25
MENTAL HEALTH AND DEVELOPMENTAL PROBLEMS OF CHILDREN IN POVERTY* MARGARET E. HERTZIG, M.D. Associate Professor of Psychiatry Director, Child and Adolescent Outpatient Department Cornell University Medical College-New York Hospital New York, New York
T O SURVEY THE MENTAL HEALTH and developmental problems of children in poverty is to survey much of psychiatric epidemiology. With few exceptions, conditions that place children at increased risk for a wide range of adverse behavioral and developmental outcomes are exaggerated among the poor. Today I hope to highlight some of the major results of child psychiatric epidemiologic research, to consider the implications of the findings within a developmental context, and finally to direct attention to the question of protective factors as they may operate in the lives of children and their families in mitigating or ameliorating the adverse effects of exposure to risk. One of the most robust findings over the past 25 years of systematic epidemiologic study is the association between organic brain dysfunction and psychiatric disorder in children. The carefully designed and executed Isle of Wight studies of Michael Rutter and his collaborators' clearly established that psychiatric problems are some twice more frequent among children identified as suffering from clinically evident disorders of the central nervous system as among those neurologically intact. The intelligence quotients of affected children are also substantially lower. However, the presence of brain injury, in and of itself, does not give rise to a distinctive clinical picture. Rather, the mix of behavioral and emotional disorders that occur in association with demonstrable brain damage is closely similar to that found among the child population at large. Children born into poverty are at greater risk for a host of biologic insults that threaten the integrity of the central nervous system. Poverty increases the probability that a pregnancy will end in the delivery of a low birth weight infant-the incidence of low birthweight being some two to three times *Presented as part of the 1991 Annual Health Conference, Children At Risk: Poverty and Health, held by the Committee on Medicine in Society of the New York Academy of Medicine May 20 and 21, 1991.
Vol. 68, No. 1, January-February 1992
26
HERTZIG M.E. HERTZIG 26M.E.
higher among lower socioeconomic groups. Although estimates of adverse neurodevelopmental outcomes vary widely, in general the risk for serious handicap is inversely related to birthweight. Low birth weight survivorsless than 2,500 grams-experience approximately three times the rate of significant neurologic sequelae as infants of normal birth weight. Very low birthweight survivors -less than 1,500 grams -are at even greater risk, between 12 and 25% experiencing serious neurodevelopmental handicaps.2 While the fundamental causes of both prematurity and interuterine growth retardation are as yet only partially understood, many associated conditions-poor nutrition, small stature, obstetric complications, less than adequate maternal health-are all more common among poor women, as is reduced access to prenatal care. Poverty also is associated with behaviors that have a direct impact on fetal development-the association between cigarette smoking and lower birth weights is well known, as are the range of deleterious effects associated with alcohol consumption and illicit drug use during pregnancy-heroin and, increasingly since the mid 1980s, cocaine. Admissions to neonatal intensive care units in cities in which crack/cocaine is especially prevalent have soared. Precipitous delivery, abruptio placentae, evidence of fetal monitor abnormalities, and fetal meconium staining are present in a significant number of pregnancies complicated by cocaine use. At birth, infants are more poorly developed than those who are drug free. Newborns exposed to cocaine exhibit a high degree of irritability and tremulousness and deficiencies in state control-often more severe than those seen in babies exposed to heroin related drugs in utero. Primitive reflex patterns, abnormalities in muscle tone, and in the execution of volitional movements are described as persisting through at least four months of age.3 Furthermore, intravenous drug use during pregnancy or before carries the risk of exposure to HIV infection, with well documented deleterious effects on central nervous system functioning- including acquired microcephaly, bilateral pyramidal tract signs, and cognitive deficits.4 Most children with AIDS are born to mothers who themselves carry the virus. While the dimensions of the AIDS epidemic remain to be fully defined, estimates developed in the late 1980s suggest that the number of newborns who ultimately will acquire HIV is approaching 1 in 150 births, while in particularly impoverished communities the rate may be as high as 1 in 60.5 Clearly, children of poverty carry a disproportionate burden of biologic vulnerability as a consequence of exposure to these and other health risks. But it is also important to recognize that epidemiologic evidence indicates that Bull. N.Y. Acad. Med.
