Chapter 3

The following figure illustrates the direct correspondence between contextual influences on the one hand and protective processes as they appear in the research literature on resilience on the other.

For those suffering the effects of stigma associated with a label, the answer to overcoming these effects may actually be more labels. According to social psychologist Ellen Langer, Ph.D. (1989), when people view others through different and varied labels rather than one or two global ones, they become more discriminating. And when people become more discriminating they’re less likely to discriminate. What’s particularly encouraging about this is that with a little practice, we can learn to think in more discriminating ways. Even more encouraging, we’re capable of learning this at a young age, as Langer illustrated in a study she conducted many years back. In the study, children were shown slides of individuals performing different tasks. Each individual in the slide also had a specific disability. In some slides, the disability negatively affected the person’s ability to perform the task. In other slides, the disability had no effect, as was the case, for example, in a slide of a woman identified as a cook who also happened to be deaf. Children were then asked to write down four reasons why people in the slides might be good at the jobs they were doing, and four reasons why they might not. Children in the control group were shown the same slides but asked to give only one answer. Those in the control group were required to think globally, while children in the first group were required to make much finer distinctions in their thinking.

Part two of the experiment required that children in the first group describe, in detail, how a person with a handicap might be able to do a task or job with their particular challenge. For example, how might a woman in a wheelchair be able to drive? Children in the control group simply had to answer whether the task could be accomplished or not. In part three of the experiment, children in the first group were shown slides depicting mishaps, such as a girl spilling coffee, for example, then asked to generate different explanations for why this happened. Children serving as controls were shown the same slides but asked to give only one explanation for the mishap.

Following the training period, children were shown slides of other children with and without handicaps. Children were then asked to think of a variety of different activities and, for each activity, to decide who they wanted on their team. Children were presented with a range of activities to think about, among them, soccer, checkers, a tug-of-war, a game of Frisbee, a sing-along, and pin-the-tail on the donkey. Some activities placed children with certain handicaps at an obvious disadvantage. But others did not. Results showed that children who learned to be more discriminating also learned that a person’s disability is related entirely to context. And compared to children in the control group, these children were now less likely to avoid a person with a handicap. Langer found that children learned to be discriminating without prejudice.

According to Langer, the more discriminating we become, the less likely we are to be guided by prejudice, negative stereotypes, and stigmatizing global labels. And the reverse is true as well. The less discriminating we are, the more likely that prejudice, negative stereotypes, and global stigmatizing labels will guide our perceptions and blind us to the strengths, qualities, and different attributes of those we encounter, particularly those struggling with various challenges (Langer, 1989; Langer & Chanowitz, 1988)

ADHD Diagnostic Criteria: Individuals exhibiting a persistent pattern of inattention and/or hyperactivity-impulsivity beginning before age 12 that interferes with functioning or development and that cannot be attributed to other known causes, are evidencing behavioral characteristics consistent with attention-deficit/hyperactivity disorder, or ADHD (American Psychiatric Association, 2013). A more complete listing of diagnostic criteria, including examples of ADHD behavioral characteristics and other factors to consider before making the diagnosis, appears in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM is the standard reference guide that mental health professionals and others in the healthcare field refer to for diagnostic criteria pertaining to all mental health disorders. Published by the American Psychiatric Association, the manual is updated periodically to reflect advances in the field of mental health. The fifth and most recent revision (DSM-5) was published in May, 2013. According to the DSM-5, ADHD is considered to be a neurodevelopmental disorder. Neurodevelopmental disorders represent a group of conditions typically appearing early in a child’s development, usually before the child begins school. The DSM-5 created a separate section for neurodevelopmental disorders in order to distinguish them from other conditions appearing in the manual. Specific learning disorders are also considered neurodevelopmental disorders based upon the DSM-5’s new classification system.

ADHD represents the most commonly diagnosed behavioral disorder of childhood (National Institute of Health, 1998), estimated to affect 9 percent of children between the ages of 3-17, including twice as many boys than girls, and twice as many children in fair or poor health as opposed to those in good health (Bloom, Cohen, & Freeman, 2010; National Resource Center on ADHD, 2012). Researchers also now believe that for many, it represents a lifespan condition.

