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. 2025 Sep 1;60(5):462–468. doi: 10.5152/TurkArchPediatr.2025.25108

Staying Strong Despite Adversity: Resilience in Children and Adolescents

Gizem Durcan 1,✉, Mesut Yavuz 1
PMCID: PMC12432124  PMID: 40958511

Abstract

Resilience is a dynamic adaptation process defined as an individual’s ability to overcome and recover from stress or unhappiness. A person’s resilience is determined by the balance between risk factors and protective factors. Risk factors increase the likelihood of negative outcomes, whereas protective factors modify responses to the negative event, thereby avoiding potential negative outcomes. Studies on the neurobiology of resilience are heterogeneous and have associations in the structure, activity, and connectivity of prefrontal and subcortical areas. Chronic diseases, which have increased in frequency in children and adolescents over the years, are an important risk factor for resilience. Resilience in chronic diseases is closely related to both the course of physical illness and mental outcomes. In chronic diseases, family resilience is of great importance in addition to individual-level characteristics such as self-efficacy, self-confidence, and coping strategies. The whole family in the child’s life, which cannot exist alone, is affected by the disease and the process and affects each other. Family resilience mainly includes shared family belief systems, forms of family organization, and family members’ open communication and problem-solving skills. Through the resilience they develop, families cope with the stress of chronic illness, thereby improving their children’s ability to cope with stress. As a dynamic concept, resilience can change and be developed over time. Increasing resilience through community, family, and individual interventions at different levels can have a positive impact on medical and psychosocial outcomes.

Keywords: Adolescent, children, chronic disease, resilience

What is already known on this topic?

  • Resilience is an individual and dynamic process of adaptation.

  • Improving resilience has a positive impact on physical and psychosocial outcomes.

Introduction

Efforts to address global challenges such as climate change, natural disasters, economic fluctuations, wars, and terrorism have increased interest in resilience.1 In the early 20th century, global disasters such as the Great Depression and World War II, which affected tens of millions of children and families worldwide, encouraged clinicians to better understand how adversity threatens human adaptation and what can be done to reduce risk and promote recovery. Initially, such phenomena were described as invulnerability or stress resistance, but later the term resilience was adopted to describe the ability to adapt in the context of dysfunction or adaptive problems, broadly referring to the study of processes and outcomes.1 This article is a narrative review and discusses the definition of resilience, its history, associated risk factors and protective factors, resilience in chronic illness, family resilience, and methods for improving resilience. Google Scholar, PubMed, and Web of Science databases were searched for literature selection for this narrative review research. The keywords “Child,” “Adolescent,” “Resilience,” and “Chronic Disease” were used for the literature review. Since it is a specific topic, no time interval was specified in the literature review. After the abstract check, the studies that were deemed appropriate were included in the current review. Studies written in a foreign language other than English and published in journals that are not included in internationally recognized indexes were excluded.

Definition of Resilience

The word resilience comes from the Latin verb “resilire” (to bounce back). As a technical term, resilience in physics is considered to be the ability of a stretched body to regain its size and shape after deformation. In psychology, resilience is often defined as a person’s ability to overcome and recover from stress and adversity.2 In other words, it is the ability to recover from a difficult situation—the opposite of psychopathology. Stress resilience is the ability to recover quickly after being exposed to a stressor (trauma) based on experience and adaptation.3 Some researchers have conceptualized resilience as an outcome; that is, a positive response to distress.4-6 In this context, resilience is also characterized as a process, a dynamic adaptation to adversity over time.7

History of Resilience

An examination of the development of resilience studies shows that the context and the samples on which the studies focus have changed considerably.

In the early years, resilience studies focused on young people who had been exposed to childhood maltreatment or trauma to understand the development of psychopathology.8 While childhood adversity increases the risk for various psychological disorders, resilience plays a critical role in adapting to adverse experiences.9 In an article summarizing early research, Rutter described resilience in terms of processes and milestones, pointing to the “steeling effects” through which the stress response better prepares the individual for later adaptation.10

Subsequent researchers have emphasized that there is no single indicator of risk and that children are often exposed to multiple risk factors or adversities.11 Two main approaches have been developed to identify resources and protective factors associated with resilience: individual characteristics of the person and characteristics of the stressor.12 The focus of research has been on psychopathologies such as post-traumatic stress disorder, and differences between patients and healthy controls have been examined.13 Although context is emphasized as important, research during this time did not focus enough on protective factors that may cause contextual and cultural differences.14

