posttraumatic adjustment in childhood and beyond
Avenue 5: Unpacking interventions to promote wellness-oriented public health goals
A fifth promising application of an unpacking-oriented approach involves delineating the procedures that are employed in public health-oriented inter-ventions for trauma-exposed populations and articulating the implications of the four unpacking-based approaches described earlier hold at each stage. Figure 2.4 presents eleven procedures that are often conducted in a progressive sequence, returning to previous steps or iterating the cycle as needed. These steps are described in detail elsewhere in this volume (Ford, Albert, and Hawke, Chapter 12; Van Horn and Lieberman, Chapter 13;
Saltzman et al., Chapter 15).
Assembling the components to guide interventions:
an illustration using COR theory
We now further develop the theme described in Avenue 5 by illustrating ways in which unpacked stages of intervention can be assembled to guide wellness-oriented public health interventions following trauma exposure. We chose COR theory (Hobfoll et al. 1988, 1998) on the basis of its ecological perspec-tive, its emphasis on prevention and early intervention, and its capacity to address both traumatic and less severe stressors, and because of its capacity to account for the ways in which adverse and beneficial life events may intersect to influence the clinical course of posttraumatic adjustment.
Pre-event surveillance and prevention
Based on the COR principles that loss is more salient than gain, and that gain cycles proceed more slowly than loss cycles, the pre-event period is a critically important window of opportunity in which to carry out wellness-oriented preventive activities. These include:
•
identify populations at risk for exposure to the traumatic stressor•
where possible, reduce the risk for exposure to the stressor•
anticipate the demands that the stressor will likely impose on those exposed•
identify configurations of coping resources that will provide a good ‘fit’for the stressor
•
implement programs where possible to build up these resources in devel-opmentally and culturally appropriate ways (Layne et al. 2007).Stopping or slowing resource loss cycles is also a high priority. Accordingly, the optimal elements from which such preventive efforts should be built are promotive and beneficial synergistic factors. Because these resources exert a beneficial effect regardless of whether the focal risk factor(s) is present, pro-grams that enhance these resources are a good investment for promoting Figure 2.4 Unpacking public health-oriented, trauma-focused interventions into their
con-stituent steps.
general wellness and positive youth development. Also desirable are robust resources, which are potent in relation to a range of different stressors, and facilitative factors. Collectively, these beneficial agents may serve as the nucleus around which constellations of resources can aggregate through gain cycles, creating stress-inoculating resource caravans that accompany youths through critical developmental periods and beyond. Extra care is needed during developmental transitions to ensure that resource caravans maintain their continuity and momentum while being appropriately reconfigured to accommodate emerging developmental tasks, challenges, and competencies (Masten et al. 2004).
Moreover, in accordance with the public health principle that dispro-portionately more resources should be allocated to subgroups with greater needs, additional preventive goals include:
•
identify subgroups that are vulnerable to the stressor(s)•
where possible, reduce vulnerability to the stressor(s).By definition, the resource profiles of vulnerable subgroups match up poorly with the anticipated demands of the stressor. Their resources may lack potency, durability, transportability, accessibility, or a mechanism for replen-ishment; may have an insufficient shelf life given the anticipated duration of the stressor and access to replenishment; may inefficiently consume scarce resources; or may consist of an insufficient amount of well-fitting resources.
Accordingly, in addition to promotive factors described above (which benefit
‘resilient’ and ‘non-resilient’ groups alike), the primary elements from which vulnerability-reducing interventions should draw are promotive/protective synergistic and protective factors. Because synergistic factors, when found, are
“powerhouse” resources that exert both a direct promotive effect and an incremental protective effect in the presence of the risk factor(s), they are generally more desirable vulnerability-reducing tools than protective factors, which yield their benefits only under stressful circumstances.
Situation analysis and needs assessment
Once a given traumatic event has occurred, wellness-oriented public health interventions should seek to evaluate the nature and effects of the event with respect to its breadth, duration, the levels of the ecology that have been impacted, and the types and amounts of resource loss that have occurred.