A number of children meeting diagnostic criteria for ADHD can be expected to show symptoms of the condition decades later, although these symptoms are typically expressed in more subtle and varied ways. Left unrecognized, ADHD can have potentially serious consequences, including school failure, problems in the workplace, and a host of other health and life adjustment problems (CHADD, 2005). From a public health point of view, therefore, recognizing ADHD and understanding how to effectively manage its symptoms throughout the lifespan remains a high national priority, since doing so can improve the quality of millions of people’s lives, from school-age children to adults in the workplace, to those in their senior years.

It’s important to also remember that while people with ADHD typically experience challenges in areas associated with executive functioning, including those that help us regulate our emotions and control our behavior, people experiencing challenges in areas associated with executive functioning may not experience ADHD. What this means is that other conditions can potentially generate the same four entirely understandable yet erroneous perceptions. Researchers have identified executive function challenges in people with mood related difficulties, with those experiencing other behaviorally based problems, with those on the autistic spectrum, with those impacted by neurodevelopmental learning disabilities much like Carl’s, and with those exposed to traumatically stressful events much like those Carl, his brother Steven, and his mother were exposed to when Carl was a child. Other challenges can impact these functions as well. Those mentioned above are done so simply to illustrate an important point, and that is, once we realize these erroneous perceptions are indeed erroneous, we’ve taken an important step in legitimizing the plight of people impacted by a number of neurodevelopmentally and/or environmentally based challenges. 

Learning disabilities can co-occur with ADHD 20-50 percent of the time. And just as experts in the field believe many of us underestimate the potential impact of ADHD through the lifespan, they believe, too, that we underestimate the potential lifelong impact of reading and other learning disabilities as well. Research shows, for example, that those impacted by learning disabilities are more likely to drop out of school, more likely to be retained, more likely to fail academically, more likely to have difficulty finding a job, and less likely to attend college. Those who do attend are also less likely to earn their degree (A.P.A, 2013; Cortiella, 2009; Katz, 1997). But perhaps their greatest impact is the toll they take on the human spirit, especially during our childhood and adolescent years. Misunderstanding the nature of learning disabilities, in and of itself, can lead to demoralization and hopelessness. Other co-occurring challenges need not be present. Carl can attest to this. Particularly worrisome is that learning disabilities can potentially also place school-age children at risk for suicide. In the 1980s, for example, researchers in Los Angeles County analyzed all youth suicides within a three year period of time and found the presence of learning disabilities in 50 percent of the cases studied (Peck, 1985). Some may consider this to be exaggerating the emotional impact these challenges can have upon school-age children. However, a second study conducted in Canada suggests not. In the study, researchers analyzed suicide notes of 27 teenagers who took their lives, and concluded that the majority of notes contained errors in writing similar to those made by teenagers with learning disabilities. They arrived at this conclusion by asking a group of teenagers with learning disabilities to transcribe the notes word for word from dictation. They asked a second group of similarly aged youth without learning disabilities to do the same. Of the notes written by teenagers with learning disabilities, 89 percent showed deficits similar to those observed on the original suicide notes left by teenagers who committed suicide. The majority of notes written from dictation by the non-learning disabled teenage comparison group showed no similar deficits (McBride et al., 1997). Understanding reading and other learning disabilities in a new light not only prevents demoralization. It can also save lives. And if you ask Carl, he’ll be the first to tell you, this is no exaggeration.

While the DSM definition of reading and other learning disabilities differs somewhat from the definition as it appears in federal law (both definitions appear below), nowhere in either definition is their cause attributed to a lack of effort. Those who struggle with reading and other learning disabilities are not struggling because of laziness, a moral defect, weak character, or a lack of resilience.

According to the DSM-5, specific learning disorders (the term used in place of specific reading and other learning disabilities) are characterized by difficulties in one or more specific academic areas (e.g., word reading, reading comprehension, spelling, written expression, math calculation, math reasoning), where the affected skills are significantly low in relation to chronological age (A.P.A., 2013). Federal law (Individuals With Disabilities Education Act or IDEA) defines a specific learning disability as “a disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, which disorder may manifest itself in the imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations” (Cortiella, 2009). Both DSM-5 and IDEA distinguish learning disabilities/disorders from those resulting from hearing or vision problems or intellectual, emotional, or cultural influences.

