We are the Association for Child and Adolescent Mental Health, or ACAMH for short, and this is ACAMH Learn. Hello. My name is Stephan Collishaw. I'm a professor in youth mental health research based at Cardiff University. I'm also one of the co-directors of the Wolfson Centre for young people's mental health, together with Frances Rice, my colleague. Today, I want to talk about mental health resilience, in particular, why I think it's an important concept, and what we can do to study it, and to understand how and why it is that young people develop resilience in the face of adversity. So in terms of the overview of the talk, I'm going to begin by talking about childhood adversity. Some of the common experiences that can impact on children's mental health and their lives and future. And really, what I want to highlight there is that there's lots of variability in outcomes for children exposed to adversity. I'm then going to move on to talk more about resilience as a theoretical construct. You mean by resilience, how do we study it? And then I'm going to talk through what the literature tells us about the kinds of protective factors that might be important in promoting resilience in children, and really, what I want to stress there is that we need to take a multi-systems approach to looking at resilience. And I'm going to try and bring that to life at the end by talking about one research example of a study that is ongoing in Cardiff University, looking at the children of depressed parents. So unfortunately, childhood adversities are common, and many children experience difficulties in their lives, at least at some point, and they can range from very severe experiences such as maltreatment, through to perhaps more common experiences such as family conflict. Having a parent who is depressed or has some other mental illness, exposure to bullying, poverty, exposure to violence or discrimination. And children who experience these adversities, are more likely to develop difficulties with their mental health, but as I said, not all children experience negative outcomes. And it's important to note, I think, that children may also be at risk of poor mental health due to individual risk factors such as neurodiversity or physical health difficulties. Traditionally, many studies have compared the risks associated with childhood adversities by comparing children who are in high risk groups and low risk groups. For example, children who've been bullied and children who haven't. But that ignores, to some degree, that there's a huge amount of variability in outcomes following exposure to adversity. To take one example, if we think about children who've experienced maltreatment, maltreatment is associated with substantially increased risks of conditions such as PTSD, anxiety, depression. Some children experience multiple mental health conditions, but there're also some children who appear resilient or who make a good recovery from previous difficulties following maltreatment. And so that brings us to this idea that actually, it's quite important to think about what explains that variability, what explains resilience? And so let's start by thinking about what resilience might look like for children. As I said, it's a pretty universal finding that some children do not develop mental health problems, even in the context of some of the most severe adverse experiences that children might face. And resilience might look like the maintenance of positive adaptation, good recovery from problems following adversity, or better than expected functioning than might be expected given the severity of exposure to adversity. In terms of resilience as a theoretical framework, so Professor Michael Rutter, who had the privilege of working with early stages of my career, highlighted that resilience is not simply the flip side of poor mental health. It rather, it's a synergistic construct that where we need to be thinking about presence of a good psychosocial outcome in spite of adversity. It's also important to not think of resilience necessarily as an intrinsic trait or general quality that some people have and others don't, but rather a more dynamic construct that develops over time, and that requires the right resources and social frameworks within which resilience can develop. If we think about resilience as a dynamic process, model developed by a variety of researchers at Harvard University, have highlighted that we can conceptualise resilience as a balance between exposure to stress and exposure to support. And that actually, the way that we are affected by a stressful situation will depend on the nature of the stressor, but also the supports that can buffer the impact of that stressor. And each individual will vary in the degree of support that they might need in the context of exposure to stress. So the nature of the fulcrum at the bottom of this balancing tipping scale, if you like, highlights this concept, and children will bring their own individual strengths and vulnerabilities to a situation. And in fact, past experiences of successful coping can also move that fulcrum so that in future, children may require less support than they did initially to cope with the stressful experience. So why is resilience important to understand? Well, firstly, it's theoretically important because protective mechanisms may be very different from mechanisms that explain the transmission of risk from a particular situation to children, and allows us to move away from a deficit model of young people's mental health. And resilience is also of practical importance. It's not always possible to remove or to reduce risk, or adversity that children experience. So, for example, if we think about children who've lost a parent, or children who have a parent with mental illness, which