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,
Steven J. Hardy
Children’s National Medical Center, Washington, DC
and The George Washington University School of
Gertrud Soﬁe Hafstad
Norwegian Centre for Violence and Traumatic Stress
Studies, Oslo, Norway
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.
With its emphasis on the transformative elements of
one’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
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
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.
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American Journal of Orthopsychiatry © 2014 American Orthopsychiatric Association
2014, Vol. 84, No. 5, 506–518 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
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). Moreover, a given
child must be able to recognize and express emotions, both posi-
tive and negative, regarding the experience (see Harter, 1986,
2006;Harter & Buddin, 1987;Kilmer, 2006). These consider-
ations, as well as the fact that several important cognitive resources
and operations do not emerge until middle childhood—including
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POSTTRAUMATIC GROWTH IN CHILDREN AND YOUTH
increased competence in regulating emotions and trauma-related
thoughts (Salmon & Bryant, 2002), increased capacity for
emotion-focused and cognitively oriented coping, and more real-
istic control expectations (Aldwin, 2007;Compas, Connor-Smith,
Saltzman, Harding Thomsen, & Wadsworth, 2001;Salmon &
Bryant, 2002)—point to a potential lower age limit for PTG of
approximately 7 years of age (Kilmer, 2006).
Although some authors have raised concerns about whether
PTG is possible in children, findings suggest that PTG does occur
among children and youth; however, some have questioned
whether this growth simply reflects normative maturation (e.g.,
Cohen, Hettler, & Pane, 1998). Few studies have addressed this
potential issue, but existing data (Alisic et al., 2008;Taku, Cal-
houn, Kilmer, & Tedeschi, 2008;Taku et al., 2011) suggest that
PTG reflects a process beyond normative growth (Kilmer & Gil-
Posttraumatic Growth and Resilience
It is also necessary to distinguish PTG from resilience. Resil-
ience and PTG in children clearly share conceptual variance
(Kilmer, 2006), and some have suggested that they are inter-
changeable. Although similar in that they tap into some positive
manifestation of one’s response postadversity, the weight of the
writings in this area suggest they are distinct constructs (Clay et
al., 2009;Kilmer, 2006;Kilmer & Gil-Rivas, 2008,2010a). Mul-
tiple authors (Clay et al., 2009;Cryder et al., 2006;Kilmer, 2006;
Kilmer & Gil-Rivas, 2008) have delineated the differences: Al-
though resilience refers to “a dynamic developmental process
reflecting evidence of positive adaptation despite significant life
adversity” (Cicchetti, 2003; also see Luthar, Cicchetti, & Becker,
2000;Masten, 2001), PTG refers to a transformative process by
which one experiences positive changes (i.e., extending beyond
sound adjustment) as a result of his or her struggle in trauma’s
As another critical distinction, PTG does not equate to positive
adjustment (e.g., Kilmer & Gil-Rivas, 2008). That is, those report-
ing PTG may actually report less emotional well-being or positive
adjustment than those evidencing resilience (Calhoun & Tedeschi,
2006;Cryder et al., 2006;Tedeschi et al., 2007). Indeed, consistent
with theoretical models in which distress is viewed as necessary
for catalyzing the growth process and, perhaps, maintaining
growth, multiple authors have noted that PTG and distress (includ-
ing posttraumatic stress symptoms, PTSS) may coexist (e.g.,
Kilmer et al., 2009;Laufer & Solomon, 2006;Salter & Stallard,
2004;Shakespeare-Finch & Lurie-Beck, 2014;Tedeschi et al.,
2007). Furthermore, some research supports a curvilinear “in-
verted U” relationship between PTSS and PTG (Levine et al.,
2008; see Shakespeare-Finch & Lurie-Beck, 2014 for a detailed
consideration of the relationship between PTSD and PTG). These
findings suggest that PTG is not consistent with most conceptual-
izations of resilience in children and youth.
Furthermore, early returns suggest that PTG and resilience are
distinct processes. One study warrants particular mention. In their
study involving 7- to 10-year-olds affected by Hurricane Katrina,
Kilmer and Gil-Rivas (2010a) drew from the resilience literature
(e.g., Hoyt-Meyers et al., 1995;Luthar et al., 2000;Masten &
Coatsworth, 1998) and existing PTG theory (e.g., Kilmer, 2006)to
hypothesize that caregiver warmth and perceived competence
would relate positively to PTG. Contrary to expectations, caregiver
warmth was not related to PTG at either time point, and perceived
competence was correlated negatively with PTG at baseline and
did not contribute to PTG at follow-up, roughly 22 months post-
disaster (Kilmer & Gil-Rivas, 2010a). In considering these results,
Kilmer and Gil-Rivas (2010a) hypothesized that resilience and
PTG may reflect different paths to adaptation, influenced in large
part by the resources (i.e., both intraindividual and those in the
larger environment) a youngster is able to marshal. Put another
way, the findings suggest that, while those factors may promote
resilience under conditions of major life stress, they may actually
reduce the likelihood of PTG (Kilmer & Gil-Rivas, 2010a). Warm,
supportive caregiving and positive views of one’s competence may
reduce the degree to which youngsters perceive their assumptive
worlds as “shattered” or find themselves shaken in trauma’s after-
math, thereby limiting the ongoing distress (and intrusive ideation)
that appears critical to the PTG process (Hafstad et al., 2011;
Jensen, Dyb, & Nygaard, 2009). Supporting this notion further,
these researchers reported significant negative associations be-
tween perceived competence and both intrusive rumination and
What Does the Research Tell Us?
