Welcome to the New Year 2020! I have been missing-in-action for the past few months, just too much going on in life to be able to create any new posts. I am back and am committing to posting at least once per month from now on.
I have been thinking a lot about resilience lately and the effect it has on coping and recovery from chronic illness, in particular, chronic headache. We all know kids and their families that meet every health challenge with a positive attitude, able to thrive and bounce back despite their challenges. We also all know those kids and families who meet every challenge like it is the end of the world, unable to cope and catastrophizing about every little thing. Fortunately, there are far more of the former than the latter. The difference often comes down to resilience.
What is resilience? According to the American Psychological Association, resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress. It means the ability to bounce back from difficult challenges. Resilience is not an extraordinary trait. People commonly demonstrate resilience in many situations in everyday life. Being a resilient person means that despite experiencing emotional pain, sadness, or distress during times of trauma or upheaval, the person is able to return to their usual functioning, after a period of recovery. We all have the innate human ability to be resilient by developing positive behaviors, thoughts and actions.
So what contributes to the development of resilience? The primary factor in resilience is having healthy, loving and supportive relationships both within and outside the family. These relationships foster trust, provide role models and offer support to help build a person’s resilience. For kids, their primary relationships are within the family- parents and siblings. And for teens, it might also include close friendships, with other teens and adults, like coaches or teachers.
Most of us have the capacity to develop resilience, and there are a variety of strategies to use to help. A few appropriate ways for young people to grow and foster resilience include: making and keeping connections with caring family and friends; being active in groups with values you admire; seeing obstacles as opportunities to grow and learn; making and working toward realistic goals; developing a positive mantra to use at difficult times to stay hopeful (‘It could always be worse’); doing good self-care such as getting enough sleep, exercising, eating a healthy diet, relaxing and having fun. We each can identify ways that will work for ourselves to foster resilience.
I think the difficulty of dealing with a chronic medical issue is learning to cope with the challenges in a healthy positive way. The importance of the parent-child relationship in developing resilience has been studied a lot, especially by psychologists who specialize in pain.
There is the biopsychosocial model of chronic pain which links the development of chronic pain with biological, psychological and social factors. Pain coping is one of the psychological factors that plays a big role in the ability of the person with pain to function in a healthy way, helping them to experience lower levels of somatic pain and mood disturbances. Positive pain coping strategies include pain acceptance, cognitive flexibility, optimism, and distraction. Negative pain coping strategies include self-isolation, behavioral disengagement, and pain catastrophizing (negative mindset, magnification and rumination). In the developing child, pain coping abilities are related to brain maturation, with improvement in coping usually seen during puberty and adolescence, when the brain is developing at peak rate.
So this is what is happening to our kids and teens developmentally. But what about the effect of parental coping on these kids? As you would expect, and as a number of studies have verified, the role of parental coping patterns is huge. Parental thinking patterns, psychological states and pain behaviors have all been shown to be related to pain behaviors and functioning in children. Parental (over) protectiveness does contribute to increased pain, disability, and somatic complaint. Examples of this include excusing their child from doing chores, keeping their child home from school, or giving special treats, when experiencing pain.
Why do parents behave this way? Well, it is certainly natural for parents to want to protect their children from pain. Perhaps they believe that their child could not possibly be able to deal with and function normally while having pain. And this parental behavior is appropriate when the pain is protective (touching a hot stove hurts, thus you don’t touch the hot stove again- protective pain). But when dealing with chronic pain, including chronic abdominal pain, musculoskeletal pain, or chronic headache, the pain is no longer protective and parental over-protectiveness continues the maladaptive pattern. Rather than helping their child develop healthy pain coping mechanisms, these parental behaviors work in the opposite way, and end up increasing both distress and disability for the entire family.
Interestingly, I just read a study out of Stanford that looked at the effect of adolescent peer relationships, as it relates to parent and adolescent cognitive and behavioral response to pain. From their results: “As expected, associations between parent and adolescent cognitive and behavioral pain responses were moderated by peer relationship quality. Contrary to expectations, for adolescents endorsing low-quality peer relationships, maladaptive adolescent outcomes were elevated across levels of parental cognitions and behaviors. For adolescents endorsing high-quality peer relationships, adolescent and parent pain responses were linearly related. Results suggest that adolescents’ adaptive responses to chronic pain may be best supported by the simultaneous presence of adaptive parenting and high-quality peer relationships.” Healthy parenting and friendships foster healthy pain coping.
So what does this all mean? The more we foster developmentally-driven, appropriate parenting for kids and teens with chronic pain, the better chance these kids have to avoid disability, to grow and thrive. The pain psychologists at my hospital developed a program called “Comfortability’, which incorporates a cohort of parents and children/teens (each group separately) to learn the basics of appropriate pain coping strategies and response to their child’s pain. This program has been expanded to several other pain programs across the country and is a model for fostering pain coping.
I see it in practice all the time. The teen is fully functional and the parents demonstrate healthy coping, as well. Or, the teen is not going to school, socially isolated, and is on their way to disability, and the parents demonstrate over-protectiveness, hand-wringing; no one is coping. The message we give in my clinic is function is more important than pain elimination; go to school every day, be with your friends, do your activities now, in spite of the pain. Don’t wait until the pain goes away- checking out of life because of pain is a guarantee that you will not get better.
They do not always like to hear that message but it is our job to keep giving it, even when it is unpleasant.
Ross, A.C., Simons, L.E., Feinstein, A.B., Yoon, I.A. and Bhandari, R.P., 2017. Social risk and resilience factors in adolescent chronic pain: Examining the role of parents and peers. Journal of pediatric psychology, 43(3), pp.303-313.