isn't-- that's resistant to treatment, in those kind of situations, we really need to be thinking about protective factors that might buffer the impact of stress on young people's outcomes. And if we can understand the protective mechanisms involved and identify modifiable protective factors, that then puts us in a good place to think about what we can do to help support children and young people in practise. So how do we study resilience in practise? Research studies take a number of different approaches here. Many studies in the past have used person-based approaches, where they've thought about the types of negative outcomes that might flow from a particular experience of risk. For example, maltreatment is associated with a range of different psychiatric outcomes, risk of these, and so we might look at children who avoid any or all of those difficulties. And so we can then compare groups of young people who show good outcomes with groups of young people who show poorer outcomes in the context of risk. Likewise, we could compare young people have shown a good recovery from previous problems with those who've shown poorer recoveries over time. Another approach is to use variable-based approaches, where we look at each outcome in turn. So for example, we might look at symptoms of depression at outcome point, and predict this using a regression framework based on the severity of risk exposure. And the graph on the top right just shows this approach where, in green, you can see children who have better psychosocial functioning at-- given the severity of exposure to childhood maltreatment, whereas those shown in red on this graph, experience poorer than predicted outcomes. So we could conceptualise these residual scores as a measure of resilience in our population. Another approach uses test interaction between protective factors and risk factors, and considers protective factors as moderators of the association between risk and an outcome. So, for example, in the bottom right, you can see a study-- results from a study by myself, published a number of years ago now, showing that the association between the exposure to maltreatment and risk of adult psychiatric disorder depends on the quality of individual's relationship functioning across a number of different domains. So what types of protective factors might we be interested in, if we're looking to explain resilience. And as I mentioned, it's really important to think about resilience using a multi-systems perspective. Biological factors and genetics are important, so are psychological and cognitive factors, as well as social factors at broader social context, and I'll talk through, briefly through, each of these domains in turn. We know from a huge amount of research that environmental risks impact on children in different ways, and the susceptibility of children to environmental risk is very likely to be, in part, at least, genetically influenced. We also know that there are neurobiological processes and neurocognitive processes that are involved in explaining why it is that some children adapt better than others in the context of risk. And in particular, studies have looked at stress reactions, as well as immune response, and those might be important biological correlates of resilience and vulnerability. Turning to psychological factors, there are a number of psychological processes and factors that are replicated in numerous studies of resilience. Things like children self-efficacy, their capacity and ability to plan for the future, the attributions and interpretation of particular events, the meaning that they give to these, as well as their capacity to regulate their behaviour and their emotions, are important features of why some children are resilient and more resilient than others in the context of risk. So if we start by thinking about the attributions that we make, about the reasons why particular events occurred, it's clear that the way that we subjectively filter, interpret, and make sense of our reality varies between people, and it's really incredibly important in terms of explaining why it is that some children have better outcomes than others following adversity. It's been known for many years that children fare better following the divorce of their parents, if they don't blame themselves for their parent's separation. And likewise, their long lasting effects associated with attributions of blame amongst survivors of childhood maltreatment. Next, if we think about children's emotion regulation capacities, this is another very important developmental process which children learn over time and allows them to adjust their emotional responses appropriately to particular situational demands. An effective emotion regulation allows children to employ more effective coping strategies in the face of stress. Numerous studies in a variety of different adversity contexts have shown that better emotion regulation is predictive of greater resilience in the context of adversity. Thirdly, social relationships are, of course, also important, and in terms of family relationships, there are many aspects of family life that can be protective in the context of adversity-- parental warmth, parental interest and emotional support are important. Seeing one's own parents cope successfully with a particular sort of negative experience, is also helpful for children to learn successful coping strategies. Parents own mental health is important when we think about the connection between adversity and children's mental health, as is family climate. And I think it's important not to focus simply on the parent-child relationship, but to recognise the role that siblings, and grandparents, and other family members can play. When we think about the processes by which family factors can