MENTAL HEALTH HEALTH MENTAL
27 97~~~~~~~~~~~~~~~~~~~~~~~4
only a tiny minority of the psychiatric disorders of childhood are associated with overt organic brain lesions. Although the proportion of cases whose mental retardation can be directly attributable to injuries to the central nervous system sustained during the perinatal period or childhood years is somewhat greater; still, this is the case for only some 15% of retarded children.6 Hence the question arises whether a higher proportion of psychiatric and developmental problems may occur as a consequence of insults to the nervous system that are not clinically evident. Certainly this was the conclusion reached by Pasamanack and Knobloch7 when they proposed a "continuum of reproductive casualty" to explain the findings of a series of retrospective studies of the pregnancy and birth histories of children with a variety of subsequent disorders. Not only cerebral palsy and epilepsy, but mental retardation, behavior disorders, as well as reading disabilities were significantly associated with greater numbers of complications of pregnancy and prematurity. However, a linear cause and effect relationship between risk and outcome-what has been termed a Main Effects Model -has not proved entirely adequate to explain the data of prospectively organized investigations. When subjects with early characteristics thought to be implicated in the cause of later disorder are studied longitudinally, social class emerged as a powerful predictor of long-term developmental outcome for infants born at risk. For example, in the Kauai studies of child development, Werner8 reported that children from advantaged homes with the most severe perinatal complications -if free of obvious physical defect-had mean intelligence quotients closely similar to those of children with no perinatal complications from poor homes. By 18 years of age, 10 times as many children had problems that could be related to the effects of poor early environment than to the effects of perinatal stress. Results of the Kauai study seem to indicate that perinatal complications taken alone are not consistently related to later mental and psychological development, but that adverse medical conditions and adverse social conditions act synergistically to worsen the fate of children who are doubly exposed. In 1975 Sameroff and Chandler proposed a "continuum of caretaking casualty" to incorporate the environmental risk factors contributing to poor developmental and behavioral outcome, suggesting that while reproductive casualties may initiate the production of later problems their importance, in Sameroff's words, "pales in comparison" to the effects of the caretaking environment.9 How may we begin to understand the nature of the caretaking environment? While social class is a time honored marker of potential psyVol. 68, No. 1, January-February 1992
28
28
M.E. HERTZIG
ME.
HERT7TCT
chosocial risk, it is only a summary variable incorporating a number of different risk factors including, among others, family size, marital and minority group status, unemployment, maternal mental health problems -most particularly anxiety and depression-negative child-rearing attitudes and beliefs, impaired mother-child interactions, poor coping skills, inadequate social support, and stressful life events that interfere with a family's ability to provide a nurturant context for the developing child. Sameroff and colleagues have shown that while no single factor is always present or always absent when high levels of social-emotional and intellectual difficulty are found, the greater the number of risk factors the poorer the outcome for the child. Although this cumulative deleterious effect is, to some extent, evident within all social class groupings, environmental risk factors tend to cluster in poor families. 10 Homelessness imposes yet another burden on poor families. During the past decade, not only has the number of homeless people increased sharply, but single mothers and young children constitute the fastest growing segment of this country's homeless population, accounting for one third of the more than 2.5 million homeless people nationwide. Recent studies of the behavioral, emotional, and developmental attributes of homeless children attest to the importance of cumulative risk. Particularly damaging consequences are found in the preschool age group. Shelter children between the ages of three and five are significantly more delayed in receptive vocabulary and visualmotor development, and have significantly higher rates of behavioral and emotional symptoms when compared to children of similar age and background living in homes, and significantly fewer are enrolled in early childhood programs. Homeless youngsters between 6 and 12 years of age are similar in many ways to their domiciled peers from poor inner city families. As Rescorla and colleagues have emphasized, this is not because homeless children of school age are doing well, but because statistically significant differences are obscured by the large numbers of children in both groups who suffer from below average intelligence, delayed academic achievement and behavioral and/or emotional difficulties. 11,12 A "transactional" model of child development initially proposed by Sameroff9 provides a framework to describe the processes through which environmental factors and an individual child's strengths and vulnerabilities contribute to the shaping of outcome. Central to this model is recognition that neither constitution or environment are necessarily constant. Rather, characteristics of both change in important and mutually influential ways over the developmental course. Children are active partners in their interactions with Bull. N.Y. Acad. Med.