With advances in genes and biological processes, studies on neurobiology in resilience have been enhanced. Contemporary systems models assume that many systems interact and act together, from the molecular level to the influence of physical and sociocultural ecologies. An individual’s resilience depends on the function of complex adaptive systems that interact and transform throughout the developmental process.14 With these approaches, the view that characteristics previously defined as individual protective factors in children reflect contextually shaped adaptive systems has come to the fore.15 In the last 4 decades, research on the role of culture in resilience has evolved, with more attention being paid to cultural practices, such as religion, that can promote resilience in individuals and communities.14 Research has moved away from the clinical population and toward the mentally healthy population, with a greater focus on understanding the socioeconomic and neurobiological aspects of individuals and their interactions.16,17

Principles of Resilience

There is great variation in the way children respond to stressors in their lives. Some children appear to be relatively unaffected, while others develop a variety of psychological, behavioral, and physical consequences. Resilience has been proposed to explain these differences in the expression of pathology in traumatized children. Most definitions of resilience refer to overcoming stress or adversity or a relative resistance to environmental risks.18 Protective factors help to avoid potential negative outcomes by modifying responses to adverse events. Risk factors are conditions that increase the likelihood of negative outcomes. The important point is that protective and risk factors are not static units; they can change depending on the context and lead to different outcomes.19 A summary of risk and protective factors is given in Table 1.

Table 1.

Major Risk Factors and Protective Factors Associated with Resilience

Risk Factors Protective Factors
Individual factors
 Prematurity
 Low birth weight
 Chronic illness
 Physical disabilities
 Low cognitive capacity
 Presence of psychopathology
 Low self-esteem
 Low self-regulation
Family factors
 Parental mental disorders
 Parental neglect or abuse
 Family violence
 Inconsistent parenting styles
 Divorce or death of parents
 Poor family environment
 Poverty
Social and cultural factors
 Migration
 Terrorism
 War
Violence,
 Ethnic minority
 Peer bullying
 Social exclusion
 Poor social support networks		 Individual factors
 Self-control
 Self-efficacy
 Focus on problem solving
 Acceptance
 Optimism
 Social skills
 Extraversion
 Self-confidenc
 Seeking social support
Family factors
 Secure attachment
 Maternal warmth
 Positive family atmosphere
 Good parent-child communication
 Low parental stress
 Rules and routines
Social and cultural factors
 Social resources and support
 Peer support
 Access to education
 Safety and security
 School attendance and engagement
 Positive neighborhood environment
 Religious belief
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Risk Factors

An important point regarding risk factors is that there is more than 1 pathway between risk and a problematic outcome and that there is often not just 1 risk, but different combinations of risk factors are required, and that the impact of a risk factor depends on its timing and its relationship to other risk factors.18 Even when a genetic or biochemical mechanism has been identified, the occurrence of the disorder is influenced by environmental or biological events. Furthermore, the concept of risk may differ between groups or cultures. For example, corporal punishment and strict parenting may be seen as evidence of parental care in some societies, while in others, they may be considered child maltreatment.20 The continuity and intensity of exposure to risk factors are also influential. Resilience can develop as a result of repeated short-term exposures that enable individuals to cope, such as immunizing people against disease through the administration of vaccines that are attenuated forms of the pathogen.21 Continuous and intense exposure to multiple risk factors can prevent the development of resilience.

A recent study revealed a wide range of risks, including exposure to terrorism, war or violence, homelessness, poor family environment, sexual abuse, ethnic minority membership, parental mental disorders, poverty, risk of social exclusion, and substance abuse.22 Individual biological factors such as prematurity and low birth weight, chronic illness, and physical disabilities also pose a risk.23

Protective Factors

Factors such as individual characteristics, social, and family support systems are protective factors that play a role in high resilience.24 The dynamic and contextual dimensions should be taken into account when assessing protective factors. Some factors may be neutral or potentially risky in the absence of environmental risk but protective in the presence of environmental risk.25 For example, if safe and nurturing maternal care is present, the positive effect of non-maternal care is not expected. However, in cases where the mother is unable to provide adequate care, such as due to mental illness, substance abuse, or domestic violence, the presence of non-maternal supportive care may be a protective factor.26 The commonly recognized protective factors are discussed below.