promote resilience, it's important to think about the direction of the association between our proposed protective factors and outcomes, and also how they interact with other factors, such as other social factors. I've got two examples here from recent research from our group. The first is a study by Liam Mahady, and colleagues, looking at the link between parental father support and youth depression amongst children who have a mother with depression. And what you can see here is that in this longitudinal design, there's a strong continuity in youth depression across the course of the study. Strong continuity in terms of paternal support to children across the study and across lagged links. So the link between paternal support at baseline and lower rates of depression at follow up. But conversely, we found no evidence for a link between youth depression and lower levels of paternal support at follow up. On the right, you can see a summary of the design of the study by Vicky Powell, who was interested in the link between ADHD symptoms and depressive symptoms, again, within a longitudinal design. And the study tested and found evidence for an indirect pathway whereby the quality of friendships mediated, at least in part, the link between ADHD symptoms and depressive symptoms. Very interestingly, however, the study also found some evidence that the quality of parent-child relationships could buffer this indirect pathway and reduce the strength of that indirect association from ADHD, to poorer quality friendships, to depression in future. So this brings me then to the importance of children's social relationships within the resilience framework, with many studies showing the impact of positive friendships, peer support, support from romantic partners, and also highlighting that actually relationships with teachers and other adults may also be important in promoting resilience in high risk groups. It's really important, however, to recognise that children are active partners in these relationships. They're not simply passive, lucky or unlucky recipients of good or bad relationships. And actually, one way to be thinking about promoting resilience, in children, is in terms of the skills that are needed to build, maintain, and benefit from good relationships as children grow up. And then finally, I just wanted to note that broader social context is also important, and the capacity for young people to deal with stress will vary enormously according to the nature of the broader social context. With studies showing the importance of a positive school climate, neighbourhood cohesion and safety, cultural beliefs and acceptance and community support, as well as, of course, appropriate and timely access to evidence-based support services. So next I want to talk about some research examples. In our group we're interested in understanding resilience, what can promote better outcomes for children in a variety of high risk groups. In the past, I've led on studies looking at resilience in the context of maltreatment and bereavement, and currently supervising work looking at resilience in the context of parental depression. We're also interested in factors, protective factors that might improve outcomes for children with individual vulnerabilities, with work looking at resilience in children with ADHD and children with intellectual difficulties. And most of these studies we've taken this multi-systems approach looking at child factors such as cognitive factors, lifestyle factors such as exercise, family factors, friends, and community all are likely to play an important role as I've discussed. I'll present some data from one particular study, which looked at resilience in offspring of depressed parents, and it's data from something called the Cardiff Early Prediction of Adolescent Depression study, now led by Professor Francis rice. And the context and background to this study is that, we know that parental depression is one of the most common risk factors that children experience growing up, but it's also associated really quite so much greater levels of risk for psychopathology in children themselves, and that intergenerational risk is, in large part, socially transmitted, so not purely due to inheritance of risk. Now, one observation that one thing that we know, as with many other contexts, not all children will develop problems even when parents depression is recurrent or very severe. And that begs the question, what protective factors might be important in promoting resilience in the context of parental depression. So, briefly, the design of this study, it started in around 2008, 2009, with 337 families where parents, or at least one parent, had a clinical history of recurrent major depressive disorder. And they and their children were interviewed on three occasions, initially, with children aged roughly around age 12 at baseline, and followed first, a year and a half and then a year later across three time points. And the study was provided really detailed psychiatric assessments with data from parents and from children, both about parents mental health and about young people's mental health. And what the study showed is that indeed, this is a high risk group of children. 