MENTAL HEALTH
MENTAL HEALTH
29 29
the environment, affecting changes in the world around them, as this changed world in turn further changes them. For example, let us consider the longitudinal course of temperamental organization. Children with difficult temperaments, those who are intense, nonadaptive, irregular, and frequently moody, are at increased risk for the development of behavior disorders as a consequence of poorness of fit between temperamental style and parental expectations. However, appropriate environmental modifications can result, not only in the amelioration of disordered behavioral patterns, but in diminution of difficult temperamental attributes as well. 13 Interactions between the factors subsumed under the continuums of both reproductive and caretaking casualty are in continuous dynamic interplay. From this perspective, cumulative risk can be thought to reflect the continuation of forces that, by perpetuating dissonance between child and environment, inhibit the emergence of self-righting and self-organizing tendencies that would, in more benign circumstances, move the developing child closer to normality. Nevertheless, it has long been known that even in the most discordant and impoverished homes, some children, some even with physical handicaps as well, emerge with all of the hallmarks of competence -stable personalities, good peer relations, academic achievement, commitment to education and to purposive life goals -and who display a remarkable degree of resilience in the face of life's adversities. In recent years increased attention has been directed toward the study of factors that facilitate "escape from risk." One of the most comprehensive efforts has been the investigation, now spanning some 30 years, of the children of Kauai. 14 Some one third of the initial sample of 698 infants were considered "at risk" because they had experienced moderate to severe degrees of perinatal stress, were born into poverty, were reared by mothers with little formal education, and lived in family environments troubled by discord, desertion, divorce, or marred by parental alcoholism or mental illness. Although two of three of these at-risk children developed serious learning or behavior problems by the age of 10, or had delinquency records, mental health problems, or pregnancies by the age of 18, one in three developed into competent, confident, and caring young adults. Comparisons between these two groups of individuals exposed to comparable levels of initial risk led to the identification of characteristics within the individuals, within their families, and outside the family circles that contributed to resiliency. As infants, resilient subjects were temperamentally easier, Vol. 68, No. 1, January-February 1992
30 30
M.E. HERTZIG
good-natured, and affectionate, with fewer eating and sleeping difficulties than high risk infants who later developed serious behavior problems. As toddlers, resilient children were seen as more alert, autonomous, socially oriented, and more advanced in communication and self-help skills. Though not especially gifted, in school these children tended to use whatever skills they had effectively. They had many interests and engaged in activities and hobbies that provided solace in adversity and a reason for pride. Resilient children tended to grow up in families with four or fewer children and a space of at least two years between themselves and their next sibling. Few had experienced prolonged separations from their primary caretaker during the first year of life and had had an opportunity to establish a close bond with at least one caregiving person during the first years of life. Nurturance, however, could have come from substitute parents including grandparents, older siblings, neighbors, or regular babysitters who played important roles as positive models of identification. As they grew older, resilient children tended to have at least one and usually several close friends. They relied on an informal network of kin, neighbors, and peers for counsel and support in times of crisis. Some had a favorite teacher who became a role model, friend, and confidant. Participation in extracurricular activities played important parts in the lives of resilient youth, especially in cooperative enterprises. As the number of stressful life events accumulated over time, more of such protective factors were needed as counterbalance to insure continued positive adaptation. In reviewing data from this and other studies, Rutter15 suggested that protective processes include those that reduce the impact of risk through alterations of exposure to or involvement in risk situations directly, those that reduce the likelihood of negative chain reactions stemming from risk encounters, those that promote self-esteem and self-efficacy through the availability of secure and supportive personal relationships or successful task accomplishments, and those that open up new opportunities. Protection, in Rutter's view,15 lies less in the psychological chemistry of the moment than in the ways in which people of all ages deal with life changes and what they do about their stressful or disadvantageous life circumstances. While the importance of early interventions directed toward improving mother-child interactions during infancy and the preschool years are undeniably important, attention needs to be directed as well toward the identification of later potential turning points in peoples lives -school entrance with opportunities for peer relationships as well as task mastery, school leaving with accompanying Bull. N.Y. Acad. Med.
MENTAL HEALTH
31
preparations for work, intimate relationships, and parenting, geographic moves, and the like-when risk trajectories may be redirected onto more adaptive paths. REFERENCES 1. Rutter, M., Tizard, J., and Whitmore, K.: Education, Health and Behavior. London, Longman, 1970. 2. Wise, P.H. and Meyers, A.: Poverty and child health. Ped. Clinics North Am. 35:1169-86, 1988. 3. Heagarty, M.C.: Crack cocaine. A new danger for children. Am. J. Dis. Child. 144:756-57, 1990. 4. Belman, A.L., Diamond, G., Dickson, D., et al.: Pediatric acquired immunodeficiency syndrome. Am. J. Dis.
