It’s been said often, especially in health care – kids are resilient. It's true that kids can completely surprise adults with how well they cope and weather the storms of life. However, resiliency in children is not universal, and we cannot expect our children to be resilient innately. Resiliency must be taught and fostered.  

From kids getting ready to attend kindergarten, to teenagers on the cusp of adulthood have all survived a pandemic. Parents and teachers could easily and quickly tell you that not all kids are resilient. It is reported that emergency room visits due to mental health concerns increased by 24% for children 5-11 years old and even more for children 12-18 years old from March 2020 to October 2020. In early 2021, suicide attempts more than doubled in girls from two years prior, according to MedStar. Given social media and cyberbullying in conjunction with a pandemic and economic crisis, we can be sure that our children are not innately resilient.

While children can often appear to be coping more effectively than adults, we cannot ignore the increase in children who are in mental health crises. Many areas where children struggle with resilience could be helped by simply limiting their exposure. We are asking our children to live and function outside their developmental ability to understand the world they are being exposed to. It is no wonder that children are struggling. 

So before diving into resilience, consider your child’s age and developmental abilities and what they are currently being exposed to. If there is a gap, consider narrowing the gap by ensuring that your child is involved in developmentally appropriate activities and is exposed to developmentally appropriate media and material. 

Resilience can be defined as children’s ability to thrive when faced with challenges, according to the American Psychological Association. Challenges for kids can range from starting a new school or having a friend move away to bullying and harmful exposure on social media. Parents should be aware of the many things that may be causing a child stress or testing their resilience. The goal would be for children to quickly return to their baseline following any kind of stressful or challenging experience.

All my girls have had a school year that included heavy challenges. Following the pandemic and upon just returning to school in person, one of my daughter’s teachers went out on maternity leave. While this was so exciting and something to be celebrated, my daughter did not handle to the change to a new teacher well at all especially following such an uncertain time. It resulted in some very difficult evenings. 

Now another daughter has experienced a leave-of-absence for her teacher, and it became very difficult for her to cope with the constant changes in her classroom each day due to not having a long-term substitute. While these challenges may seem simple to adults, the change in daily routines, the anxiety of getting to know someone new, and the unmet expectations along with other stressors test our children’s resiliency. 

There are so many things that children experience that could be breaking their resiliency. As parents and caregivers, it is our job to help build their resiliency. The American Psychological Association says, “Building resilience—the ability to adapt well to adversity, trauma, tragedy, threats, or even significant sources of stress—can help our children manage stress and feelings of anxiety and uncertainty.”

It may surprise you that there are some very simple ways to help children build their resiliency.

1. Perceived control is a large part of resiliency. Offering children opportunities to increase their perceived control will help to build their resiliency. Perceived control is a child’s belief in their ability to control events or situations. If a child has high perceived control, they believe that their response to a situation or event matters to the overall feeling of that experience. For example, a child who spills a glass of milk on the floor with low perceived control may just sit down and cry or run away from the spilled milk. The child with higher perceived control will grab the paper towels and start to clean up the milk because they believe they can, and they believe it will make it better. So, as parents and caregivers, we can grow children’s perceived control by offering choices and giving them independence. This can be difficult for adults who love to be in control. However, it is important that children recognize that they can move through a challenge based on their response or actions to that challenge. The more opportunities we provide for our children to be challenged and then be successful, we will be giving them the opportunity to grow their perceived control. Playing sports, learning a new instrument, or cooking a meal are all places that may present challenges that a child could learn how to respond to that challenge and feel successful.
2. Maintaining structure and routine will help to grow resiliency for your child. Maintaining structure will show children how to prioritize and manage their time and circumstances so that when life inevitably throws them a curveball, they know how to adapt and adjust. When children are constantly out of routine without an opportunity to get a handle on anything, they are adapting so often that they are not able to learn follow-through, time management, or how to emotionally cope with the constant change. Structure and routine create a safe space to learn to feel confident in completing tasks, making plans, and managing emotions. This safe space of routine will also allow children to be successful which builds their confidence. This will help them to quickly return to their baseline when something is challenging.
3. A strong community and/or supportive adult relationships are also paramount to building resiliency. This cannot be said enough. A strong relationship with an adult will provide a sense of strength to any child to let them know they are not alone in whatever challenges they face. No one wants to feel alone while feeling overwhelmed. Spending time with your child, asking intentional questions, and really listening will provide a space for resilience to grow. When a child can hear how parents or caregivers have handled difficult situations and circumstances, it will help to guide how they choose to respond. Outside of close relationships with adults (coaches, teachers, parents, neighbors, etc.), it is important for your children to feel a part of a community and something bigger than themselves. This may be a place where faith is also mobilized like within a church or other community. By partnering with others who are like-minded and will offer hope and perspective in difficult situations, resiliency is given a chance to grow.  Relationships grow resiliency in every way. We were made to do this life together.