40% experienced met criteria for psychiatric disorder on at least one occasion across the three time points of the study, and many more experienced subthreshold symptoms of depression, conduct disorder and other mental health difficulties. Over a quarter reported feeling suicidal or self-harming on at least one occasion, but still, around one in five of this sample had good mental health and avoided all of these types of problems on each occasion of the study. So we were interested to understand why it is that some children in this sample have good mental whilst the majority don't. As I mentioned, we looked at a variety of factors, and first we looked at mood resilience and behavioural resilience using residual scores approach where we looked at which children had lower symptoms than was predicted according to the severity and persistence of parent's depression. And what you can see here are that certain factors, so self-efficacy was a strong predictor of both mood and behavioural resilience. Some family factors predicted depression, others predicted behavioural resilience, and social factors are also very important during adolescence. Interestingly, and I think an important thing to note is there some specificity in these protective associations. So for example, physical exercise was a strong predictor of lower depression at follow up. In contrast it did not predict behavioural resilience in this study. There were also cumulative influences on adolescent resilience. So when we looked at this mark of sustained resilience for children in the study, we can see that there's a strong-- they're much higher rates of resilience, if you like, for young people who had experienced multiple protective factors across these different domains of their life. In contrast, those with only one or two protective factors had very low rates of resilience. OK. So our next question then was to examine whether resilience is sustained in the long term, and a PhD student of mine [INAUDIBLE], looked at whether resilience was sustained across when the study entered its 10-year follow up, which was recently completed. And as you can see, the study used exactly the same design as the first three occasions, with detailed assessments of mental health, and other protective factors amongst parents and by young adults. Just to note that the children in the study are, on average, aged around in the early 20s, and when we looked at the number who had good mental health on all four occasions of the study, that number now dropped to below 10%. However, there are some young adults who have recovered from past problems, as well as many who experience new difficulties at this phase of their lives. We looked at our original protective factors, which we had assessed at baseline when children were around age 12. And you can see here that-- and I've put the results of the two studies side by side, so our original study and Eglay study published last year. And you can see that, in relation to the family factors we'd found to be important in adolescence, these didn't predict mood resilience or lower depression symptoms when 10 years later. So this was positive expression, expressed emotion father support. In contrast, there was sustained beneficial effects of good quality friendships in early adolescence that persisted into young adulthood, and some evidence and some suggestion that physical exercise might also have some sustained benefits long term. So I'm going to wrap up now, and I just wanted to really note that the importance of protective factors is likely to vary by developmental stage. The things that might make a positive difference to children's lives when they're young children, are very likely to be, to at least to some degree, different from the things that are important when they're teenagers, or when they're entering adult life. They're also likely to be important differences according to risk context. Whilst there are certain-- there's certainly evidence that some things like good interpersonal relationships are important regardless of risk context, there may also be some specific things that are of particular importance in the context of particular circumstances. And then finally, as noted, the benefits of particular protective factors will also likely vary according to the outcome of interest. So as we found, exercise seems to be of particular benefit in relation to depression, but perhaps less important when we think about behavioural outcomes. And really just to highlight again that it seems that a multi-systems perspective is crucial when we think about resilience, that there is apparently no silver bullet, not one thing that we can change that will make all the difference, if you like. I've just summarised results from three different studies looking at resilience in a longitudinal study of children orphaned by HIV/AIDS in South Africa. The study I just talked about, of children with a parent with depression, and a study that's ongoing at the moment, looking at resilience in children with mild intellectual difficulties. And you can see the same pattern across all these different studies. There's up to a 10-fold difference in the probability of resilience between those with the lowest and the highest number of protective factors. So as an overall conclusion then, what I've hoped I've shown, childhood adversity can have long lasting impacts on mental health, but that's not needed, that's not necessarily the case for every child. Many children are remarkably resilient, even in the context of very severe adversity. And understanding the protective mechanisms involved here is really important because it can help us inform preventative interventions, and interventions to help children recover from problems they might experience in the wake of a negative experience. Resilience is also, I think, something that we should be conceptualising as something that we can all play a role in terms of promoting resilience in children. As Anne Marsden said, she started looking for the extraordinary things that might make a difference to children in the context of adversity, but found evidence for the everyday magic of the ordinary. So as parents, as friends, and as educators, we all play an important role in promoting resilience, and optimising outcomes for children who have experienced adversity. So thank you very much. [MUSIC PLAYING]