As is the case with ADHD, reading and other learning disabilities are neurodevelopmental in nature. And as with ADHD, they’re often inherited. A child of a parent with a reading disability, for example, is about 8 times more likely to also have a reading disability (Torgesen, 2000). Though never formally diagnosed, in retrospect, Carl believes his father likely suffered from multiple learning disabilities, including a learning disability in reading.

While reading and other learning disabilities tend to run in families. it’s important to note that neurodevelopment can also be impacted by our environment. Impoverished living conditions, neglect, malnutrition, all influence our neurobiology, and our cognitive, linguistic, and academic development (Torgesen, 2000). As we will soon see, so too can exposure to extreme stress.

By the time Carl reached high school, his reading skills lagged several years behind grade level. By the time his brother Steven reached high school, his reading skills were several years above grade level. These differences in reading skills were not entirely the result of Carl’s reading disability. The difference in the amount of time each engaged in reading over the course of many years was likely a factor as well.  Researchers have found that children who read well will read more in two days after school than poor readers will read in an entire year (Cunningham & Stanovich, 1998; Hale et al., 2004). According to some estimates, by the time good readers reach middle school they may have read upwards of one million words. In comparison, poor readers may have read roughly 100,000 words. By virtue of sheer exposure to written text, good readers such as Steven enjoy experiences that make them better readers. These experiences also improve their vocabularies, their fund of general information, and other areas important to school success. Poor readers such as Carl tend to avoid reading at all cost. And poor readers who avoid reading are very likely, over time, to fall significantly behind others, and also likely to find themselves at a significant disadvantage in school.

Research has clearly shown that reading and other learning disabilities among otherwise resilient school-age children can lead to a host of negative life outcomes. But research also shows that the damaging effects of these challenges can be offset by protective processes and life experiences. Consider, for example, the life trajectories of 22 children with learning disabilities being followed by Werner and colleagues as part of the Kauai Longitudinal Study. Despite experiencing significant difficulties through age 18 that required professional attention, by age 32 they were now adapting well (Werner, 1993). Carl’s life trajectory was quite similar. Up through age 18 and even beyond, he struggled academically, emotionally, and behaviorally. By the time he reached his 30’s, however, he was functioning far more successfully. According to Werner and colleagues, by age 32 those adapting well had benefited from protective processes, sources of resilience, and turning point experiences quite similar to those found in the lives of individuals who rebounded from various other childhood risks and adversities. These included the ability to draw upon sources of support from others, a faith and belief that they could overcome the odds against them, the opportunity to assume an important responsibility perceived as helpful to others, and the opportunity to engage in activities that helped promote a sense of mastery or self-efficacy (Werner, 1993). By his 30’s, Carl appeared to have accessed similar protective processes and life changing experiences as well.

Historically speaking, a host of negative life outcomes have been associated with reading and other learning disabilities. Results of the Kauai Longitudinal Study, however, present a different picture. So too does a study conducted by Paul Gerber, Ph.D. and colleagues that identified characteristics associated with vocationally successful adults with learning disabilities. These characteristics overlap considerably with several of the contextual influences associated with Carl’s successful life outcome. According to Gerber and colleagues, vocationally successful adults with learning disabilities were able to find alternative ways to handle tasks and responsibilities that would otherwise be impacted by their challenges. In addition, they were willing to seek out support from those around them. Furthermore, they were able to find or create environments that matched well with their particular strengths and talents. And importantly, they were able to re-frame their learning disabilities in a new light (Gerber, 2001; Gerber, Ginsberg, & Reiff, 1990). Perhaps the single biggest reason why Carl never accomplished these tasks during his school-age years can be traced back to human misunderstanding. Growing up, Carl had no idea that otherwise resilient school-age children could perform so inconsistently and unpredictably on tasks that most other children could perform effortlessly. And he certainly had no idea that children with profiles such as his could conceivably excel at far more difficult and complex intellectual and/or creative tasks. Unable to see his challenges in a new light, he would eventually grow demoralized and come to believe that trying harder did not result in doing better. Carl has benefited significantly simply by being able to view reading and other learning disabilities in historical context.

Interpersonal Trauma and the ACE Score (ACE = Adverse Childhood Experiences) – In a New Light

“Ah, this is, uh, Cactus 1539, hit birds, we lost thrust in both engines; we’re turning back towards LaGuardia.” From the control tower: “Cactus 1529, if we can get it to you, do you want to try to land Runway 1-3?”

Captain Chesley B. Sullenberger III would soon realize that he couldn’t make it back to LaGuardia, or to nearby Teterboro Airport in New Jersey. His only option was to land the US Airways airliner with 155 passengers on board in the Hudson River, which he did successfully. All on board survived. Throughout the crisis, Captain Sullenberger remained remarkably focused, and for that matter, so did the controller at LaGuardia. Both were in complete control and performed the functions they were trained to perform exceptionally well under emergency conditions.

“Cactus 1539”? “Cactus 1529”? In the middle of this emotionally charged life and death scenario, who had the correct flight number, Captain Sullenberger, or the air traffic controller? Actually, neither one. The correct flight number was 1549, the point being that even emotionally strong people are affected by stress, sometimes in subtle and not easily detectable ways, like in the ability to retrieve information, or hold information in mind long enough to use it to solve a problem or reach a goal (working memory), or execute tasks they know how to execute very well under calmer, less emotionally charged situations. 

Stress can impact our ability to execute. And the greater the stress, the greater the impact. Among those suffering the effects of traumatic stress exposure, neuroimaging studies reveal a decrease in activation in brain regions associated with executive functioning (van der Kolk, 2006). On some occasions at least, it’s very possible that during his earlier school years, Carl struggled in his ability to execute important school-related skills not only because of neurodevelopmentally based executive function delays, or a neurodevelopmentally based reading disability, but because of normal biological reactions to abnormally stressful life experiences.

When posttraumatic stress disorder was established as a diagnostic classification in 1980, it validated what many in the mental health community already knew all too well: Otherwise normal and healthy people, free of serious emotional challenges, can be changed psychologically and biologically as a result of exposure to traumatically stressful experiences. But what was less known at the time was the potential harm that can result from “interpersonal trauma,” or trauma occurring within the context of human relationships, particularly relationships we depend upon as children to feel safe and protected. Examples of interpersonal trauma include child abuse, physical abuse, sexual abuse, verbal abuse, exposure to domestic violence, neglect on the part of a caregiver as a result of mental illness, and to the surprise of many, severe bullying (D’Andrea, Stolbach, Spinazzola, & van der Kolk, 2012). For the student being tormented by a more powerful student at school, and who feels powerless to stop it, experts in the bullying prevention arena believe the effects can be traumatic.

“The beginning of wisdom is calling things by their right name”

                                                                                    Ancient Chinese Proverb

The term interpersonal trauma seems to capture how individuals, regardless of age or background, can be affected behaviorally, emotionally, and physiologically by virtue of trauma occurring within the context of their personal relationships. Other terms appear in the research literature as well, all in an effort to capture similar effects. These terms include disorder of extreme stress not otherwise specified (DESNOS), complex posttraumatic stress disorder, developmental trauma disorder, and chronic trauma. A number of experts in the field prefer the term interpersonal trauma, since it’s one of the few terms without the word “disorder” attached to it. As a result, it may enjoy an advantage in helping us appreciate that there are limits to emotional endurance, even for the most resilient among us. 