Child. 142:29-35, 1988.
5. Cooper, E.R., Pelton, S.I., and LeMay, M.: Acquired immunodeficiency syndrome: A new population of children at risk. Ped. Clinics North Am. 35:1365-88, 1988. 6. American Psychiatric Association: Diagnostic and Statistical Manual. Third Edition-Revised. Washington, D.C.,
American Psychiatric Association, 1987. 7. Pasaminick, B. and Knobloch, H.: Retrospective studies in the epidemiology of reproductive casuality: Old and new. Merrill-Palmer Quart. 12:7-26, 1966. 8. Werner, E. and Smith, R.: Kauai's Children Come ofAge. Honolulu, University of Hawaii Press, 1977. 9. Sameroff, A. and Chandler, M.: Repro-
Vol. 68, No. 1, January-February 1992
10.
11.
12.
13. 14.
15.
ductive Risk and the Continuum of Caretaking Casualty. In: Review of Child Development Research, vol. 4, Horowitz, F., Hetherington, M. ScarrSalapatek, S., and Siegel, G., editors. Chicago, University of Chicago Press, 1975, pp. 187-244. Sameroff, A., Seifer, R., Barocas, R., et al.: Intelligence quotient scores of 4 year old children: Social environmental risk factors. Pediatrics 79:343-50, 1987. Bassuck, E. and Rosenberg, L.: Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-61, 1990. Rescorla, L., Parker, R., and Stolley, P.: Ability, achievement and adjustment in homeless children. Am. J. Orthopsychiat. 61:210-20, 1991. Thomas, A. and Chess, S.: Temperament and Development. New York, Brunner/Mazel, 1977. Werner, E.: High-risk children in young adulthood: A longitudinal study from birth to 32 years. Am. J. Orthopsychiat. 59:72-89, 1989. Rutter, M.: Psychosocial resilience and protective mechanisms. Amer. J. Orthopsychiat. 57:316-31, 1987.
MENTAL HEALTH AND DEVELOPMENTAL PROBLEMS OF CHILDREN IN POVERTY* MARGARET E. HERTZIG, M.D. Associate Professor of Psychiatry Director, Child and Adolescent Outpatient Department Cornell University Medical College-New York Hospital New York, New York
T O SURVEY THE MENTAL HEALTH and developmental problems of children in poverty is to survey much of psychiatric epidemiology. With few exceptions, conditions that place children at increased risk for a wide range of adverse behavioral and developmental outcomes are exaggerated among the poor. Today I hope to highlight some of the major results of child psychiatric epidemiologic research, to consider the implications of the findings within a developmental context, and finally to direct attention to the question of protective factors as they may operate in the lives of children and their families in mitigating or ameliorating the adverse effects of exposure to risk. One of the most robust findings over the past 25 years of systematic epidemiologic study is the association between organic brain dysfunction and psychiatric disorder in children. The carefully designed and executed Isle of Wight studies of Michael Rutter and his collaborators' clearly established that psychiatric problems are some twice more frequent among children identified as suffering from clinically evident disorders of the central nervous system as among those neurologically intact. The intelligence quotients of affected children are also substantially lower. However, the presence of brain injury, in and of itself, does not give rise to a distinctive clinical picture. Rather, the mix of behavioral and emotional disorders that occur in association with demonstrable brain damage is closely similar to that found among the child population at large. Children born into poverty are at greater risk for a host of biologic insults that threaten the integrity of the central nervous system. Poverty increases the probability that a pregnancy will end in the delivery of a low birth weight infant-the incidence of low birthweight being some two to three times *Presented as part of the 1991 Annual Health Conference, Children At Risk: Poverty and Health, held by the Committee on Medicine in Society of the New York Academy of Medicine May 20 and 21, 1991.
