The Research Domain Criteria (RDoC) Project and Studies of Risk and Resilience in Maltreated Children

Abstract

Objective

The Research Domain Criteria (RDoC) project was initiated to develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures. This article reviews the rationale behind the RDoC program, its goals, and central tenets; discusses application of an RDoC framework to research with maltreated children; and highlights some clinical implications of this work.

Method

Published RDoC papers were reviewed, together with relevant preclinical and clinical studies that guide our work on risk and resilience in maltreated children.

Results

The ultimate long-term goal of the RDoC initiative is precision medicine in psychiatry. In the interim, the RDoC initiative provides a framework to organize research to help develop the database required to derive a new psychiatric nomenclature that can appropriately match treatments to patients. The primary focus of RDoC is on neural circuitry, with levels of analyses that span from molecules to behavior. There has been some concern that the RDoC framework is reductionist, with an overemphasis on neural circuits and genetics; however, the briefly reviewed, burgeoning literature on neuroplasticity and epigenetics highlights that this concern is unwarranted, as one cannot study neural circuits and genetics without considering experience.

Conclusion

The study of maltreated children has a number of advantages for the RDoC project, including the following: study of a subset of patients who are often not responsive to standard interventions; examination of a relatively homogenous sample with onset of psychopathology proposed to be associated with stress-related mechanisms; and well-established, relevant animal models to facilitate translational research.

The brain is not organized, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). Although the DSM has been an invaluable tool in establishing reliability of psychiatric diagnoses and creating a common language to facilitate communication about mental illnesses,^1,2 the validity of the DSM psychiatric nomenclature has come under considerable scrutiny^3,4 and has spurred the initiation of the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project.^5,6 This article reviews the rationale for the NIMH RDoC program, its goals, and its central tenets (http://www.nimh.nih.gov/research-priorities/rdoc/index.shtml). It also discusses the application of an RDoC perspective in research with maltreated children.

RATIONALE FOR THE NIMH RDoC INITIATIVE

Although rates of infant mortality have dropped 50% since 1980,⁷ mortality has not decreased for any psychiatric disorder, and prevalence rates are similarly unchanged.⁵ Psychiatry has lagged behind multiple areas of medicine in gaining insights into the pathophysiology of disease.⁸ Heterogeneity within diagnostic categories^4,9 and comorbidity among disorders^10,11 are the rule, compromising treatment efficacy and research on pathophysiology of mental illnesses. Related to this, DSM diagnostic classifications do not delineate distinct paths of treatment; instead, single classes of drugs, such as selective serotonin reuptake inhibitors (SSRI), are indicated for a wide range of anxiety, mood, and eating disorders.³ Yet, although SSRIs are approved for these different conditions, treatment response is varied, and on average across diagnoses, a marketed psychiatric drug is efficacious in only half of the patients who take it.⁵ The effect size for the drugs used in psychiatry range from small to large, with the efficacy of psychotropic drugs on average in the medium range, which is actually approximately comparable to the efficacy of many drugs used across multiple fields in medicine.¹² Psychiatry, like many areas of medicine, is in need of reliable diagnostic tests to better match treatments to patients. There are currently few data to guide our efforts to determine which patients will have a favorable response to any given treatment, to reliably assess risk of disorder, or to prevent or alter the course of illness onset.

GOALS AND GUIDING PRINCIPLES OF THE NIMH RDoC INITIATIVE

The ultimate long-term goal of the NIMH RDoC initiative is precision medicine in psychiatry so that clinicians can tailor treatments to optimize outcomes for individual patients.^5,8 The near-term goal is to devise a framework to organize research to help develop the database required to derive a new psychiatric nomenclature that can use the research findings to appropriately match treatments to patients.⁵ It is believed that this new psychiatric nomenclature will facilitate precision medicine in psychiatry. The NIMH is agnostic about what this new nosology will look like, but has delineated a set of guiding principles to move toward the goals of the RDoC initiative.