Investigations have largely focused on the degree to which
children and youth evidence PTG, with a small proportion of
studies helping identify factors related to individual differences in
PTG (Cryder et al., 2006;Kilmer & Gil-Rivas, 2010a;Salter &
Stallard, 2004; see Meyerson et al., 2011 for a review). On the
basis of this work, ongoing distress and rumination (both intrusive
and deliberate) seem important (Kilmer & Gil-Rivas, 2010a;
Kilmer et al., 2009). The evidence highlights the key role that
rumination—both negative, distressing thoughts and deliberate,
repetitive thinking—may play. As one case in point, deliberate
rumination was the only significant factor in a baseline model
(which also included caregiver positive reframing coping advice,
perceived competence, and intrusive rumination) predicting PTG 1
year after Hurricane Katrina (Kilmer & Gil-Rivas, 2010a). Nearly
2 years postdisaster, baseline intrusive rumination was the lone
significant predictor of PTG in the final model.
The picture is more mixed for self-system variables, that is,
those that reflect one’s self-schema or internal beliefs and percep-
tions about oneself, such as future expectations, perceived com-
petence, self-esteem or global self-worth, and coping competency
beliefs (e.g., Cryder et al., 2006;Kilmer & Gil-Rivas, 2010a).
Some research has pointed to the possible role of positive future
expectations (Kilmer et al., 2006), which may influence how
children and youth perceive and respond to an event as well as the
degree to which they sustain effort in grappling with the event, its
aftermath, and its potential meaning (Kilmer, 2006;Wyman, Co-
wen, Work, & Kerley, 1993). To date, there is little support for
perceived competence (Kilmer & Gil-Rivas, 2010a), and few stud-
ies have investigated the role of coping competency beliefs; those
that have reported contrasting findings (Cryder et al., 2006;Kilmer
& Gil-Rivas, 2010a).
Social support appears relevant to the PTG process, although
findings have been mixed and understanding of the role of care-
givers in this context is still evolving (Meyerson et al., 2011; see
also Cryder et al., 2006;Gil-Rivas & Kilmer, 2013;Kilmer &
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508 KILMER ET AL.
Gil-Rivas, 2010b;Kilmer et al., 2006;Salter & Stallard, 2004).
There appear to be varying results related to the source of support
(Meyerson et al., 2011), suggesting that support, whether familial
(Kimhi, Eshel, Zysberg, & Hantman, 2009) or from teachers or
peers (Yu et al., 2010), may be associated with PTG. In the end,
the source of support may matter less than the specific nature of
the support, the degree to which it matches the youngster’s needs,
or whether there are particular objectives to the support, such as
concrete guidance around coping. Although conceptually it ap-
pears that support is a necessary component of posttrauma adap-
tation in general (Alisic et al., 2011) as well as the PTG process for
children and youth, further work is needed to better understand the
role(s) of caregivers and the kind of support that appears to foster
Figure 1 draws on the existing empirical literature and concep-
tualizations of PTG to frame a model of PTG in children and
youth. Specifically, it illustrates hypothesized linkages among key
constructs. Consistent with research to date, rumination variables
are at the core, and the caregiving system is believed to play a
supportive role (with caregivers’ responses influenced by their
own resources and functioning), contributing to more positive
future expectations as well as greater levels of deliberate rumina-
tion and, in turn, PTG. Because the research base testing the
associations suggested by this model is limited, with minimal work
examining these linkages over time, the figure does not include an
explicit temporal component.
Unanswered Key Questions of
Although these first generation studies have laid groundwork
upon which future research can build, several salient questions
remain. Research must continue to identify the network of factors
related to PTG and, of greater relevance, go beyond those foci to
better understand the mechanisms of the PTG process and its
implications for children and youth (Kilmer & Gil-Rivas, 2010a).
For instance, although rumination (both deliberate and intrusive)
appears key in the process, scant research has explored the asso-
ciation between both types of rumination and PTG (see Kilmer &
Gil-Rivas, 2010a for an exception), and further work needs to
elucidate the role(s) and timing of these ruminative processes.
More broadly, although others have commented on the dynamic
nature of PTG (Kilmer et al., 2009), additional research is neces-
sary to ascertain the degree to which PTG changes, in presentation
and process, over time.
Additionally, research is needed to investigate rigorously the
most substantive ongoing question in the area (Kilmer & Gil-
Rivas, 2010a): To what degree does PTG relate to youngsters’
adjustment over time? Put another way, does the experience of
PTG influence their developmental and/or adjustment trajectories?
No study, for example, has documented a prospective link between
PTG and long-term well-being or positive adjustment (e.g., in-
creased positive mental health, positive affectivity, quality of life)
or reported reduced trauma-related symptomatology (Kilmer &
Gil-Rivas, 2010a;Salter & Stallard, 2004). This critical question
has very real implications for determining the clinical relevance of
PTG. Some findings have been suggestive; for example, Ickovics
et al. (2006) reported that adolescents who reported higher PTG
evidenced less emotional distress up to 12- and 18-months poste-
vent, and Milam, Ritt-Olson, and Unger (2004) found a link
between PTG and health-related behaviors. However, it is also
necessary to go beyond typical mental health adjustment indicators
to consider, for example, the degree to which child or youth reports
of PTG are associated with their subsequent involvement in com-
munity service, their career choices, and their engagement in work
to benefit others who have been affected by adversity. Future
Child Pre-trauma Risks
e.g., prior/lifetime trauma
exposure and adversities
Child Pre-trauma Resources
e.g., temperament, perceived
competence, realistic control,
social competence, school
relationship, adult support,
caregiver mental health
e.g., mental health,
warmth, support, PTG
Caregiver Coping Guidance
e.g., positive reframing,
modeling coping, acceptance
e.g., PTSS, depressive
symptoms, anxi ety
Resources and Functioning
e.g., future expectations
Broad Contextual Factors
e.g., neighborhood characteristics, cultural norms
DISTAL FACTORS PROXIMAL FACTORS
Figure 1. Conceptual model of PTG in children and youth: Cross-sectional relationships among key constructs
(adapted from Kilmer, 2006). To simplify presentation, this figure focuses on child, caregiver, and caregiving
variables. PTSS ⫽posttraumatic stress symptoms.