Individual characteristics such as self-regulation, self-efficacy, focus on problem solving, planning, acceptance, optimism, social skills, extraversion, self-esteem, self-confidence, and seeking social support have been identified in many reviews as protective factors for the development of resilience.20,22,23,27 High self-control is also protective for resilience. Poor self-control in children has been found to be associated with negative outcomes in a variety of physical, psychological, and social domains, and this effect is independent of IQ and social class.28

Since humans are social individuals, family and other social environments have important effects on resilience in addition to individual factors. In other words, the resilience of a developing person is not limited to the body and mind of that individual.29 Early secure attachment to caregivers, maternal warmth, positive family atmosphere, good parent-child communication, low parental stress, rules, and routines are important family protective factors for the development of resilience.22,23 Parenting and, in particular, the caregiver-child relationship have always been identified as a central factor for children’s resilience. Masten and Barnes (2018)29 state that a close bond with a caregiver and effective parenting protect a young child in many ways that are not “within the child.” In the context of the extra-familial social environment, factors such as social resources and support, socioeconomic status, peer support, access to education, safety and security, school attendance and engagement, and a positive neighborhood environment are important.22,23,25 In addition, cultural influences such as religious belief, spirituality, and ethnic identity are also important for the development of resilience.

Neurobiological Basis of Resilience

A good understanding of the neurobiology of resilience can provide guidance on how to improve resilience. In addition, biological assessment of resilience can eliminate errors in psychological measurements and subjective measurement differences.30 In this context, studies on the hypothalamic-pituitary-adrenal (HPA) axis, neurotransmitters, and brain imaging have increased in recent years. The most important results of these studies are discussed here.

Activation of the HPA axis has been shown to induce hormonal and neurochemical changes that affect resilience.31,32 The ability to normalize the ratio of hormones such as cortisol and dehydroepiandrosterone, which are secreted by the adrenal cortex in response to stress, has been shown to influence resilience.31

Among neurotransmitters, monoamines (such as dopamine, serotonin, and noradrenaline) in particular have been linked to resilience.33 This effect is attributed to the fact that monoamines influence neuronal activity in brain regions associated with resilience, such as the ventromedial prefrontal cortex, anterior cingulate cortex, posterior cingulate cortex, and medial prefrontal cortex.16,33,34

In a review of resting-state functional magnetic resonance imaging (fMRI) studies in mentally healthy individuals, regions in the emotional network, such as the amygdala and orbitofrontal cortex, were most frequently associated with resilience.30 The subgenual anterior cingulate cortex (sgACC) and insula are brain regions associated with experience and emotional regulation and are important for resilience.35 Shao et al (2018)34 showed that 2 groups with high and low resilience differed in the functional connectivity between the sgACC and insula after stress compared to the resting state. The dorsolateral prefrontal cortex is mainly responsible for executive functions, planning, and regulation and has been shown to be associated with resilience.36 An fMRI study showed that childhood poverty was associated with lower dorsolateral prefrontal cortex activity during emotion regulation in adulthood.37 A recent review found that increased prefrontal regulation of amygdala activation was associated with greater gray matter volume in the prefrontal cortex and hippocampus and lower activity in the amygdala during negative stimuli with resilience in adolescents.16

A proposed neural model for resilience suggests that genes, protective factors, or traits that can influence individuals to pay more attention to positive or negative environmental stimuli are linked to brain function, which in turn determines whether an individual is resilient or vulnerable.38 This balance between resilience and vulnerability is proposed to be related to the changing activity of 3 basic brain networks and the interaction between them. The default mode network (DMN) can be defined as the resting state network, which is associated with self and future thinking, memory, and internal mental and affective processes; the central executive network (CEN) is the network active in cognitive tasks that require attention; and the salience network (SN) is the network that provides the transition between default mode and task-related states.39,40 In this neural model, increased SN activity, increased connectivity of the SN with the DMN, and increased connectivity of the SN with the CEN have been proposed to be associated with attention shifting and cognitive flexibility.38

Although the results of studies on the neurobiology of resilience are heterogeneous, some consistent findings suggest that the neural mechanisms of resilience may involve the structure/activity of prefrontal and subcortical regions and the connectivity between these regions.41 In light of all this data, although neurobiological links with individual and environmental factors associated with resilience are highlighted, further studies are needed in this area.

