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Resilience and

Posttraumatic Growth

Resilience
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


PTG
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


symptoms
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)
Religiosity
Higher levels of social support
Calhoun & Tedeschi, 1999, 2004 (Milam et al., 2004)

Discussion
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


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

PTGI-Revised for Children and Adolescents


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

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


2001)
1 open-ended question
9 items

Other measures for children and


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

framework technique (Ritchie & Spencer,


1994)
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
adolescents
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

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

Adolescent cancer survivors


Barakat et al. (2006)

150 adolescents cancer survivors (11-19


years)
Hypothesis
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
accident
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

PTGI-C
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
support)

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
regression)
No corr. with age
T1 PTG only sign. predictor of T2 PTG

Model of PTG in children


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

Social
support

Ruminative thinking
Competency beliefs
PTG

Extended model (see Kilmer, 2005)

Critique
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


inflated

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.
2004)

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


children
Schemas not as clearly set in children
New experiences incorporated into internal
representations
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
states
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)

>5y
Whichyoull
one do
Later
getyou
like the
whats
in most?
this
box. So, put
the one you
Which
one do
like
the most
in you
likebox.
the least?
the

doll
sponge

ToM: Belief-based emotions


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


>5y
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
Before
you
open
theyou
box?
How
do
Whathow
did did
you
the box,
feel
now?
Verythink
good,
isnow
in the
you
feel
you get whats
box?
in the box.

doll
sponge

ToM: Introspection
(Flavell et al., 1995)

Do not
think
< 8 years
No
thoughts

While you where sitting in the


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

easy
having no
thoughts

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

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.,
1995)
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
entrenched/embedded
Open to adaptive inputs
Protective

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,
transform
(Janoff-Bulman, 1992)

Discussion
Do you think PTG in young children is
possible?

Some problems:
Extend of literature (two fields: clin. and dev.)
Dev. lit: childrens understanding quite
sophisticated
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

Resilience

Three facets of resilience


Lepore & Revenson (2006)

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

Resistance
Tree stands still, undisturbed, in face of howling wind

Reconfiguration
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)
Recovery
Stressor disrupts a persons normal state of functioning,
When stressor passes, person resumes her normal pre-stressor
level of functioning

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

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

Discussion
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
(invulnerable)
But ordinary phenomenon
Common operation of basic human adaption
systems
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
resources
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
(assets)

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
delinquency

Internal
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)

Low SES
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
compensate/protect)

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

Variable focused studies


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

Three models
Main effect
Indirect
Interaction

Variable focused studies


Main effect models
Asset

Bipolar +
predictor Risk

Outcome

Variable focused studies


Indirect models (example)
Asset

+
+
Effective
parenting

Risk

Outcome

Variable focused studies


Interaction models
Moderator
Outcome

Risk
Risk activated
moderator

Not found very often (difficult to detect)

Variable focused studies


Factors emerging
Parenting quality
Intellectual functioning
SES
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
Academic
Conduct
Social

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?