POSTTRAUMATIC GROWTH IN CHILDREN AND YOUTH
studies must employ: (a) a broader range of indicators of adjust-
ment; (b) multiple respondents; (c) more data collection points,
over a greater time period; (d) larger sample sizes; and (e) assess-
ments of the network of variables thought to be related to the
process, so that it is possible to explore developmental processes as
well. The use of qualitative methodologies may help reveal devel-
opmental differences, by drawing on children’s specific reports
It bears mention that research in other contexts has identified
factors that influence the sequelae experienced by children and
youth following trauma, including qualities of the trauma (i.e.,
discrete event vs. chronically traumatic context; exposure intensi-
ty/severity; known vs. unknown perpetrator; nature of the trauma,
whether reflecting a mass trauma event vs. act(s) perpetrated by an
individual, etc.; Manly, Kim, Rogosch, & Cicchetti, 2001;Martin,
Cromer, DePrince, & Freyd, 2013;Norris et al., 2002;
Shakespeare-Finch & Armstrong, 2010). However, findings in this
area do not yet point to differences in PTG or PTG trajectories
related to the nature of the traumatic experience. For instance,
although research involving adults has described PTG in adult
survivors of diverse childhood abuse experiences (e.g., Easton,
Coohey, Rhodes, & Moorthy, 2013;McElheran et al., 2012;
Shakespeare-Finch & De Dassel, 2009), some writing in this area
have speculated that some trauma may be “too intense and too
devastating,” overly taxing the child’s resources and precluding
the potential for PTG (see Kilmer, 2006). This research base has
also not elucidated the effects related to multiple traumas—chil-
dren (and, in some cases, their caregivers) are typically asked
about the worst thing that has happened or about a specific,
identifiable trauma (e.g., a natural disaster, a road traffic accident).
Little is known about the influence of events that occur subsequent
to the trauma about which respondents report, or those that may
have preceded the trauma of focus. As research in PTG continues
to evolve, findings about the factors that influence PTG’s trajec-
tory or inhibit growth will hold relevance to researchers and
Research with youth also needs to examine potential cultural
differences in PTG, both in the mechanism(s) and the nature of the
growth experienced. The extant research makes clear that culture
plays a meaningful role in many aspects of traumatic events and
their effects—what is perceived as stressful, the nature of the
adverse events experienced, and how individuals respond to and
cope with them may vary greatly across countries and cultures
(e.g., Chun, Moos, & Croncite, 2006). Such variability raises
questions regarding universal versus culture-specific aspects of
PTG, and these have both methodological and practical implica-
tions; however, relatively few studies have used standardized
measures to explore PTG in youth outside the United States.
Notwithstanding those limitations, there are indications in the
literature that PTG as well as potential underlying factors of the
PTG process (e.g., social support and faith-based or religious
frameworks, see Meyerson et al., 2011) are experienced and ex-
pressed differently across cultures. With regard to the experience
and expression of PTG itself, studies with non-U.S. adults have
typically found lower mean scores on the Posttraumatic Growth
Inventory (PTGI), as well as individual items or dimensions that
are not endorsed in the manner or degree observed in U.S. samples
(e.g., Hafstad et al., 2010;Shakespeare-Finch & Copping, 2006).
McMillen (2004) suggested that attention to the positive side of
trauma may be more evident in the United States than in other
contexts. As such, notwithstanding the clear heterogeneity of the
U.S. population, we would expect samples drawn from U.S. soci-
ety to report more and different types of growth after adversity
than non-U.S. samples. It may also be that the experience itself is
similar, but that it is expressed differently. For instance, because
the U.S. social context tends to promote children’s self-expression
more than, for example, Asian cultures (Cole, Bruschi, & Tamang,
2002), Asian children may express less PTG than children from or
living in the United States, although they may have equivalent
feelings or perceptions of positive change.
So far, studies of PTG involving children and youth outside the
United States have been conducted in Canada (Yaskowich, 2002),
China (e.g., Yu et al., 2010), Israel (e.g., Kimhi et al., 2009;Laufer
& Solomon, 2006;Laufer, Raz-Hamama, Levine, & Solomon,
2009), Japan (Taku et al., 2011), the Netherlands (Alisic et al.,
2008), and Norway (Glad et al., 2013;Hafstad et al., 2010,2011).
It is important to note that these efforts have largely relied on
translations or adaptations of measures of PTG originally devel-
oped in the United States (e.g., Kilmer et al., 2009), which may not
adequately capture culture-specific elements of growth (Taku et
al., 2011). Moreover, although there is variability in the PTG
levels reported in these samples, it is difficult to draw definitive
conclusions regarding cultural differences in PTG. This is consis-
tent with work conducted among diverse populations within the
United States. That is, Meyerson et al.’s (2011) review describes
five studies that examined the relationship between ethnicity/race
and PTG; their findings were mixed—three studies found no
meaningful differences, one suggested higher levels of PTG for
Latinos and European American youth compared to Persian youth,
and another reported more growth for African American youth
than their European American counterparts.
In considering cultural differences in the correlates of PTG in
children and youth, several factors may be of importance. For
example, the roles of community influences, including social sup-
port, can vary across cultures, and cultural factors can even influ-
ence the likelihood of growth (e.g., a girl shamed and expelled
from her family or community following sexual assault may hold
a minimal chance of developing PTG). Other factors, which inter-
sect meaningfully with culture, such as socioeconomic status, may
also be relevant. For this article, two elements tied to culture
warrant particular focus: the role of faith or religion, and the role
Although multiple studies have found that youth who are reli-
gious report significantly higher levels of PTG than others (Laufer
et al., 2009;Laufer & Solomon, 2006;Milam et al., 2004;Milam
et al., 2005;Vaughn et al., 2009), there are differences in religi-
osity and faith-based beliefs across cultures. For example, many
European countries have become increasingly secularized in recent
decades (e.g., Hafstad et al., 2011). In turn, some Europeans may
not see religiosity as an asset, helpful perspective, or form of
strength (e.g., Znoj, 2005, as cited in Shakespeare-Finch & Cop-
ping, 2006, p. 367) and, as such, they may not view turning to
formal religion as “a healthy adaptive process” (Shakespeare-
Finch & Copping, 2006, p. 367). To that end, Znoj (2006, p. 183)
has written that, “[a] religious belief may help to order life, but it
may also hinder new experiences and challenges and [sic] that
respect may even become maladaptive.” The observed trend to-
ward secularization in Europe may contribute to lower levels of
510 KILMER ET AL.
reported PTG, particularly given that multiple common measures
of the construct include spiritual growth among its core domains.