Resiliency can be grown. We can help our children to become more resilient, and adults can also work to become more resilient. We want children to be empowered by the challenges they face, not paralyzed. The more we can help them grow in resiliency, the more we are supporting the health and well-being of future generations. We want our kids to know how to bounce back. We never know when another experience similar to the pandemic will occur, but we want to and raise others to rise above the challenge and come out stronger on the other side!

I am shocked at the number of patients we see where bad posture plays a role in their pain and physical limitations. Whether it be sports injuries, overuse injuries or postural dysfunction, the trend is younger patients are starting to report more injuries. I see technology driving our kids to be more active in an online space than it does in a physical space.

So I would like to take a minute to address how to get our kids active again, but not just any activity. I want to talk about core activity.

What is the core?

The core is a muscular system that works synergistically to provide support and power generation to the body in all positions and with every activity. Think of a soda can to explain the core. The can has a front (deep abdominals), back (multifidi muscles), top (diaphragm muscle) and bottom (pelvic floor muscles). And just like the can, as long as no one pokes a hole in it, it is very strong. As soon as someone creates a weak spot in the can/core, it can easily be crushed.

When do you use your core?

The core should be used during all of life’s daily tasks, but we lose this ability as children when no one teaches us how to use the core during modern-day tasks such as playing on your Ipad or texting your friends.

How do I train the core of a child?

Return to the basics. Too often we see young athletes who have been given formal instruction in how to pitch a ball or perform a round-off back handspring, but little or no training on what it means to use their core functionally. Schools have our kids doing pushups before teaching how to plank. Physical therapy can definitely help patients of all ages with core training, but there are also some things you can do at home. For really young children (3-6yrs) this can mean returning to games that require you to hold positions, such as Twister or Untying the Knot. For slightly older children (7-12yrs), yoga or even just plank holds (3 positions) help build core strength and endurance. For our teens and young adults more formalized training for power generation and power transfer using the core can be very beneficial.

What does a strong core mean?

For your child a strong core means improved performance in their activities whether that is football, dance or band. It can mean no pain when sitting in class or when trying to be active with peers.

For parents, a strong core means fewer complaints from your child, better posture, and less risk of injury while your child is performing their activities.

If you or your child would like help with core training, please contact your physician and seek a referral to Cook Children’s Physical Therapy Department.

More SPORTS resources related to this topic:

• Top 10 questions parents have about sport injuries
• Young athlete's injury prevention guide

More and more young athletes are experiencing pain while participating in sports. Some have traumatic injuries like sprained ankles and torn ligaments, while others experience overuse injuries like low back pain and tennis elbow. All of these athletes can suffer from significant pain on and off the field. No athlete is exempt.

All sports require a baseline of flexibility, strength, stability and endurance, as well as a time of rest between activities to safely perform the required activities. With the rise in athlete specialization in a single sport, played year-round, we have seen an increase in injuries and pain in these young athletes. These young athletes are also starting at a much younger age. Many more stress injuries have resulted, such as ligament tears, shoulder strains, stress fractures and back strains. In addition, there has been a rise in chronic pain (pain lasting longer than 3 months) among younger athletes. I never heard of a teenager with chronic pain when I was growing up! How do we deal with this growing population? “No pain, no gain?” “Just grin and bear it, the pain will go away?” “Slap some ice on it and get back out there?” There needs to be a better way. Fortunately, there is!

