The landscape of the Hawaiian islands is as idyllic as a postcard: long, sandy beaches, hibiscus flowers, clear waters of tropical fish and coral reefs. When you arrive at the airport the air is warm and ukulele music is piped out at you. Flower garlands are for sale.
There are hundreds of islands in the Hawaiian archipelago, spread over 1,500 miles in the central Pacific Ocean. The eight main islands include Kauai, Maui and the island of Hawaii, nicknamed The Big Island to differentiate it from the whole state. The Big Island has a live but well-tempered volcano, which has created a dream-like landscape of black rock. Hawaiian myths explain the weird natural features including the tiny, tear-shaped lava rocks that lie all around on the volcano’s sides, named “Pele’s tears” after the Hawaiian fire goddess. The legend has it that if you take any of Pele’s tears away with you, you will be cursed for the rest of your life, unless you return them to where they belong. In the midst of all the beauty, Hawaii has some dark and sinister stories.
Mirena*, who is now 60, was born on the island of Kauai. I meet her on Skype: me in my sitting room in the evening, the English weather dark outside; her in the office where she works at a local school, early in the morning, the light bright and palm trees visible from the window. Mirena is a charismatic woman who speaks with passion. She comes across as warm, caring and professional, and her silver earrings flash against her dark, short hair. Mirena remembers a Hawaii from before the tourism boom, growing up playing in the red Anahola dirt, running through the cane fields. She recalls the simplicity of much of the lifestyle then, the excitement when the first stop light was erected for the cane field trucks, with children walking across the island to go and look at it.
Despite the setting, Mirena’s childhood was far from a paradise. “I saw things…” she says. “I saw things children shouldn’t see.”
Mirena was born in 1955, the year that an experiment began. Mirena’s family, like all families on Kauai who had babies in that year, was approached by two researchers: Emmy Werner and Ruth Smith. Werner and Smith were psychologists who had become interested in which factors in a child’s early life set them off on a positive trajectory, and which ones really get in the way of them reaching their full potential. Little did the families or the researchers know that this would turn into one of the longest studies of child development and childhood adversity that there has ever been.
“We were not even born when the initial investigations started,” says Mirena. “There were 698 families that said, ‘Yes, we’ll support whatever you need.’” The researchers monitored the families from before the babies’ birth, following them and checking in at ages one, two, 10, 18, 32 and 40. They managed to track most of the cohort. “When you come from an island such as Kauai, people don’t move away,” explains Mirena. “And if they do move away, chances are you’re going to find somebody, some relative, who knows where they are… they were pretty successful in tracking us down.”
The researchers followed first the parents and then the children, finding out all sorts of things about how the cohort were doing and what sort of background they had come from. They used a mix of semi-structured interviews, questionnaires and community records of mental health, marriage, divorce, criminal convictions, school achievement and employment.
“My recollection of being a participant, I think the first time, age 18, I was already a young mother,” says Mirena. “I got a phone call from Dr Ruth Smith… she introduced herself and said, ‘Can I come and talk story?’ – which is interview. We’re talking story right now.”
Mirena spent her childhood in a three-bedroom house, with her parents and six siblings. The children walked the mile to and from school, arriving back home to a house they were responsible for keeping clean and tidy. She recalls the black-and-white TV with a piece of shaded paper stuck on the front to make it look like colour.
Hawaii back then was a mix of plantations and a growing hotel industry. Mirena’s father worked for the coastguard. Her mother worked for Aloha Airlines as an entertainer, hula dancing and singing. Mirena’s family had very little money to feed the seven children, and her father drank heavily. Her parents’ marriage was often difficult and sometimes physically violent. “We were very poor, my father was an alcoholic,” Mirena says.
The researchers in the Kauai study separated the nearly 700 children involved into two groups. Approximately two-thirds were thought to be at low risk of developing any difficulties, but about one-third were classed as “high-risk”: born into poverty, perinatal stress, family discord (including domestic violence), parental alcoholism or illness.