For example, Hafstad, Kilmer, and Gil-Rivas (2011) found that
items from the Posttraumatic Growth Inventory for Children-
Revised (PTGI-C-R) reflecting spiritual growth exhibited the low-
est absolute means and seemed to contribute disproportionately to
the relatively low total score mean in a sample of Norwegian
youths. In contrast, children exposed to Hurricane Katrina along
the U.S. Gulf Coast reported the most absolute growth on these
items (Kilmer et al., 2009). The latter finding may reflect the
context in which the children were raised, as this region is largely
regarded as highly religious and thus children could have been
influenced by faith-based explanations or encouragement of faith-
based coping (Kilmer et al., 2009). PTG and its manifestation may
vary across cultural groups as a function of their religiosity (vs.
secularism), prime faith-based values, and broader cultural values
that align with many faiths (e.g., sense of meaning of suffering,
compassion, importance of self/individual vs. community).
Cultural differences in caregiver behavior may also influence
children’s reports of PTG and the nature of the growth they
experience, as caregivers play a critical role in the adaptation of
children and youth following trauma. During challenging times,
the manner in which parents discuss the experience(s) with their
children affects children’s integration of the experience as well as
the specific problem-solving and coping strategies they employ
(Haden, Haine, & Fivush, 1997;Salmon & Bryant, 2002). In a
similar vein, conversations children have with their parents about
their experiences have important implications for the way they
appraise and evaluate a particular event (Fivush, Hazzard, McDer-
mott Sales, Sarfati, & Brown, 2003). Broadly, parental responses
to children’s narratives and self-disclosure are central to how
children express and regulate emotions and employ coping strat-
egies (Eisenberg, Cumberland, & Spinrad, 1998). Of salience here,
the manner in which parents discuss emotions and events varies
across cultures. For example, European American mothers tend to
focus more on explaining children’s feeling states, while Chinese
mothers tend to take a directive role emphasizing discipline and
conduct when discussing children’s experiences (Wang & Fivush,
2005). These differing foci may also influence the way in which
parents and children shape narratives around PTG. All in all, there
are several indications that culture influences PTG in children;
however, the literature to date is insufficient to appreciate these
Because many unanswered questions persist, clinicians should
be aware of potential cultural differences in PTG. Although re-
search has documented PTG across diverse cultures (see e.g.,
Weiss & Berger, 2010a), the literature raises a number of consid-
erations for clinical practice. Available evidence suggests that
children living in the United States report higher levels of PTG
than those in other countries. That said, these early findings do not
necessarily mean that children from other countries experience less
PTG; rather, they may reflect a need for culturally specific assess-
ment of PTG (Taku et al., 2011). Until more is known, clinicians,
consistent with more general calls for culturally competent prac-
tice, must be aware of and responsive to potential culture-specific
meanings and manifestations of trauma experiences, distress, and
PTG (Weiss & Berger, 2010a,2010b).
Going forward, the development and use of culturally appropri-
ate instruments could help practitioners meaningfully assess
growth. The translation and validation of one instrument in differ-
ent cultures (for instance, the PTGI-C-R, Kilmer et al., 2009)
would make findings more comparable across cultures; however, it
could be argued that instruments grounded in and informed by
specific cultural contexts need to be developed. Qualitative explo-
rations of PTG across age and cultural groups could guide the
development and refinement of such scales.
Do the Early Findings Point to Applications?
Although not an “intervention,” facilitating PTG has been ac-
knowledged as a legitimate aim in work with those who have
experienced trauma (Calhoun & Tedeschi, 1999,2013;Ickovics et
al., 2006;Kilmer & Gil-Rivas, 2008;Linley & Joseph, 2004;
Tedeschi & Calhoun, 2009). Notwithstanding the notable unan-
swered questions, research has supported several key elements of
the PTG process. The following factors (all with at least some
support in the literature; see Meyerson et al., 2011) may hold
relevance for clinical applications: deliberate, constructive rumi-
nation; positive future expectations, hope, and optimism; coping
guidance and, in particular, positive reframing coping advice (a
factor that may be especially important for younger children);
active coping; and social support.
Because this research area is still in a generative stage, appli-
cations need to be framed cautiously. As described by others
(Tedeschi & Calhoun, 2009;Tedeschi & Kilmer, 2005), the notion
of facilitating PTG does not reflect a “technique” or step-by-step
approach; rather, it is a dynamic process that plays out over time.