The best plan is obviously prevention. However, for the purpose of this article, we will assume the athlete is already experiencing pain. In this case, there are several things to be done. Pain should not be ignored! Our body is trying to tell us there is something wrong. Acute pain should be addressed with the gold standard: Rest, Ice, Compression and Elevation (RICE). We are typically willing to ice, compress and elevate, but many times rest is not followed properly. “He’s our best pitcher!” “If she’s not playing, we will lose our chance to make it past district!” “I really want to play, so I won’t tell coach about the pain.” If we do not allow the tissue to heal properly, the tissue can become weaker and will be at a higher risk for being injured again, maybe even worse than the first time. Now that pain is being addressed properly, what do we do? Now is the time to work on the basics again:

Flexibility: Muscular flexibility is vital. Tight muscles are much more prone to injury than flexible muscles. Tight muscles can be damaged during high velocity movements. Also, tight muscles can alter how our joints move, making other structures more prone to injury, such as ligaments, joints and bones.

Strength: Muscular strength is also very important. Strong muscles allow our bodies to perform the tasks that we put them through. Strong muscles also allow greater protection from injury.

Balance/control: And don’t forget about core strength! This is maybe the most missed strengthening component in most sports and possibly the most important muscle group for any sport! A weak core places an increased stress on other body parts and increases our risk for injury. How can we expect a soccer player to avoid ankle or knee injuries if he/she can’t even balance on one foot?

Return-to-sport: If the athlete’s strength is improving and the pain is under control, we can work on sport specific activities. This is where a physical therapist or athletic trainer with a strong knowledge of sports performance is vital. Coaches properly trained in technique can do this as well as long as they are able to spend dedicated one-on-one time with the athlete.

If pain from a recent injury is not properly dealt with, or the injury leaves the athlete with pain that lasts more than 3 months, chronic pain may develop. Now our focus as a physical therapist is more on return of function versus the pain itself. Seeing a physician that specializes in pain, such as Dr. Artee Gandhi and Dr. Aimee McAnally at Cook Children’s, can be beneficial as well. The physician could prescribe or recommend one or more of the following treatments in conjunction with the physical therapy:

1. Medications to reduce pain or inflammation while working on regaining function.

2. Biofeedback therapy with a psychotherapist, such as Wayne Martin, LCSW, psychophysiologist at Cook Children’s, to help the athlete learn how to relax muscles, reduce stress and visualize performance for relief of pain and return to normal activities.

3. Pediatric massage therapy to address tension and/or increased sensation.

4. Acupuncture therapy to help control pain.

Related links:

• Football injury prevention
• Baseball injury prevention
• Softball injury prevention
• Basketball injury prevention
• Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• Tee-ball injury prevention
• Swimming injury prevention
• Tennis injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Dance injury prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries
• Pain that won't go away

Strength:  As these athletes push themselves to achieve the lifting goals set by coaches, is their form being supervised by someone trained to observe any breakdowns?  Complex lifts such as cleans, snatch, push-jerks, etc. put enormous strain on the athlete’s muscles, especially when they are younger and still developing, but if their form is poor it also makes them susceptible to back, shoulder, knee and neck injuries. Often the athlete lacks the core strength and stability to provide a solid foundation so that the body can move correctly. Core strengthening should be an integrated part of every strengthening program. Unfortunately, many of our athletes are never taught to control their core in basic sitting and standing postures, but yet we expect that they will somehow find their core while in the weight room or on the field. If you think core strengthening is all about abs, then you are missing the bigger picture.

Conditioning/ nutrition/ hydration: Cardiovascular conditioning is often an area that coaches hit pretty hard in the offseason, and most athletes have been working on some kind of conditioning program. However, the nutrition and hydration components of this area are often over-looked. Understanding how to fuel your body for peak performance is just as important as knowing how to perform the activity. Working with a nutrition/dietitian specialist can give your athlete the tools needed to unlock their full potential.

