Evidence for resilience

There is considerable evidence that children can grow up in all sorts of difficult circumstances (not just with substance misuse) without developing significant problems. This research is not confined to children in families in which there are substance misuse problems: it seems to be a general finding (e.g. Reference GilliganGilligan, 2000; Reference Friedman, Chase-Lansdale, Rutter and TaylorFriedman & Chase-Lansdale, 2002; Reference NewmanNewman, 2002; Reference LutharLuthar, 2003).

A study that followed 698 individuals from birth to the age of 35 allowed identification of protective factors in children exposed to challenging family environments as they grew up, and clarification of how these developed and changed through the life cycle (Reference WernerWerner, 1993). About 200 of the children were classified in a high-risk cohort typified by a disharmonious family environment (including parental alcoholism). A third of this cohort ‘grew into competent, confident and caring young adults. None developed serious learning or behavioural problems in childhood or adolescence … [They] succeeded in school, managed home and social life well, and expressed a strong desire to take advantage of whatever opportunity came their way’ (p. 504).

A number of studies have focused on the effects of parental alcohol misuse (Reference Velleman and OrfordVelleman & Orford, 1993a ,Reference Velleman and Orford b , Reference Velleman and Orford1999). One such study (Reference Velleman and OrfordVelleman & Orford, 1999) included 244 adults aged 16–35 years; 164 were the children of problem drinkers; the remaining 80 formed a ‘normal’ comparison group matched for age and recruitment source. It identified many of the risk factors shown in Box 4 for the offspring of problem drinkers, but many of the sample who had experienced a very deleterious upbringing seemed to be as well-functioning, happy and successful as those in the comparison group (p. 246).

Resilience and protective factors

Resilience should be conceptualised as a process, rather than a static trait and/or something solely internal to the individual (Reference RutterRutter, 1987; Reference Masten, Best and GarmezyMasten et al, 1990; Reference WernerWerner, 1993; Reference Glantz and JohnsonGlantz & Johnson, 1999; Reference Little, Axford and MorpethLittle et al, 2004). And as a process it is the product of an interaction between the individual and their social context: hence, it is potentially open to influence.

It is useful to distinguish between protective factors (which make it more likely that a child will develop resilience) and evidence that the child is being resilient. Resilience is self-perpetuating: behaving in a resilient way increases the probability of further resilient behaviour.

Protective factors and resilience have been identified in a number of studies, both general and specific to parental substance misuse (e.g. Reference WernerWerner, 1993; Reference Velleman and OrfordVelleman & Orford, 1999; Reference Beinart, Anderson and LeeBeinart et al, 2002; Reference Bancroft, Wilson and Backett-MilburnBancroft et al, 2004). For example, Reference Bancroft, Wilson and Backett-MilburnBancroft et al(2004) interviewed 37 young people aged 15–27 who were children of substance-misusing parents, and found that a number of protective factors could lead to more resilient outcomes. These included support from school, immediate and extended family, and individuals and services outside of the family. It should not be thought, however, that this was easy to maintain. Although the participants in this study said that some support from immediate and extended family was obtainable and was certainly beneficial, they also said that longer-term, unconditional support was rare, and certainly nowhere near the level they needed or desired. Strategies used to deal with the misuse included escape (e.g. spending time in their room or going to visit friends) and challenging the user (although this latter was rarely successful). In common with participants in other studies (e.g. Reference Velleman and OrfordVelleman & Orford, 1999), the young people interviewed by Bancroft et al were helped to move on from their difficult pasts by their own actions: identifying goals and dreams and making them happen; making the most of education or work opportunities; moving away from their parents; and developing their lives through their own family and children. A central issue in their success was the feeling that they had choices and were in control of their lives.

A list of the protective factors and evidence of consequent resilience, gleaned from the studies we have reviewed, is given in Box 5.

The key issue for resilience is the overcoming of psychological risk (Reference RutterRutter, 1987; Reference Friedman, Chase-Lansdale, Rutter and TaylorFriedman & Chase-Lansdale, 2002). Protective factors make it more likely that a child can overcome this risk because they provide a more positive setting. Resilience makes this more likely because it equips the child with a set of skills and feelings that enable him (or her) to be forward-looking and to bounce back from adversity.

It is also clear that developmental changes and stages, and interactions with other factors (such as gender, temperament, parent–child relationships, marital support, planning, school experiences and early parental loss) at key transition points in life, can have a particular impact on the development of resilience (Reference RutterRutter, 1987; Reference WernerWerner, 1993; Reference Cleaver, Unell and AldgateCleaver et al, 1999).

Is resilience always positive?

A few notes of caution must be sounded in relation to resilience. All strategies have potential associated risk; their success or levels of benefit are by no means guaranteed. This means that the processes that allow young people to become resilient may not all be totally positive, either in the short or the long term.