In turn, practitioners can create an appropriate environment to
foster PTG and serve as a “guide” (see Tedeschi & Calhoun,
2009). That said, although this article focuses on research-
supported elements for professionals’ work with those who have
been exposed to trauma, the intervention of clinical professionals
is not necessary to support the PTG process. Indeed, some findings
in the child literature suggest that proximal (i.e., direct) influences
beyond professional clinicians may contribute to the PTG process;
specifically, parents and other supportive adults can play an im-
portant role (Kilmer & Gil-Rivas, 2008,2010a). Moreover, chil-
dren could benefit meaningfully (perhaps even reducing the like-
lihood of posttraumatic distress and symptomatology and, in turn,
PTG) from systematic efforts to modify community norms and
understanding and improve supportive and humane responses
across domains (e.g., in schools, one’s neighborhood, one’s faith-
Clinical Implications of PTG Work:
Theory to Frame the Discussion
In considering the PTG process, potential approaches to facili-
tating PTG clinically, and work with those who have experienced
trauma, it is necessary to ground the discussion in theory. Bron-
fenbrenner’s (1977) ecological systems theory (revised as the
bioecological model, Bronfenbrenner & Morris, 2006) is particu-
larly well-suited. In his view, development and adaptation occur
within the context of “nested” levels that mutually interact and
influence one another, with proximal factors (e.g., family milieu,
peer group, school personnel) directly influencing the child and
distal factors (e.g., neighborhood and community characteristics)
POSTTRAUMATIC GROWTH IN CHILDREN AND YOUTH
indirectly influencing the child through an impact on his or her
larger ecology. In this theory, behavior, development, and well-
being are influenced by the interactions within and among the
multiple levels of a child’s contextual world.
These ideas have implications for both research and interven-
tions (Farmer & Farmer, 2001;Kilmer & Gil-Rivas, 2010a). Put
simply, in work with youth, one cannot lose sight of context—it is
critical when considering issues of posttrauma adaptation or, more
broadly, adjustment (Kilmer & Gil-Rivas, 2010a,2010b). For
instance, social and contextual factors (e.g., available support,
culture, socioeconomic status, faith, family history) may each
carry weight and contribute to one’s reactions, responses, risks,
and recovery following trauma. Because trauma has the potential
to influence multiple levels of a youngster’s ecology, intervention
must be equally comprehensive in scope (Farmer & Farmer, 2001;
Kilmer & Gil-Rivas, 2010b). In turn, regardless of the nature of the
trauma, the setting, or the intervention, “one size does not fit all,”
and practitioners must be mindful of “correlated constraints,” or
clusters of factors that support positive developmental paths or
problematic trajectories (e.g., Farmer & Farmer, 2001;Kilmer &
Gil-Rivas, 2010b); otherwise, interventions will be limited in their
impact and reach.
Attending to Context: What Can
Practitioners would be well-served by taking into account the
multiple influences at play and, in particular, attending to the
caregiver-child dyad. Parents and caregivers can have a profound
influence on children’s adaptation postadversity through monitor-
ing, organizing, and regulating youngsters’ contact with the exter-
nal world; providing nurturance and emotional support; assisting
with interpreting and understanding what has taken place; sharing
their perspective; and guiding or modeling responses and coping
strategies (Gil-Rivas, Holman, & Silver, 2004;Kilmer & Gil-
Rivas, 2008,2010a;Masten, Best, & Garmezy, 1990;Masten &
Coatsworth, 1998;NCTSN, n.d.).
In turn, practitioners can sup-
port and guide caregivers’ efforts to help their children by educat-
ing them about youngsters’ reactions to trauma, partnering with
them to develop strategies that may foster discussion, and helping
them feel efficacious and comfortable with their attempts to sup-
port their children (Gil-Rivas et al., 2004;Kilmer & Gil-Rivas,
2008;NCTSN, n.d.). Indeed, intervening at multiple levels and
considering context are empirically supported strategies for facil-
itating positive outcomes posttrauma that, along with other clinical
techniques described below, comprise well-established interven-
tions for children.
Work With Children, Youth, and Caregivers
Given that approaches to facilitating PTG among children and
youth are emerging, it may be fruitful to seek direction from the
broader trauma literature. Indeed, those mindful of PTG and the
potential for fostering it would approach their clinical work as they
would in trauma-focused work more generally. That is, critical
early steps would be similar to many posttrauma approaches in
which clinicians seek to create an accepting and safe atmosphere
and take steps to aid youngsters in reestablishing a sense of
normalcy, safety, and structure (Kilmer & Gil-Rivas, 2008;
NCTSN, n.d.). In such approaches, clinicians are open to discuss-
ing the trauma and feelings associated with it; listen actively and
acknowledge the difficulty of the situation; provide support; help
youth reappraise the experience and regulate their emotions; and
assist them in their efforts to cope, providing guidance about and
even modeling the use of adaptive coping strategies (Calhoun &
Tedeschi, 1999,2006;Gil-Rivas et al., 2004;Kilmer, 2006;Kilmer
& Gil-Rivas, 2008;NCTSN, n.d.;Tedeschi & Calhoun, 2009;
Tedeschi & Kilmer, 2005).
In recent years, several interventions designed to reduce distress
following trauma have been described, many of which include
these common steps or characteristics. In fact, although existing
treatments for PTSS do not specifically aim to promote growth per
se, many standard treatment components directly or indirectly
support proposed pathways (e.g., deliberate rumination, caregiver
support, positive reframing, focusing on the future) to PTG. Fur-
thermore, these evidence-based interventions provide useful tem-
plates for effectively integrating temporal, developmental, and
cultural issues in the design of clinical interventions for facilitating
The weight of the evidence supports cognitive–behavioral ap-
proaches to treating PTSS in children and youth (Dorsey, Briggs,
& Woods, 2011;Kowalik, Weller, Venter, & Drachman, 2011). A
recent meta-analysis of existing treatments for PTSS among youth
indicated that there was strong support for the effectiveness of
cognitive behavioral therapy (CBT) while there was less empirical
evidence for other approaches (Wethington et al., 2008; also see
Kowalik et al., 2011). For instance, recent reviews (e.g., Dorsey et
al., 2011;Silverman et al., 2008) have found that trauma-focused
cognitive-behavioral therapy (TF-CBT) met the Chambless criteria
(e.g., Chambless & Hollon, 1998)forawell-established treatment
for trauma. Although TF-CBT was originally designed for and has
been primarily studied with survivors of childhood sexual abuse
(Cohen, Deblinger, Mannarino, & Steer, 2004;Deblinger, Lip-
pman, & Steer, 1996), evidence also supports its effectiveness with
youths exposed to terrorist attacks (CATS Consortium & Hoag-
wood, 2007), physical abuse (Kolko, 1996;Kolko & Swenson,
2002), and childhood traumatic grief (Cohen, Mannarino, & De-
blinger, 2006). Specifically, TF-CBT is associated with improve-
ments in social competence and reductions in PTSS, depression,
anxiety, and behavior problems (CATS Consortium & Hoagwood,
2007;Cohen et al., 2004;Jensen et al., 2013). The paragraphs that
follow describe specific components of TF-CBT (see Cohen et al.,
2006), although many are widely accepted practices that have been
incorporated in other interventions (see, e.g., Dorsey et al., 2011).