“Well, my family definitely fell in the ‘at-risk’ category,” says Mirena. “And you know, I didn’t fully… when you live in an environment, that’s just where you are. You don’t ever stand back and say, ‘Well, I was at risk.’”
The researchers expected to find that the “high-risk” children would do less well than the others as they grew up. In line with those expectations, they found that two-thirds of this group went on to develop significant problems. But totally unexpectedly, approximately one-third of the “high-risk” children didn’t. They developed into competent, confident and caring individuals, without significant problems in adult life. The study of what made these children resilient has become as least as important as the study of the negative effects of a difficult childhood. Why did some of these children do so well despite their adverse circumstances?
The study of how some of these Kauai children thrived despite early adversity is still ongoing. Lali McCubbin is the current principal investigator. The daughter of Hamilton McCubbin, who worked with the original researchers, she knows the history of the project well and has some Hawaiian heritage herself.
“This was a really groundbreaking study,” she says. “What made the study unique was that despite these risk factors… that wasn’t a guarantee… that you would be on a certain trajectory. And in fact, what we found was there was resilience. These children were able to thrive, were able to grow, were able to develop… able to live productive and fulfilling lives.
“A lot of these risk factors are what my father grew up with,” McCubbin adds. “Alcoholism, strict discipline, domestic violence. And I was very fortunate, I didn’t grow up with that, I had a stable home, a very loving home. None of those risk factors. So I was fascinated with how you can take a risk factor intergenerationally and create not intergenerational trauma but intergenerational resilience.”
Three clusters of protective factors tended to mark out the children who did well despite being “high-risk”: aspects of the child’s temperament, having someone who was consistently caring (typically but not necessarily a family member), and having a sense of belonging to a wider group.
Overall, the third of “high-risk” children who showed resilience tended to have grown up in families of four children or fewer, with two years or more between them and their siblings, few prolonged separations from their primary caregiver, and a close bond with at least one caregiver. They tended to be described positively as infants, with adjectives such as “active”, “cuddly” or “alert”, and they had friends at school and emotional support outside of their families. Those who did better also tended to have more extracurricular activities and, if female, to avoid pregnancy until after their teenage years.
The picture was complex, though, with different factors seeming to be important at different ages, McCubbin explains. At age 10, doing well was linked to having been born without complications and having parents with fewer difficulties such as mental health problems, chronic poverty or trouble parenting. At age 10 and 18, positive individual personality traits seemed to help, as well as the presence of positive relationships, though not necessarily with the parents. At age 32 and 40, having a stable marriage was protective, as was participation in the armed forces.
Strikingly, even some children who had “gone off the rails” in their teenage years managed to turn things around and get their lives back on track by the time they were in their 30s and 40s, often without the help of mental health professionals.
Many of the factors involved in such turnarounds, and several of the factors associated with resilience throughout the children’s lives, involve relationships of some kind, whether within the context of a larger community – a school, a religion, the armed services – or in the context of one important person.
“Our relationships really are key,” says McCubbin. “One person can make a big difference.”
Wider research suggests that the more risk factors children face, the more protective factors they are likely to need to compensate. But as McCubbin says, “A lot of the research supports this idea of relationships, and the need to have a sense of someone that believes in you or someone that supports you – even in a chaotic environment, just having that one person.”
“Children don’t know what goes on in the lives of the adults who care for them,” says Mirena. “They’re subject to that life and not by choice. No child chooses to be poor, no child chooses to have alcoholism in their home. It just is, and you deal with it.”
Mirena has done a lot of thinking about her parents’ role in her life, and the importance of having caring and supportive people and environments outside the immediate family home. “My parents, bless their hearts, love them to pieces, but they didn’t do what parents ought to do,” says Mirena. “They were too busy trying to figure out themselves… trying to figure out what do you do with this house full of kids and not enough money to support them… My mom was too busy coping with an alcoholic husband …”
As the eldest child, Mirena often felt responsible for trying to resolve family rows. She has memories of her parents’ violent arguments. “I saw my mom just raging with my dad. He’s in the kitchen, sitting, she’s busted all the bottles all over the kitchen… There’s blood everywhere and I’m thinking, ‘What can I do? I’m just a kid.’”
