Can children be made more psychologically 'resilient' to traumas?
"It was one of those perfect days. I think that's what everyone remembers. And now whenever the day's too perfect and the sky's too blue, I think: what might happen?"
September 11, 2001. Lisa Siegman was in her first year as principal of Public School 3 (PS 3) in downtown Manhattan. Up on the fourth floor, the fifth-graders had a direct view down to the World Trade Center. "They had a perfect view of the towers," Lisa says. "The kids saw people jumping. People were running into the halls of the school, just doubled over."
PS 3 was far enough away to escape evacuation. But children from two other schools, PS 150 and PS 89, which were closer to the devastation, were sent there for safety. "People started converging on the school," says Lisa. "We had parents wanting to take their kids, parents wanting to help; we had only two working phone lines." By the afternoon the school had been identified as a potential site for a temporary morgue. Refrigerated trucks were lining up outside, along Hudson Street.
On what was just the sixth day of the school term, more than 5 000 schoolchildren and 200 teachers had to run for their lives. But kids all across the city were affected - from those who heard the non-stop sirens of the fire engines and ambulances to those in quieter neighbourhoods, who watched replays of the strikes over and over and over on TV.
By the end of that day the September 11th Fund had been established by two major local charities. Donations poured in. Money first went on immediate aid - hot meals for rescue workers, emergency cheques for victims and their families - and then funds were made available for programmes to help New Yorkers to recover. The damage wasn't only physical, but psychological. Counsellors set up services in local churches, and psychiatrists came from around the country to offer their expertise and their insights. Thoughts turned to the city's children - how would they deal with the stress and trauma?
Into the debate stepped Linda Lantieri. A former school principal in East Harlem and administrator with the city's Department of Education, she had helped to develop social and emotional learning programmes for US schools, and was head of the National Center for Resolving Conflict Creatively, an organisation she'd co-founded to tackle school violence. Helping kids handle trauma and manage their emotions was Lantieri's forte. She approached the Fund with her own take on resolving the problem: enhancing 'resilience' - a person's ability to get through difficult circumstances without lasting psychological damage.
For scientists the concept of psychological resilience began in the 1970s with studies of children who did fine - or even well in life - despite significant early adversity, such as poverty or family violence. For a long time a person's level of resilience was thought to be inherited or acquired in early life. This idea was supported by the often-replicated statistics on what happens after a trauma: while most people bounce back to normal relatively quickly, and some even report feeling psychologically stronger afterwards than they did before, about 8% develop post-traumatic stress disorder, according to US figures.
The degree to which someone bounces back, or does even better - his or her resilience - has a genetic component. But "genes are not destiny here," says Professor Dennis Charney, Dean of the Icahn School of Medicine at Mount Sinai, New York City. He bases this statement in part on interviews with people like Jimmy Dunne.
Dunne is a co-founder of the financial services firm Sandler O'Neill, which was formerly based in the South Tower of the World Trade Center. On 11 September 2001 he was out playing golf when he heard about the first plane crash. As further details emerged, he realised his colleagues were among those trapped above the burning wreckage. By mid-afternoon Dunne was on a train to Manhattan. He ran from Grand Central Station towards the small midtown satellite office where the firm's survivors were gathering. About four blocks away he stopped running and started walking. "I remember thinking, as soon as I get there everybody's gonna be looking at me, everyone's gonna be looking for direction from me. I want to set a very different tone, one of total calm," he said later.
Dunne told Charney that while he felt he was naturally quite pessimistic, "the moment I heard what the terrorists wanted, I decided to do exactly the opposite. Osama bin Laden wanted us to be afraid. I would show no fear. He wanted us to be pessimistic. I would be incredibly optimistic. He wanted anguish. I would have none of it." His firm lost 66 of the 83 people who'd been working in its main offices, as well as its computer system and almost all of its records. Just six days after the attacks, it reopened for business.
Before 9/11 Charney and his collaborator Professor Steven Southwick at the Yale School of Medicine had been avidly studying people who'd experienced a trauma, looking for clues as to why some people are more resilient than others. Their interviewees include former American prisoners of war in Vietnam, serving members of the US Special Forces and their trainers, victims of sexual abuse in Washington DC, survivors of an earthquake in Pakistan, and later people who were hit hard by 9/11. "We started out with a blank slate," Charney says. To the people who recovered well, they asked: "Tell us how you made it? What were the factors?"
