From Trauma to Resilience

In the fallout shelter, I sat and drew bright, cheerful pictures of animals, beaches, whatever was requested (see images throughout). According to my mother, instead of the usual explosive fights and stress-fueled tirades, people crowded around in silence just to watch a little girl draw. I was born in Croatia in 1988, three years before a devastating war broke out in former Yugoslavia. War is an undeniably traumatic human experience, and its emotional and physical toll permeates and profoundly disrupts daily life. In the midst of this chaos, my instinct was to provide solace for others during times of emotional turmoil. Doing so became a powerful coping mechanism, and ultimately inspired my decision to train in Child and Adolescent Psychiatry. Though childhood trauma and adversity are associated with multiple harmful sequelae, they can also shape positive future outcomes.

In the era of COVID-19, discussions about childhood trauma and adversity are especially critical. The pandemic has magnified differences in the social determinants of health, worsened social isolation, increased exposure to death and illness, and exacerbated domestic violence. Exposure to childhood trauma or adversity such as these, confers an increased risk for psychopathology including major depressive disorder, post-traumatic stress disorder (PTSD), anxiety disorders, and learning/behavioral disorders.^1,2 Recent epigenetic studies also support a long-suspected connection between childhood trauma and a wide array of physiological consequences, spanning from cardiovascular disease to various cancers ^3,4 The deleterious consequences of Adverse Childhood Experiences (ACEs) appear to be cumulative, underscoring the importance of screening for trauma and adversity exposure in pediatric settings as a first step to early intervention.^2,3

Though important and clinically significant, these risk factors are far from deterministic. Fortunately, the vast majority of children and adolescents exposed to trauma and early stress do not develop psychopathology, and instead return resiliently to their baseline.⁵ Perhaps more surprisingly, Post-traumatic Growth is a more common outcome than PTSD following trauma exposure.⁶ The most common aspects of Post-traumatic Growth include increased personal strength, enhanced appreciation of life, identification of new possibilities, and improved relationships with others.⁷ As an added bonus, human and laboratory animal research suggests that there might be an “optimal” level of stress that can “inoculate” against subsequent stressors as well as the development of psychopathology.^8,9 We can, therefore, hope that he COVID-19 pandemic leaves our pediatric patients with unique adaptions and life lessons that they otherwise would not have been able to access, buffering them against potential future stressors.

Pediatricians have a unique opportunity to frame the COVID-19 experience for children and teens during primary care appointments and hospital admissions. After moving from Croatia, I vividly remember interpretations from adults shaping how I internalized my trauma exposure. The most common reactions to a child growing up during wartime were apologetic, pessimistic, and negative. These opinions, which were so far from my own lived experience, contributed to a sense of isolation, hopelessness, and shame. I wish instead that those early conversations consisted of questions like “What are you learning from this experience?” “How has this situation changed things for the better?” or simply, “Tell me more about the people who are supporting you through this challenging time.” Making the conversation growth-oriented has the potential to highlight positive elements of a child’s social support system, community connectedness, and personal insight during an undeniably challenging time. Imagine how many more inspiring stories there are to uncover and shape if we create space for children to discuss their trauma and adversity from a positive lens?

Take a second look at the artwork included with this piece and consider your preconceived notions of a child exposed to trauma. My memories of wartime left me with an ability to take risks while maintaining a sense of comparative safety, gratitude, and perspective. Many of your patients may surprise you with similar self-assessments of their own COVID-19 experiences. During this difficult time, I encourage you to remember that while we should be more vigilant than ever about checking in on our pediatric patients’ mental health, the most common outcome following trauma exposure in children is, in fact, resilience.⁵ Patient stories of strife and triumph can help us anticipate a broader spectrum of outcomes and find inspiration for novel resilience-building interventions. We have much left to learn about childhood trauma, adversity, and resilience, whether through clinical research endeavors or, simply, starting the conversation.

Jelena MacLeod, MD, MHS is a Clinical Fellow in the Albert J. Solnit Integrated Adult/Child Psychiatry/Research program. She is originally from Zagreb, Croatia, and has lived in Belgium as well as the Washington, D.C. area. At the Johns Hopkins School of Public Health, her master’s thesis explored the public health potential of incorporating epigenetics into our understanding of trauma, stress, and PTSD. She subsequently studied neuroendocrinological and behavioral correlates of pediatric anxiety disorders as a postgraduate at the Yale Child Study Center. During her time at the University of Connecticut School of Medicine, she founded and developed a Peer Support program to train medical students in basic mental health counseling skills. Her current work focuses on the optimization of mental health screening in pediatric primary care through systems design, healthcare data mining, and implementation science.