Vol. 68, No. 1, January-February 1992
26
HERTZIG M.E. HERTZIG 26M.E.
higher among lower socioeconomic groups. Although estimates of adverse neurodevelopmental outcomes vary widely, in general the risk for serious handicap is inversely related to birthweight. Low birth weight survivorsless than 2,500 grams-experience approximately three times the rate of significant neurologic sequelae as infants of normal birth weight. Very low birthweight survivors -less than 1,500 grams -are at even greater risk, between 12 and 25% experiencing serious neurodevelopmental handicaps.2 While the fundamental causes of both prematurity and interuterine growth retardation are as yet only partially understood, many associated conditions-poor nutrition, small stature, obstetric complications, less than adequate maternal health-are all more common among poor women, as is reduced access to prenatal care. Poverty also is associated with behaviors that have a direct impact on fetal development-the association between cigarette smoking and lower birth weights is well known, as are the range of deleterious effects associated with alcohol consumption and illicit drug use during pregnancy-heroin and, increasingly since the mid 1980s, cocaine. Admissions to neonatal intensive care units in cities in which crack/cocaine is especially prevalent have soared. Precipitous delivery, abruptio placentae, evidence of fetal monitor abnormalities, and fetal meconium staining are present in a significant number of pregnancies complicated by cocaine use. At birth, infants are more poorly developed than those who are drug free. Newborns exposed to cocaine exhibit a high degree of irritability and tremulousness and deficiencies in state control-often more severe than those seen in babies exposed to heroin related drugs in utero. Primitive reflex patterns, abnormalities in muscle tone, and in the execution of volitional movements are described as persisting through at least four months of age.3 Furthermore, intravenous drug use during pregnancy or before carries the risk of exposure to HIV infection, with well documented deleterious effects on central nervous system functioning- including acquired microcephaly, bilateral pyramidal tract signs, and cognitive deficits.4 Most children with AIDS are born to mothers who themselves carry the virus. While the dimensions of the AIDS epidemic remain to be fully defined, estimates developed in the late 1980s suggest that the number of newborns who ultimately will acquire HIV is approaching 1 in 150 births, while in particularly impoverished communities the rate may be as high as 1 in 60.5 Clearly, children of poverty carry a disproportionate burden of biologic vulnerability as a consequence of exposure to these and other health risks. But it is also important to recognize that epidemiologic evidence indicates that Bull. N.Y. Acad. Med.
MENTAL HEALTH HEALTH MENTAL
27 97~~~~~~~~~~~~~~~~~~~~~~~4
only a tiny minority of the psychiatric disorders of childhood are associated with overt organic brain lesions. Although the proportion of cases whose mental retardation can be directly attributable to injuries to the central nervous system sustained during the perinatal period or childhood years is somewhat greater; still, this is the case for only some 15% of retarded children.6 Hence the question arises whether a higher proportion of psychiatric and developmental problems may occur as a consequence of insults to the nervous system that are not clinically evident. Certainly this was the conclusion reached by Pasamanack and Knobloch7 when they proposed a "continuum of reproductive casualty" to explain the findings of a series of retrospective studies of the pregnancy and birth histories of children with a variety of subsequent disorders. Not only cerebral palsy and epilepsy, but mental retardation, behavior disorders, as well as reading disabilities were significantly associated with greater numbers of complications of pregnancy and prematurity. However, a linear cause and effect relationship between risk and outcome-what has been termed a Main Effects Model -has not proved entirely adequate to explain the data of prospectively organized investigations. When subjects with early characteristics thought to be implicated in the cause of later disorder are studied longitudinally, social class emerged as a powerful predictor of long-term developmental outcome for infants born at risk. For example, in the Kauai studies of child development, Werner8 reported that children from advantaged homes with the most severe perinatal complications -if free of obvious physical defect-had mean intelligence quotients closely similar to those of children with no perinatal complications from poor homes. By 18 years of age, 10 times as many children had problems that could be related to the effects of poor early environment than to the effects of perinatal stress. Results of the Kauai study seem to indicate that perinatal complications taken alone are not consistently related to later mental and psychological development, but that adverse medical conditions and adverse social conditions act synergistically to worsen the fate of children who are doubly exposed. In 1975 Sameroff and Chandler proposed a "continuum of caretaking casualty" to incorporate the environmental risk factors contributing to poor developmental and behavioral outcome, suggesting that while reproductive casualties may initiate the production of later problems their importance, in Sameroff's words, "pales in comparison" to the effects of the caretaking environment.9 How may we begin to understand the nature of the caretaking environment? While social class is a time honored marker of potential psyVol. 68, No. 1, January-February 1992
28
28
M.E. HERTZIG
ME.
