Exploring the perspectives of child health strategy stakeholders on resilience and well-being in children and youths in Singapore: A qualitative study

Dear Editor,

Resilience has been defined as the capacity of a dynamic system to adapt well to potential threats,¹ while mitigating the negative impact of behavioural and physiological changes due to chronic stress,² and the resumption of positive functioning thereafter.³ Resilience enables one to adapt positively to adversities in life and allows the transformation of toxic stress to tolerable stress. The factors associated with resilience are homogeneous across studies, which are individual attributes such as self-regulation and problem-solving skills, relational attributes such as secure attachment relationships, and connections to school and community.⁴ This is relevant to the Singaporean context, as the Singapore Mental Health Study conducted from 2016 to 2018 revealed that 1 in 5 youths, aged between 18 and 34 years old have a mental disorder.⁵ Mental disorders were also reported to be the largest contributor to disease burden for Singaporeans aged 10 to 34 years old, peaking for 15 to 19 year-olds, for whom it represented 25.8% of total disability-adjusted life years (DALYs).⁵ In 2020, suicide is the leading cause of death for those aged 10 to 29 years old. Parent-child relationships are the focus of resilience studies in how they shape a child’s resilience to bounce back after encountering adversities. Parental influence is key to the resilience and well-being of the child and family systems.⁶

The single most common finding of children with adverse childhood experiences with good outcomes in life is the presence of at least one stable and committed relationship with an adult who is their parent or caregiver. A highly responsive caregiver with consistent “serve and return” interactions with the child stimulates brain development in the cognitive, executive, social and emotional domains.⁷ This happens when a child attempts to communicate their needs, and the parent or caregiver responds appropriately to the child’s signals and needs.⁸ The supportive relationship enhances positive experiences and adaptive skills in children, which forms the basis of resilience-building. There is little data regarding the framework of resilience-building and well-being in children and youths. The understanding of how resilience can be built provides opportunities for designing more upstream  measures to improve a child’s life outcomes—through enhancing capacity and resilience-building. Our study is timely as there is increasing focus in the area of resilience and well-being in children and youths as upstream measures to prevent mental health issues.

We conducted a qualitative study based on the interpretative approach to understand the different perspectives of child-health strategy stakeholders on resilience and well-being, and explore enablers and challenges in resilience-building and well-being in children and youth aged between 0 and 18 years in Singapore.

We carried out 16 in-depth semi-structured interviews in Singapore between December 2021 and April 2022, both virtually and on-site. Participants were identified as potential child-health stakeholders if they were parents or caregivers to children and/or youths, or had worked with them for at least 1 year, and invited for the interview via purposive sampling. Further respondents were recruited via snowball sampling. A conceptual framework based on Walt and Gilson’s Triangle Framework⁹ and Socio-Ecological Model¹⁰ was used for the interview guide. Both inductive and deductive analyses were used to identify themes and subthemes from the data. QSR NVivo 12 software (Lumivero, CO, US) was used for analysis.

The study involved participants with an average of 18 years of experience working with children in the public sector. The cohort was diverse, including parents, youths, educators, school counsellors, paediatricians, psychiatrists, psychologists and social workers.

Data triangulation was carried out through having comparable groups of stakeholders. Recruitment of participants was stopped when data saturation was reached. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist was used to ensure the study design, data collection and analysis were comprehensive.

Table 1 encapsulates the key enablers and challenges identified across various domains impacting the resilience and well-being of children and youths.

Table 1. Summary of key findings and recommendations.

Our key and most consistent finding is that having parents with good socio-emotional skills helped children build resilience and well-being as the adults were attuned to their child’s emotional needs and were able to cope with their tantrums. The children were described as having developed ways to express themselves appropriately and built emotional and mental health literacy to cope with life’s challenges. This provides children with an emotionally safe environment to emulate their parents and gain intrapersonal and interpersonal relational skills for resilience-building. Positive parental role-modelling during adversities also influence how children perceive and deal with future challenges.

The main challenge is the lack of time in modern-day parenting to invest in socio-emotional literacy and parenthood skills to support their children and enhance their relationships. Our data suggests that individual resilience is shaped by family behaviour and practices. These results are consistent with our literature review.

Singapore has progressed rapidly from a third-world country to a first-world society. To keep up with the rising cost of living, family units are getting smaller, where dual-income parents are common. With less time invested in the parent-child relationship—because both parents work—quality family time is affected, and family bond and identity suffer. The social fabric significantly weakens with bearings on future generations. This is exacerbated by excessive use of screen time, which impairs social connection and relationships. Unregulated excessive screen time diminishes sleep efficiency and duration,¹¹ impacts socio-emotional development, language, cognitive and executive functions, which worsens intrapersonal and interpersonal skills, with impact on mental health. The COVID-19 pandemic amplified this, increasing social isolation and leading to worsening relational and communication skills, with a rise in mental health issues.

The Singapore government has recognised the importance of maternal and child health, resilience and well-being. The development and implementation of various programmes such as KidSTART and the formation of multi-ministry and cross-agency taskforces, with active public engagement and consultations, show that the government is taking proactive steps towards upstream preventive measures. Despite the positive steps made by the government, major areas of concern from the study were identified: the Singaporean identity and values; lack of time and support in modern-day parenting; unregulated excessive screen time; and lack of human resources, expertise and funding for programmes targeting children and youth.

In the pursuit of success—often defined by Singaporean societal standards to be academic and achievement-focused—there is cultural and societal separatism, with a loss in sense of community.¹² A strong family unit forms the basis of a community, where there is shared identity that can confer purpose to one’s being and is an important contributor to life satisfaction.¹³ This is important in the formation of a child’s identity and sense of belonging. However, it is acknowledged that as children enter various life transitions, they struggle with forming their personality while still belonging to a shared identity, and may find it difficult to conform. With the influence of social media and the pressure to fit in, children may lose their sense of self, leading to mental health issues. This can be mitigated with better socio-emotional literacy.

Being a pragmatic society with good governance, funding to initiate or sustain various programmes in promoting health and socio-emotional literacy need to be substantiated with data and evidence. While recognised as necessary, this is reported as a barrier for existing programmes. Current manpower in schools, healthcare and community organisations is often stretched with increased workload but inadequate funding and resources to meet programmes’ goals, leading to burnout. It is important to reconsider the support structure for such programmes prior to scale-up.

Our data’s key recommendation is for family health to be considered as an expansion from maternal and child health. We recommend that family health, which includes family and parental resilience, take on a Life Course Health Development model,¹⁴ looking at the family structure, family decision-making processes and communication, family cognitions and health-related behaviours.¹⁵ Parental role-modelling in relational skills within a stable marriage, cognitive processes, socio-emotional literacy and health behaviour has a large influence on the child’s growing years.

The spotlight on child and maternal health and well-being, and mental health in recent years, brings an opportunity to reassess the nation’s priorities and evaluate the root causes of issues of concern such as rising youth mental health problems. Going upstream into resilience-building and promoting well-being can stem these. Further studies need to be undertaken to understand the gaps and priorities of Singaporean families prior to the design and implementation of strategies to improve family and individual resilience and well-being.

Supplementary Materials

References

1. National Scientific Council on the Developing Child. Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience. Working Paper No. 13. Harvard University, 2015. developingchild.harvard.edu.
2. Russo SJ, Murrough JW, Han MH, et al. Neurobiology of resilience. Nat Neurosci 2012:15:1475-84.
3. Davydov DM, Stewart R, Ritchie K, et al. Resilience and mental health. Clin Psychol Rev 2010;30:479-95.
4. Masten AS. Resilience Theory and Research on Children and Families: Past, Present, and Promise. J Fam Theory Rev 2018;10:12-31.
5. Subramaniam M, Abdin E, Vaingankar JA, et al. Tracking the mental health of a nation: prevalence and correlates of mental disorders in the second Singapore mental health study. Epidemiol Psychiatr Sci 2019;29:e29.
6. Gavidia-Payne S, Denny B, Davis K, et al. Parental resilience: A neglected construct in resilience research. Clinical Psychologist 2015;19:111-21.
7. Scherer E, Hagaman A, Chung E, et al. The relationship between responsive caregiving and child outcomes: evidence from direct observations of mother-child dyads in Pakistan. BMC Public Health 2019;19:252.
8. Center on the Developing Child at Harvard University. Serve and return, 27 January 2020. https://developingchild.harvard.edu/science/key-concepts/serve-and-return/. Accessed 18 June 2022.
9. Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan 1994;9:353-70.
10. McLeroy KR, Bibeau D, Steckler A, et al. An ecological perspective on health promotion programs. Health Educ Q 1998;15:351-77.
11. Domingues-Montanari S. Clinical and psychological effects of excessive screen time on children. J Paediatr Child 2017;53:333-8.
12. Collier P. The Future of Capitalism: Facing the New Anxieties. New York: Harper Collins; 2020.
13. Heng MA, Fulmer GW, Blau I, et al. Youth purpose, meaning in life, social support and life satisfaction among adolescents in Singapore and Israel. J Educ Change 2020;21:299-322.
14. Halfon N, Russ SA, Schor EL. The Emergence of Life Course Intervention Research: Optimizing Health Development and Child Well-Being. Pediatrics 2022;149:e2021053509C.
15. Feinberg M, Hotez E, Roy K, et al. Family Health Development: A Theoretical Framework. Pediatrics 2022;149:e2021053509I.