Also important are an evaluation of the types of resource loss cycles set in motion or accelerated by the event, as well as barriers to gain cycles. Of equal importance is the need to appraise the specific demands that the event and its aftermath will likely place on exposed individuals, families, and communities, and the types of well-fitting coping resources that intervention programs should seek to deliver or support.
Risk screening, case identification, and triage
Efforts to identify and appropriately triage victims should place highest prior-ity on identifying individuals at risk for severe persisting distress, dysfunction, and developmental derailment. Markers of high risk include:
•
massive resource loss induced by exposure to trauma-related risk factors, as these factors interact with vulnerability factors•
insufficient amounts of well-fitting coping resources•
the exhaustion of well-fitting coping resources•
interference in the capacity to access or replenish well-fitting coping resources•
the use of inefficient coping resources•
the use of ineffective coping resources•
the presence of significant resource loss cycles•
barriers to orchestrating gain cycles, including insufficient resources or opportunities for resource investment, or the adoption of defensive resource-conserving strategies that inhibit investment (Hobfoll et al., Chapter 9 in this volume; Steinberg and Ritzmann 1990).In-depth assessment, case conceptualization, and intervention planning
The overarching aim of wellness-oriented public health interventions is to channel as many trauma-exposed survivors into adaptive posttraumatic adjustment trajectories in as many developmentally salient life domains; and to channel as many survivors away from less desirable posttraumatic adjust-ment trajectories in as many developadjust-mentally salient life domains, as possible under the circumstances. Key intervention objectives include promoting stress resistance and resilient recovery through such activities as facilitating the use of maximally potent and efficient coping resources and strategies;
enhancing accessibility; and enhancing resource replenishment. Enhancing effective coping strategies may be equally as important as enhancing the use of coping resources – for example, potent resources that lack durability (e.g.
money) may nevertheless be managed to function like durable resources when paired with access to replenishment (e.g. a regular income). Just as a hemor-rhaging medical patient requires procedures that both staunch the loss of blood and replace lost blood, resource-based interventions should target both halting or slowing loss cycles and, as soon as possible, initiating and accelerat-ing gain cycles. Because highly impacted groups possess comparatively fewer resources and will tend to employ defensive resource-conserving strategies (Hobfoll et al., Chapter 9), assisting these groups will often require undertak-ing specialized, resource-intensive, multi-tiered interventions. These interven-tions will likely target both the enhancement of naturally existing coping
resources (e.g. support-seeking and parenting skills), and the inculcation of specialized skills shown to be potent in coping with the stressor (e.g. teaching skills for coping with trauma reminders). In addition, multi-tiered interven-tions within the individual, family, and broader community will set the stage for beneficial “trickle-down” and “trickle-up” effects across levels of the ecology.
Implementation of the intervention, program monitoring, and surveillance
As intervention progresses, efforts should be directed towards reducing the risk for exposure to subsequent trauma and secondary adversities, and in seeking opportunities to halt or slow loss cycles and to initiate or accelerate gain cycles.
Conclusion
As readers have been cautioned concerning the overuse of the term “risk factor” (Vogt et al. 2007), we also caution that many “protective” and
“vulnerability” factors may be mislabeled in the literature. Such looseness in our conceptual and methodological terminology unfortunately blurs distinc-tions between classes of variables that vary in important ways in their impli-cations for intervention planning and implementation. This looseness in how we think and communicate will also slow the rate at which we accumu-late scientific knowledge about various forms of posttraumatic adjustment (Layne et al. 2007). Until we are better able to accurately describe, explain, and predict how adverse and beneficial causal factors intersect and causally influence posttraumatic adjustment, it is possible that our greatest single advances in undertaking wellness-oriented interventions will be made in refining our risk screening technology: we will get better and better at identi-fying those in need of intervention, but we will still lack crucial knowledge about how to best help them – knowledge that only a well-grounded under-standing of how their difficulties and strengths are caused, maintained, and influence one another can bring. Until that time, our interventions may rely as much on borrowing from other fields (as evidence-informed practices), clinical lore, and educated assumptions, as on the solid footings of our own rigorously tested theories and empirical evidence. We hope that the unpacked, integrative framework we have proposed will promote further discovery of the processes through which beneficial resources are built up, utilized, depleted, and replenished over time. These advances will, in turn, promote the development of evidence-based, theoretically grounded, wellness-oriented public health interventions that strategically build up stress resist-ance before traumatic events occur and, when needed, promote resilient recovery afterwards.
