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Resilience and

Posttraumatic Growth

dynamic developmental process
positive adaption
despite adversity or trauma
personality trait or attribute
Two-dimensional construct
Exposure to adversity
Positive adjustment outcomes

Posttraumatic Growth (PTG)

growth process
experienced positive change
as a result of traumatic experience
traumatic event itself, but aftermath
Change beyond effective coping
Beyond pre-trauma level of adaption
Qualitative change across different domains

Posttraumatic Growth

Some changes associated with

Increased sense of personal strength
discover new perspectives about relationships
Identify salient characteristics in others
(pos. and neg.)

Modified priorities, shift in perspectives and

value systems
appreciate smaller things in life
increased appreciation of life in general
richer religious, spiritual, and existential lives
(Calhoun & Tedeschi, 2004; Tedeschi & Calhoun, 2004)

PTG and posttraumatic stress

Although benefits and positive change
Still distress and struggle
Less emotional well-being in individual reporting PTG
(compared to resilient)
contributes to growth process
facilitates constructive cognitive processing of trauma

Attempts to make sense of trauma and aftermath

Productive ruminative process yields schema change
Supportive others
provide means to craft narratives
offer new perspectives
(Calhoun & Tedeschi, 2004)

Factors (potentially) affecting PTG

Age (older)
Gender (female)
Severity and type of stressor/trauma
Higher income
More time since traumatic event
Existential awareness (lifes fragility)
Higher levels of social support
Calhoun & Tedeschi, 1999, 2004 (Milam et al., 2004)

Does this sound a bit like a clich to you?

So, whats the evidence?

Measures of PTG
Qualitative (indirect) measures
Secondary analysis of PTSD interviews
Coding for elements of PTG
(Salter & Stallard, 2004)

Quantitative measures
For adults: Posttraumatic Growth Inventory (Tedeschi
& Calhoun, 1996)
PTGI-Revised for Children and Adolescents
(Yaskowich, 2002)
Posttraumatic Growth Inventory for Children Revised
(PTGI-C-R) (Kilmer et al., 2009)
Perception of Changes in Self scale (Kazak et al., 2001)

Posttraumatic Growth Inventory for

Children Revised (PTGI-C-R)
Kilmer et al. (2009), used with 7-10 yearolds
Two open ended questions
10 items assessing PTG in five domains
New possibilities
Relating to others
Personal strength
Appreciation of life
Spiritual changes

Other measures for children and

Posttraumatic Growth Inventory for Children
(PTGI-C) (Cryder et al., 2006)
21 items from pool of 29 items (same five domains as

PTGI-Revised for Children and Adolescents

(Yaskowich, 2002)
21 items (same five domains)

Perception of Changes in Self scale (Kazak et al.,

1 open-ended question
9 items

Other measures for children and

Secondary analysis of PTSD interviews
(Salter & Stallard, 2004)

framework technique (Ritchie & Spencer,

Five steps (Familiarization, thematic framework,
indexing, charting, interpretation)

3 areas of PTG
Perception of Self
Interpersonal relationships
Philosophy of life

PTG in children and adolescents

Empirical studies with children and
Milam, Ritt-Olson & Unger (2004)
Barakat, Alderfer & Kazak (2006)

Studies with young children

Salter & Stallard (2004)
Cryder, Kilmer, Tedeschi & Calhoun (2004)
Kilmer et al. (2009)

Adolescent with negative life events

Milam, Ritt-Olson & Unger (2004)
435 adolescents (grades 9-12, m= 15.8y)
Predominantly Hispanic

Negative life events (within previous 3 years)
Closed-ended checklist of life change units, including
10 major neg. events (Coddington et al, 1972)
Common neg. life events

Death of family member (34%)

Move to new home (16%)
Loss of close friend (11%)
Major illness to family member (10%)
Parents divorce/separation (10%)

Adolescent with negative life events

Milam, Ritt-Olson & Unger (2004)

Mean PTG score was 3.56 (=mild amount)

No different in PTG between types of
No different in amount of PTG for gender,
Correlations between PTG and
Age (+)
Religiosity (+)
Substance use (-)

Adolescent cancer survivors

Barakat et al. (2006)

150 adolescents cancer survivors (11-19

More time since, and higher perceived
intensity of treatment = more PTG
Older age at diagnosis = more PTG

PTG Measure
Perceptions of Changes in Self (PCS)
Kazak et al., 1996, 2001

Adolescent cancer survivors

Barakat et al. (2006)
84.7% of adolescents reported at least one
positive consequence
53% think about life
42% plans for future
41% how careful

32% reported 4+ pos. conseq.

