Rudolph's Pediatrics, 22nd Ed.

CHAPTER 101. Resiliency in Children and Adolescents

Saul Levine

Resiliency is the ability to rebound from real, experienced adversity. It refers to an individual’s use of inner strengths and outer resources to overcome seriously adverse, even traumatic, circumstances and still continue to pursue and succeed in one’s endeavors. Resiliency varies according to personal hardiness and social supports, as well as the nature and degree of the imposed hardship or impediment.

There are conflicting perspectives on the nature of resiliency. Conventional wisdom says that significant early deprivation and childhood trauma inevitably and predictably result in adult suffering and psychopathology. There is evidence that prolonged and adverse early childhood stress can cause significant damage to the developing brain and can culminate in adult physical and emotional disorders.1 On the other hand, an inherent resistance or immunity to misfortune in some individuals has been postulated, going so far as to invoke the unfortunate term invulnerable to describe either a genetic attribute or a vital strength of character. Neither polar opinion is entirely correct.

It is understandable that clinicians working with adult patients with major psychopatho-logical and social disorders often attribute the illness’s derivation to the patients’ early experiences of abuse, brutality, or deprivation. Similarly, those working with children who have been neglected, traumatized, brutalized, and oppressed often conclude that both the causality and the inevitability of emotional and behavioral scars are determined.

However, if one looks—without an a priori psychopathological perspective—at youth who have experienced painful, even destitute, childhoods where the emphasis of study is on individual strengths and longitudinal follow-up, the picture is remarkably transformed. Our assumptions that these individuals will see themselves as victims are not only incongruent, but they are also unfair to the many who do in fact overcome their early calamities.

In this regard, there is cause for optimism. Research studies over the last two decades have shown that, even without therapeutic interventions, most at-risk children do remarkably well over the course of their lives.2-6 Contrary to absolutist opinions, many of the children who suffer early oppressive circumstances grow up to be productive, law-abiding, fulfilled, and generative adults.

In a large population of children followed over four decades, it has been discovered7-9 that one third of the most at-risk children, defined by having at least four early risk factors (eg, poverty, family conflict, perinatal stress, abuse, etc), developed well personally, socially and educationally. Additional studies support these findings.5,10,11

This chapter reviews the factors that impact upon the individual’s makeup that determines their inherent resilience in relation to external and societal influences.


Prospective studies indicate that there are consistent enhancing personal characteristics that contribute to resiliency. These include secure early attachments, a fluid and easy temperament, higher intelligence, good physical health, attractive appearance, good interpersonal skills, self-awareness, optimism and a sense of purpose as detailed in eTable 101.1 .17,18 These are cumulative in nature and positively enhance each other; the result is a strengthening of the individual’s inner resolve. They are also bidirectional, in that a severe trauma or deficit can cause a decrease in the positive attributes. Although these positive personal attributes are correlated with personal resilience, none of the attributes by themselves are uniquely sufficient to determine success.


The most salient finding demonstrated in many studies is that we can all meet our Waterloo—even the most resilient person can be downtrodden, degraded, and ultimately defeated if there is a sufficient confluence of risk factors and a concomitant absence of personally enhancing factors.6-8,15,19,20 Potential risk factors for psychosocial problems include poor pre- and perinatal care for the mother and child, abject poverty, abuse/neglect/and molestation, family discord, parental psychopathology, poor schools, lack of nurturing adults, absence of mentors, or occurrence of war, violence or natural environments during childhood, as detailed in eTable 101.2 . In addition, early risk factors can potentiate each other, allowing cumulative risk to be magnified, and the chances of symptomatology or dysfunction are in turn significantly increased. However, none of these risks individually are predictive of inevitable problems. Conversely, most of these risk factors can be significantly ameliorated or even overcome.


In studies of youth and young adults in a variety of settings,5,38-41 and in research interviews with elderly people,42 four psychosocial determinants were found when individuals evaluated self-perceived satisfaction and worth of one’s life:

• Being (personal). This refers to one’s self-image and accommodation to one’s sense of identity. It includes an appreciation of strengths and an awareness of limitations, and it reflects a perception of being “grounded,” or comfortable in one’s skin.

• Belonging (social). This refers to a sense of being an integral, accepted, appreciated part of a community. It is more than merely being with like-minded people; support and nurturance are necessary. It encompasses the sharing of noteworthy personal (pain and pleasure) experiences, mutual empathy, common goals, and a sense of being affiliated and “connected” in a basic, meaningful way.

• Believing (ideological). This is the sense of having a personal overriding system of values and principles of life, beyond the everyday mundane aspects of living. This is especially so beyond unbridled competition, materialism, and acquisitiveness. It refers to “a “higher order” raison d’étre, a moral compass, and even a spiritual guide (although it need not be religious in nature).

• Benevolence (altruism). This encompasses the degree to which an individual is authentically generous and generative. It is related to being, belonging, and believing and depends on the existence of others. This is the ultimate criterion in the personal evaluation of one’s self-image—the extent of self-initiated mentoring and magnanimity; caring for and charity to others; being nurturing and supportive; giving of one’s self for the benefit of family, friends, the less fortunate, and so on. This is particularly meaningful in the healing process following deprivation, where a battered individual is still committed to sharing, giving, and mentoring.