Acknowledgements
Support for this work was provided by research grants to the first author from the Family Studies Center and the Kennedy International Studies Center, both of Brigham Young University; and the UCLA Trauma Psychiatry Bing Fund. The authors are grateful for the assistance of members of the BYU Developmental Psychopathology Research Lab, including Anthony Albano, Jacob Tanner, Jonathan Zabriskie, and Paul Hanson; and for the administrative support of Preston Finley. The authors wish to thank Drs.
Qing Zhou, Joseph Olsen, and Susan Ko for their helpful suggestions on an earlier draft of this chapter.
Notes
1 Kaufman et al. (2004) found evidence of genetic vulnerability to develop childhood depression when childhood maltreatment is present: homozygosity of the short allele of the 5-HT transporter gene appears to increase the likelihood of childhood depression only in children with histories of maltreatment.
2 The correlational nature of non-experimental longitudinal research makes causal inference pertaining to “risk” and “protective” factors a probabilistic enterprise.
Intervention research (especially randomized controlled trials) may provide more definitive evidence of causal links between risk factors and outcomes (Masten 2007).
3 The role a given variable may play (e.g. risk vs. vulnerability vs. synergistic factor) may vary across studies, and within the same study, as a function of the type of disaster, other variables in the model, guiding theory, and analytic strategy. Replica-tion is thus essential for identifying consistently influential variables and their
“behavioral” tendencies across studies and contexts.
4 In contrast to “unipolar” variables, “bipolar” variables (see Masten 2001) may exhibit not only inhibitory and facilitative moderating effects at opposing ends of their continua in relation to a given promotive factor, but also protective and vulnerability-enhancing moderating effects in relation to a given risk factor. Such variables should be termed facilitative/inhibitory factors and protective/vulnerability factors respectively; each can be represented in a single model. Bipolar promotive/
risk factors may be found in circumstances where direct beneficial versus adverse effects are found at opposing ends of the variable’s continuum.
5 Not all agents that enhance stress resistance are socially desirable, and not all agents that increase vulnerability are socially undesirable (e.g. empathic distress vs. indif-ference in a child who witnesses a classmate’s victimization).
References
Baron, R.M., and Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical consider-ations. Journal of Personality and Social Psychology, 51, 1173–1182.
Benson, P.L., Scales, P.C., Hamilton, S.F., and Sesma, A. (2006). Positive youth devel-opment: Theory, research, and applications. In W. Damon and R.M. Lerner (eds.), Handbook of child psychology (pp. 894–941). Hoboken, NJ: Wiley.
Bernat, D.H., and Resnick, M.D. (2006). Healthy youth development: Science and strategies. Journal of Public Health Management and Practice (suppl.), S10–S16.
Brown, G.W. (2000). Emotion and clinical depression: An environmental view. In M.
Lewis and J.M. Haviland-Jones (eds.), Handbook of emotions (pp. 75–90). New York: Guilford.
Brown, G.W., and Harris, T.O. (1978). The social origins of depression: A study of psychiatric disorder in women. London: Tavistock.
Charney, D.S. (2004). Psychobiological mechanisms of resilience and vulnerability:
Implications for successful adaptation to extreme stress. American Journal of Psychiatry, 161, 195–216.
Cooke, D.J. (1985). Psychosocial vulnerability to life events during the climacteric.
British Journal of Psychiatry, 147, 71–75.