As well as investigating psychological attitudes and mental strategies linked to resilience, Charney and Southwick have probed the neurobiology behind it. People whose bodies respond rapidly to a threat - with a surge of the stress hormones adrenaline, noradrenaline and cortisol - but who then recover quickly seem to cope better with stressful situations and jobs, such as working in the special forces.
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More resilient people also seem to be better at using the hormone dopamine - which has a role in the brain's reward system - to help keep them positive during stress. Charney's team, along with colleagues from the National Institutes of Health, studied a group of US Special Forces soldiers. They found that the amount of activity in the reward systems of the soldiers' brains remained high when they lost money in an experimental game, unlike in the brains of regular civilian volunteers. This suggests the system in resilient people's brains may be less affected by stress or adversity. Each of the soldiers' brains also featured a healthily large hippocampus (which as well as enabling the formation of new memories also helps regulate the release of the fight-or-flight hormone adrenalin) and a strongly active prefrontal cortex, the brain region dubbed 'the seat of rational thinking'. This in turn helps inhibit the amygdala, the part of the brain that processes negative emotions such as fear and anger, allowing the prefrontal cortex to come up with a sensible plan to cope with a threat.
Through their research Charney and Southwick have identified ten psychological and social factors that they think make for stronger resilience, either alone or ideally in combination:
having a moral compass
drawing on faith
using social support
having good role models
being physically fit
making sure your brain is challenged
having 'cognitive and emotional flexibility'
having 'meaning, purpose and growth' in life
Charney and Southwick are convinced that it is possible to develop these 10 factors, and that this can lead to a positive change for generally healthy people in their ability to cope not just with a major trauma, but also with the day-to-day stresses of life.
Academic questionnaires to measure resilience do exist. They measure some of the factors that Charney and Southwick have identified. They're decent tests, Charney says, but they haven't yet been used to evaluate the extent to which a person's resilience might be improved. Still, based on what he's found out, Charney says that the extent to which these factors could be modified, in theory, is "a lot".
For kids Charney's first suggestion is 'stress inoculation' - getting them to learn that they can cope with a challenge and overcome setbacks, perhaps by playing competitive sport or through wilderness adventures. "I used this with my own kids," he tells me. "I have five - four daughters and a son - and they like to say I got tougher on them."
But Charney is also interested in another technique. It's been shown in lab studies by other researchers to increase activity in the left prefrontal cortex. In theory this should allow people to recover more quickly from a negative emotion, in part by reducing inputs from the amygdala, as well as, studies suggest, by increasing activity in the brain's reward system - all of which should boost resilience. Until recently this technique was relatively obscure. Now it's everywhere: mindfulness.
Could you 'vaccinate' kids against stress? (John McCann)
Mindfulness has its origins in the Zen Buddhist tradition, but its central ideas - involving attention and awareness - are secular. A modern explanation is that it means paying attention, on purpose, in the present moment and non-judgementally, to the unfolding of experience, moment to moment.
Lantieri believes that mindfulness and other fundamental stress-reducing strategies are vital foundations for the kinds of changes Charney talks about. "Many of the factors he mentions are internal strengths that can be cultivated through mindfulness - such as cognitive and emotional flexibility or facing fear. We can't just tell people that it's better to face their fear without helping them figure out how," she says.
Mindfulness practices play a prominent role in Lantieri's programmes for both adults and kids. Just before 9/11 Lantieri completed a series of intensive retreats, learning contemplative practices, including mindfulness - which involves meditation but also a conscious attempt to be 'in the moment', a strategy used by some psychologists to help people manage depression and anxiety.
After 9/11, to best help the city's kids, "I knew I had to start with the adults - with the teachers," Lantieri says. The adults in a child's life can have a huge influence, she says, and if they're not coping they can't be expected to adequately help the kids. She put forward a proposal to the September 11th Fund and it was accepted.
