From adverse childhood experiences to wellbeing: Portfolios of resilience

Resilience has always been present across human history, as we have contended with the wide array of adversities. Resilience research has gained significantly increasing momentum as a core principle of the trauma-informed approach to service. Resilience research supports not only targeting psychopathology symptom reduction, but also recognizing a portfolio of resilience components to harness in youth interventions. The present discussion considers the innovative research work of Hamby and colleagues (2020) in terms of their portfolio of resilience model and current evidence for a dual-factor model of social support (social support seeking and social support receiving). Social support is a frequent intervention component, particularly in developing help-seeking skills, within youth programming. Their findings support this factorial approach that considers the giving-receiving experience, and how the four categories of Interconnected, Rebuffed, Tended, and Isolated may relate to differing resilience profiles. This research raises important questions for future work in terms of the fit between seeking and receiving that places the youth centrally in this consideration. Youths’ journey from trauma to resilience in a way that validates their portfolio of resilience assets, strengths, and potential is central to a trauma-informed approach to youth well-being, as well as how we negotiate youth rights with our developmental, clinical and health responsibilities.


Introduction
The Global Status Report on Preventing Violence Against Children (World Health Organization, 2020a) summarized global estimates on child maltreatment. The levels of violence in the lives of youth are staggering: 300 million toddlers receive physical and/or psychological abuse; 120 million girls and young women have experienced forced sexual contact; and there are 40k-plus child and youth homicides yearly (World Health Organization, 2020b). Stunningly, Hillis and colleagues (2016), in a systematic review of data from 96 countries, concluded that 50% of children had experienced past-year violence in Asia, Africa and North America. In the US, substantiated maltreatment to infants and toddlers (newborn to 3 years old) occurred at a rate of 15 per 1000; substantiated neglect increased from 1990 (49% of all substantiated maltreatment) to 2017 (75% of all substantiated maltreatment) (U.S. Department of Health andHuman Services, 2002-2019). In the US, from 2016 to 2017, the rate of violence victimization of youth aged 12 to 17 increased significantly by 34% (Morgan & Truman, 2019). Even more disruptive to the social fabric and social safety nets, is the knowledge that child abuse is considered widely to be under-captured. Grievously, we have seen time and again perpetrators of multiple victims by severe means fail to be met with justice. High-powered offenders and enablers -Ted Heath, Jimmy Savile, Jeffrey Epstein, Cardinal Pell -have revealed the concealed systematic, organized harms to children. Who allows this all to happen? How do we remediate such failings to children and youth?
Children have rights and adults have responsibilities. We have our intelligence and our agents of change.
Positively, there has been near universal commitment that children need to be considered a privileged population, with the United Nations Convention on the Rights of the Child, which celebrated its 30 th anniversary in 2019. So, what has gone so very wrong in the past 30-plus years that we seem to be further away from achieving zero tolerance on attacking a child? The 2030 Sustainable Development Goals highlight that only 10 years remain for us to course correct so that SDG 16.2 may be realized (i.e., ending abuse, exploitation, trafficking, and all forms of violence against and torture of children). Research has made it clear that abuse and neglect, particularly in poly-victimization contexts, interferes with adolescent well-being (Turner et al., 2015;, as well as adult health (Banyard et al., 2017). For example, in a British cohort study, childhood victimization increased the likelihood of poor socioeconomic outcomes at the age of 50 (Pereira et al., 2017). Violence reverberates and ricochets.
Does it make sense to be optimistic? Two lines of research justify optimism: (1) child maltreatment prevention, and (2) resilience to address potential cycles of violence. Childhood limited maltreatment does not seem to increase the likelihood of perpetrating child maltreatment (Thornberry & Henry, 2013), or that it may operate, in part, via financial strain when the victim becomes a parent (Henry et al., 2018). Women who had child maltreatment histories were shown to be more likely to experience intimate partner violence (IPV) and have poor health in pregnancy, as well as at oneyear and four-years postpartum (Gartland et al., 2019). Interestingly, resilient outcomes were suggested for children when IPV was not present. Policies that strengthen household financial security and reduce partner violence are tangible, and perhaps essential, components of child maltreatment prevention.