HERT7TCT
chosocial risk, it is only a summary variable incorporating a number of different risk factors including, among others, family size, marital and minority group status, unemployment, maternal mental health problems -most particularly anxiety and depression-negative child-rearing attitudes and beliefs, impaired mother-child interactions, poor coping skills, inadequate social support, and stressful life events that interfere with a family's ability to provide a nurturant context for the developing child. Sameroff and colleagues have shown that while no single factor is always present or always absent when high levels of social-emotional and intellectual difficulty are found, the greater the number of risk factors the poorer the outcome for the child. Although this cumulative deleterious effect is, to some extent, evident within all social class groupings, environmental risk factors tend to cluster in poor families. 10 Homelessness imposes yet another burden on poor families. During the past decade, not only has the number of homeless people increased sharply, but single mothers and young children constitute the fastest growing segment of this country's homeless population, accounting for one third of the more than 2.5 million homeless people nationwide. Recent studies of the behavioral, emotional, and developmental attributes of homeless children attest to the importance of cumulative risk. Particularly damaging consequences are found in the preschool age group. Shelter children between the ages of three and five are significantly more delayed in receptive vocabulary and visualmotor development, and have significantly higher rates of behavioral and emotional symptoms when compared to children of similar age and background living in homes, and significantly fewer are enrolled in early childhood programs. Homeless youngsters between 6 and 12 years of age are similar in many ways to their domiciled peers from poor inner city families. As Rescorla and colleagues have emphasized, this is not because homeless children of school age are doing well, but because statistically significant differences are obscured by the large numbers of children in both groups who suffer from below average intelligence, delayed academic achievement and behavioral and/or emotional difficulties. 11,12 A "transactional" model of child development initially proposed by Sameroff9 provides a framework to describe the processes through which environmental factors and an individual child's strengths and vulnerabilities contribute to the shaping of outcome. Central to this model is recognition that neither constitution or environment are necessarily constant. Rather, characteristics of both change in important and mutually influential ways over the developmental course. Children are active partners in their interactions with Bull. N.Y. Acad. Med.
MENTAL HEALTH
MENTAL HEALTH
29 29
the environment, affecting changes in the world around them, as this changed world in turn further changes them. For example, let us consider the longitudinal course of temperamental organization. Children with difficult temperaments, those who are intense, nonadaptive, irregular, and frequently moody, are at increased risk for the development of behavior disorders as a consequence of poorness of fit between temperamental style and parental expectations. However, appropriate environmental modifications can result, not only in the amelioration of disordered behavioral patterns, but in diminution of difficult temperamental attributes as well. 13 Interactions between the factors subsumed under the continuums of both reproductive and caretaking casualty are in continuous dynamic interplay. From this perspective, cumulative risk can be thought to reflect the continuation of forces that, by perpetuating dissonance between child and environment, inhibit the emergence of self-righting and self-organizing tendencies that would, in more benign circumstances, move the developing child closer to normality. Nevertheless, it has long been known that even in the most discordant and impoverished homes, some children, some even with physical handicaps as well, emerge with all of the hallmarks of competence -stable personalities, good peer relations, academic achievement, commitment to education and to purposive life goals -and who display a remarkable degree of resilience in the face of life's adversities. In recent years increased attention has been directed toward the study of factors that facilitate "escape from risk." One of the most comprehensive efforts has been the investigation, now spanning some 30 years, of the children of Kauai. 14 Some one third of the initial sample of 698 infants were considered "at risk" because they had experienced moderate to severe degrees of perinatal stress, were born into poverty, were reared by mothers with little formal education, and lived in family environments troubled by discord, desertion, divorce, or marred by parental alcoholism or mental illness. Although two of three of these at-risk children developed serious learning or behavior problems by the age of 10, or had delinquency records, mental health problems, or pregnancies by the age of 18, one in three developed into competent, confident, and caring young adults. Comparisons between these two groups of individuals exposed to comparable levels of initial risk led to the identification of characteristics within the individuals, within their families, and outside the family circles that contributed to resiliency. As infants, resilient subjects were temperamentally easier, Vol. 68, No. 1, January-February 1992
