How to help children who are highly susceptible to stress

How to help children who are highly susceptible to stress
Image: Hokyoung Kim for Quartz
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Why is it that some children thrive in the worst circumstances while others are remarkably sensitive? Tom Boyce, a pediatrician and researcher at University of California San Francisco, has been asking that question for more than 40 years.

Starting in the 1970s, Boyce, like many pediatricians, observed that most kids were physically and mentally resilient—relatively immune to illness, injury, and disease. But a small group of kids seemed to accumulate a disproportionate number of health and behavior problems: from severe respiratory disease, injuries, and developmental delays, to more mental and behavioral issues, like anxiety, depression, and aggression. He could see these kids tended to come from families that faced a lot of stress or adversity, in the form of socioeconomic disadvantage or general misfortune.

He found a consistent link between family stress, adversity, and all kinds of childhood illnesses, injuries, and behavioral disorders. But the associations were modest. They were statistically significant, meaning they were unlikely to be due to chance, but they could only explain a small portion—just 10%—of different outcomes, of why a child with more stress would have worse health and behavior.

Boyce wondered: What if it was a child’s reaction to the stress, and not the type or amount of stress, that predicted who would suffer most? Clearly excessive stress is bad for all children (as it is for adults); governments, doctors, and communities should focus on reducing poverty and violence to support families and minimize stress. But were some kids better able to weather those stressors?

He found they were. As Boyce details in his 2019 book The Orchid and the Dandelion: Why Some Children Struggle and How All Can Thrive, about 80% of kids were what he dubbed “dandelions,” resilient creatures that can bloom in almost any climate or circumstance. The other 20% were more like orchids, deeply sensitive flowers that require careful attention and nurturing to thrive and grow.

“Like their namesake flowers,” he writes, “[orchids] are both endowed and burdened with an exquisite sensitivity to the inhabited, living world, and, also like the orchid, have both frailties that can threaten their existence and health, as well as hidden capacities for lives of beauty, honesty, and notable achievement.”

When he followed these children over time, he found something remarkable. The kids who fared the worst were, unsurprisingly, the orchids who had grown up in the worst circumstances: without a loving caregiver, facing neglect and sometimes abuse, living in violent neighborhoods, with deep family instability.

But the ones with the best health and life outcomes were not the dandelions. Instead, it was the orchids who had been reared with love and attention. They had an unusual capacity to thrive, but only with an extraordinary amount of care.

How to stress kids out

It’s not exactly obvious how to determine if young kids are stressed out. Even the average kid can fall apart over a dropped ice cream, but seem fine when you tell them they will be moving 3,000 miles away (“Will I get my own room?”). The challenge, then, is isolating the stress.

Boyce devised some strategies. He’d bring children ages three to eight into a lab and create situations that were emotionally, cognitively, and even physically (though only slightly) stressful. He would put a tiny bit of lemon on their tongues, have them recite a few digits, or have them watch an emotional video and then have an unknown examiner monitor two manifestations of stress: the autonomic nervous system, which produces the fight-or-flight reaction, and the stress hormone cortisol. Both affect the immune and cardiovascular systems. If the two are chronically and substantially elevated, they can affect a child’s ability to fight off infection, or impair healthy cardiovascular development that will help prevent hypertension or high blood pressure.

Kids reacted as he suspected: Most did not produce usually high responses to being stressed out, though about a fifth did. 

Boyce and his team then followed these kids in the real world to see how they reacted to real stress: to parents’ divorce or death, to violence or maltreatment, to neglect. And indeed, the pattern stuck: 80% of kids showed almost no increase in poor health or behavior outcomes under naturally-occurring adversity, but 20% of kids who had high reactivity in the lab also had high reactivity in the real world. These “were the kids who were the sickest, the most injured, the most behaviorally disorder[ed] of all of the children in our samples,” Boyce said.

“The sense we made of this is maybe that was maybe these one in five were not just vulnerable, but they were just really sensitive to the kinds of environments that they embedded within,” he said. “They were deriving more of the good stuff of good environments and more of the bad stuff from the bad environments.” In other words, it’s not nature or nurture that determines an orchid’s outcome but both nature and nurture, working together. With others, his work showed that children are built differently, and depending on their temperament, different environments alter genetic expression, in turn, leading to different developmental outcomes.

How to manage orchids (or just be a really good parent)

Policy-makers and parents could justify a number of different actions based on these results. Some could argue against helping the 80% because they will be fine. Boyce said that’s not how he interprets it. “It doesn’t mean that we shouldn’t address adversity and poverty or disadvantage—of course we should, because that’s bad for all kids.”

But what it does mean is that scientists and doctors have a lot more information to work with. They can pinpoint who needs help, but also, who is most likely to respond to interventions to ameliorate the effects of stress—something that’s eluded pediatricians. “If we target highly reactive kids who are living in true adversity, they not only are the ones that are most likely to have poor health as a consequence of those certain circumstances,” Boyce said. “They’re also the ones who are going to have the greatest impact of beneficial intervention that could potentially really reverse their fortunes.”