Central tenets of the NIMH RDoC initiative include the following: Mental illnesses are brain circuit disorders⁶; Psychopathology is conceptualized in terms of component abnormalities in discrete, but frequently highly interconnected, brain circuits¹³; Brain circuit abnormalities cut across traditional diagnostic boundaries¹³; Behaviors linked to different brain circuits vary dimensionally from impairment to healthy functioning¹³; and Brain circuit function varies across development and is significantly influenced by experience.¹⁴ The RDoC further assumes that diagnoses based solely on observable signs and symptoms are nonspecific and inevitably reflect heterogeneity in terms of pathophysiology,⁸ and that, in time, data from the fields of genetics and clinical neuroscience will yield meaningful biomarkers to augment clinical symptoms in guiding treatment.⁶

Table 1 delineates key features that distinguish RDoC from the DSM. First, RDoC is a research framework; it is an evolving structure designed to guide research, not replace the DSM as a tool for clinicians at the present time.¹⁵ RDoC also conceptualizes mental illnesses as comprising component parts that can be represented on dimensional scales, not as categorically discrete entities. In addition, the RDoC framework takes a bottom–up approach by starting with neural circuits to understand behaviors, rather than a top–down approach of starting with symptoms to understand the pathophysiology of mental illnesses. It also aims to reflect understanding of the biology of discrete circuits and behaviors, not multifaceted clinical syndromes.

TABLE 1.

Primary Distinctions Between the DSM and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

DSM	RDoC
Clinical nosology	Research framework
Categorical approach	Dimensional approach
Symptom-based definitions of disorders	Neural circuit-based delineation of behaviors

RDoC Matrix

As depicted in Table 2, the RDoC Matrix currently consists of 5 domains and a series of interrelated constructs. The domains and constructs were selected during a series of thoughtful workshops facilitated by NIMH over the past several years.¹⁶ For constructs to be included in the RDoC Matrix, evidence demonstrating that they are reliable and valid behavioral functions and are subserved by an identified neural circuit was required.¹⁴ The 5 initial domains identified by the RDoC workshops include negative valence (e.g., anxiety, loss), positive valence (e.g., reward), cognitive systems (e.g., attention, working memory), social processes (e.g., affiliation), and arousal/modulatory systems (e.g., sleep–wake). Over time, it is likely that additional domains and constructs will be added to the matrix. Although the table may appear to suggest sharp boundaries between the separate domains and constructs, research has demonstrated that the domains and constructs function interactively via highly integrated brain circuits.¹⁷

TABLE 2.

Research Domain Criteria Domains and Constructs

Negative Valence Systems	Positive Valence Systems	Cognitive Systems	Systems for Social Processes	Arousal/Regulatory Systems
Acute Threat (Fear) Potential Threat (Anxiety) Sustained Threat Loss Frustrative Nonreward	Approach Motivation Initial Responsiveness to Reward Sustained Responsiveness to Reward Reward Learning Habit	Attention Perception Working Memory Declarative Memory Language Behavior Cognitive (Effortful) Control	Affiliation and Attachment Social Communication Perception and Understanding of Self Perception and Understanding of Other	Arousal Biological Rhythms Sleep-Wake

The primary focus of RDoC is on neural circuitry, with levels of analysis progressing in 1 of 2 directions: upward from measures of circuitry to clinical symptomatology, and downward to the genetic and molecular factors that ultimately influence function.⁶ The RDoC initiative promotes the examination of each construct across 7 units of analyses: genes, molecules, cells, circuits, physiology, behavior, and self-reports. It also identifies paradigms that can be used to assess each construct. Table 3 delineates a nonexhaustive set of data for each of these units of analyses for the construct “acute threat” (or “fear”) to illustrate the clinical utility of the RDoC perspective that calls for incorporating units of analyses from molecules to behavior, with this construct chosen, given its relevance to our work with maltreated children.

TABLE 3.

Research Domain Criteria Units of Analyses for Acute Threat (“Fear”)

Genes	Molecules	Cells	Circuits	Physiology	Behavior	Self-Reports	Paradigms
5-HTTLPR	NMDA Receptors	Neurons	Fear Circuit: vmPFC	Fear Potentiated	Avoidance	STAI99	Fear Learning
GABRA2	Glutamate	Glia	Hippocampus	Startle	Freezing	SCARED100	Extinction Paradigms
CRH	Glycine	Pyramidal cells	Amygdala	Heart Rate		MASC101	Exposure Therapy
FKBP5

Note: 5-HTTLPR = serotonin-transporter-linked polymorphic region; CRH = corticotropin releasing hormone; FKBP5 = FK506 binding protein 5; GABRA2 = gamma-aminobutyric acid receptor subunit alpha-2; MASC = Multidimensional Anxiety Scale for Children; NMDA = N-methyl-D-aspartate; SCARED = Screen for Child Anxiety Related Emotional Disorders; STAI = State-Trait Anxiety Inventory; vmPFC = ventromedial prefrontal cortex.

Starting with circuits, preclinical and clinical research suggest the amygdala, ventromedial prefrontal cortex (vmPFC), and hippocampus are key structures within the fear circuit.¹⁸ Moving to symptoms, deficits in fear learning and fear extinction are hypothesized to be related to the onset of posttraumatic stress disorder (PTSD) and other anxiety disorders,¹⁹ with knowledge about fear extinction behavioral paradigms instrumental for the development of exposure therapies.²⁰ Moving downward, variation in polymorphisms in the serotonin transporter gene (a particular variant, 5-HTTLPR),²¹ γ-aminobutyric acid (GABA) A receptor gene α 2 (GABRA2),²² and oFK506-binding protein 5 (FKBP5) gene (the protein product that interacts with the glucocorticoid receptor^23,24) have been found to alter risk for the development of PTSD after child abuse. These gene-by-environment studies have helped to elucidate why some individuals develop psychopathology after abuse and others do not. On the molecular level, glutamate transmission, and particularly its actions at N-methyl-d-aspartate (NMDA) receptors, underlies extinction learning.²⁵ This finding has been translated into clinical practice, with administration of the NMDA receptor partial agonist d-cycloserine (DCS) found to augment the efficacy of exposure therapy for PTSD and other anxiety disorders,²⁵ providing a powerful illustration of the clinical utility of the RDoC perspective, and incorporating units of analyses from molecules to behavior.

There has been some concern expressed that the RDoC framework is reductionist, with an overemphasis on neural circuits and genetics, and minimal attention to contextual factors.^26,27 The incorporation of preclinical translational studies of fear extinction at both the behavioral and molecular level into treatments (e.g., exposure therapy and DCS) demonstrates the potential value of the integrated approach proposed by RDoC, and the burgeoning literature on neuroplasticity and epigenetics further highlights that this concern is unwarranted, as one cannot study neural circuits and genetics without considering experience.^25,28 Old dichotomies of nature versus nurture, or biology versus experience, are obsolete and have been so for decades. The dynamic interactions among genes and environment, and experience and the brain, are innumerable.

RESEARCH APPLICATIONS OF THE RDoC PERSPECTIVE TO STUDIES OF MALTREATED CHILDREN

The study of maltreated children has a number of advantages for the RDoC project, including: the study of a subset of patients that are frequently treatment resistant to standard interventions;^9,29,30 examination of a relatively homogenous sample with the onset of psychopathology proposed to be associated with stress-related mechanisms;^9,31,32 and well-established, relevant animal models to facilitate translational research.^33,34 It also focuses on an exposure that impacts known neural circuits, rather than a DSM entity, and involves a process that occurs in a developmental context, an aspect critical to the RDoC matrix.

Children who experience maltreatment are at high risk for developing a wide range of psychiatric problems, including PTSD,³⁵ depression,²⁹ and substance use disorders.³⁶ These various conditions frequently co-occur and often persist into adulthood.^9,36 Anxiety, mood, and substance use disorders are associated with alterations in interlocking brain circuits, with each of these brain circuits included in the RDoC matrix (Figure 1). As discussed previously, PTSD and other anxiety disorders are associated with alterations in fear circuitry.¹⁸ Depressive disorders are associated with changes to the structure and function of the emotion processing circuit involving the amygdala, hippocampus, orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), and medial prefrontal cortex (mPFC).³⁷ Substance use disorders are associated with changes to the structure and function of regions within the reward circuit, including the hippocampus, amygdala, hypothalamus, and the nucleus accumbens and ventral tegmental area (VTA), which have extensive connections with prefrontal cortex.³⁸ Problems in attention, memory, and impulse control, which frequently co-occur with these other trauma-related psychiatric disorders, are associated with alterations in the executive control circuit that overlaps extensively with these other brain systems.³⁹ In addition, as shown in Figure 1, the neural regions implicated in these psychiatric and substance use disorders are also key structures involved in the stress response.⁴⁰ Given the overlap among these neural systems and the brain regions involved in stress, it is not surprising the individuals with a history of abuse frequently meet diagnostic criteria for these multiple cooccurring conditions.⁴¹

FIGURE 1.