They are noted briefly here because these steps are potentially
Although the critical role of parents has been established in diverse
clinical and applied developmental research studies with varying samples
following adversity, it is important to note that, in some cases, caregivers
may have perpetrated the trauma or may not have intervened despite
ongoing trauma affecting the child. The PTG literature has not yet devel-
oped sufficiently to include studies that explore this phenomenon in child
and youth samples.
512 KILMER ET AL.
salient for clinicians interested in supporting PTG in their work
with youth posttrauma.
In work with children and youth, psychoeducation is an essential
early task; it can address children’s confusion about the nature of
the trauma and questions about their safety (Cohen et al., 2006).
Subsequently, youths are taught behavioral skills (e.g., progressive
muscle relaxation, deep breathing) for coping with anxiety and to
prepare them to interact with potentially distressing trauma mem-
ories later in treatment. Children are also taught to identify a range
of emotions, label their affective experiences, express emotions
appropriately, and distinguish emotions from thoughts. A basic
CBT model linking thoughts, feelings, and behaviors is presented
and used to demonstrate the utility of cognitive coping (e.g.,
reframing, positive self-talk); such steps hold clear relevance to
PTG. With this as a foundation, youths are encouraged to produce
a trauma narrative that chronicles specific events, thoughts, and
feelings that were experienced during the trauma. Creating a
trauma narrative is considered a crucial exposure technique that
also allows clinicians to identify and eventually correct cognitive
distortions. Similarly, in vivo mastery of trauma reminders is
promoted through graduated exposure to reduce avoidance of
Caregiver involvement in treatment is invaluable, as research
has shown that approaches that do not include caregivers are less
effective than those that do (e.g., Deblinger et al., 1996). Caregiver
sessions entail teaching many of the same skills taught to youths,
as well as general and trauma-specific parenting skills. Sessions
are designed to aid caregivers as they cope with their own reac-
tions to the trauma and equip them to support children’s coping at
home (e.g., providing accurate and reassuring information, mod-
eling and reinforcing coping skills). Near the conclusion of treat-
ment, joint child–caregiver sessions are conducted in which chil-
dren are encouraged to share their trauma narratives with
caregivers, questions can be discussed, and measures can be im-
plemented to enhance safety and prevent future trauma exposure.
Of relevance, elements of these components can be adapted to
increase their cultural and developmental relevance (see Kerig,
Sink, Cuellar, Vanderzee, & Elfstrom, 2010).
Given TF-CBT’s empirical base, burgeoning approaches to fa-
cilitating PTG with youth (e.g., Kilmer & Gil-Rivas, 2008) may
benefit from drawing on its components. Clinicians may also look
for guidance from other interventions with growing support that
have implemented cognitive–behavioral strategies with success
using group formats in school- and community-based settings
(Chemtob, Nakashima, Hamada, & Roitblat, 2002;Salloum &
Overstreet, 2008;Stein et al., 2003). Intended outcomes may differ
fundamentally between interventions designed to reduce PTSS and
those seeking to promote PTG; however, their shared goal of
fostering adaptive posttrauma responses contributes to overlap
between hypothesized mechanisms of change. For example, pro-
viding accurate information and answers to youths’ questions
during psychoeducation can be an early step in promoting reas-
sembly and stabilization of their core beliefs, processes implicated
in both the reduction of distress and development of PTG. Fur-
thermore, coping skills training, caregiver involvement, and care-
fully paced activities that encourage productive rumination are
supported by the PTG literature as potential intervention targets.
Overall, such steps can also lay groundwork for later discussions
of potential gains and losses experienced as well as one’s struggle
as a result of the trauma (Tedeschi & Kilmer, 2005).
Assessing and Facilitating PTG
In clinical or supportive work with children and youth, profes-
sionals can play an important role not only in aiding youth in their
efforts to adjust, but also in creating an appropriate environment
and context to facilitate PTG. Clinical roles can take different
forms, from assessment to intervention or treatment.
Although assessment of PTG was the focus of a recent article
(Clay et al., 2009), other measures have emerged since the time of
that review, including a brief scale adapted for use both in clinical
settings and research contexts. Specifically, the PTGI-C-R is a
revision of the 21-item PTGI-C used by Cryder, Kilmer, Tedeschi,
and Calhoun (2006). The new measure (Kilmer et al., 2009, p. 253)
includes open-ended items to assess perceived changes in young-
sters’ lives and themselves since the trauma (e.g., “Sometimes I act
nice to people when I think of times when I was sad and I don’t
want them to feel that way”), followed by 10 child-completed
quantitative items that assess change across new possibilities (“I
now have a chance to do some things I couldn’t do before”),
relating to others (e.g., “I feel closer to other people (friends or
family) than I used to”), personal strength (e.g., “I have learned
that I can deal with more things than I thought I could before”),
appreciation of life (“I know what is important to me better than I
used to”), and spiritual change (e.g., “My faith (belief) in God is
stronger than it was before”). The scale’s language and response
metric were simplified for children, and findings regarding its
reliability and validity were promising and have been reported
elsewhere (e.g., Kilmer & Gil-Rivas, 2010a;Kilmer et al., 2009;
the latter article includes the measure as an appendix). The mea-
sure has been used (or translated for use) in multiple countries,
including the United States, India, Norway, the Netherlands,
China, and Japan (e.g., Alisic et al., 2008;Hafstad et al., 2011;
Taku et al., 2011;Yu et al., 2010).