30 30
M.E. HERTZIG
good-natured, and affectionate, with fewer eating and sleeping difficulties than high risk infants who later developed serious behavior problems. As toddlers, resilient children were seen as more alert, autonomous, socially oriented, and more advanced in communication and self-help skills. Though not especially gifted, in school these children tended to use whatever skills they had effectively. They had many interests and engaged in activities and hobbies that provided solace in adversity and a reason for pride. Resilient children tended to grow up in families with four or fewer children and a space of at least two years between themselves and their next sibling. Few had experienced prolonged separations from their primary caretaker during the first year of life and had had an opportunity to establish a close bond with at least one caregiving person during the first years of life. Nurturance, however, could have come from substitute parents including grandparents, older siblings, neighbors, or regular babysitters who played important roles as positive models of identification. As they grew older, resilient children tended to have at least one and usually several close friends. They relied on an informal network of kin, neighbors, and peers for counsel and support in times of crisis. Some had a favorite teacher who became a role model, friend, and confidant. Participation in extracurricular activities played important parts in the lives of resilient youth, especially in cooperative enterprises. As the number of stressful life events accumulated over time, more of such protective factors were needed as counterbalance to insure continued positive adaptation. In reviewing data from this and other studies, Rutter15 suggested that protective processes include those that reduce the impact of risk through alterations of exposure to or involvement in risk situations directly, those that reduce the likelihood of negative chain reactions stemming from risk encounters, those that promote self-esteem and self-efficacy through the availability of secure and supportive personal relationships or successful task accomplishments, and those that open up new opportunities. Protection, in Rutter's view,15 lies less in the psychological chemistry of the moment than in the ways in which people of all ages deal with life changes and what they do about their stressful or disadvantageous life circumstances. While the importance of early interventions directed toward improving mother-child interactions during infancy and the preschool years are undeniably important, attention needs to be directed as well toward the identification of later potential turning points in peoples lives -school entrance with opportunities for peer relationships as well as task mastery, school leaving with accompanying Bull. N.Y. Acad. Med.
MENTAL HEALTH
31
preparations for work, intimate relationships, and parenting, geographic moves, and the like-when risk trajectories may be redirected onto more adaptive paths. REFERENCES 1. Rutter, M., Tizard, J., and Whitmore, K.: Education, Health and Behavior. London, Longman, 1970. 2. Wise, P.H. and Meyers, A.: Poverty and child health. Ped. Clinics North Am. 35:1169-86, 1988. 3. Heagarty, M.C.: Crack cocaine. A new danger for children. Am. J. Dis. Child. 144:756-57, 1990. 4. Belman, A.L., Diamond, G., Dickson, D., et al.: Pediatric acquired immunodeficiency syndrome. Am. J. Dis.
Child. 142:29-35, 1988.
5. Cooper, E.R., Pelton, S.I., and LeMay, M.: Acquired immunodeficiency syndrome: A new population of children at risk. Ped. Clinics North Am. 35:1365-88, 1988. 6. American Psychiatric Association: Diagnostic and Statistical Manual. Third Edition-Revised. Washington, D.C.,
American Psychiatric Association, 1987. 7. Pasaminick, B. and Knobloch, H.: Retrospective studies in the epidemiology of reproductive casuality: Old and new. Merrill-Palmer Quart. 12:7-26, 1966. 8. Werner, E. and Smith, R.: Kauai's Children Come ofAge. Honolulu, University of Hawaii Press, 1977. 9. Sameroff, A. and Chandler, M.: Repro-
Vol. 68, No. 1, January-February 1992
10.
11.
12.
13. 14.
15.
ductive Risk and the Continuum of Caretaking Casualty. In: Review of Child Development Research, vol. 4, Horowitz, F., Hetherington, M. ScarrSalapatek, S., and Siegel, G., editors. Chicago, University of Chicago Press, 1975, pp. 187-244. Sameroff, A., Seifer, R., Barocas, R., et al.: Intelligence quotient scores of 4 year old children: Social environmental risk factors. Pediatrics 79:343-50, 1987. Bassuck, E. and Rosenberg, L.: Psychosocial characteristics of homeless children and children with homes. Pediatrics 85:257-61, 1990. Rescorla, L., Parker, R., and Stolley, P.: Ability, achievement and adjustment in homeless children. Am. J. Orthopsychiat. 61:210-20, 1991. Thomas, A. and Chess, S.: Temperament and Development. New York, Brunner/Mazel, 1977. Werner, E.: High-risk children in young adulthood: A longitudinal study from birth to 32 years. Am. J. Orthopsychiat. 59:72-89, 1989. Rutter, M.: Psychosocial resilience and protective mechanisms. Amer. J. Orthopsychiat. 57:316-31, 1987.