For example, strategies that are beneficial and effective for a young child may be harmful in the longer term (e.g. Reference Velleman and OrfordVelleman & Orford, 1999; Reference Kroll and TaylorKroll & Taylor, 2003; Reference Bancroft, Wilson and Backett-MilburnBancroft et al, 2004). For example, strategies of detachment, avoidance and withdrawal such as those noted by Reference Werner, Johnson, Glantz and JohnsonWerner & Johnson (1999), who described detachment from ‘family members whose domestic and emotional problems threaten to engulf them’, are often very effective when used by a powerless child. However, they can result in attachment and relationship difficulties when these children grow older. Along the same lines, in the longitudinal study mentioned above, Reference WernerWerner (1993) noticed that some of the sample were detached from things and people: ‘they had learned to keep the memories of their childhood adversities at bay by being in the world but not of it’. Learning to get on with their own life may make people seem aloof or detached.

Not everyone can make use of each protective strategy. Although the research outlined above found the support of friends to be an important protective factor for young people, the same research reported that many individuals, particularly younger children, found it hard to make friends. Similarly, although many young people tended to leave home earlier than they otherwise might have done, wanting to escape and try to achieve independence, adulthood and normality, a number of these young people were left feeling that they had lost their childhood and youth, and some were at risk of developing their own problems (with substances, early pregnancy, housing difficulties, etc.)

The essence of resilience

Most people deal with adversity, on a greater or smaller scale, on a daily basis. Few of us lead such cushioned lives that we do not sometimes face challenges and change. What is so unique about ‘resilience’? Reference Glantz, Sloboda, Glantz and JohnsonGlantz & Sloboda (1999: p. 113) believe that ‘part of the essential character of “resilience” seems to be that the positive outcome was unexpected … a model or theory fails to accurately predict behaviour for some individuals’. Hence, the level of difficulty faced by many children of parents with serious substance use problems is such that theory predicts they will develop problems in turn (Reference Friedman, Chase-Lansdale, Rutter and TaylorFriedman & Chase-Lansdale, 2002).

Others have suggested that resilience is a basic human characteristic that might be lost in some individuals because of the depth of the problems they face, problems that lead to such a loss of confidence and self-esteem that their natural resilience cannot easily be instituted. Thus, the capacity for resilience is within us all; it is just hidden sometimes and needs teasing out. Reference Bancroft, Wilson and Backett-MilburnBancroft et al(2004), who studied older children of substance-misusing parents, write that resilience did not necessarily mean growing up or being stronger: it ‘involved creating space to focus on themselves and their needs, and to have fun, without responsibilities for others … they were often having to relearn, or learn for the first time, the joys and pleasures of being young, or being able to focus on themselves and their own needs' (p. 78). It is important to get it right in youth, because resilience, much like other traits and characteristics, is amenable to change in childhood, but starts to stabilise through adolescence and adulthood: if you get it right earlier, you are more likely to keep it right.

Interventions to build resilience are not concerned with developing something unusual: they are concerned with enabling young people to develop a characteristic that is inherent in basic human adaptational systems (Reference Flynn, Ghazal and LegaultFlynn et al, 2004). Interventions may therefore be more about raising awareness of the possibilities of resilience and putting into place strategies for promoting such resilience.

Reducing risk

As we outlined above, a key finding is that promoting a safe and stable family environment (maintaining family roles and rituals, ensuring family harmony) is vital, and that the major risk factors relate to such family issues, as opposed to the drinking or drug-taking in themselves.

All of these major risk factors are amenable to intervention, even if the parental substance misuse is not at the time. This means that practitioners working with families in which parents have substance misuse problems should not necessarily focus their risk-reduction efforts on enabling the substance misuser to change (although, of course, if this is a possibility it should be encouraged). Instead, they need to work on:

1. • family disharmony, in particular

   1. • violence (including physical, verbal or sexual abuse)

   2. • parental conflict

   3. • parental separation and loss

2. • inconsistent, neglectful and ambivalent parenting.

These things seem to pose the greatest risk to the short- and long-term well-being of children. Moreover, they can all be worked on using the skills and techniques (conflict resolution, anger management, couples counselling, parenting skills training) that are available in most practitioners' toolboxes.

Increasing protective factors and resilience

The second way that practitioners can help to promote resilience is to work on protective factors and resilience itself. As far as protective factors are concerned, clinicians can work with:

1. • the other parent (if there is one and if they do not also have a substance problem), enabling them to provide a stable environment and give the time and attention that children require

2. • the parental relationship, enabling parents to retain its cohesion and present a united and caring front to the children

3. • the family, ensuring that family relationships, family affection and family activities are maintained

4. • adult figures outside of the nuclear family, ensuring that there is at least someone who can provide the necessary stabilising influence.