Overlap in brain regions involved in the stress response and brain circuits implicated in stress-related psychiatric syndromes. Note: Several brain regions that are a part of interconnected neural circuits that regulate fear, emotion, reward, and executive function are also involved in the stress response. The stress response is initiated with the release of corticotropin-releasing hormone (CRH) from the hypothalamus. CRH stimulates the release of adrenocorticotropin hormone (ACTH) from the pituitary, which causes the release of cortisol from the adrenals, and a cascade among the multiple brain structures indicated above with the black arrows. ACC = anterior cingulate cortex; Amy = amygdala; Hp = hippocampus; LC = locus coeruleus; mPFC = medial prefrontal cortex; NAc = nucleus accumbens; OFC = orbitofrontal cortex; vmPFC = ventral medial prefrontal cortex; VTA = ventral tegmental area. Reprinted by permission of Oxford University Press, Inc. as Fig: 8.1 in Kaufman J,Weder N. Neurobiology of Early Life Stress: Evolving Concepts. Martin A, Scahill L, Kratochvil CJ, eds. Pediatric Psychopharmacology. Second ed. New York: Oxford University Press; 2010:112–123. (http://ukcatalogue.oup.com/p2p/endecaSearch.do?keyword=9780195398212). This figure does not come under a Creative Commons license (http://creativecommons.org/licenses/), or any other open access license that would allow reuse without requiring permission from OUP. For permissions, please contact academic.permissions@oup.com.

Consistent with research in the field, in our prior studies of this population, PTSD was the most common diagnosis experienced by the children, present in more than half of the maltreated cohort.³⁵ The maltreated children in our prior studies also had high rates of clinically significant depression^42,43; and, at longitudinal follow-up, 29% of our predominantly preadolescent and young adolescent maltreated cohort reported alcohol use, a rate more than 7 times the rate observed in controls. Maltreated children also had a full drink of alcohol, on average, more than 2 years earlier than controls (11.2 versus 13.5 years), and at the time of follow-up, 15% had already experienced an episode of being intoxicated.⁴⁴

Given the role of fear conditioning in the neurobiology of PTSD,^19,45–47 we are presently studying the RDoC construct acute threat, or fear, using an emotional Go–No Go task developed by Casey et al.⁴⁸ in a new cohort that we are currently recruiting. We are also collecting structural, diffusion tensor, and resting-state imaging data that will allow us to examine the impact of child maltreatment on other brain circuits implicated in the regulation of relevant RDoC domains that are also altered in response to child maltreatment—even independent of psychopathology.^49,50 Inclusion criteria for the study are not set by DSM diagnostic categories but, rather, by a history of child maltreatment to identify a relatively homogenous sample with the onset of psychopathology proposed to be associated with stress-related mechanisms.^9,31,32 Maltreatment and other adverse childhood experiences are being quantified, dimensionally integrating information derived from multiple informants and data sources⁵¹: symptoms across a wide range of domains and constructs are being collected, using dimensional rating scales and computerized tasks, and a range of genetic and environmental factors are being collected to better understand risk and resilience in this population.

CHILD ABUSE AND GENETICS RESEARCH IN AN RDoC ERA

There is emerging evidence that alternations in stress-reactivity and many of the structural and functional changes in the brain that are associated with early adversity are mediated by epigenetic mechanisms.^52–54 Epigenetics refers to functionally relevant modifications to the genome that do not involve a change in DNA nucleotide sequence.⁵³ These modifications can alter gene activity and play roles in acute regulation of genes in response to changes in the environment.⁵⁵