Beyond adversities that may be relatively constant at the family and community level, there are those that arise opportunistically. The COVID-19 pandemic measures meant more youth were online as an adaptive response to restrictions. In an online survey of over 2000 respondents (U-Report Voice Matters, 2020), 67% of youth reported that their friends were able to help during the COVID-19 pandemic. At the same time, the U-Report study found that 47% of youth reported increased negative experiences online (e.g., cyber-bulling, harassment, inappropriate content, and unwanted contact). Further, 85% "worried about the future". Oosterhoff and colleague's (2020) population-based survey of US youth found that most were not engaging in social distancing, but were monitoring the news and disinfecting daily. For youth wellness, the positive social ecology increases in saliency wherein the affiliation system confers stress buffering, as well as motivation for engagement in resilience actions (Hamby et al., 2019;Kent, 2012;Supkoff et al., 2012). This can be seen powerfully in the peaceful protesting for right action for people of color, where youth advocates and participants dominate.

Resilience portfolios
Resilience is defined in the first instance by the presence of adversity (i.e., something to work through and overcome, a trauma event that may or may not engender trauma-specific symptoms, or may yield reactivity subsequently, with or without a stress trigger; Wekerle et al., 2020). There is a trauma adaptation process, whereby functional impairment is time-limited, recovered from, or avoided by means of galvanizing inner resources with external resources (Ungar, 2012). Resilience provides a greater emphasis on positive health, rather than the absence or return to "normal" psychological distress and trauma symptomology. Like an investment portfolio, the brilliance of a portfolio concept is that it reflects dynamism, monitoring and future orientation. It can reference surviving to thriving after the adversity of poly-victimization (Grych et al., 2015;Hamby et al., 2018a). Key social support processes include emotion regulation via social support and positive social referencing (Clément & Dukes, 2017), and the instrumental value of social support via provision of resources and access to networks (i.e., social capital; Lui & Ngai, 2019). The goal of the resilience portfolio model is integrative across domains, building from the extant literature on key resilience factors (Hamby et al., 2018a). Personal understandings are important (e.g., "I have something to be proud of"; "I changed my priorities about what is important in life"). Resilience from trauma has been labelled post-traumatic positive growth; resilience factors significantly related to growth included compassion, religious meaning-making, purpose, emotion awareness and regulation, and a sense of endurance. A sense of purpose was significant across the prediction of various resilience outcomes (subjective well-being; post-traumatic growth; mental health). Clearly, purpose is relational where feedback on its validity and impact would seem important, as would be the contexts and support in which purpose could be realized. In this issue, Hamby and colleagues ask the question for social support: Is it better to seek or to receive? Social support Hamby et al. (2020) focus on the important developmental stage of adolescence to young adulthood. In this age grouping, behavioral patterns are not crystallized and, as such, resilience is a critical counterpoint to risk-taking. Social support seeking and receiving were considered as a two-by-two quadrant of present/absent, yielding categories of Interconnected (seeking and receiving), Rebuffed (seeking but not receiving), Tended (non-seeking but receiving) and Isolated (neither seeking nor receiving). The Rebuffed and Tended group were more similar than not, potentially suggesting that youths' experience of mismatch with personal agency may be at issue. Given that trauma is correlated with domination, loss, shame and dissociation, threat may be more activated when agency is not at the forefront of an experience. This fits with qualitative work that "advocating for self" may be an important resilience component of redefining self-identity (Yoon et al., 2020).