This work might involve direct intervention with other key adult figures, for example grandparents or teachers. In a qualitative study of 62 drug-using parents in Scotland, Reference BarnardBarnard (2003) reported that the extended family's involvement in caring for the children and supporting the parents was pivotal to the children's well-being. Most importantly, they found a clear correlation between the absence of such support and the child being taken into local authority care. These factors within a child's environment will mean that they are more protected and hence more likely to develop resilience.

Resilient children (and adults) share key characteristics: planning, high self-esteem and confidence, self-efficacy, the ability to deal with change, problem-solving skills, the feeling that they have choices and are in control, and previous experience of success and achievement. The task for practitioners, therefore, is to enable vulnerable children and young people to develop these attributes. Essentially, within the remit of a professional role that will dictate the level of contact with and responsibility for a child, practitioners can use this relatively basic knowledge of protective factors to contribute to the child's development of resilience. The practitioner needs to work directly with the children involved, enabling them to:

1. • maintain positive family rituals

2. • remove themselves from the disruptive behaviour of the problem parent or parents

3. • disengage from the disruptive elements of family life

4. • engage with stabilising people outside the family

5. • develop ‘confidants' outside the family

6. • engage in stabilising activities (school, clubs, sports, culture, religion) within which the child can develop a sense of self and self-esteem

7. • develop a desire to be, and pride in being, a survivor.

A key task of the practitioner in developing children's resilience, then, is to help them to identify and build on their strengths, including the social support they can call on, enabling them to build meaning and motivation into their lives, helping them to acquire social skills that bring self-control, self-esteem and a sense of humour (Reference Little, Axford and MorpethLittle et al, 2004), and helping them to reframe negative events and emotions into positive ones.

Obviously, interventions should take into account the age, gender and developmental level of the child. For example, it may be more difficult for younger children to seek external support: there may be problems with transportation, money, parents' permission, protection and safety. Girls seem less affected by parental problem-drinking in the short term but if the situation continues then there is an increased likelihood of problems developing (Reference Cleaver, Unell and AldgateCleaver et al, 1999). Reference WernerWerner (1993) also found that individual disposition was more important for females, whereas external support was more important for males. Boys often feel that conflict is more of a threat to them, whereas girls tend to appraise conflict in terms of how it affects them and are more likely to blame themselves (Reference ReynoldsReynolds, 2001). The setting in which the intervention is undertaken can also be important: this work with children need not be conducted in individual counselling or case-work sessions: there is evidence that a group approach can be effective in promoting resilience in young people with stressful backgrounds, including parental substance misuse (Reference Waaktaar, Christie and BorgeWaaktaar et al, 2004).

Reference GilliganGilligan (2000) and Reference NewmanNewman (2002) offer further and more detailed guidance on increasing individuals' resilience. Although not written specifically for work with children who have experienced parental substance misuse, there is much within these two guides that is useful for such a situation.

Responsibilities and holistic contexts

Even when practitioners have the skills, many feel that it is not their role to work with children, or families or parents with substance misuse problems. We take the view that we all have both clinical and moral responsibilities to think about the wider systems and not solely about our identified and referred ‘patients’. Indeed, the possibility that any case might involve child protection issues is a powerful argument for services to take a broader view of their remit. Hence, in any adult healthcare service, practitioners need to know whether the adult they are helping has children and family, and what impact that person's problems and behaviour may be having on those family members. Similarly, in child and adolescent services, practitioners must be alert to the influence on children of their parents' problems. And ‘alert’ does not simply imply onward referral. Very often practitioners need to intervene in a more holistic and systemic way, and not imagine that intervening with the child in the absence of their problem parents, or the adult in the absence of their wider family, will lead to a successful outcome: dealing with the impact of parents' substance (or mental health) problems on their children is an issue not just for child and adolescent mental health services: it is the responsibility of all healthcare practitioners. The report on the inquiry into the death of Victoria Climbié, a child under the care of social services, made it clear that practitioners could no longer walk away from situations that might put anyone, child or adult, at risk (House of Commons Health Committee, 2003).

The key points here are that as practitioners we can intervene to help these children; and that the focus does not have to be on the parental substance misuse problem, but on promoting necessary beneficial factors in children's lives. This is especially important: one of the main myths in the substance misuse field is that there is nothing that anyone can do (about anything) unless the substance misuser decides to change their substance misuse behaviour. This is entirely untrue: there is a very large amount of evidence that significant change can be brought about by focusing on other issues, and even by intervening with key family members in the absence of the substance-misusing adult (Reference Copello, Velleman and TempletonCopello et al, 2005). In the context of this article, which focuses on children, it is vital that practitioners do not get sidetracked into concentrating solely on parental problems: instead we must focus on the child's needs and how to meet them.