In our current research, we aim to replicate our recently published findings that showed that depression symptoms in maltreated children are associated with epigenetic changes in 3 genes: DNA binding protein inhibitor ID-3 (ID3), Tubulin Polymerization Promoting Protein (TPPP), and a Glutamate NMDA Receptor subunit (GRIN1).⁵⁶ Methylation changes in these genes appear to be independent predictors of depression, above and beyond the effects of maltreatment history. These genes are all biologically relevant: they are involved in the stress response, neural plasticity, and neural circuitry, as follows. ID3 is upregulated in the pituitary in response to chronic stress.⁵⁷ It is also upregulated with stimulation by pituitary adenylate cyclise-activating polypeptide (PACAP).⁵⁸ This is interesting, as levels of PACAP in peripheral blood have been linked to PTSD symptoms in females,⁵⁹ and variation in the gene that encodes the PACAP receptor has been associated with risk for PTSD in some^59–61 but not all⁶² studies. PACAP genetic variation has also been associated with individual differences in brain activation and connectivity within the fear circuit.⁶³ ID3 is also involved in neurogenesis and has been implicated in neural plasticity.⁶⁴ TPPP is critical for oligodendrocyte differentiation,⁶⁵ and the protein TPPP is present in myelinating oligodendrocytes and is believed to have a role in development and maintenance of white matter tracts in brain.^66,67 GRIN1 transcription is downregulated in frontal cortex in response to stress in animal models of depression⁶⁸; glutamate is implicated in the pathophysiology of depression and anxiety disorders^69,70; and NMDA receptors play a critical role in synaptic plasticity, memory, and fear conditioning.⁷¹

The field of psychiatric genetics is evolving, and it is becoming increasingly evident that the genetic architecture of psychiatric illness does not map onto the DSM.^72–74 There is also emerging evidence for a role of mitochondrial DNA,^75,76 tissue-specific mutations,⁷⁷ and noncoding DNA regulatory elements⁷⁸ in the etiology of psychiatric illnesses. Less than 2% of the more than 3 billion DNA base pairs in human genome code for proteins, and many sites in intergenic regions are enriched for transcription factor binding sites that influence the 3-dimensional organization of the genome and play key roles in gene regulation.^79,80 Transcription factor binding sites and chromatin insulators within intergenic regions are believed to mediate intra- and interchromosomal interactions, affecting gene expression at both proximal and distal locations.⁸⁰ There are numerous instances in which intergenic genetic variation is associated with disease risk,⁸¹ and methylation in intergenic regions has been implicated in neuropsychiatric⁸² and other diseases. Novel methods have been developed to characterize the 3-dimensional configuration of the genome, and a better understanding of the regulatory role of these 3-dimensional changes will open up new frontiers in human brain research and psychiatric genetics.⁷⁸

CHILD ABUSE AND RESILIENCE RESEARCH IN AN RDoC ERA

Data collected in Connecticut in 2007 found that children committed to protective services due to abuse or neglect made up approximately 65% of all admissions to psychiatric hospitals, despite comprising only about 1% of the child population.⁸³ With an infusion of state, federal, and private foundation dollars, Connecticut recently implemented a trauma-informed system of care. Child welfare administrators, caseworkers, and contracted mental health providers received training on trauma-informed practices. Learning collaboratives were created to disseminate evidenced-based psychotherapies to treat PTSD and other trauma-related psychiatric problems in children. Although correlation does not imply causality, since the training of providers around the state to assess for and treat PTSD in children, there has been a contemporaneous change such that children committed to protective services due to abuse or neglect now make up only 30% instead of 65% of all admissions to psychiatric hospitals.⁸⁴

There is emerging evidence that the clinical benefits of cognitive-behavioral therapy (CBT) interventions may be mediated by adaptive changes in brain circuits that control emotion regulation.^85–87 Although the reduction in rates of inpatient care among children committed to the state is praiseworthy, even with the improvement in the system of care, these children remain at inordinately high risk for significant psychiatric problems serious enough to warrant inpatient hospitalization—a rate about 30 times greater than expected by population estimates. Evidence-based treatments work better than other practices, but, as discussed previously, there is no treatment in psychiatry that works for all patients with a given mental health condition.