PTG and other variables (correlations)
Age at diagnosis (+), time since treatment (-),
household income (n.s.)
(perceived) past and current life threat, treatment
intensity, PTSS (IES-R) (all correlations = +)

Children in road traffic accident

Salter & Stallard (2004)
158 7-18y old children
Secondary qualitative analysis of PTSD
interviews (CAPS-C), IES
42% report PTG
37% of them also PTSD
Mean age of children reporting PTG = 16y

Domains of PTG
Perception of Self
least applicable
None used words survivor or victim
Face reality of vulnerability

Children in road traffic accident

Salter & Stallard (2004)
Domains of PTG
Interpersonal Relationships
improved IR: 12% general, 20% with people involved in
Relationships closer cemented
learning to disclose more about feeling, and ability to
express more openly

Philosophy of Life

Most common theme

Appreciation of life (31%)
Reevaluation of what was important (13%)
Feeling if there is something that you want to do, try do itdont wait
Few reports of a more relaxed approach to life

Children affected by a natural

disaster (Cryder et al., 2004)
Hurricane Floyd (Sept 1999)
1 year later

Of 321 contacted only 46 (15%)

6-15 years (m=9.54y)
50% evacuated/displaced

PTG score 37-84 (m=65.11)
Correlations with other variables
Sign. corr. with competency belief
No other sign. corr. (e.g. age, gender, severity, social

Children affected by a natural

disaster (Kilmer et al., 2009)
Hurricane Katrina (Aug 2005)
T1=1y later, T2=2y later

68 7-10 year olds (m=8.3y)

Majority African American
73.5% prior Trauma

PTGI-C-R (range 0-30)

T1=20, T=19.2 (50% avg., 10.6% little)
No gender difference

Correlations with other variables

Sign corr. With subjective response to HK and PTSS (only PTSS in
No corr. with age
T1 PTG only sign. predictor of T2 PTG

Model of PTG in children

(Cryder et al., 2004)
Pre-trauma beliefs


Ruminative thinking
Competency beliefs

Extended model (see Kilmer, 2005)

Hypothesized model
Several factors remain untested
Cryder et al. discuss link between PTG and
social support (but no sign. Corr.)

No control groups
Normal developmental process?

Positive bias

A positive bias?

N=276 adults
Two factors

Exposure (to traumatic event)

Method (PTGI)

42.5% exposure
linked to stressful event
not linked to specific event (generally past 4 years)

PTG higher in unlinked group (with event exposure)

sign. Interaction exposure x method

Suggests that growth underestimated, rather than


PTGI usually linked to specific event

Development and PTG

Cognitive maturity and psychological mindedness
Interpersonal awareness and insight (Cryder et al., 2004)

Affective quality of change and learning

Response reflects dev. level/task
Lieberman & Van Horn (2004)

Understand + internalize depending upon

cognitive/emotional capacities (Osofsky, 2004)
Cognitive capabilities may influence understanding +
appraisal of trauma (Hasan & Power, 2004)

Attributions about circumstances

Repertoire of coping skills/strategies
Ability to marshal resources effectively
Capacity to attend to and report internal experiences (Cryder et al.

Development and PTG

Possibly years before PTG (on some dimensions)
manifests in children
Positive relationship between age and PTG
(Milman et al., 2004)
Cognitive maturity necessary

PTG process maybe qualitatively different in

Schemas not as clearly set in children
New experiences incorporated into internal
Children more vulnerable (Janoff-Bulman, 1992)

Age and PTG

Barakat et al. (2006)
Age 5y at diagnosis as cutoff
Age 5 shift in cognitive functioning, better process and
reflect on their experiences (Alderfer et al., 2003)
< 5y fewer positive consequences
Only 6.3% reported 3+ positive changes
In comparison: 44% of > 5y reported 3+ pos. changes

Childe age >5y more PTSS

But sign. Correlation between PTG and PTSS in both
>5y and <5y

Relevant research areas

Theory of mind (ToM)
Understanding of own and others mental
Desires, beliefs, emotions, intentions

Important area in developmental psyc

Age 5y important shift in development

ToM: Belief-based emotions

(Harris et al., 1989; Sprung, 2008)

one do
like the
in most?
box. So, put
the one you
one do
the most
in you
the least?


ToM: Belief-based emotions

(Harris et al., 1989; Sprung, 2008)

Now, lets work
How do you feel now,
on another task
about whats in the box?
and later you
get whats in
the box.

ToM: Belief-based emotions

(Harris et al., 1989; Sprung, 2008)

< 5y
Whats in
did did
the box,
in the
you get whats
in the box.


ToM: Introspection
(Flavell et al., 1995)

Do not
< 8 years

While you where sitting in the

no thinking chair, did you
have no thoughts or did you
have some thoughts?

having no

Theory of mind
Not mentioned in literature on PTG
Although Kilmer mentions psychological

Theory of mind and Trauma

More advanced ToM = more reports of PTSS
Sprung (2008)
PTG not assessed

Other relevant research areas

internal working models
John Bowlby
Attachment theorist (strange situation)
First caregiver-child, later extended to
other people/situations
Also not addressed in PTG lit.

