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M4 - Posttraumatic Growth in Children In this discussion, we will address the possibilities of posttraumatic growth. As you know, most of the attention of researchers, health care providers, and parents is focused on the long term negative impacts of trauma and how to help the child resolve them. However, there is growing research interest in the long term growth that can derive from trauma – often alongside the negative impacts. Child trauma researcher, Eva Alisic and her team have asked those of us in the trauma field to "look beyond posttraumatic stress disorder" in children, to consider also the posttraumatic growth (PTG) and the child's quality of life after trauma (Alisic, van der Schoot, van Ginkel, & Kleber, 2008). Sadly, there is still little research to date that documents PTG in children. Before posting to the discussion, please read the short discussion sections in the two studies below that asks children about their growth – one after a natural disaster and the other after a car accident: · Cryder, C. H., Kilmer, R. P., Tedeschi, R. G., & Calhoun, L. G. (2006). An exploratory study of posttraumatic growth in children following a natural disaster. American Journal of Orthopsychiatry, 76, 65–69. · Salter, E., & Stallard, P. (2004). Posttraumatic growth in child survivors of a road traffic accident. Journal of Traumatic Stress, 17, 335–340. Then, read the article that considers posttraumatic growth – as well as the harm – that can influence our interventions with children: · Kilmer, R. P., Gil-Rivas, V., Griese, B., Hardy, S. J., Hafstad, G. S., & Alisic, E. (2014). Posttraumatic growth in children and youth: clinical implications of emerging research literature. The American Journal of Orthopsychiatry, 84(5), 506–518. After you have completed the readings, please post your responses to the following four questions: 1. What were the strongest areas of growth that children reported? Which areas were surprising to you? 2. What additional questions might you have liked to ask the children in these studies? Explain your answer, please. 3. How do you think taking PTG into account can change a counselor's interventions with a child and family? 4. How and when would you imagine raising the issue of PTG with a child and family to be respectful of their experience of crisis? Posttraumatic Growth in Children and Youth: Clinical Implications of an Emerging Research Literature Ryan P. Kilmer and Virginia Gil-Rivas University of North Carolina at Charlotte Brook Griese Judi’s House for Grieving Children and Families, Denver, Colorado Steven J. Hardy Children’s National Medical Center, Washington, DC and The George Washington University School of Medicine Gertrud Sofie Hafstad Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway Eva Alisic Monash University Posttraumatic growth (PTG), positive change resulting from the struggle with trauma, has garnered significant attention in the literature on adults. Recently, the research base has begun to extend downward, and this literature indicates that youth also evidence PTG-like changes. Researchers have sought to assess the construct, examine its correlates, and understand the factors that contribute to PTG in youth. Drawing from this work, this article considers clinical implications for youth. After briefly describing the PTG construct, its hypothesized process, and its distinction from resilience, the article focuses on key themes in the literature and, with those findings as backdrop, ways in which professionals can facilitate growth in youth who have experienced trauma. This discussion situates PTG within the broader trauma literature and includes specific applications used to date as well as the role of cultural factors. Future directions—salient to practitioners and researchers alike—are considered. W ith its emphasis on the transformative elements ofone’s reactions and response to adversity, posttrau-matic growth (PTG), defined as positive change experienced as a result of the struggle with trauma, has received considerable attention in the adult clinical and research literatures (e.g., Calhoun & Tedeschi, 2006; Helgeson, Reynolds, & Tomich, 2006; Joseph & Linley, 2008; Knaevelsrud, Liedl, & Maercker, 2010). In the last several years, this research base has begun to extend downward, with researchers exploring the degree to which children and adolescents evidence PTG. Indeed, an emerging literature supports that youth demonstrate a PTG-like phenom- enon (Meyerson, Grant, Smith