“This work is important because it highlights how individual differences in childrens’ temperament can interact with their caregiving environments to give rise to very different developmental trajectories,” said Charles Nelson, a pediatrics professor at Harvard Medical School, who has spent 20 years documenting what happens to infants in severe adversity. In caring and nurturing environments, orchids will thrive, he explained, whereas in others, characterized by neglect, abuse, violence and strife, they may suffer. “The context in which children are raised interacts powerfully with their inherent temperaments.”

The research is still ongoing. A team of pediatricians, community workers, and researchers are refining ways to measure stress much earlier, in infancy, to get support for families who need it. Designing the measures has been challenging, because it is not always clear what interventions work best, and access to support is limited.

Since Boyce published his book, every parent of course asks him how to know if their child is an orchid or a dandelion. Some basic traits (extroversion vs introversion, comfort level in new situations, sensory hypersensitivities) can point to one category over the other, though clinical measures would be more accurate.

He suggests this is the wrong question, however. As a culture, we typically think about kids as vulnerable or resilient, but his research points to the fact that environment helps determine that. So parents, teachers, and communities have to work hard to create supportive environments.

All kids need loving and attentive care, but the orchids even more so. To help those parents, Boyce devised a list, to be released in March with the paperback version of the book, of what exactly those kids need. It follows the mnemonic “Orchid”:

  • O: one’s own true self. This is the idea, attributed to Alice Miller’s The Drama of the Gifted Child, that one of the principal tasks of growing up is to figure out who we are and to allow that one true self to “flourish and to come to the foreground and express itself,” Boyce said. Parents play a starring role in that, and need to take care to parent the child they have, not the one they want. They should strive to let a child’s essential quirkiness shine, rather than pushing them to conform.
  • R: routines and sameness. All kids, Boyce notes, thrive with rich family routines and structure, but orchid children seem to need it more. “Highly reactive kids seem to do best with a very structured day to day, week to week,” he said. This has implications for teachers, too, who face a classroom of kids, one-fifth of whom are likely orchids and will need more structure and predictability. “Routines and rituals, far from rendering life boring or monotonous, seem to have tangibly protective effects on the young people and families who pursue them,” he writes.
  • C: caritas, the Latin word for steadfast love. “Obviously we want to give all of our children steadfast love, this kind of enduring, dependable care and nurturance that we all strive for as parents and grandparents. But it seems to be particularly and uniquely advantageous to kids with these high sensitivities,” Boyce said.
  • H: respect for human differences, or treating every child as they are, and not the same due to the fact that they are part of the same family. “One-size-fits-all parenting, after all, is easier, and it conforms to the cultural value of treating all of our kids the same,” he writes. Boyce said, in his 40 years as a pediatrician, he’s seen lots of families try to obscure the differences between their children. But as any parent with more than one child can attest, no two children are the same; they have different wants, likes, and needs.
  • I: imaginative play. Children need it. “Many people think of children’s play as a trivial and nonproductive,” Boyce says. “In fact, it’s just the opposite: imaginative play, particularly to young children, helps them identify who they are. It helps them learn how to deal with social groups and social relationships,” Boyce said.
  • D: danger, which orchid parents might feel for their children. This, Boyce explains, is “the dilemma that parents of orchid children always are facing, which is when to nudge them forward into a potentially fearful situation versus letting them withdraw from that fearful situation.” There is no right answer, but he encourages the parents of orchid children to trust their instincts. “Parents also get better at this over time, learning by trial and error what may be best for their kid in specific situations,” he said.

Boyce’s work recasts vulnerability as potential, helping parents reframe what can be popularly viewed as weakness as strength. He also offers assurance to parents who know they have kids who are more sensitive, and perhaps demanding, that they are not alone. “Though orchids may sometimes appear weak or inconsequential within the buzzing, feverish activity of family life, they always have an array of gifts and potencies of great significance and advantage,” he writes.

Here, parents have power to unleash something beautiful while managing a challenging child. This can feel like a lot of pressure, but it is also a bit liberating: There is a small universe of children who need a bit more care.

There are more macro takeaways from his research as well. One big one: Policies that perpetuate inequality and induce trauma, such as the Trump administration’s family separation policy, are bad for society, but can have negative life-changing effects on orchid children’s mental and physical health. How the most vulnerable and sensitive children fare is a reflection on our society as a whole.

“At the level of human populations and societies, it is the children who are the orchids of those societies,” Boyce said. “All of our children are the canaries in the mineshaft of an ugly and misguided society that is ignoring at best and maltreating at worst its own children.”

Read more from our series on Rewiring Childhood. This reporting is part of a series supported by a grant from the Bernard van Leer Foundation. The author’s views are not necessarily those of the Bernard van Leer Foundation