Mirena thinks her grandmother played a pivotal role. “Luckily for me, we had a gran-ma down the street,” she says. “My mother’s parents lived nearby. They made a huge difference for me, just knowing that somebody loved me no matter what. And I was not always the easiest child. I was sometimes very aggressive and you become that when you have to defend your family. And we spent most of our days outside, so dirty, we were always dirty. Long, tangled hair.
“When things were really bad I would end up at my gran-ma’s house. She was not living that far away… I cut through the park and cut through the cane fields and by the time I got to her there was red dirt and mud everywhere. And my gran-ma was immaculately clean. Her house was spotless… And so when I showed up, on her doorstep, full of Anahola red dirt and mud… I just think, what did my gran-ma think when she saw me, coming her way?
“But not once do I remember being turned away from her home, not once. What she would do is she would take me in the outside cement tub. And she would wash the mud off me. And then she’d take me in the inside bathtub and I remember my gran-ma is the only one who would scrub me clean.
“You know we were on our own as children: if we took a bath, we took a bath – if we didn’t, we didn’t. There was no hot water so most of the time we didn’t until we were forced to. But my grandmother would scrub me clean, to get all the dirt out of my very long hair. And then… she’d sit me at her knee, and she’d patiently take every tangle out of my hair… And I’m crying cos it hurts and she’s saying to me ‘almost pau’ – Hawaiian word for finished. ‘Almost pau’ – very gentle. ‘Almost pau.’ And sometimes finishing would take an hour… I’m sitting at her knee for an hour. But she would be eventually pau, and I remember I’d stand up, and she’d take that comb and she’d go all the way down the back. And I remember as a little girl just feeling clean. And feeling pretty. And feeling like maybe somebody could love me today, maybe I’m OK today. That’s what my gran-ma did for me. Just made me feel like I was OK.”
Mirena also thinks the boarding school she went to when she was 12 helped. “I realised when I came here and I lived in the dorm, with all these different people, that families didn’t have to be like this,” she says. The school’s sense of community was important for her, and she remains working there today. It’s also where she met her future husband, with whom she now has seven children and 15 grandchildren of her own. She says she recalls her grandmother often, particularly when thinking how she wants to be with her family.
“I remember on some of my darkest hours, raising these children in my life, thinking about her and knowing that I need to give as much as she gave to me. There is nothing that surpasses for me that example of love and caring. So I do my best to be that kind of gran-ma to my own.”
It seems blindingly obvious that how we are cared for by our parents or primary caregivers is crucial, but the growing realisation of just how important love and affection are to children has only come about in the last century. Many of the studies that helped us to understand how childhood experiences can affect our adult selves hadn’t been published back when Mirena and the rest of the Kauai cohort were born.
Some of what we know about the effect of parenting comes from watching animals. At Stanford University in the 1930s, in a series of experiments that would be unlikely to get through an ethics committee today, Harry Harlow separated baby rhesus monkeys from their mothers, and raised them in separate cages. He allowed the baby monkeys access to two models of a larger monkey: one made only of wire, but with a bottle of milk attached, and one with no milk attached but which was covered in a soft terry-towelling-type material. The young monkeys spent all their time on the soft model mother, craving the comfort, and only went to the wire one for food, before quickly returning to the towelled surrogate. This put into question all previous ideas about food and shelter being the primary drives for an infant, and suggested that the role of comfort might be much more important than was previously thought.
How foster carers can help traumatised children recoverWe often talk about “getting attached” to someone or something, but the psychological understanding of attachment is more specific. The father of attachment theory was John Bowlby, a psychiatrist, psychologist and psychoanalyst, who defined it as a “deep and enduring emotional bond that connects one person to another across time and space”. Most babies and their caregivers form an attachment, and the quality of this attachment can be affected by the sort of care the baby experiences. We know now that these early attachment relationships can form the basis, to some degree, for the way we relate to others as we grow up, even in adult romantic relationships.