Childhood Chronic Diseases and Resilience

One of the individual risk factors identified for resilience is chronic diseases. While there are different definitions of the term chronic disease, the Centers for Disease Control and Prevention defines it as “conditions that generally last 1 year or longer and require continuous medical intervention or limit activities of daily living, or both” (https://www.cdc.gov/chronic-disease/about/index.html). Since the early 20th century, innovations in medicine and public health have led to significant changes in the epidemiology of health conditions in infants, children, and adolescents. Infectious diseases have declined dramatically, and survival rates of children with cancer, congenital heart disease, leukemia, and other diseases have improved substantially. In parallel with these changes, the prevalence of chronic health problems in children and adolescents has increased.42,43 In the United States, the prevalence of children with chronic diseases increased from 12.8% in 1994 to 26.2% in 2006.44 The most common chronic diseases among school-age children include asthma, cancer, cystic fibrosis, cerebral palsy, chronic renal failure, malnutrition, diabetes, epilepsy, autism, obesity, and attention and hyperactivity disorders.45,46

Reactions to chronic diseases and quality of life may vary by disease,47 but they also differ from person to person, even if it is the same disease, because the problems experienced by the patient and the process of adaptation to the chronic disease are heterogeneous.48 Resilience is an important factor in successful adaptation to chronic diseases.49 A systematic review found a negative correlation between resilience scores and chronic disease progression, suggesting that resilience may influence the disease process and health outcomes.50 In addition, children with chronic diseases have an increased risk of behavioral, emotional, and cognitive problems in childhood,51 and adolescents who show resilience have better mental health outcomes.52,53 In this context, it can be said that young people with chronic diseases who show high resilience have fewer psychosocial problems.

From an individual perspective, intrinsic personality traits, which are a product of internal and external factors, play a role in the development of resilience outcomes, which are often based on personal strengths and coping skills.54 These include acceptance of oneself and the diagnosis of a chronic disease, an early and reliable knowledge base about the diagnosis, realistic coping strategies for chronic disease-related stress, self-confidence, self-care, self-efficacy, and a positive self-perception.55

Children and adolescents need varying degrees of support from caregivers as part of normal developmental processes, depending on their age and stage of development. Therefore, the influence of factors such as self-care and self-management is becoming increasingly important in chronic diseases in children and adolescents. Self-management is multidimensional and refers to adherence to daily tasks such as nutrition, infection prevention, and responsibility for improving health outcomes.48 It has been shown that people with an intrinsic health locus of control (the belief that they can have a sense of control over their disease) are able to manage self-management more easily and have a higher quality of life, self-esteem, and life satisfaction.56,57 The belief that the disease can be controlled may differ depending on the disease. For example, individuals with illnesses at risk of recurrence, such as cancer, may have lower internal locus of control beliefs. Low controllability of illness and low self-regulation have been associated with low resilience in adolescents with chronic illness.47

Researchers have suggested that the response to stress may have a greater impact on health and well-being than the stressor itself.58 In this context, resilience has been shown to contribute to the healing and recovery process by buffering the negative effects of stress and transforming it into positive learning, thus promoting self-care in people with chronic illness.59 Recent meta-analyses have also confirmed a positive and bidirectional relationship between resilience and self-care in chronic diseases.60 Patient education and support often focus on the barriers and risks to self-care, while resilience may be neglected. However, it should not be forgotten that promoting resilience can also contribute to self-care.60

A person’s ability to see the illness in a new and positive light can also empower the person by boosting the self (e.g., self-esteem and self-confidence). This new perspective can also maintain learning opportunities and the desire to share experiences and new knowledge with others, which in turn strengthens the individual’s external ties.55

One of the most important contextual factors for resilience in chronic diseases is religious support.61 Religious beliefs and the practice of prayer provide hope and confidence, a way of finding meaning in a negative situation.62 Spirituality helps individuals develop a sense of purpose in life and cope effectively with stress.63 For example, the spiritual well-being of parents affected by childhood cancer proves to be an important component in supporting their resilience throughout the cancer journey.64,65

Family Resilience in Childhood Chronic Diseases

The presence of a child with a chronic illness is a challenge not only for the sick child but for the entire family, and families as a whole are at risk of adjustment difficulties.66 In addition to the sick child, chronic illnesses also present parents with the challenge of coping and managing the chronic illness in everyday life.67 At the same time, the family is often the most important source of emotional support (such as closeness and comfort) for children with chronic diseases and plays a key role in effective disease management and coping with the challenges and risks of the disease.68

