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Troubled children often become troubled adults, but pediatricians can help to stop the cycle by promoting resilience and offering support to both patients and their caregivers.
Raising a strong and resilient child is easier than trying to repair damage an adult, and pediatricians can give parents the tools.
This was the focus of the session titled, “Building Strong Children Instead of Repairing Broken Adults: Promoting Resilience in Pediatric Practice,” on Octocber 27, 2019 at the 2019 American Academy of Pediatrics (AAP) Annual Conference and Exhibition in New Orleans, Louisiana. Led by Heather Forkey, MD, a pediatrician at the University of Massachusetts Medical Center and associate professor of pediatrics at the University of Massachusetts Medical School in Worcester, the goal of the session was showing how to promote and enhance skills of resilience in the office setting. The effect of adverse childhood experiences plays a role, but the more important part of promoting resilience is not undoing trauma, but rather promoting buffering and support by caregivers.
“Pediatricians can really make the most difference, and we are uniquely positioned as the professionals that can treat the caregiving relationship,” Forkey says. “We are addressing children and families longitudinally, and are among the only professionals who can work with caregivers and children together-with the relationship as our ‘patient,’ improving attachment, attunement, co-regulation, connection, and all the things demonstrated to promote resilience and buffer against trauma.”
Forkey didn’t hold back in her expectations for the session and her goals for the profession.
“We hope to completely change the perspective of the people present-to recognize that the behaviors and concerns they are already addressing in the office or hospital may be reframed so that they recognize trauma when it presents, and promote resilience in all their interactions with families,” Forkey says. “This can be done with tools that are easy to remember and use in busy clinical settings, and doesn’t need to disrupt the whole day but can significantly change outcomes.”
When it comes to the tools needed for this daunting task, Forkey says pediatricians can focus on the three R’s when addressing stress and adverse events: reassuring a child that they are safe; returning the child to a routine; and regulation, or being able to identify and modulate feelings. Attachment is key, as children often falter without the support of a caregiver. The foundation of the caregiving relationship is important here, she says, with adequate support centering on predictable compassionate availability, the ability to keep the child’s perspective of a situation in focus, and serving as the child’s emotional container. In the heat of a tantrum or outburst, it can be difficult to not take a child’s anger or frustration to heart, but it’s important to remember that it’s not personal, and children are often not capable of understanding and regulating their own emotions, Forkey says.
“How caregivers hold those feelings for kids and help them discharge emotions is one of the critical ways caregivers provide attachment,” Forkey says.
For parents and caregivers, this doesn’t always come easy-especially for older children, she explains.
“One of the things we forget is that it’s not automatic for the caregiver, and we have to support that,” she says. It’s more natural to hold a baby who is crying to console them, but people often forget that you can do the same for a teenager.
“We have to say, ‘It’s okay, you’re safe.’ We do this automatically for babies, and for children who didn’t get that early on, we still need to do it,” Forkey says. “We emotionally contain a baby, we just forget that this is what older kids need, too. You have to be holding their emotions.”
Screening for adverse effects and addressing them is one part of building resilience, as is understanding that when under threat the lower brain will grow in ways to protect a child but at the cost of higher brain functions which require safety and attachment to develop. Caregivers play a critical role here, and pediatricians can’t forget to support them, too.
“People trust us and come to us,” she says. “The patient isn’t just the kid, it’s the relationship between children and their caregivers.”