Vulnerability versus protection

Basic assumptions (safety, protection from harm,
predictability) violated (Goldman, 2002)
Loss of trust, meaning, faith
Formation of traumatic expectation distorting (Pynoos et al.,
Emotional, cognitive, moral concepts
Inner representations of self, object relations, social environment

Disrupt sense of self/others, emotion regulation,

explorative learning (Lieberman & Van Horn, 2004)
Trauma in infancy/early childhood derails normative
developmental course
(Lieberman & Van Horn, 2004)
Pynoos (1990)
Difficulties in multiple domains (Bosquet, 2004)

Vulnerability versus protection

Childrens basic assumptions less firmly
Open to adaptive inputs

Factors to help buffer against traumatic impact

Emotional caring/interpretive effort of others
(especially parents)
Supportive environment for child to attempt
understand, incorporate
Input of others can guide interpretation, reframe,
(Janoff-Bulman, 1992)

Do you think PTG in young children is

Some problems:
Extend of literature (two fields: clin. and dev.)
Dev. lit: childrens understanding quite
struggle about similar issues

But limitations (e.g. introspection)

PTG: reality or illusion

Real vs. illusory process (Sumalla et al, 2009)
Real (positive) identity change
Illusory process
Coping strategy


Three facets of resilience

Lepore & Revenson (2006)

Tree will bend to accommodate wind, so it wont
break, and will return to upright position when wind

Tree stands still, undisturbed, in face of howling wind

Tree not simply make temporary accommodation,
then resume original shape
instead, it changes its shape (making it more resitant
to break in future winds)

Three facets of resilience

Lepore & Revenson (2006)
Stressor disrupts a persons normal state of functioning,
When stressor passes, person resumes her normal pre-stressor
level of functioning

People who exhibit normal functioning before, during, and after a
stressor (even long after a stressor)

Individuals reconfigure their cognitions, beliefs, and behaviors in
manner that allows them to adapt to traumatic experiences
Possibly withstanding future trauma

Whats normal response following
traumatic event?
E.g. loss of a loved one

Resilience an ordinary phenomena

(Masten, 2001)

Originally (1970s): something special,

remarkable about resilient children
But ordinary phenomenon
Common operation of basic human adaption
If major systems intact function well
If impaired, adversity = risk

Two kinds of judgments

(1) Threat (Not resilient, if no threat)
Risks, such as: low SES, negative life events,
community trauma, etc. (also cumulative)
Co-occur with psychosocial competence,
psychopathology, health
Risk gradients can be inverted to assets or
Pure risk = car accident, pure asset = talent or friend
Mostly pos. and neg. end
e.g. good parenting vs. poor parenting
Competent parents produce fewer stressful fam. life events
(risks), choose to live in neighborhoods with low crime (risks),
good community resources (assets), more likely to hire tutors

Two kinds of judgments

(2) Quality of adaption or dev. outcome
assessed or evaluated as good or OK
(a) Meeting major expectations of a given
society or culture (=salient developmental
tasks, competence criteria, cultural age
expectation) (Elder, 1998; Masten et al., 1998)
(b) Absence of psychopathology or low level of
symptoms and impairment (Tiet et al., 1998)
(c) Both a+b (Greenberg et al., 1999)

Related question
External adaption criteria
Accommodation, achievement, absence of

Psychological well-being, low level of distress

Or both
(Luther et al. 2000)

Historical overview
Atypical schizophrenics (Garmezy, 1970)
Children from mothers with schizophrenia (Garmezy, 1974;
Masten et al., 1990)

Emmy Werners groundbreaking studies with Children in

Hawaii (Werner et al., 1971; Werner & Smith, 1977)
Studies of multiple adverse conditions (search for
protective factors)

Parental mental illness
Urban poverty
Community violence
Chronic illness
Catastrophic live events

Models/approach to resilience
(Masten, 2001)

Variable focused
Link among measures of degree of risk/or
adversity, outcome, potential quality of
individual or environment (to

Person focused
Compare people with different profiles (within
or across time) on sets of criteria to ascertain
what differentiates resilient from non resilient

Variable focused studies

Compensatory effects
Enough positive assets could offset the
burden in childs life from one or many risk

Three models
Main effect

Variable focused studies

Main effect models

Bipolar +
predictor Risk


Variable focused studies

Indirect models (example)




Variable focused studies

Interaction models

Risk activated

Not found very often (difficult to detect)

Variable focused studies

Factors emerging
Parenting quality
Intellectual functioning
Positive self-perception

Broad, pervasive corr. with multiple

domains of adaptive behavior

Person focused studies

Single case studies (Masten & OConnor, 1984)
Groups of individuals with patterns of good
versus poor adaptive functioning (in context or
high vs. low risk/threat)
Two groups from same high-risk groups (Werner &
Smith, 1982; Cowen et al., 1984)
Low risk groups
Variety of stress-affected and stress-resilient

Person focused studies

Emerging profile (Masten, 2001)
Average or better competence on three
salient domains

Resulting in similar psychosocial resources

intellectual functioning
Parenting quality
Positive self-concepts

Pros and Cons

Variable focused
+ Max. stats power, suitable for searching
specific links between predictor and outcome
- Fail to capture striking patterns in lives of real
people, risk of losing sense of the whole

Person focused
+ variables assembled in naturally occurring
configuration, well suited for search for
common and uncommon patterns in lives
- Can obscure specific linkages

Positive Psychology
The role of positive emotions
Fredericksons broaden-and-built theory

More positive emotions = more resilient?