Carter, & Kilmer, 2011), and recent efforts have sought to develop means to better assess the construct in youngsters (Kilmer et al., 2009), examine its cor- relates (Cryder, Kilmer, Tedeschi, & Calhoun, 2006), and un- derstand the factors that contribute to PTG (Kilmer & Gil- Rivas, 2010a). Subsequently, researchers have begun to articulate possible clinical applications of this work to youth populations. This article draws on recent findings to build on and extend two contributions (Clay, Knibbs, & Joseph, 2009; This article was published Online First August 11, 2014. Ryan P. Kilmer, Professor of Psychology, University of North Car- olina at Charlotte; Virginia Gil-Rivas, Associate Professor of Psychol- ogy and Director, Health Psychology Doctoral Program, University of North Carolina at Charlotte; Brook Griese, Co-Founder and Executive Director, Judi’s House for Grieving Children and Families, Denver, Colorado; Steven J. Hardy, Assistant Professor of Pediatrics and Psy- chiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC; The George Washington University School of Med- icine; Gertrud Sofie Hafstad, Senior Researcher, Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway; Eva Alisic, Larkins Research Fellow, Monash Injury Research Institute, Monash University. An earlier version of this work was presented as a paper at the European Conference on Traumatic Stress in Vienna, Austria in June, 2011. The Hurricane Katrina research referenced here was funded by National Insti- tute of Mental Health Award R03 MH078197-01 (Gil-Rivas and Kilmer). Research and programs at Judi’s House are supported by private and corporate sponsors, listed in annual reports at www.judishouse.org. The authors would also like to acknowledge the contributions of key collaborators, including Lawrence Calhoun, Arnie Cann, Louise Silvern, Kanako Taku, and Richard Tedeschi. Correspondence concerning this article should be addressed to Ryan P. Kilmer, Department of Psychology, The University of North Carolina at Charlotte, 9201 University City Boulevard, Charlotte, NC 28223-0001. E-mail:
[email protected] T hi s do cu m en t is co py ri gh te d by th e A m er ic an Ps yc ho lo gi ca l A ss oc ia tio n or on e of its al lie d pu bl is he rs . T hi s ar tic le is in te nd ed so le ly fo r th e pe rs on al us e of th e in di vi du al us er an d is no t to be di ss em in at ed br oa dl y. American Journal of Orthopsychiatry © 2014 American Orthopsychiatric Association 2014, Vol. 84, No. 5, 506–518 http://dx.doi.org/10.1037/ort0000016 506 http://www.judishouse.org mailto:
[email protected] http://dx.doi.org/10.1037/ort0000016 Kilmer & Gil-Rivas, 2008) regarding the practical applications of the developing knowledge base. The following sections: (a) introduce the PTG construct and its hypothesized mechanisms and processes; (b) discuss its conceptual and empirical differences from resilience; (c) summarize key themes and findings in the extant research; (d) consider unan- swered questions and gaps in the literature and their potential implications; and (e) outline means by which professionals can facilitate PTG in children and youth, including some specific applications used to date. What Is Posttraumatic Growth? Although the term posttraumatic growth (and its present con- notations) was coined fairly recently (Tedeschi & Calhoun, 1995, 1996), the notion of PTG has historical grounding in psychology, philosophy, and other disciplines. In the last two decades, the construct has spawned over 900 articles, chapters, special issues, and volumes (Calhoun & Tedeschi, 2006; Joseph & Linley, 2006, 2008), including sources for practitioners (Calhoun & Tedeschi, 1999, 2013; Tedeschi & Calhoun, 2009; Tedeschi & Kilmer, 2005). These works largely focus on adults. The scholarly literature is less well-developed for children and adolescents, but researchers have documented PTG-like changes in youth who have experienced natural disasters (Cryder et al., 2006; Hafstad, Gil-Rivas, Kilmer, & Raeder, 2010; Hafstad, Kilmer, & Gil-Rivas, 2011; Kilmer et al., 2009; Yang, Lin, & Qian, 2010; Yu et al., 2010), terrorism (e.g., Laufer & Solomon, 2006; Levine, Laufer, Hamama-Raz, Stein, & Solomon, 2008), traffic accidents (Salter & Stallard, 2004), cancer (e.g., Barakat, Alderfer, & Kazak, 2006), parental loss and institutional deprivation (Kilmer, Cal- houn, Tedeschi, McAnulty, & Gil-Rivas, 2006), and a range of potentially traumatic events (e.g., Alisic, van der Schoot, van Ginkel, & Kleber, 2008; Ickovics et al., 2006; Milam, Ritt-Olson, & Unger, 