In September 2001, as New Yorkers began to clear away the physical debris of the terrorist attacks, Lantieri developed her Inner Resilience Program (IRP) for teachers. Working with them, she developed a suite of tools for use in the classroom, to help children cope not only with serious traumas, like the terrorist attacks, but also with more everyday stressors, from exams to poverty to conflict in the home. These include exercises designed to improve conscious awareness of the body and how to calm it down, in part to tackle stress and anxiety, and in theory to boost long-term psychological resilience.
Having a moral compass and faith are just two things that can help you face the day - and become more resilient. (Retts Wood)
We've been stuck in Manhattan rush-hour traffic for an hour, but now we're on the FDR (the Franklin D Roosevelt expressway) speeding uptown, towards East Harlem. "Tom, the traffic angels have come to our aid," says Lantieri down the phone. "We're like at 103rd already, so we'll be there by 20 after." At 119th Street we turn off. The car stops by a complex marked with a Costco sign. "People come and park here and do their shopping," says Lantieri, as the vehicle comes to a halt. "They have no idea they're right round the corner from kids living in incredible poverty."
Public School 112 is right across from the Costco. A rectangular block of a building, it's three storeys high with diamond-patterned security gratings across the windows of the first two floors. Above the entrance, painted in uneven rainbow-coloured letters, are the words "Live your dreams". Higgledy-piggledy kids' paintings adorn the front walls. There are robots, a princess, something that might perhaps be a crocodile. Waiting inside is Tom Roepke, one of the teachers. He and Lantieri hug, and he leads us up to a kindergarten classroom.
It's a bright, welcoming room, the walls plastered with artwork, an alphabet, a number chart. There are circular tables with little chairs, and two Apple iMacs on a low desk by the wall. Roepke goes and sits cross-legged on a rug in a circle with 14 kids.
He places a folded cloth down in front of him, and slowly, deliberately, opens it. "A chime!" cries one little boy. Roepke nods. In a quiet, warm voice, he asks the kids to put their hands on their bellies and take a few deep breaths. Everyone obeys. He strikes the chime, and the kids listen attentively to the clear, pure sound. At last, when the echo finally dies away, they all raise their arms very slowly. No one giggles. No one fidgets. They're only five or six years old, and they're fully engaged.
Roepke puts on a baseball cap. "I'm going to take you on a journey," he says quietly. "We'll cross a bridge, and take nectar from our pockets with our fingers. A butterfly may land on your finger. If something happens on the trail, what could you do to calm yourself down?" A girl puts one hand up and the other on her lower belly. "Yeah," says Roepke. "Let's practise. Low and slow." He breathes deeply, three times, and the kids follow suit. Then he unfurls a long canvas strap.
One by one, the kids cross the imaginary bridge. All the time, Tom talks in an animated near-whisper, encouraging and guiding them. "Be careful of that bridge. It's a little shaky... Pay attention to your breath as you're going. Slow, low breaths." The class teacher offers tips, and praise. "Watch your feet... Good, Makari, you're being so careful and calm." The kids are calm. But when they're all at the other side, a few start to chatter. "Anybody excited?" asks Roepke. They nod. "Me too. What can we do to calm down?" As one, they put their hands on their bellies. Immediately, the room goes silent. They breathe. Roepke puts his finger in a pot of imaginary nectar and holds it up, and the kids do the same. They whisper about what they're seeing. Roepke says: "Now one, two, three... Watch them go... "
Eyes still closed, the kids talk happily about where their butterflies flew off to. "Mine landed on a tree," says one. "Mine went to planet Earth!" says another. Roepke passes round imaginary bottles of water. "Everybody's thirsty. But don't gulp it," he says. "Feel it going down your throat." Obediently, they pretend to drink, all apart from one little girl, who asks, "You got any soda?"
Through the butterfly hunt the kids learn two concepts crucial to Lantieri's programme: how to connect with the body - to be 'mindful' of the physical signals of stress and excitement - and strategies to combat this. Lantieri recommends other exercises, such as more structured meditations and progressive muscle relaxation, which might be used during 'Peace Time', a defined period in the school day that slows the pace - helping the kids to calm down after the lunch-break, for example. Peace Time acts as a space in the curriculum for kids to learn ways to help themselves. The main goals are to teach students how to calm themselves when they're upset, relax their bodies and minds, and help them pay attention, whether that's in class or at home.