In children and adolescents who have risk factors that are potentially detrimental to development, a variety of factors appear to foster the development of a sense of personal satisfaction and fulfillment that improves their later coping skills. These include:

• A primary attachment. The single most important factor in an infant’s life is the bond formed with a primary caretaker. This is the foundation of an awareness that needs can be met, comfort can be provided, pain can be alleviated, and inner peace can be achieved.

• Love. Love in childhood represents affection, appreciation, nurturance, commitment, dedicated time, interest, and caring—all constant reminders of being regarded as a vital presence.

• Limits. Rules, laws, and consequences define expectations and, by implication, the boundaries of safety and social interaction in every community.

• Stimulation. Without stimulation of the senses through visual, auditory, olfactory, and tactile explorations and cognitive stimulation, a child is cheated of opportunities to learn, inquire, and discover.

• Relationships with peers. Contacts with family, friends, and companions help a child to answer questions like “Where do I fit in?” “What am I all about?” and “Who am I?”

• Models and mentors. Older peers or trustworthy adults can guide, counsel, and inspire a child or youth.

• Space. Children need both physical and emotional privacy, and they need physical space for exploration. Space to be alone, to experiment, to fantasize, and to make mistakes is necessary, within limits of safety, for the internal, private reflections that often occupy children’s thoughts.

• Respect. By modeling civility in everyday discourse and empathy for others, respect is evident in words and deeds and is “transferred” to future generations.

• Consistency. Children need a sense of predictability, stability, routine, and ritual. They need to know that those who care for them are reliable, dependable, and stable and are there in good times and in bad.

• Responsibilities. Holding children responsible for certain obligations invites them to share in the adult’s reality, teaches mutual dependence, and dispels the notion of a perpetual free ride.

• Safety and subsistence. Freedom from fear and want is a prerequisite of freedom for growth, exploration, and opportunity.

• Opportunities. All children should have access to quality medical care, education, recreational activities, and vocational choice.

• Traditions. Ritual and repetitive family, cultural, or religious events enhance the present, enrich the future, and endow the past with a sense of continuity and community.

• Altruism. To receive or bestow a kindness can be a moving experience for anyone, at any age. Children model their parents’ generosity and altruism.

• Values. Young people need to be inspired, to believe in a reason for being. Idealism can more readily be kindled in youth than at any other time in life.


This leads us to the most crucial and salient question on the concept of resiliency. Given that (1) many individuals do recover from destitution and go on to lead meaningful productive lives; (2) that there are social risk factors associated with the appearance of personal difficulties, symptoms, and maladaptive or destructive behaviors; and (3) that there are equally well-documented personal characteristics that are shared by those who demonstrate resiliency in their personal trajectories, are there active preventive and interventional programs that can help foster resiliencies? Such programs will need to prospectively demonstrate efficacy by significantly reducing social risk factors, ameliorating personal distress and debilitating behaviors, significantly improving the resiliency potential of an individual at risk, and dramatically improving the outcomes of children.

Fortunately, such programs do exist.2,21,22,24,25 Numerous prospective studies confirm the positive effects of early interventions in children and adolescents (eg, Carolina Abecedarian Project, National Scientific Council on the Developing Child, High Scope Educational Research Foundation, Center of the Developing Child). These programs have shown that early childhood education from infancy through age 5 results in improved long-term outcomes for at risk children.26-44 However, implementing these protective interventions requires a societal commitment due to their expense. All these programs involve similar approaches (see eTable 101.3 ).32-38


From many studies of resilience and interviews with resilient individuals, the following salient and instructive lessons have been learned:

• Early trauma and destitution by no means inevitably leads to permanent scarring and debilitation.

• Early devastating trauma can take many forms: severe, acute, or chronic illness; abject poverty; brutality; abuse; natural disasters (earthquakes, floods, fire, landslides, drought, hurricanes); persecution; omnipresent danger and fear. The nature and severity of the trauma, the presence or absence of internal and external resources, and the immediate and subsequent mobilization of these resources determine the quality of the coping process and the resiliency of the individual.

• Nobody is invulnerable. All children and adults have their limitations and breaking points. Given an existing stress or, more often, a confluence of different stressors with sufficient severity, any individual can succumb to these oppressive forces and become debilitated.

• Few are helpless. Almost all children, adolescents, and adults have some resources (biopsychosocial fortifications) that can be strengthened and built upon to enhance their resiliency potential.

• Nobody does it alone. In literally every case of those we have studied, there has been at least one crucial individual who took an interest and served as a nurturer or mentor helping recalibrate a corrective trajectory.

• Individuals have different levels of personal resources and levels of tolerance for stress.

• The resilient individual utilizes social skills, trust, initiative, and motivation to grasp the extended arm.6,24,25

• Even those resilient people who have thrived after calamitous losses will have suffered some ill effects down the road.

• The presence of a personally committed, consistent, nurturing caregiver in the first year or more of life is a vital advantage to any child.

• As risk factors increase in a population, so, too, does the appearance of deleterious problems in children and adolescents.

• As resources (preventative, interventional) develop in a community, at-risk children and adults manifest increased evidence of coping skills and resilience.

• It does, indeed, take a village to raise a child (Zulu proverb).

In this era of seemingly omnipresent conflicts, turmoil, and wars, humanity does have the capacity to take a quantum leap forward in assuring the health-promoting growth and development of children. This can be done by enhancing a child’s innate resources and, in turn, by capturing their resiliency, fostering their maturation into adults who can maximize their potential and contribute significantly to society and to themselves.