2004; Taku, Kilmer, Cann, Tedeschi, & Calhoun, 2011). Indeed, sufficient research on PTG (and related constructs) in children and adolescents has been conducted to justify a compre- hensive, systematic review of the literature (Meyerson et al., 2011), with recent additions since that review (Glad, Jensen, Holt, & Ormhaug, 2013; Yablon, Itzhaky, & Pagorek-Eshel, 2011). This emerging literature provides the foundation for the present work, laying needed groundwork for its applied emphasis and the rec- ommendations put forth. Hypothesized Key Elements of the Posttraumatic Growth Process in Youth Although the area is nascent in its development, theoretical and conceptual writings related to PTG in children and adolescents (e.g., Alisic, Boeije, Jongmans, & Kleber, 2011; Clay et al., 2009; Kilmer, 2006; Kilmer & Gil-Rivas, 2010a) have drawn from the larger trauma and adult PTG literatures (e.g., Calhoun & Tedeschi, 2006; Janoff-Bulman, 1992) to articulate the hypothesized growth process. In many cases, trauma can shake a young person’s inter- nal working model and basic assumptions about the world, influ- encing and even altering central assumptions or core beliefs about one’s self, others, one’s world, and the expected course of one’s life (Cann et al., 2010; Janoff-Bulman, 1992; see Alisic et al., 2011 for an alternative view) and, in turn, stimulating attempts to cope and adapt. As other authors have emphasized, growth is thought to evolve as a result of this struggle with trauma and its aftermath, not solely the experience of the trauma itself—that is, it is thought to develop as one comes to grips with his or her new reality and works to understand what has happened and its implications for life going forward (Calhoun & Tedeschi, 2006). In fact, it is thought that this continuing distress and efforts to reconcile one’s posttrauma reality facilitate a constructive cognitive processing of trauma, or what has been deemed productive rumination (Calhoun & Tedeschi, 2006; Tedeschi, Calhoun, & Cann, 2007). Through this deliberate and constructive ruminative process (see Watkins, 2008), one may try to make sense of the event(s) and integrate the trauma and its aftermath in a manner consistent with prior internal representations, or working models. Subsequently, this ruminative process is thought to yield schema change, which consolidates changed perspectives on self, others, and one’s new life and way of living (Calhoun & Tedeschi, 2006; Janoff-Bulman, 1992). Research suggests that the changes framed as PTG tend to cohere in several main domains: a greater sense of one’s personal strength; a different perspective on one’s relationships; a changed philosophy of life, such as a greater appreciation for life and its new possibilities; and spiritual growth (see Calhoun & Tedeschi, 2006; Kilmer, 2006 for descriptions). The PTG Process: Some Caveats and Developmental Considerations Existing evidence suggests that, following trauma, the reactions and responses of children and youth at different ages and stages vary, in part because their cognitive and emotional capacities lead them to understand and internalize the experience differently (Na- tional Child Traumatic Stress Network [NCTSN], n.d.; Osofsky, 2004; see Kilmer & Gil-Rivas, 2010a for a detailed discussion). In light of these realities, and because PTG appears to require the cognitive capacity to allow both losses and gains to be recognized, the extent to which the growth process in children accords with the process observed among adults is unclear (Cryder et al., 2006; Kilmer, 2006). Recent research, however, has uncovered some of the key elements of this process, including some that appear “active” for both youngsters and adults, such as ruminative pro- cesses (Kilmer & Gil-Rivas, 2010a; Meyerson et al., 2011). Nevertheless, it is imperative to acknowledge the variability in children’s psychological mindedness or self-understanding and awareness. That variation—and the fact that children’s internal representations, basic assumptions, and working models are not yet set—has implications for the degree to which a child has the capacity to go through the process that yields PTG, and also points to the potential role of caregivers and other important adults in the child’s life in supporting the PTG process (Kilmer & Gil-Rivas, 2010a; Osofsky, 2004; Shahinfar & Fox, 1997). Indeed, a young- ster’s response to trauma, understanding of what happened, and coping repertoire will be influenced meaningfully by caregivers (see below for a more detailed discussion)