Bowlby was interested in what happened to children who were separated from their caregivers early on. One of his earliest studies was of 88 adolescent patients from his clinic in London. Half had been referred for stealing, and half had emotional troubles but had not shown delinquent behaviour. Bowlby noticed that the “44 thieves”, as he called them, were much more likely than the control group to have lost a caregiver when they were young, which led him to think about how early experiences of loss can have profound effects.
Bowlby went on to write extensively about the importance of attachment and loss of attachment figures, influencing his colleague Mary Ainsworth to develop a way of measuring the quality of attachment between a caregiver and child, which is still used today. The “strange situation”, as it’s called, involves observing a child’s reaction to their caregiver leaving the room and later returning, and also their reaction to a stranger. Based on their reactions, their attachment can be classified in ways that can partly predict their later development. The most worrying classification, “disorganised attachment”, tends to be seen in children whose attachment figures have caused them harm, and has been linked to much poorer abilities to relate to others and regulate emotions in later life.
In the Kauai study, the children living in adverse circumstances largely remained in their homes, and some of them thrived regardless. But across the other side of the world, anyone in Europe old enough to watch TV in 1990 is likely to have a memory of the Romanian orphans. Images of children found in orphanages after the collapse of Nicolae Ceausescu’s rule are deeply sad: bleak rooms, packed full of small children with big eyes, pulling themselves up on their cot bars to see the Western camera operators filming them. Under Ceausescu, abortion and contraception had been banned, leading to a massive rise in birth rates. Children without anyone to care for them had been left in institutions, to experience immense emotional deprivation and neglect. They had very little individualised care, no one to hug them or comfort them, no one to sing them to sleep. Their basic physical needs were met in terms of being given food and kept warm, but their basic emotional needs for affection and comfort were not. They learned not to even bother reaching out when adults were around.
The discovery of the conditions in the orphanages prompted a rush of compassion and charity initiatives to adopt the children. The UK Department of Health contacted a researcher at King’s College London’s Institute of Psychiatry, Psychology & Neuroscience, Michael Rutter, to ask him to measure what was going on.
“Like everyone else, I saw the media,” explains Rutter, sitting with me in his light and airy office at the Social Developmental and Genetic Psychiatry Centre in south London. “But [the research] all started because the Department of Health contacted me, to say they didn’t know what was going to happen to these kids, would it be possible to do a study, follow them through, and find out what were the policy and practice implications? … So I said, let’s have a go.”
For Rutter, this was a scientific opportunity as well as a practical one: “This was a natural experiment.” All previous studies of children in care had involved groups of children who had entered institutions at a range of ages, meaning that variation in their behaviour and wellbeing might be related to things that had happened before they were in care. The Romanian orphans, though, had all been admitted within the first two weeks of life. “It’s a horrible thing to have happened,” says Rutter, “but given that it did happen, one may as well learn as much as possible.”
Rutter’s study assessed the children over time as they settled into new adoptive families. “The findings were surprises all along the line,” he says. Prevailing wisdom at the time was that serious adversity in childhood led to a range of emotional and behavioural problems. Rutter’s research found something different when the children were followed up: apart from a minority who had specific patterns of extreme social difficulties, such as autistic spectrum disorders, “There was no increase in the ordinary emotional and behavioural problems,” he says. “So that was one surprise.” Another surprise was that if the children were adopted out of care early enough – within six months – then they seemed to go on to develop well.
Rutter sees this resilience in the face of adversity as a dynamic process: “Resilience initially was talked about as if it were a trait, and it’s become clear that’s quite the wrong way of looking at it,” he says. “It’s a process, it’s not a thing.
“You can be resilient to some things and not others,” he explains. “And you can be resilient in some circumstances and not others.” He acknowledges that “children, or for that matter adults, who are resilient to some sorts of things are more likely to be resilient to others,” but he stresses that resilience is not a fixed trait.