Trauma-informed principles (Elliott et al., 2005), in bringing together trauma, empowerment and relational theories, focus on agency so that there is a higher likelihood of post-traumatic growth and a lower likelihood of revictimization. Mutuality and collaboration are underpinning processes for conscious choice and control over actions that are in opposition to traumatic correlates of powerlessness and being overwhelmed. When the environment does not match expectations, greater non-positive reinforcement or punishment may dampen the continuation or impact of resilience behaviors. Based on a clinical practices perspective, Elliott et al. (2005) emphasize that, as trauma occurs in relationships, healing may benefit most from an interpersonal context; experiences that confirm the opposite of traumatization are needed (i.e., respect, accurate information, genuine connection, hope -RICH relationship). In trauma contexts, personal and psychological safety are fleeting, if present at all. Safe relationships are wanted, accepted, consistent, predictable and non-violent; Elliott et al. (2005) further highlights that safety includes the cognizance of perceived sexualization, whereby touch, graphic content, etc. may be triggering trauma reactivity. The experience of sexual abuse seems to be under-queried when other forms of maltreatment exist, with research pointing to the significant overlap of sexual abuse with all other forms of maltreatment (e.g., Wekerle et al., 2020).
As Hamby et al. (2020) note, the optimal scenario is when a distressed person seeks support, their circle of support activates and provides responsive care. As noted, a challenge may exist when those involved in the traumatization remain options for support among few others, when perpetrators may actively seek to engender dysfunctional family dynamics. Even in support seeking, then, those betraying and coercive transaction may drive "support" provision. In this way, Hamby et al.'s dual-factor approach to social support better approximates the reality of victim/survivors. In Hamby's et al. (2020) measurement model, social support items reflect general experiences as "not true about me" to "mostly true about me," rather than being anchored to specific trauma events or a timeframe of high need for support. In this way, it is not possible to disentangle changes in youths' approach to social support. As noted by the authors, this contribution represents a new approach that provides many interesting options to capture change and outcome in the youths' key persons (confidants), peer group constellations, adult mentors, access to spiritual directors or Elders, or the extent to which professionals are part of the support network. It will be interesting to follow as to whether the Hamby et al. (2020) social support conceptualization develops further in its developmental approach. Part of resilience is deciphering what sort of support you can reasonably obtain from what supporters and to identify and fill the gaps in the social safety net. The dual-factor model of social support has opened up this avenue of resilience work.

Trauma and recovering joy
We do understand from research that trauma increases the salience of negative or threat signals in the environment, which can translate into an impairing form of hypervigilance whereby stress narrows the attentional field (Wekerle et al., 2020). Consequently, positive information in the environment or with respect to the self may process at slower speeds or be ignored. While positive and negative activity and activation have been considered discreet, recent work suggests that in contexts of dysphoria, they may be more linked than orthogonal (Dejonckheere et al., 2018(Dejonckheere et al., , 2019. When experiencing high stress, information processing for both positive and negative affective content may be overloading. Coherent, consistent engagement with positive feelings and support should buffer distress and mitigate anhedonia (i.e., the inability to experience joy or pleasure). Negative expectations may also influence whether positivity and negativity remain distinct (Dejonckheere et al., 2019), which argues for a consideration of proactively considering social support when there are anticipated known distress events, such as being transitioned out of foster care when age limits are reached. Context-dependent fluctuations would seem to be met better with social support seeking flexibility. The scale, Recovering Positive Affect, has items such as "I can cheer myself up after a bad day" (Hamby et al., 2018b). This seems very significant for youth who have experienced poly-victimization, where violence may come unpredictably from in-person and/or on-line sources. It is interesting that Hamby et al. (2020) found that males had higher scores than females on endurance and recovering positive affect; females had higher trauma symptoms. Such gender differences may be interesting to pursue, and may relate to whether or not sexual violence victimization was experienced, as this tends to predominate among females. In our research with youth receiving child welfare services, males who reported childhood sexual abuse experiences were more likely than those maltreated in other ways to identify more motives for engaging in adolescent sex, including partner and peer approval, as well as coping with negative affect. For males without child sexual abuse, pleasure motives seemed more salient (Wekerle et al., 2017).