Crawford, E., Wright, M.O., and Masten, A.S. (2006). Resilience and spirituality in youth. In E.C. Roehlkepartain, P.E. King, L. Wagener, and P.L. Benson (eds.), The handbook of spiritual development in childhood and adolescence (pp. 355–370).
Thousand Oaks, CA: Sage.
Dohrenwend, B.P. (2006). Inventorying stressful life events as risk factors for psycho-pathology: Toward resolution of the problem of intracategory variability. Psycho-logical Bulletin, 132, 477–495.
Dohrenwend, B.P., Raphael, K.G., Schwartz, S., Stueve, A., and Skodol, A.E. (1993).
The structured event probe and narrative rating method (SEPRATE) for measur-ing stressful life events. In L. Goldberger and S. Breznitz (eds.), Handbook of stress:
Theoretical and clinical aspects, 2nd edition (pp. 174–199). New York: Free Press.
Edwards, J.R., and Lambert, L.S. (2007). Methods for integrating moderation and mediation: A general analytical framework using moderated pathway analysis.
Psychological Methods, 12, 1–22.
Foy, D.W., Osato, S.S., Bouskamp, B.M., and Neumann, D.A. (1992). Etiology of posttraumatic stress disorder. In P.A. Saigh (ed.), Posttraumatic stress disorder: A behavioral approach to assessment and treatment. New York: Macmillan.
Friedman, M.J., Resick, P.A., and Keane, T.M. (2007). Key questions and an agenda for future research. In M.J. Friedman, T.M. Keane, and P.A. Resick (eds.), Handbook of PTSD: Science and practice (pp. 540–561). New York: Guilford.
Harris, T.O., Brown, G.W., and Bifulco, A. (1986). Loss of parent in childhood and adult psychiatric disorder: The role of lack of adequate parental care. Psychological Medicine, 16, 641–659.
Harris, W.H., Putnam, F.W., and Fairbank, J.A. (2006). Mobilizing trauma resources for children. In A.F. Lieberman and R. DeMartino (eds.), Interventions for children exposed to violence. Johnson and Johnson Pediatric Institute. Retrieved June 1, 2007 from www.jjpi.com
Harvey, P.D., and Yehuda, R. (1999). Strategies to study risk for the development of PTSD. In R. Yehuda (ed.), Risk factors for posttraumatic stress disorder (pp. 1–22).
Washington, DC: American Psychiatric Press.
Haynes, S.N. (1992). Models of causality in psychopathology: Toward synthetic, dynamic and nonlinear models of causality in psychopathology. Des Moines, IA:
Allyn and Bacon.
Hobfoll, S.E. (1988). The ecology of stress. New York: Hemisphere.
Hobfoll, S.E. (1998). Stress, culture, and community: The psychology and philosophy of stress. New York: Plenum.
Hobfoll, S.E., Hall, B.J., Canetti-Nisim, D., Galea, S., Johnson, R.J., and Palmieri, P.A. (2007). Refining our understanding of traumatic growth in the face of ter-rorism: Moving from meaning cognitions to doing what is meaningful. Applied Psychology: An International Review, 56, 345–366.
Holmbeck, G.N., Friedman, D., and Abad, M. (2006). Development and psycho-pathology in adolescence. In D.A. Wolfe and E.J. Mash (eds.), Behavioral and emotional disorders in adolescents: Nature, assessment, and treatment (pp. 21–55).
New York: Guilford.
Kaufman, J., Yang, B.-Z., Douglas-Palumberi, H., Houshyar, S., Lipschitz, D., Krystal, J.H., et al. (2004). Social supports and serotonin transporter gene moder-ate depression in maltremoder-ated children. Proceedings of the National Academy of Sciences USA, 101, 17316–17321.
Kraemer, H.C., Kazdin, A.E., Offord, D.R., Kessler, R.C., Jensen, P.S., and Kupfer, D.J. (1997). Coming to terms with the terms of risk. Archives of General Psychiatry, 54, 337–343.
Kraemer, H.C., Stice, E., Kazdin, A., Offor, D., and Kupfer, D. (2001). How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. American Journal of Psychiatry, 158, 848–856.
Layne, C.M., Warren, J., Watson, P., and Shalev, A. (2007). Risk, vulnerability, resist-ance, and resilience: Towards an integrative conceptualization of posttraumatic adaptation. In M.J. Friedman, T.M. Keane, and P.A. Resick (eds.), Handbook of PTSD: Science and Practice. (pp. 497–520). New York: Guilford.
Liberman, R.P., and Corrigan, P.W. (1992). Is schizophrenia a neurological disorder?
Journal of Neuropsychiatry, 4(2), 119–124.
Liberman, R.P., and Corrigan, P.W. (1993). Designing new psychosocial treatments for schizophrenia. Psychiatry, 56, 238–249.
Luthar, S.S. (2006). Resilience in development: A synthesis of research across five decades. In D. Cicchetti and D.J. Cohen (eds.), Developmental psychopathology, Volume 3: Risk, disorder, and adaptation, 2nd edition (pp. 739–795). Hoboken, NJ:
Wiley.
Luthar, S.S., Sawyer, J.A., and Brown, P.J. (2006). Conceptual issues in studies of resilience: Past, present, and future research. Annals of the New York Academy of Science, 1094, 105–115.
Masten, A.S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227–238.
Masten, A.S. (2007). Resilience in developing systems: Progress and promise as the fourth wave rises. Development and Psychopathology, 19, 921–930.
Masten, A.S., and Obradovic´, J. (2007). Disaster preparation and recovery: Lessons from research on resilience in human development. Ecology and Society, 13(1), 9.
Masten, A.S., Burt, K.B., Roisman, G.I., Obradovic´, J., Long, J.D., and Tellegen, A.
(2004). Resources and resilience in the transition to adulthood: Continuity and change. Development and Psychopathology, 16, 1071–1094.
Maxwell, J.A. (2004). Using qualitative methods for causal explanation. Field Methods, 16, 243–264.
Muthén, B.O., and Muthén, L.K. (2000). Integrating person-centered and variable-centered analyses: Growth mixture modeling with latent trajectory classes. Alcohol-ism: Clinical and Experimental Research, 24, 882–891.
Pynoos, R.S., and Steinberg, A.M. (2006). Recovery of children and adolescents after
exposure to violence: Developmental ecological framework. In A.F. Lieberman and R. DeMartino (eds.), Interventions for children exposed to violence (pp. 17–43).
New Brunswick, NJ: Johnson and Johnson Pediatric Institute.
Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316–331.
Seligman, M.E. (2002). Positive psychology, positive prevention, and positive therapy.
In C.R. Snyder and S.J. Lopez (eds.), Handbook of positive psychology (pp. 3–9).
New York: Oxford University Press.
Silva, R.R., and Kessler, L. (2004). Resiliency and vulnerability factors in childhood PTSD. In R.R. Silva (ed.), Posttraumatic stress disorders in children and adolescents (pp.18–37). New York: Norton.
Steinberg, A., and Ritzmann, R.F. (1990). A living systems approach to understand-ing the concept of stress. Behavioral Science, 35, 138–146.
Vogt, D.S., King, D.W., and King, L.A. (2007). Risk pathways for PTSD: Making sense of the literature. In M.J. Friedman, T.M. Keane, and P.A. Resick (eds.), Handbook of PTSD: Science and Practice (pp. 99–115). New York: Guilford.
Watson, P.J., Ritchie, E.C., Demer, J., Bartone, P., and Pfefferbaum, B.J. (2006).
Improving resilience trajectories following mass violence and disaster. In E.C.
Ritchie, P.J. Watson, and M.J. Friedman (eds.), Interventions following mass vio-lence and disasters: Strategies for mental health practice (pp. 37–53). New York:
Guilford.
Wiesner, M., and Capaldi, D.M. (2003). Relations of childhood and adolescent fac-tors to offending trajectories of young men. Journal of Research in Crime and Delinquency, 40, 231–262.
Zubin, J., and Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86, 103–126.