Beyond clinical treatment, research data now also show that there are other experiences that can promote positive brain changes via neuroplasticity, including exercise,⁸⁸ mindfulness and meditation,⁸⁸ and music training.⁸⁹ There is growing interest in understanding sensitive time windows when the brain is more responsive to experiential inputs⁹⁰ and the mechanisms necessary to reopen and strengthen windows of plasticity.⁸⁸ Investigations of underlying mechanisms for the re-establishment of new windows of plasticity are focusing on the balance between excitatory and inhibitory transmission and removing molecules that limit plasticity.⁸⁸

The availability of positive social supports is also believed to facilitate neuroplasticity.⁹¹ Studies have repeatedly documented that the availability of positive social supports is 1 of the most important factors in promoting resilience in maltreated children and other traumatized populations.⁹² In our studies, the availability of a positive adult support was found to ameliorate risk for depression associated with maltreatment, with the positive effect of social support most beneficial for those children at elevated genetic risk for depression.^42,43 Studies with socially monogamous prairie vole have demonstrated that paraventricular nucleus oxytocin is a critical component of the neurobiological mechanisms by which social supports can alleviate the negative effects of stress, and it has therefore been suggested that oxytocin may be a target for treatment of stress-related disorders.⁹¹ Ongoing translational research studies using an RDoC perspective, from molecules to behavior, may help to elucidate novel therapeutic approaches for the prevention and treatment of stress-related psychiatric disorders.

In addition to psychiatric and substance use outcomes, our group is also interested in the effects of stress on health outcomes.^93–95 There is a robust literature documenting that adverse early life experiences increase risk for a broad range of health problems,⁹⁵ and data suggesting that social supports can help to buffer against the negative health effects associated with stress as well.⁹² Common biological mechanisms may or may not be involved in promoting psychological and physical well-being after early adversity, and ongoing multidisciplinary and translational research will help to address these questions.

When we conducted our whole-genome methylation study, given preclinical research findings on the effects of adverse early rearing experiences on the glucocorticoid receptor and other stress-related genes,⁵⁴ we expected to see epigenetic changes in genes known to be involved in the stress response. Although we did see maltreatment-related group differences in certain of these genes, after controlling for whole-genome multiple comparisons, maltreated and control children had significantly different methylation values at 2,868 methylation sites. The gene set showing differential methylation between the maltreated and comparison children contained genes involved not only in biological processes relevant to psychiatric and substance use disorders (e.g., neurogenesis, axonal guidance), but also heart disease (e.g., cardiac development), stroke (development of blood vessel morphogenesis), respiratory disease (e.g., interleukin regulation), diabetes (e.g., leptin signaling), and cancer (e.g., WNT signaling, NOTCH signaling)—all medical illnesses that have been associated with a history of adverse childhood experiences.⁹⁶

Data frequently lead to surprises. The explosion of large-scale, high-throughput technologies has necessitated a shift away from reductionism and fueled the development of new computational tools.^97,98 As Schadt et al. stated,

… future successes in biomedical research will likely demand a more comprehensive view of the complex array of interaction in biological systems and how such interactions are influenced by genetic background, infection, environmental states, lifestyle choices, and social structures more generally. This holistic view requires embracing complexity in its entirety, so that complex biological systems are beginning to be seen as dynamic, fluid systems that are able to reconfigure themselves as conditions demand.⁹⁸

There is no area of medicine in which this holds more truth than in psychiatry.

CONCLUDING REMARKS

As discussed at the outset of this article, the long-term goal of the RDoC initiative is precision medicine in psychiatry, so clinicians can tailor treatments to optimize outcomes for individual patients. The study of maltreated children is important for the RDoC project, as patients with a history of child abuse are often not responsive to standard interventions. The near-term goal of the RDoC initiative is to devise a framework to organize research based on dimensions of observable behavior and neurobiological measures. The primary focus of RDoC is on neural circuitry, with levels of analysis progressing upward from measures of circuitry to clinical symptomatology, and downward to the genetic and molecular factors that ultimately influence function. Maltreated children comprise a relatively homogenous sample with the onset of psychopathology proposed to be associated with stress-related mechanisms, with well-established relevant animal models to facilitate translational research. In the current paper, the anticipated value of the RDoC framework that extends from molecules to behavior was highlighted with clinical and research examples. RDoC and the tools used within this framework will continue to evolve, and if the aims of the RDoC initiative are attained, morbidity and rates of mortality associated with psychiatric illnesses will at last decrease.

Clinical Guidance.

• Think dimensionally, and develop interventions to target discrete domains.

• Remember that risk, whether due to genetic or environmental factors, is dynamic. There are multiple approaches that can be used to promote resilience and recovery (e.g., evidence-based treatment strategies, facilitating positive attachments and social supports, and wellness interventions).