Rutter offers a medical analogy: “The way to protect children against infections is either to allow natural immunity to develop or to immunise.” Either way, children benefit from limited early exposure to pathogens. To prevent this from happening is, in the long term, harmful. Likewise, children need some stress in their lives, so they can learn to cope with it. “Development involves both change and challenge and also continuity,” says Rutter. “So to see the norm as stability is wrong.”
This suggests that there is something about the way that some children adapt to and cope with adverse circumstances that enables them to be emotionally resilient. It’s not the stress itself that inevitably causes problems, although in the face of enormous adversity it would be much harder to remain resilient, but it’s the interaction between the stress and the ways of coping that is really important. Maybe some ways of coping are more helpful than others, and maybe some protective factors mean that the stress gets managed better.
Rutter recalls a child he saw early on from the Romanian cohort who was really struggling with his behaviour and emotional wellbeing, but who has now gone on to develop in a seemingly resilient way. “He has done very well,” says Rutter. “Relationships at home are splendid, so there was a complete turnaround and it’s difficult to know precisely why that happened, but the fact that it did happen reminds you that it’s a mistake to write off situations as if they can’t be changed.”
What if there are some children who need extra help, though, to boost them up to the same level of development as their more resilient peers? We still know very little about the mechanisms involved in resilience and how we can help them to be more effective. If we think of it as an adaptive process, how do our brains, our thought processes and our behaviours change to help us to cope with adverse early circumstances? Eamon McCrory, Professor of Developmental Neuroscience and Psychopathology at University College London, is investigating just this.
McCrory and his team are collecting a combination of brain images, cognitive assessments, DNA and perceptual data, from children who have been maltreated and allocated a social worker, and also from a control group who have not. The two groups have been painstakingly matched by age, pubertal development, IQ, socioeconomic status, ethnicity and sex. The researchers aim to follow their cohort for as long as funding allows, trying to unpick what would predict which of the children who have been maltreated will go on to develop difficulties and which will be resilient.
McCrory used to work clinically for the National Society for the Prevention of Cruelty to Children and he understands the clinical challenges that are involved with this population: “Resources are very limited,” he explains, “so if you have a hundred children referred to social services who experienced maltreatment, we know that the majority of them actually won’t develop a mental health problem. But then a minority are at significantly elevated risk… At the moment, we have no reliable way of knowing which kid is which. So it seems sensible to try and move the focus back from the disorder to a much earlier stage in the process and characterise the risk profile… Only longitudinal designs can give us this information.”
McCrory’s research is searching for reliable clues that a child will go on to develop difficulties, so that we can begin to know who to target to help. So far, McCrory has identified three main areas where there are likely to be differences: threat processing, brain structure, and autobiographical memory.
Studies of war veterans as well as maltreated children reveal that areas of the brain involved in processing threats, such as the amygdala, are more responsive both in the soldiers coming back from war and in children who have experienced early abuse. It makes sense that if you have been in danger a lot, then your brain may have adapted to be very sensitive to threat. “Our main theoretical proposal at the moment is around a concept of latent vulnerability,” McCrory says, “which is the idea that maltreatment… leads a number of biological and neurocognitive systems to adapt to a context characterised by early stress, threat and unpredictability, and adaptations to those systems may be adaptive and helpful in that context, but embed vulnerability in the longer term.”
The team are also scanning the children’s brains to try to see whether difference in brain structure in maltreated children are stable over time or changeable. “We know very little about malleability of brain structure over time,” explains McCrory. “We know there are structural differences in the orbitofrontal cortex and the mediotemporal lobe, for example, which are quite robust, but we’ve no idea whether they are static or whether they may shift over time, at least in certain children.”
The third area the team think is important is autobiographical memory. The brain system involved in thinking about and processing memories of personal history might also be shaped by early traumatic experiences in a way that is adaptive in the short term but unhelpful in the longer term.