Beyond assessment, some practitioners may have interest in
taking steps to facilitate PTG. Proximal influences such as parents,
school personnel, and mental health professionals can aid youth in
their efforts to adjust, supporting them in trauma’s aftermath.
Practitioners can work to build on youths’ resources, support their
active coping, and help them grapple with their new reality. They
can play a key role in helping children and youth develop a
narrative of what happened and, in those discussions, listen for
youths’ representations of changes in their beliefs about the world
and assist as they question and try to understand them (see Kilmer
& Gil-Rivas, 2008;Tedeschi & Kilmer, 2005). In noticing state-
ments about perceived positive changes that may be consistent
with PTG, practitioners can prompt in low-key ways. For instance,
as Kilmer and Gil-Rivas (2008, p. 19) note, one could follow-up,
“You mentioned earlier that, in the face of all of this, you never
realized you could be this strong—can you tell me more about
this?” It is, of course, critical to consider the timing of such steps
or statements, judging when it may be useful (and acceptable) to
draw attention to perceived positive changes (Kilmer & Gil-Rivas,
2008;Tedeschi & Kilmer, 2005;Tedeschi & Calhoun, 2009). In
doing so, practitioners can recognize and reinforce these notions,
consider ways to frame both difficulties and possible benefits, and
POSTTRAUMATIC GROWTH IN CHILDREN AND YOUTH
discuss and integrate benefits into the youth’s narrative (Tedeschi
& Kilmer, 2005).
Throughout these discussions, it is important to support young-
sters’ capacities to maintain positive views of themselves and their
futures (Kilmer, 2006;Kilmer & Gil-Rivas, 2008). In fact, as one
recognizes, reinforces, and helps build on youth strengths and
competencies, particular attention can be paid to those that may be
relevant to growth and/or those that appear important for positive
adaptation (and symptom reduction), such as positive future ex-
pectations, optimism, hope, and efficacy (Gil-Rivas, Hypes,
Kilmer, & Williams, 2007;Kilmer, 2006;Kilmer, Gil-Rivas,
Hypes, Roof, & Williams, 2009). Beyond supporting children’s
self-system resources, the available data support the potential
benefit of working to restructure youngsters’ appraisals of trauma
and foster productive rumination. This ruminative process appears
to be central to PTG’s development and can also contribute to the
development of children’s posttrauma narratives.
The Application of These Ideas:
The Example of Judi’s House
Judi’s House (JH) is a nonprofit, community-based grief center
providing comprehensive assessments and care for bereaved chil-
dren and youth aged 3–25 years, as well as their caregivers. The
organization uses interventions tailored to diverse needs—includ-
ing individual, family, and group modalities—with the overarch-
ing goal of promoting resilient adaptation and growth following
trauma and loss. Most families at JH participate in their primary
intervention, Pathfinders (Judi’s House, 2012), in parallel but
separate groups for children and their caregivers. Youth are further
divided by developmental level to facilitate normalization and
decrease isolation by supporting connections among bereaved
peers of similar ages. This 10-week, modular intervention inte-
grates diverse practices drawn from cognitive–behavioral, family
systems, trauma, and attachment theories, including narrative, ex-
periential and expressive approaches, such as art therapy. Findings
reveal that a majority of the individuals who have sought JH
services have experienced a traumatic loss and report elevated
levels of distress, including significant traumatic grief reactions
(Griese, Giusto, & Silvern, 2012). In turn, the grief-focused Path-
finders curriculum intentionally integrates components common to
evidence-based trauma interventions, including TF-CBT (e.g.,
Goodman et al., 2007;Layne et al., 2001).
Across interventions at JH, clinical staff members attempt to
restore feelings of security and provide social support, helping
youth recognize that, notwithstanding the pain of their loss, they
are not alone. This is done by fostering support within the inter-
vention groups, as well as through promoting supportive connec-
tions with family, friends, caring adults, and organizations outside
of JH. The interventions are also designed to help promote emo-
tional regulation and provide psychoeducation about trauma and
loss, grief reactions and responses, and diverse positive coping
strategies. To that end, the staff supports the development of
youths’ trauma narratives by providing children and adolescents
multiple modalities for sharing their experiences and expressing
themselves safely. Doing so in the context of the group can help
youth feel connected and supported and allow them to draw from
the collective experience and wisdom of others. Moreover, the
peer support, validation, and normalization experienced in the
groups can provide a fruitful environment for helping youth pro-
cess and integrate the loss into their lives, so that they can feel
more hopeful about the future, experience compassion and caring,
and develop empathy for others’ circumstances and pain.