Some families are able to effectively utilize both internal and external resources, so that the family can recover with a more effective and resilient response to crises and challenges. This positive family adaptation process is referred to as family resilience.69 In the case of chronic illness, the importance of family resilience increases in addition to the individual resilience of the sick child. Various studies have shown that family resilience significantly supports children’s quality of life and psychological adjustment.70-72

Family resilience includes 3 main elements: shared family belief systems, forms of family organization, and family members’ open communication and problem-solving skills.73 Families demonstrate family resilience by using coping strategies such as taking responsibility, supporting each other, promoting family communication, being flexible in roles, seeking outside help, adjusting family lifestyle, or changing life goals.74 Parenting style, which is important for parent-child communication, is also an important variable for family resilience. A recent study showed that parents of children with chronic illness reported lower family resilience and authoritative parenting and more problems with peers than parents of healthy children. However, authoritative parenting fully mediated the relationship between family resilience and psychosocial adjustment in chronically ill children.75 Authoritative parenting may promote family resilience in families of children with chronic disease. It may be important for pediatric clinicians and nurses to provide parent education and family-centered interventions to improve children’s psychosocial outcomes.

Through resilience, parents cope with the burden of caregiving, adapt to the chronic illness, and deal with the stress of the disease. Thus, they develop their children’s ability to cope with the stress associated with the demands of chronic illness.67 In other words, the resilience of the child with a chronic disease and the resilience of the family are in continuous and reciprocal interaction with each other. High levels of individual and family resilience have been associated with fewer behavioral, emotional, and peer problems in children with chronic illness.71,76

An important point in the context of chronic illness and family resilience is healthy siblings. Depending on the needs of the child with chronic illness, there are many changes in the life of the healthy sibling, such as daily life, sharing with parents, and parental attention. While this situation may create developmental risks for the healthy sibling, it has also been observed that the healthy sibling may experience improvements in terms of taking responsibility and empathetic thinking. These results suggest that the support systems to be provided for the healthy sibling will be important for their emotional well-being and resilience.77

Improving the Resilience

A growing body of evidence shows that resilience can be enhanced and maintained at any stage of life through learning and education, regardless of age and disease status.27,78

Improving the resilience is a complex process that requires interventions at different levels.79 Macro-level interventions to strengthen the resilience of the entire population include economic and social policies to create safe, supportive, and healthy community environments and behaviors.20 These interventions aim to prevent adverse childhood experiences while supporting community strengths.

Family resilience intervention aims to promote the use of family strengths and family resources, improve the family’s ability to cope with difficulties and challenges, and promote family recovery from adversity by reducing family risk and vulnerability.80 Resilience processes such as spirituality and emotional sharing can be supported to help families overcome a period of disintegration and fragility.81 Interventions to strengthen family resilience have been shown to reduce the harmful effects of chronic illness on children’s behavior,82 family social support, 83, and improve overall family functioning and developmental capacity.80,82

Building a “hospital-family-community” system as an external social support network for chronic diseases can contribute to the development of a positive meaning of chronic illness in the family and the child.84

At the individual level, the aim is to develop individual characteristics that increase resilience.79 Recognizing and supporting children’s individual strengths (academic, athletic, artistic, etc.) can build a sense of accomplishment and self-confidence and facilitate the development of peer relationships.20 A meta-analysis evaluating the effectiveness of resilience interventions in children and adolescents has shown that the programs were effective in promoting resilience, especially in adolescents, and that this effect was maintained after 6 months.85

Conclusion

Resilience is a dynamic process that has a neurobiological basis and is shaped by individual, family, and environmental influences. Improving resilience in children and adolescents with chronic diseases can have a positive effect on both psychosocial and chronic disease-related outcomes. Therefore, it is important that healthcare professionals pay attention to individual and family resilience during pediatric follow-up and intervene to improve it.

Funding Statement

The authors declare that this study received no financial support.

Footnotes

Data Availability Statement: The data that support the findings of this study are available on request from the corresponding author.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – G.D., M.Y.; Design – G.D., M.Y.; Supervision – G.D., M.Y.; Resources – G.D., M.Y.; Materials – G.D., M.Y.; Data Collection and/or Processing – G.D., M.Y.; Analysis and/or Interpretation – G.D., M.Y.; Literature Search – G.D., M.Y.; Writing – G.D., M.Y.; Critical Review – G.D., M.Y.

Declaration of Interests: Gizem Durcan is a member of Editorial Board at the Turkish Archives of Pediatrics, however, her involvement in the peer review process was solely as an author.

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