Research reveals how some stressed-out people stay happy in the chaos. (Retts Wood)
Meditation and relaxation techniques may help with acute stress. But there's also evidence that, when practised regularly, they can help the body become less reactive in a stressful situation, boosting resilience to stress and anxiety disorders. Mindfulness meditation isn't the only form that's been shown in lab studies to increase activity in the prefrontal cortex, as noted by Dennis Charney in his neurobiology research.
According to studies conducted at Harvard Medical School, transcendental meditation (which involves the repetition of a mantra) and yoga can also initiate what's sometimes called the relaxation response. This is the physiological opposite of the fight-or-flight stress response. It's controlled by the parasympathetic nervous system - the branch of our nerve network that calms us down after a stressful event - lowering our heart rate and reining in stress hormones. People who can calm down quickly, whose parasympathetic nervous system response is quick and effective, cope better physically and psychologically with stress. Meditation seems to be capable of improving its activity, as does exercise.
Lantieri advocates setting up a 'Peace Corner' - a part of the classroom (or even the home) with perhaps a cushion and a few stress-releasing tools, such as paper and pencils, a music-player with recordings of sounds of nature, and a water bottle filled with glitter in solution for the kids to up-end and watch while breathing slowly. In the kindergarten classroom of PS 112 this is a chair with a sheet of paper on the wall that reads "Peace Corner Choices: Sit and Breathe. Read a Book." After the butterfly hunt a few of the children talk about what they like to do in the Peace Corner or during Peace Time.
"You can draw your mother or your dad or hearts or your dog or you can write 'I love my mom'," one girl says.
The class teacher asks the kids when they might go to the Peace Corner. "If you're scared or you're nervous," says one girl. "Or if you miss your mom and you're crying." A boy sitting near us says, "If someone died in your family, you could go to the Peace Corner." There's silence for a few moments. "Does that help you?" the teacher asks. The boy nods. "Yes."
The idea, Lantieri explains, is that children learn that when they're feeling sad, anxious or angry, or even excited, they can go to the Peace Corner to calm down. It's not for the teacher to send a child there if they're misbehaving. "A child is never told to go to the Peace Corner," says Lantieri. "They learn to take themselves. This is about building self-regulation."
Lantieri's programme for teachers also includes a strong focus on methods for calming down. It involves weekend retreats, which offer yoga, workshops on stress management and conflict resolution, and introductions to mindfulness and other types of meditation, as well as opportunities for teachers to talk about the meaning of their work. There are also day courses and workshops. Teachers might have a massage, or join a session in which they are read a poem and asked to relate to a line as a way to encourage them to talk through issues that are concerning them. Lantieri also runs monthly meetings that enable local school administrators to come together, to take part in a meditation, use some of the other techniques taught in the retreats, or just to talk, without judgement.
Lantieri's is one of the longest-running 'resilience-building' programmes for schools, but it isn't the only one out there.
The concept of resilience in schools is a hot one. In February 2014 a UK cross-party government group produced a report calling for schools to promote "character and resilience". May 2014 saw the launch of an all-party group to explore the potential for mindfulness in education, as well as in health and criminal justice.
Professor Mark Williams, Director of the Oxford Mindfulness Centre at the University of Oxford, is the joint-developer of a technique for treating depression called mindfulness-based cognitive therapy. It involves encouraging patients to be aware of their thoughts and to accept them, without judgement. Research shows that it's as effective as drugs at cutting the chances of a person who's experienced one episode of major depression suffering another. What if, Williams and colleagues wondered, learning mindfulness-based skills could stop some kids from ever developing depression or an anxiety disorder? What if it could prevent stress, as well as helping them to focus and learn, and go on to be more productive, mentally strong adults?