Targeting cognition and deliberate, productive rumination con-
stitutes another core objective of the JH interventions. The clini-
cians help identify misconceptions and aversive thoughts, provid-
ing opportunities for youth to practice reframing or replacing them
with more hopeful and helpful thoughts, thereby restructuring their
appraisals of the trauma. Consistent with some notions believed to
be central to the PTG process, clinicians at JH attempt to foster the
productive rumination process by helping youth to reflect on their
experiences of trauma and loss—both what happened and their
subsequent reactions—and to share this verbally or through other
representations within a safe and supportive context. Such activi-
ties are thought to help decrease avoidance of the trauma and the
numbing children may experience, and can also help youth recog-
nize successful ways in which they have coped or adapted. These
activities contribute to facilitating thinking and talking about the
death or trauma over time, and also promote ongoing dialogue
within the family system. In fact, increasing family communica-
tion and decreasing avoidance and emotional inhibition can be a
positive posttraumatic change with a lasting impact for the entire
Individual differences in youths’ capacities to engage in this
kind of supportive reflection are salient and structured activities
and discussion can provide scaffolding to help facilitate the pro-
cess. For instance, for younger children, it can be helpful to read
Holmes’ (2000),A Terrible Thing Happened, a story about a
raccoon who had a traumatic experience and cannot get it out of
his mind. Until he shares his story, he struggles with somatic
issues, anger, and concentration difficulties. After reading the
story, children can be encouraged to draw what they believe could
be in the dark “cloud” above the raccoon’s head in the book—
something that happened to them or what might have happened to
the raccoon. Afterward, children can draw in another, lighter cloud
a “happy place” that the raccoon could imagine to help himself feel
calm, safe, or relaxed when overwhelmed or upset by reminders of
the “terrible thing” (i.e., trauma or loss); this can be followed by
practicing guided imagery in the session and encouraging its use at
Consistent with an ecological systems perspective, JH interven-
tions also support the family system and include a parallel curric-
ulum in groups with parents and caregivers, a critical element
given that caregivers and other family members are prime proxi-
mal influences on youth. The caregiver-focused curricula help
adults in accessing and receiving the support they need for their
own grief in addition to providing psychoeducation about parent-
ing a grieving child. Caregivers learn about the challenges faced by
bereaved children and youth of varied ages, how they can model
coping and sharing of feelings, and how to help their youngsters
make meaning of the loss and restore developmental progression.
These steps are significant because caregivers help children form
a narrative of what has happened and what life will look like going
In the context of their interventions, JH clinical staff use activ-
ities to foster PTG or encourage youth to consider ways in which
they may have changed or grown since the death. For instance,
toward the end of Pathfinders, participants are given opportunities
514 KILMER ET AL.
to think about ways that they may have grown since the death.
Possibilities might include: increased empathy for children who
are also bereaved or in other difficult situations; greater ability to
express their emotions through art, music, writing, or talking;
perceptions that they are stronger than they thought and are able to
cope with difficult challenges; a growing appreciation of family
and friends; and/or greater recognition that they can turn to others
for support. In addition, while attending sensitively to the timing,
youngsters can be supported in making meaning of the loss by
taking something terrible that has happened and finding a way to
bring about something positive because of it. For example, they
can be assisted in identifying ways to memorialize or honor the
person who died, such as being kind to people who are different or
struggling, donating hair to cancer survivors, or volunteering in
one’s community. Table 1 summarizes other activities that have
been employed at JH to support the PTG process.
Some Concluding Thoughts
Informed and guided by the empirical literature, this article
describes evidence for the PTG construct in children and youth,
highlights major findings and unanswered questions, and describes
specific steps that professionals may take to facilitate growth in
youngsters who have been exposed to trauma. It is clear that
methods many professionals already employ can help those af-
fected by trauma in reworking their models of the world and,
perhaps, in recognizing and even building upon some of the gains
borne of their struggle. Indeed, many of the steps described here
are consistent with posttrauma treatment approaches; the differ-
ence relates largely to more actively and pointedly listening for
indications that the individual perceives benefits, has experienced
positive change, or may be ready to consider potential positives
that have resulted from the trauma and the circumstances in its
aftermath (see Tedeschi & Kilmer, 2005).
It is also critical to underscore that those working clinically must
be mindful about the steps taken and the pacing of any work to
foster PTG. Attending to strengths, building upon child resources,
and guiding coping may take place early in therapy, but, given the
sensitivity of the experience and the weight of the posttrauma
reality, questioning about possible benefits should not occur at the
outset (Kilmer & Gil-Rivas, 2008;Tedeschi & Kilmer, 2005).
Even over time, the notion of PTG may not be welcomed by some
youth and caregivers, and clinicians and others must be sensitive to
that fact. It is crucial that professionals do not try to push or “sell”
the notion of growth, or inquire about positive changes too early
(Tedeschi & Kilmer, 2005). It is also important that children are
not left to believe that they are lacking something or something is
wrong with them if they do not evidence growth (Glad et al.,
2013). Nonetheless, facilitating PTG is consistent with broader
based efforts to build on youths’ resources, support their active
coping, and help them negotiate and navigate the changes in their
world following trauma (Kilmer & Gil-Rivas, 2008;Tedeschi &
Calhoun, 2009;Tedeschi & Kilmer, 2005).
Keywords: posttraumatic growth; children; clinical implications;
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Table 1. Selected Activities Employed at Judi’s House to Foster
PTG or Encourage Consideration of Growth and Change in
Children and Youth Experiencing Bereavement
•After the Storm, Comes a Rainbow
ŒYouth presented with a drawing of a storm cloud with a rainbow.
ŒParticipants encouraged to write, draw, or talk about the hardest
parts of their loss/trauma experience in the storm cloud, adding
lightning or rain if desired.
ŒIn the rainbow stripes, they can write or draw ways they got
through the experience or ways they grew during this difficult time.
ŒAt the bottom of the rainbow, they can draw or write how they
look or feel now, or what they hope will come in the future.
ŒParticipants provided with a picture of a blank tree trunk with
roots and the beginnings of tree branches; alternatively, can trace
arm and hand and use that as the shape of the tree trunk and limbs
or draw their own tree.
ŒParticipants can write in the roots people and/or things that have
kept them grounded or safe.
ŒParticipants draw/write about experiences and people that have
shaped and affected their growth along the tree trunk, including
trauma and loss experiences (e.g., with carvings, holes).
ŒAlong branches they can write what they hope to do with their
lives, ways they want to honor the person who died, or detail the
paths or branches that will help them reach their goals (e.g., in
leaves, fruit, etc.).
ŒChildren trace their hands and write/draw a message to other
children to reflect on their own growth and ‘give back’ to others by
sharing their wisdom (e.g., something they have learned during
their grief journey; words of hope, encouragement, or advice).
POSTTRAUMATIC GROWTH IN CHILDREN AND YOUTH
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