiological and psychological

(Sterling & Eyer, 1988)

Neuroendocrine Response to StressSubstantial evidence exists that stress take a increased toll on children and adolescents

First, stress initiates a series of biological and psychological processes as noted in the concept of allostatic load which may contribute to disease of both physical and emotional nature.Second, areas of the brain most vulnerable to the effects of prolonged stress—the hippocampus and regions of the prefrontal cortex are those most responsible for effective coping and adaptation. (Compas, 2006)

Neurochemical Response to Acute Stress Associated with ResilienceCortisol – Stress induce increase constrained feedback by means of glucocorticoid receptor and mineral-corticoid receptors

DHEA – High DHEA-Cortisol ratios may have preventive effects regarding PTSD and Depression

CRH – Reduced CRH release, adaptive changes and CRH-1 and CRH-2 receptors

Locus Coeruleus – Norepinepherine system- Reduced responsiveness of locus coeruleus – norepinepherine system. (Charney, 2004)

Neurochemical Response to Acute Stress Associated with Resilience Neuropeptide Y- Adaptive increase in amygdala neuropeptide Y is associated with reduced stress induced anxiety and depression

Galantin - Adaptive increase in amygdala galantin is associated with reduced stress induced anxiety and depression

Dopamine - Cortical and subcortical dopamine systems remain an optimal window of activity to preserve functions involving reward and extinction of fear

(Charney,2004)

Neurochemical Responses to Acute Stress Associated with Resilience Serotonin(5-HT) - High activity of post –synaptic 5-HT1A receptors may facilitate recovery

Benzodiazepine Receptors - Resistance to stress-induced down-regulation of benzodiazepine receptors

Testosterone - Increase in testosterone may promote increased energy and active coping and reduced depression

Estrogen - Short-term increase in estrogen may attenuate effects of stress-induced HPA axis and noradrenergic system activation

(Charney, 2004)

Psychological Characteristics that Promote Resilience

Altruistic toward others

Ability to attract and use support

Demonstrate outstanding leadership ability Courage in the face of great personal danger (Charney, 2004)

The Neural Basis of Reciprocal Altruism

Reciprocal Altruism is a core behavioral principle of human social life and has been related to resilience

Mutual corporation was associated with activation of the reward processing areas including the nucleus accumbens, caudate nucleus, and regions of the medial frontal cortex

It is hypnotized that this pattern of activation by means of linkage to reward circuits sustains social relationships and inhibits selfish impulses to accept but not reciprocate an act of altruism (Rilling, J. et al, 2002)

Evaluation of ResearchMuch of the work is preliminary requiring further study and replication with a variety of populations

Some of the research used animal studies Many studies had small sample sizes A number of the studies did not have matched controlsSome studies had age and racial bias

Significance to Nursing Understanding psychological and biological

processes that are involved in stress and responses to stress can provide important clues to distinguish resilient from vulnerable individuals (Compas, 2006)

As nurses, it is crucial that we recognize these clues and provide evidence-based interventions to promote resilience

Evidence-Based Interventions

Evidence-Based programs focus on teaching social-emotional skills that correlate with resilience

How to recognize and manage emotions

Develop caring and concern for others

Make responsible decisions

Establish positive relationships

Handle adversity effectively

Programs Correlating with Resilience

Nurse-Family Partnership (NFP)High/Scope Preschool ProgramPromoting Alternative Thinking Strategies (PATHS)Second StepReconnection Youth

Nurse-Family Partnership (NFP)Provides first-time low-income mothers of any age with home visitation service from public health nurses

Visits begin in the 12 to 20 week of pregnancy through the first two years of the child’s life

Designed to improve five domains of family functioningHealth

Home and neighborhood environment

Family and friends support

Parental roles

Major life events (i.e. Pregnancy planning, education, employment

High/Scope Preschool ProgramWorks closely with parents and caregivers using an active learning approach to educate children with skills that will promote their positive development

Key components include

Home visits by teachers

Provides teachers and caregivers with a blueprint for daily routines, classroom and playground organization, and teacher and child interaction

Knowledge and skills related to language, literacy, social relationships, music, math and logical thinking

– (USDHHS, 2007)

Promoting Alternative Thinking Strategies (PATHS)A Program for Children Five Through Twelve

Promotes emotional and social competence while reducing aggression

Enhances educational process in the classroom

Provides teachers with a systematic and developmentally based lessons for teaching students

Emotional literacy

Self control

Social competence

Positive peer relations

Interpersonal problem solving skills

Second StepClassroom based social skills program for preschool through junior high (Ages 4 - 14)

Designed to reduce impulsive, high risk and aggressive behaviors

Increases children’s social emotional competence, risk assessment, decision making ability, self-regulation, and positive goal setting

Lessons organized to include:

Empathy, Impulse control,

Problem solving ,Anger Management

Reconnecting YouthSchool-based prevention program for youth in Grades 9 – 12 at risk for school drop out

Used as a partnership model involving peers, school personnel, parents, and caregivers

Program Goals include:Decreased drug involvement

Increased school performance

Decreased emotional stress

Implications for Future ResearchFuture research is essential to determine effective treatment. The foci of future research must span form neurobiology to social policyResearch on Individual Interventions must consider:

Efficacy, effectiveness, timing, treatment setting, target population, cultural factors, and developmental level

Research on Group Interventions should test:Group debriefings, self-help initiatives, as well as other psychosocial approaches

Research on the Societal and Community should evaluate a range of outcomes such as:

Adaptive functioning, knowledge and attitudes concerning trauma, effective coping, and health seeking behaviors

ReferencesCaspi, A. , McClay, J., Moffitt, T. et al. (2002). Role of genotype in the cycle of

violence in maltreated children. Science, 297, p. 851-854.

Caspi, A., Sugden, K., Moffitt, T. et al. (2003). Influence of life stress on

depression: moderation by a polymorphism in the 5-HTT gene. Science,

301, p. 386-389.

Charney, D.S. (2006). Psychobiological mechanisms of resilience and

vulnerability: Implications for successful adaptation to extreme stress. American Journal of Psychiatry, 161 (2), p. 195-216.

Cicchetti, D. $ Blender, J.A., (2006). A multiple-levels-of-analysis

perspective on resilience: Implications for the developing brain, neural

plasticity, and preventive interventions. Annals of New Your Academy of

Science, 10 (94), p. 248-258.

Compas, B.E. (2006). Psychobiological processes of stress and coping: Implications forresilience for adolescence and children-Comments on the papers Romeo & McEwen and Fisher et al. . Annals of New Your Academy of Science, 10 (94),

p. 226-234.

Rilling, J.K., Gutman, D.A., Zeh, T.R., Pagnoni, G., Berns, G.S., & Kilts, C.D. (2002). A neural basis for social corporation. Neuron, 35, p.395-405.

Sterling, P. & Eyer, J. (1988). Allostasis: A new paradigm to explain arousal pathology. (In the handbook of life stress cognition and health Ed. By Fisher, S. &

Reason, J. pp. 629-649.). New York, NY: Wiley.

Substance Abuse and Mental Health Services Administration Center for Mental Health Services. (2007). Promotion and prevention in mental health: Strengthening, parenting and enhancing child resilience (DHHS Publication

No. CMHS-SVP-0186). Washington, DC: US. Government Printing Office.

University of Minnesota. (2003). Evidence-based practice: The 5-step process (Lesson 1). Retrieved April 4, 2008 from http://www.biomed.lib.umn.edu/learn/ebp/mod01/index.html