Emotion regulation is challenged by particular trauma response patterns, such as depersonalization, desensitization, and dissociation that, in some way, takes the youth out of the social interaction. As one of the factors in the resilience portfolio model, regulatory strength may be more challenging in needing to be on-going and responsive to the moment. In the Hamby et al. (2020) study, the Isolated and Tended groups reported lower regulatory strength than did the Interconnected and Rebuffed groups, the latter two showing similar levels. For some traumatized youth, isolation may feel like it creates greater safety and predictability on the one hand, but may engender greater loneliness on the other. It may be that the Tended group have a similar low outreach approach. As authors noted, cultural factors are likely to be relevant when discerning motives for social support (e.g., Ishii et al., 2017).
Overall, the resilience portfolio model held in distinguishing social support groupings, with the Interconnected group generally showing the highest levels of resilience and positive outcomes, and the Isolated group showing the lowest. While we cannot make much of negative findings, trauma symptoms did not discriminate among these groups. With females reporting more trauma symptoms than males, we may need to review our measurement model to ascertain if we are adequately acknowledging male-style trauma symptoms that tend to be more acting out. Recent research suggests that the brain region that integrates acting and emoting is accelerated in growth for girls with post-traumatic stress disorder, but not boys (Klabunde et al., 2017). These authors suggest that sex-specific approaches to bolster emotion regulation may be warranted.

Summary and implications
As the first study to explore a dual-factor approach to youth social support, this study is notable in extending and refining conceptual and measurement models of the broader resilience portfolio model. Interestingly, the Rebuffed group does not always show significant differences from the Interconnected group which may say something about trying to connect, and perceptions of successful connecting. As the authors point out, the Tended group is a relative unknown -individuals are drawn to the youth, offer bids of support, yet youth are relatively non-seeking support. That they were significantly lower than the Interconnected group raises interesting questions that may benefit from consideration of moderators of the experience of received support (i.e., from whom, when, in what context). Supporters who may be uncomfortable in distress emotion states may withdraw support or be unavailable at high need times, but be present at no-need or low-need times, leaving a youth with an experience of neglect and intrusiveness with received support. As the authors point out, it may reflect a lack of fit in terms of "readiness for support." The youth may prioritize their self-sufficiency above receiving support, such that unsolicited support may be interpreted as signaling expectations of failure or low efficacy. What is exciting about this research is the multiple ways in which to move forward with different sub-groups of youth. This study recruited from youth-serving organizations, and concentrating on specific organizations may further enhance our understanding of resilience. The authors highlight an important point in the consideration of "optimum benefit" which might assume that youth with trauma experiences are accurate (rather than developing) self-assessors in terms of what does actually seem to work better for them as support, and what is better tolerated. The benefit of a circle of trust is that the support group can be checked in with for feedback for a youth questioning their understanding, interpretation or approach in situations. Resilience is a growth process with inherent clinical implications. Hamby et al. (2020) highlight motivational interviewing as one clinical mode whereby the youth can set their goals and critically reflect on the pros and cons of their behavioral choices and patterns, as one route to moving forward towards healing and better health decision-making. It is the case, though, that resilience interventions have significantly lagged behind the development of resilience knowledge. The development and testing of intervention that attends to the broad portfolio of assets, strength, and development is a key research stream future forward.
In sum, the adolescent to young adult years amplify affiliation needs, independence strivings, and self-identity development. It remains a critical period to foster a healthy social ecology. With the 2030 Sustainable Development Goals on well-being, there is cause for optimism that we are forging our understandings of pathways to resilience and, hopefully, violence prevention. Children and youth are the most victimized segment of our world. It does not need to be this way. We have already agreed that it should not. Resilience intervention is one part of a multi-system, multi-level need that will increasingly amplify youth voices. When youth feel it is safe and appropriate to do so, speaking up and speaking us into serious positive action for their resilience will ripple across broken systems. The adults of the world set the target goal as 2030, and we have 10 years to forge a research-to-action magnum opus. A seismic change is in order.

Funding
This work was supported in part by the Canadian Institute for Health Research (CIHR; TE3-138302, 2014).