Mindfulness programmes have been designed specifically for schools - though not necessarily with the main aim of enhancing mental health. In the UK a pair of former teachers got together in 2010 to develop the Mindfulness in Schools Project. They developed a nine-lesson '.b' curriculum to teach kids mindful meditations, such as 'body scanning', to encourage them to keep their attention focused in the present and to help them deal with stress. The effects of the curriculum - rolled out in six participating schools - have been scrutinised in a pilot study conducted by Professor Willem Kuyken at the University of Exeter along with other researchers who have worked with Williams. The results, published in the British Journal of Psychiatry in 2013, found that the curriculum had promising effects on stress levels and wellbeing, and the researchers would like to investigate this further in a large-scale randomised controlled trial of the curriculum in British secondary schools.
Elsewhere, Professor Martin Seligman (sometimes dubbed the 'father of positive psychology') and a team at the University of Pennsylvania have developed the Penn Resiliency Program for late elementary and middle school students. Here the focus is on the content of thoughts. Over twelve 90-minute sessions students are taught to detect 'inaccurate' thoughts, evaluate the accuracy of them and challenge negative beliefs by considering alternative explanations (that popular girl just ignored me in the corridor because she didn't see me, not because she hates my guts). Students are also taught techniques for assertiveness, negotiation, decision making and problem solving, as well as relaxation.
The Penn Resiliency Program has been evaluated in the USA and the UK, with mixed results. A US meta-analysis of 17 controlled evaluations concluded that its effects on depressive symptoms were statistically significant but small. The UK results of the Penn programme weren't hugely encouraging either. There was a "small average impact on pupils' depression scores, school attendance and English and maths grades" according to the final report, but this only lasted until the one-year follow-up study. By the two-year follow-up its impact had vanished.
Kuyken says the effects of the UK .b pilot study were also small. But this doesn't mean the programme isn't useful, he argues. Studies that involve giving an intervention to everybody, whether or not they have a problem, generally only get small overall results. "What these interventions have the potential to do is move the bell curve - that is, to help those most at risk of depression at one end of the curve, but also those who are flourishing and those in the middle who represent most people," he says. Because mindfulness is based on a universal theory of how the mind works, rather than techniques for correcting 'problem thoughts', he hopes that a mindfulness-based intervention like the .b course may achieve longer-term results than the Penn programme. Kuyken and his team hope to carry out this research in the next ten years.
"Research is only beginning on the effects of mindfulness on youth, so it is far too early to think that such an approach would be 'best'," Joe Durlak, Emeritus Professor of Psychology at Loyola University Chicago, told me - something echoed by Ron Palomares, a school psychologist at Texas Woman's University.
There's no one silver bullet when it comes to resiliency in kids, says Palomares. Between 2000 and 2013 he was on the staff of the American Psychological Association, working on the association's Road to Resilience campaign, which it set up after 9/11 to provide public information on how to become more resilient. For adolescents with depressive symptoms, perhaps the Penn Resiliency Program approach may work best, he says. The mindfulness programmes being developed in schools in the USA and the UK are focused more on emotional regulation, which some kids may need help with but others won't.
Based on their research, Palomares's team have identified sharing feelings through talking or other forms of expression, such as art or music, as being among the factors that help kids to "bounce back" from tragic or difficult events. They also found being part of a community, through church or sports, say, to be important, and likewise being able to look to the future. "I believe that a suite of tools is the best approach," says Palomares, "because of the broad individual needs, strengths and weaknesses you come across in any group."
The multifaceted approach of the Inner Resilience Program (IRP) may be best for a group, like a class, or an entire school, because it's more likely to cover the various needs of most of the pupils. Yet, compared to the formal programmes, Lantieri's IRP is more of a 'bag of tricks' - or "a bag of practical strategies", as she describes it. She says she wants to give adults and kids options, as many as possible, to help children cope with whatever life throws at them. "As much as we like to think we can protect our children from what may come their way, we live in a very complex and uncertain world," she says. "We have to give them all the skills of inner resilience, so they're ready for just everyday life."
Resilience might be in your genes but did you know you can also build it? (Retts Wood)
Tom Roepke joined PS 112 a few years before 9/11, straight from a Waldorf (also known as a Steiner) school (which are, he explains, "very steeped in a rich conception of the human being"). "There was a lot of work among the faculty that feeds your inner life. I came from that to the NYC public schools system, and it was very unsettling," he says. "Where was that richness?" After the terrorist attacks he heard about Lantieri's programme. Roepke was among the first to sign up. "[It] gave me... what the Waldorf school used to provide," he says. "A community of educators... all getting together, knowing that this is a job that requires we take care of ourselves."