“Autobiographical memory is the process whereby you record and encode your own experiences and make sense of [them],” explains McCrory. “We know that individuals who have depression and PTSD [post-traumatic stress disorder] have… an over-general autobiographical memory pattern, where they lack specificity in their recall of past experience… We also know that kids who have experienced maltreatment can show higher levels of this over-general memory pattern. And longitudinal studies have shown that a pattern of over-general memory can act as a risk factor for future disorder.
“One hypothesis is that the over-general memory limits an individual’s ability to effectively assimilate and negotiate future experiences, because we draw on our past experiences to be able to predict the contingencies and likelihood of events in the future, and use that knowledge to negotiate those experiences well. So… over-general memory might limit one’s ability to negotiate future stressors.”
It makes sense that if horrible things have happened to you in the past, you will want to avoid thinking about and remembering them, which might lead to a tendency to have a memory that’s light on detail. McCrory’s team are finding reliable associations between over-general memory patterns and childhood maltreatment.
Back to Mirena in Hawaii, and she finds it hard to know whether her memory has been affected by her early experiences: “from a personal perspective I wouldn’t know,” she says. “We don’t know what we don’t remember.” The memories she does have of her family growing up are mixed. In our conversations, she often describes them fondly: her father as “a brilliant man” who “read all the time” and was “just kind of ordinary except when he was drunk”, and her mother as “a beautiful Hawaiian woman who had a beautiful voice, who did her best”. Alongside these descriptions are darker memories, of coming home to arguments in the kitchen, or worse: “I saw my mother try to kill my father on several occasions, cos daddy was drunk and mom was mad. And I was usually the one that would try to stop them.” While we talk, Mirena sometimes becomes tearful, remembering difficult times, and other times speaks with passion about the importance of protecting other children.
In an ideal world, we wouldn’t have to work out how to best to help children who have been abused or neglected; we would instead be able to remove those risks. Admitting that we don’t live in that ideal world, and trying to understand what we can do to prevent the negative effects of childhood adversity and to boost individual resilience, is perhaps the next best thing.
Everyone I interviewed for this piece had a sense of optimism. “That’s the psychological perspective, right?” says Lali McCubbin. “We want to believe that people can turn their lives around.”
McCrory certainly does: “I think it’s hopeful to see that recovery is possible and that these [brain systems] are systems characterised by plasticity, and so the questions are then about how do you promote that, are there developmental periods where that is more possible, and how much can we enhance plasticity over those periods?”
The concept of childhood resilience is complex. McCubbin recalls a conversation she had with her father and Emmy Werner about the use of the term, discussing whether they would have called it resilience if they had known then how much it would take off. “And they weren’t sure if they would, and I liked that… because it’s really about adaptation… A lot of people miss that take-home message, and that ‘Oh, the individual wasn’t resilient’, it kind of blames the individual rather than looking at their context. What may be resilient for you may not be the same for somebody else.”
The idea of resilience as an adaptive process rather than an individual trait opens up the potential for other people to be involved in that process. McCubbin sees the importance of relationships as being wider than only protective relationships with people, and she and her team have created a new measure of “relational wellbeing” to try to capture this. “We think of relationship as with a person,” she says. “But what we really found was that it was relationship with the land, relationship with nature, relationship with God, relationship with ancestors, relationship with culture.”
McCubbin’s team have just finished pilot interviews with eight of the original cohort, now in their 60s. She weaves in the Hawaiian idea of aloha as she describes the research. “There’s a tourist version of aloha,” she explains, talking about a word that is variably translated as “love and compassion”, “mercy” and “connectedness” or “being part of all and all being part of me”.
“Aloha means hello and goodbye, but actually aloha means ‘breath of life’,” McCubbin continues. “That was one of the things in our interviews, we were collecting their mana’o, their life’s breath… We got chicken skin when you hear it that way, just that sense of aloha and that sense of how we’re all connected.”
Mirena is clear about the importance of human connection, and so is the research, although we have a way to go before what we are learning about how to best care for children who have survived childhood maltreatment is clearly understood and communicated to all those working with children. For Mirena, the vital thing is still “that there’s somebody they know cares about them. Just one person, it can make all the difference.”
* Her name has been changed.