Today, Carl is playing an important role in helping others learn to see their challenges in a new light. And studies show that by helping others he also may be helping himself. One study, for example, found that persons (all 55 years of age or older) who volunteered for two or more organizations reduced their likelihood of dying by 44 percent, this after ruling out other possible explanations (Oman, Thoresen, & McMahon, 1999; Post & Neimark, 2007). According to the study’s authors, volunteering for two or more organizations compared very favorably to other factors associated with reduced mortality, among them, mobility (39 percent), exercising four times per week (30 percent), and attending religious services (29 percent). The only factor found to have a slightly higher effect was quitting smoking (49 percent). In a second study, chronic pain sufferers who were trained to provide voluntary services designed to help others showed a reduction in pain intensity and depressive symptoms. Researchers cited two common themes emerging from narrative data that helped explain improved well-being: “Making a connection,” and “a sense of purpose” (Arnstein, Wells-Faderman, Morgan, & Caudill, 2002). In a third study, giving behaviors in high school predicted good physical and mental health fifty years later (Post et al., 2007; Wink & Dillon, 2007). Stony Brook University Psychology Professor Stephen Post, Ph.D. reviews these and other studies in his book, Why Good Things Happen to Good People. According to Post, research shows that giving back to others protects overall health twice as much as aspirin protects against heart disease. This has not gone entirely unnoticed by doctors, according to Post. In one California HMO, Medicare patients receive written prescriptions by their physicians recommending that they volunteer. 

Turning points have also been the focus of another landmark prospective longitudinal study, the longest known study of criminal behavior over the lifespan. Conducted by principal investigators John Laub, Ph.D. and Robert Sampson, Ph.D., the study documents turning points in the lives of previously incarcerated teens with lengthy criminal histories who eventually went on to lead crime free lives. (To learn more, log on to our website.) The study originated in 1939, when then principal investigators Drs. Sheldon and Eleanor Glueck began following the lives of 500 incarcerated males ages 10-17, all of whom had amassed lengthy and serious criminal records. Concurrently, they also began following a matched control group of 500 males, similar in age, ethnicity, IQ, and socioeconomic background. All 1000 subjects resided in the same Boston neighborhoods, which, at the time, had high rates of poverty and crime. Extensive data was collected on their criminal activity at three points in time – at ages 14, 25, and 32. In 1987, researchers Laub and Sampson successfully extended the study of the original sample of incarcerated males to age 70 (Laub & Sampson, 2006).

In addition to the detailed quantitative data gathered for the entire sample, Laub and Sampson also conducted detailed life history interviews with a subsample of original members, some of whom succeeded in creating lives free of criminal behavior (“desisters”), some of whom continued to engage in criminal behavior (“persisters”) and some whose trajectories “zigzagged” between the two. Using extensive life-history interviews, Laub and Sampson were able to study underlying processes associated with these three different trajectories. And for desisters, or those who would eventually lead crime free lives, three common turning point experiences emerged: Long-term stability in marriage, long-term stability in employment, and a successful stint in the military.

Marriage As Turning Point: Many of those who remained crime free said they had their wives to thank. In addition to social support, marriage provided an element of external control. Their wives were helpful in organizing and managing household activities, planning events, and arranging the day in ways that offered an element of structure not previously present in their lives. Some wives also maintained a “zero-tolerance” toward drinking, an important factor for those who linked their prior drinking to earlier criminal behavior. For many, connecting emotionally with their wives also permanently disconnected them from others engaged in criminal activity (Laub & Sampson, 2006; Sampson, Laub & Wimer, 2006).

Employment As Turning Point: Not only did their wives help change their day-to-day lives in positive ways, so did their jobs, and in some instances, the relationships they enjoyed with their employers. Those living crime free lives were employed as cab drivers, construction workers, fire fighters, postal workers, appliance repairmen, and other wide-ranging jobs. Many also worked overtime, on evenings, and on weekends. For many, a steady job and a steady paycheck represented stability and responsibility. With a steady job also came a new identity and a sense of accomplishment.

Successful Military Service As Turning Point: Those joining the military did so during World War II. Many saw combat, and many benefited greatly from the G.I. Bill upon their return, which paid for their education and/or job training.

Physically moving from one geographical location to another also proved to be a turning point experience for some. One desister talked about how his life improved when he moved from the city to the country.

Those who would eventually lead lives free of crime were active participants in the process. According to Laub and Sampson, the personal choices they made and the personal relationships they formed led to home and work environments that provided an element of external control and monitoring. Of those who would eventually lead lives free of crime, it appeared as though context loomed large, socially, psychologically, and relationally.