Roepke fully embraced Lantieri's programme. He introduced the school's principal, Eileen Reiter, and assistant principal to the monthly meetings and IRP concepts. Faculty meetings now start with the striking of a chime and a brief meditation. This doesn't take much time, Roepke says, but it's a real mood-shifter. "If for some reason we don't do the meditation, you really notice it," says Reiter. The inner resilience strategies for children have permeated the school, she says, though there's been no formal implementation - some teachers use a lot of the techniques, others may use very few. It's up to the individual.
The IRP has been adopted by schools in Ohio and Vermont as well as Manhattan, and a pilot project has been launched in Madrid, Spain. Lantieri estimates that over 6 000 teachers and 40 000 students have been exposed to it, but she says people will often come up to her at meetings telling her they've taken ideas from her books and used them in their classrooms, so it's hard to know the exact numbers for sure.
There have been various evaluations. In a randomised controlled study involving 57 New York City teachers over the 2007/08 academic year, participants attended weekly yoga classes, monthly meetings (in which they learnt meditative techniques and other strategies to reduce their stress), a weekend residential retreat and training in the techniques for the classroom. At the end of the year these teachers reported experiencing less stress and improved attention, and felt they had better relationships with colleagues. There was also a significant drop in how frustrated third and fourth grade students said they were, and an increased sense that they had a 'voice' in the classroom. Another evaluation, focusing on school principals, found that between 70 and 80 per cent of participants felt the programme had improved their job satisfaction, their management style, their relationship with staff and their relationship with students.
As far as Lantieri is aware, the schools currently implementing her ideas for the classroom aren't evaluating them formally. Given the "pick-and-mix" adoption of the programme, as the teachers I met at PS 112 and PS 3 describe it - some using IRP strategies often and others not at all - this would be tricky. "It is very organic," Lantieri says. "It has to be, because every school is such a mix of people and attitudes and experiences. You can't make everybody do the same." PS 3, for instance, has many more middle-class, wealthier students than PS 112 in East Harlem. The atmosphere in the two schools is very different. In PS 3 the kids skip down the corridors (it's one of the rules: you can skip or walk but not run), they call out 'hi' in the corridors, they chatter in class. Instead of journals they have 'happy books' where they write about their feelings, things like "I love snack" or "I love To Day". PS 112, in contrast, seemed almost supernaturally self-controlled and calm - though to what extent that was down to a more thorough adoption of IRP practices, or the general focus of the individual principals, or the different needs of the children, it's hard to say.
Principal Reiter of PS 112 has been teaching for 50 years. Interventions have come and gone, but for her the IRP's focus on teachers as well as children sets it apart. She shares Lantieri's view that if teachers are calm and nurtured, they'll be in a better place to help their children. "It's about taking care of the teachers so they can take care of the kids," she says. And these particular children need all the help they can get.
"We have a lot of kids being raised by grandparents, or in foster care," says Reiter. Some live in shelters, some have one parent, or both, in prison. Many of the kids also have special educational needs. When the Twin Towers came down, Reiter had just recently become principal. "We're right next to the FDR and I remember hearing only ambulances or police cars," she says. "Everybody [had] felt safe before that. It was an eye-opener for everybody. That was when we really had to think more deeply about how we support kids who are living in a lot of stress, just in general."
There remains the question of how to pay for all of this. Lantieri still runs the monthly school administrators' meetings and keynotes at conferences on education around the world. But the funding for the IRP has virtually run out. Her short-term grants have expired, and when, at the start of 2013, she had to decide between fundraising or continuing to provide services, she opted for the services.
The week of my visit the National September 11 Memorial & Museum opened at Ground Zero - and Lantieri downsized from her own headquarters to a small office in a school. Both may be taken as signs of recovery from 9/11. But Lantieri hopes the part she has to play in helping the city's kids cope well with the future, as well as the past, is far from over.
Professor Mark Williams has received funding from the Wellcome Trust, who publish Mosaic.
This article first appeared on Mosaic and is republished here under a Creative Commons licence.