Flexibility: This is one of the most overlooked areas of a good training program for a football player getting ready for middle or high school ball. There is nothing glorious about stretching. There is also nothing glorious about missing a majority of the season while sitting on the bench due to a pulled hamstring. Flexibility training is about preparing the body to perform.  Dynamic stretching (moving stretches) prepares the body for immediate performance and should be used before any type of physical activity. Static stretching (prolonged holds) help prepare the body for tomorrow’s workout and promotes having the muscle length needed to achieve the greatest power. Use of a foam roller can also help improve flexibility by preparing the muscles for stretching.

Neuromuscular control: Why is it that the pros make it look so easy?  The ability to cut-back, stop-start, and change directions centers on the way an athlete’s brain can control the body. A physical therapist or trained professional can use any number of functional movement assessments to see how the body is moving and recommend corrective exercises and/or cues to improve these patterns. Learning the best patterns means the athlete can generate more power, more quickly, and in more directions. The best movement patterns also keep the body in the best alignment, and less likely to become injured.

Overtraining: The AAOS also recommends avoiding the pressure that is now exerted on many young athletes to over-train. Listen to your body and decrease training time and intensity if pain or discomfort develops.

See a physician if you begin having pain. This will reduce the risk of injury and help avoid “burn-out.”

Related links:

• Football injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries

About the author:

John Stanley, a physical therapist and SPORTS Rehab Clinical Coordinator at Cook Children's. The Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS) program offers care to children and adolescents with orthopedic or sports-related injuries.

These days many of the kids’ sporting associations, coaches, and sometimes even parents seem to be treating kids as little adults. However, kids are not just small grownups. Children are still growing, which makes them more prone to injury. They are also developing their strength, coordination and endurance as they grow. Kids participating in sports together, even though they may be the same age, vary in size as well as physical and psychosocial maturity.

Recently, there has been an increasing trend in younger children specializing in one sport. Specialization prior to adolescence can cause increased injury rates, early burn out on the sport and unwanted psychological stress for the athlete.

Counter to current trends, studies have shown that athletes at the elite level were more likely to start competing at a later age and compete in other sports until late adolescence. Research also supports that children who participate in a variety of activities and don’t specialize until reaching puberty are more likely to be more consistent in their performance.

Participating in a variety of sports helps with coordination, skill development, and gives the child a chance to rotate use of specific muscles to decrease the risk of overuse injuries.

It’s important for athletes, parents and coaches to be aware of the signs and symptoms of an overuse injury. These can include:

• Pain
• Swelling
• Changes in form
• Decline in performance
• Weight loss
• Anorexia
• Sleep disturbances.

Children also have the added risk of injuring their growth plates. What may cause a sprained ankle in an adult has the potential to fracture a growth plate in a child. These injuries have the possibility to disturb growth of the injured bone and cause deformity. A young athlete should never attempt to “push through” an injury. Too much stress on the bones or muscles can lead to tissue breakdown and further injury.

To prevent these injuries, the American Academy of Pediatrics (AAP) and American Academy of Orthopeadic Surgeons (AAOS) recommend: 

1. The athlete should be coached by properly trained people who are knowledgeable about proper form and technique.
2. Athletes should only participate at a level consistent with their abilities and interest levels.
3. It is important that the athlete is participating in activities they enjoy. The athlete’s desires should control their intensity of participation.
4. Athletes should not play one sport or type of sport (i.e. throwing) year round.

Young athletes should be followed by a health care team who can monitor the athlete’s body composition, cardiovascular system, sexual maturation and evidence of emotional stress. It’s recommended that children participating in high levels of activities have an ongoing nutritional assessment to look at total calories, balanced diet and intake of calcium and iron to ensure adequate intake for growth.

If at any time your young athlete is having pain or any of the symptoms above, please seek appropriate medical attention.

More resources from the Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS):

• The basics of sports injury prevention for kids
• Rise of overuse injuries in school-age athletes 
• Top 10 questions parents have about sport injuries
• Young athlete’s injury prevention guide

About the author

Amanda Stukey, PT, DPT, is a physical therapist for the SPORTS program at Cook Children's. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind.