Trauma-Informed Care and Posttraumatic Growth Among Bereaved Youth: A Pilot Study

Abstract

Although a fair amount has been written about posttraumatic stress disorder among bereaved children and adolescents, less has been written about posttraumatic growth (PTG) and its predictors among this population. This study examines predictors of PTG and the impact of trauma-informed care on PTG among bereaved youth. A preexperimental, pretest–posttest design was applied to measure PTG among bereaved children (N = 32) before and after attending a healing camp that provides trauma-informed care. A regression model was applied to examine predictors of PTG. Results showed that children participating in the camp increased their PTG scores to a statistically significant degree. Circumstance of death (sudden or expected) was a predictor in this study. The results are discussed in relation to limitations, implications for future research, and practice.

Keywords

trauma posttraumatic growth resilience grief camp trauma-informed care trauma-focused grief interventions

Unfortunately, 1 of the 20 children lose one or both parents to death before the age of 15 years (Steen, 1998). For many of these children, the loss of their parent is a traumatic event, and they may develop posttraumatic stress disorder (PTSD) or PTSD symptoms after the death (McClatchey, Vonk, & Palardy, 2009). Unattended PTSD symptoms in bereaved children may have serious consequences. There may be a delay in the grieving process (Brosius, 2004) due to the trauma symptoms interfering with the task of reminiscing or with the full expression of grief feelings (Eth & Pynoos, 1994).

Some researchers have focused not on the development of PTSD after a traumatic event but rather on resilience and posttraumatic growth (PTG). Youth who experience trauma may exhibit resilience and not develop PTSD or PTSD symptoms (Steele & Malchiodi, 2011). In contrast, children who struggle with the trauma may experience PTG, that is, positive changes that may include a new appreciation for life and new possibilities after an exposure to trauma (Cryder, Kilmer, Tedeschi, & Calhoun, 2006).

Echterling, Presbury, and McKee (2005) suggest that children who are resilient often use specific coping skills that focus on the present and the future. To engage their coping style, they simply need the support of people around them. However, such coping does not work for children who struggle with the trauma and may have PTSD or PTSD symptoms. Instead, these children need to tell their story and would benefit from trauma-informed care to help experience PTG and to be able to handle possible future traumas (Steele & Kuban, 2011). Yet, no study exploring the effect of such care on PTG among bereaved children could be found in the literature. Neither is the literature conclusive on what may predict PTG in some children but not in others (Kilmer & Gil-Rivas, 2010; Laufer & Solomon, 2006; Yu et al., 2010). This study looks at possible predictors of PTG among bereaved youth and examines a program that provides trauma-informed care to bereaved children and adolescents to assess whether such care impacts PTG among those who participate in the program.

Literature Review

Following a description of the differences between resilience and PTG, the literature review will look at PTG among youth, who have experienced some type of trauma, followed by studies on PTG and bereaved youth. Studies that have examined predictors of PTG among youth and an outcome study of PTG among bereaved youth complete the literature review.

Resilience and PTG

Children who are resilient adapt well in spite of life stressors (Cicchetti, 2003). Children who are resilient do not develop PTSD or PTSD symptoms after a traumatic experience; instead, they seem to handle the traumatic experience well. The term resilience is applied to children and adolescents who seem to have certain characteristics such as self-esteem and problem-solving abilities and apply these during and after a trauma experience (Cloitre, Martin, & Linares, 2005). A sense of competence appears to be a common theme among children who demonstrate resilience in the face of adversity (Cowen et al., 1992; Masten, 2001). Some researchers suggest that these youth employ what has been called a repressing coping style (Echterling et al., 2005). When using a repressing coping style, the person does not talk or think about what happened but instead looks to the future. In contrast, “active copers,” that is, those using problem-focused strategies (Ayers, Sandler, West, & Roosa, 1996), experience PTG (Aldridge & Roesch, 2008; Wolchik, Coxe, Tein, Sandler, & Ayers, 2009).

Tedeschi, Park, and Calhoun (1998) have defined PTG as “a significant beneficial change in cognitive and emotional life that may have behavioral implications” (p. 3). People who exhibit PTG, as opposed to those who are resilient, struggle with the traumatic event and experience positive change (Calhoun & Tedeschi, 2006; Kilmer & Gil-Rivas, 2010). These positive changes are initiated by the actual struggle after the trauma, for example, involuntary cognitive ruminations, which perpetuate the struggle and stimulate coping efforts (Calhoun & Tedeschi, 2006). These positive changes may include higher appreciation for life, more compassion for others, and the thought of new possibilities. It is not solely the experience of the trauma itself that creates PTG in trauma victims. It is rather the struggle they experience afterward to try to understand the trauma experience and to accept their new reality that leads to PTG (Calhoun & Tedeschi, 2006). In other words, resilience allows victims of stressful events to adapt well in spite of the stressful event, whereas PTG involves a positive alteration created by the stressful events and subsequent struggles (Cryder et al., 2006).

Although some researchers question whether PTG is synonymous with or different from maturation, Western and Eastern youth, who have gone through a trauma event, experience more PTG than youth who have not experienced a trauma situation (Alisic, van der Schoot, van Ginkel, & Kleber, 2008; Taku, Kilmer, Cann, Tedeschi, & Calhoun, 2012). Thus, it does appear that PTG is a construct in its own right and different from natural maturation.

PTG and Youth

Researchers have studied PTG extensively among adults who have experienced different negative life events such as, accidents, cancer, HIV or AIDS, and war (Cordova, Cunningham, Carlson, & Andrykowski, 2001; Milam, 2004; Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003; Zoellner, Rabe, Karl, & Maercker, 2008). Research on PTG among children and adolescents is limited, and most of these studies relate to life events other than the death of a parent. Wong, Cavanaugh, MacLeamy, Sojourner-Nelson, and Koopman (2009) interviewed 27 adults whose parents had had cancer, either terminal or nonterminal, when the participants were children or adolescents. Themes of both PTG and negative effects came to light. Among the PTG themes were improved character, an increased appreciation for life, strengthened personal relationships, and increased interest in cancer issues (Wong et al., 2009). Negative themes that emerged were feelings of loss and void, concern for own health, negative changes in outlook on life, and negative effects on personal relationships. Although some participants had experienced either positive or negative effects, some participants had experienced neither. In a similar study of 12 adolescents, who were dealing with parental cancer, Kissil, Nino, Jacobs, Davey, and Tubbs (2010) reported four domains of PTG (Tedeschi & Calhoun, 1996): greater appreciation for life, enhanced interpersonal relationships, increased sense of personal strengths, and changed priorities. The research revealed a fifth domain, apart from Tedeschi and Calhoun’s (1996) domains: change in health behaviors and attitudes.

Hafstad, Kilmer, and Gil-Rivas (2011) measured posttraumatic stress symptoms (PTSS) and PTG among 105 Norwegian children aged 6 and 17 years who had experienced the 2004 tsunami in Southeast Asia. The participants were measured over time, the last time 30 months after the tsunami. Although PTG scores were higher among participants who reported higher levels of fear during the disaster, the decrease in PTSS did not relate to PTG, and, also, the levels of PTG were lower than in other studies of PTG among children. The authors speculate that this may be due to the fact that the participants did not experience postdisaster dangers such as loss of home, community, or death of relatives but instead returned to a safe environment in their home country of Norway after the disaster. PTG theory holds that it is the struggles after the disaster or trauma that bring the growth (Tedeschi, Calhoun, & Cann, 2007).

Kilmer et al. (2009) examined PTG among children aged 7 through 10 years, who had been impacted by Hurricane Katrina, at 12 months (N = 68) and 22 months (N = 53) after the hurricane. Over half of the children reported “some change” on the PTG measure. In contrast, only somewhat over 7% at first testing and somewhat over 13% at second testing reported “a little” change. PTG scores were significantly associated with self-reported subjective responses on the University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index-1 (Steinberg, Brymer, Decker, & Pynoos, 2004) but not the objective hurricane exposure.

Children who suffered a road traffic accident also experienced PTG (Salter & Stallard, 2004). Children and adolescents aged 7 through 18 years from Norway who had experienced car crashes, pedestrian, cycling, or biking accidents showed some PTG, mostly in the area of a new appreciation of life.

PTG and Bereaved Youth

Few studies focusing on bereaved children and PTG could be found in the literature. Yet, losing a parent as a child is an overwhelming event (Worden, Davies, & McCown, 1999) and for many children, a traumatic event, whether the loss is expected or not (McClatchey et al., 2009). Oltjenbruns (1991) examined PTG among older adolescents who had lost a family member or friend to death and discovered that they felt a deeper appreciation for life and for caring for loved ones. These adolescents also felt strengthened emotional bonds with others and that they had gained emotional strength after their loss. Parentally bereaved youth from the United Kingdom aged 9 through 25 years, who had lost their parents between 2 and 10 or more years ago, reported a positive outlook, gratitude, appreciation of life, living life to the fullest, and altruism as positive changes after their losses (Brewer & Sparkes, 2011).

Predictors of PTG

The extant literature thus indicates that children who experience adverse life events may also experience PTG. It is not clear from the literature, however, what may make some children grow emotionally and cognitively and others not. Researchers have examined several possible predictors of PTG such as age, gender, ethnicity, competence, future expectations, coping, caregiver warmth, socioeconomic status, social support, resilience, time, and PTSD symptoms among youth who have experienced diverse traumas. Some researchers have looked at predictors of PTG among parentally bereaved youth, such as, psychological distress, time, coping styles, support, age, gender, and ethnicity.

Age

Findings around age of children and adolescents and PTG are contradictory. Age does not have an influence on PTG in most studies (Cryder et al., 2006; Hafstad et al., 2011; Kilmer & Gil-Rivas, 2010; Kilmer et al., 2009; Tedeschi et al., 2007). Other studies show age to have a positive relationship to PTG (Currier, Hermes, & Phipps, 2009; Milam, Ritt-Olson, & Unger, 2004; Phipps, Long, & Ogden, 2007), while others show that younger children or adolescents have higher levels of PTG (Alisic et al., 2008; Yu et al., 2010).

Gender

Another demographic, gender, does generally not show as a predictor of PTG among children and adolescents (Hafstad et al., 2011; Milam et al., 2004; Tedeschi et al., 2007; Yu et al., 2010). However, gender does show as a predictor in some studies for females (Laufer, Hamama-Raz, Levine, & Solomon, 2009; Laufer & Solomon, 2006) and in others for males (Kimhi, Esthel, Zysberg, & Hantman, 2009).

Ethnicity

Research on ethnicity as a predictor of PTG among children and adolescents also shows conflicting results. Ethnicity is a nonpredictor of PTG in some studies (Currier et al., 2009; Milam et al., 2004; Oltjenbruns, 1991) but a predictor in others. Latino youth and White youths have higher PTG scores than Persian youth, and Black youth score higher on PTG scales than White youth (Milam, Ritt-Olsen, Tan, Unger, & Nezami, 2005; Phipps et al., 2007). Thus, many of these findings are in contrast to studies on adults and PTG where PTG is strongly related to gender, age, and ethnicity (Helgeson, Reynolds, & Tomich, 2006).

Competence, expectations, coping, caregiver warmth, social support, and socioeconomic status

Other factors, such as perceived competence, future expectations, and coping competency beliefs, do not show as predictors of PTG, but caregiver warmth and coping advice such as positive reframing were positively related to PTG at 1 year but not 2 years after disaster (Kilmer & Gil-Rivas, 2010). Social support has shown a positive relation to PTG in some studies (Kimhi et al., 2009; Wolchik et al., 2009; Yu et al., 2010) but not in others (Cryder et al., 2006; Kilmer & Gil-Rivas, 2010). Positive coping, that is, “positive reinterpretation, instrumental social support, and planning” (Aldridge & Roesch, 2008, p. 510), is significantly related to levels of stress-related growth among minority adolescents. Socioeconomic status is not related to PTG (Currier et al., 2009; Phipps et al., 2007).

Resilience and time

Resilience has shown as a predictor of PTG among children who experience parentification (Hooper, Marotta, & Lanthier, 2008). This contrasts, however, with findings among Israeli youth where the relationship between resilience and PTG was inverse (Levine, Laufer, Stein, Hamama-Raz, & Solomon, 2009). Time since the trauma was negatively related to PTG in some studies (Barakat, Alderfer, & Kazak, 2006; Phipps et al., 2007) but not related in others (Alisic et al., 2008; Currier et al., 2009).

PTSD symptoms

PTSD symptoms among youth, who have experienced a tsunami, hurricane, and earthquake, are positively related to PTG (Hafstad et al., 2011; Kilmer & Gil-Rivas, 2010; Yu et al., 2010). These findings support the theoretical definition of PTG, which posits that PTG is partly created by the struggle to understand the trauma experience (Calhoun & Tedeschi, 2006). Some researchers have examined whether PTSD symptoms are required for PTG and have found that PTSS predicted PTG over time (Hafstad et al., 2011; Kilmer & Gil-Rivas, 2010; Kilmer et al., 2009).

Predictors of PTG and parentally bereaved youth

Studying parentally bereaved youth, Wolchik et al. (2009) looked at psychological distress as a condition of PTG and found a positive relationship. They also found that, when controlling for time since death, threat appraisals, active and avoidant coping, and seeking support from parents or guardians and from other adults are the statistically significant predictors of PTG. In addition, when controlling for other predictor variables and time since death, active coping, support from parents or guardians, as well as internalizing and externalizing problems were the significant predictors of PTG among this sample. However, seeking support from siblings and peers was not a predictor of PTG. Neither were age, gender, and ethnicity in this sample of parentally bereaved children, and time was negatively related to PTG (Wolchik et al., 2009). These seemingly conflicting findings underscore the need for more research on predictors of PTG as well as the relationship between PTG, PTSD, and resilience.

Outcome Studies

Only one study could be found in the literature that examined parentally bereaved youth and the impact of a program on PTG among these children. As a substudy of a larger study, 50 adolescents and young adults (aged 14–22 years) participated in either a preventive group program designed to increase adaptive coping and the affective quality of the caregiver–child relationship or to a self-study program (Wolchik et al., 2009). Six years later, the participants completed a Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996).

Pointedly, the intervention to improve the emotional relationship between the caregivers and adolescents as well as their coping skills did not increase PTG among the participants. The authors hypothesized that the reason may be that the intervention was not specifically geared toward PTG. To foster PTG, the authors suggested a setting be used where children and adolescents who have experienced a trauma can come together in a healing environment to talk and share positive changes. These suggestions, and the varied results when examining predictors of PTG, raise the two research questions for this study: (a) What are some possible demographic and death-related predictors of PTG among bereaved youth? and (b) Will a program that provides trauma-informed care as suggested by Steele and Kuban (2011) and that includes an opportunity for bereaved youth to share positive changes as suggested by Wolchik et al., (2009) increase PTG among bereaved children?

Methodology

Sample

Participants in this study were children and adolescents aged 6 through 18 years who had signed up for a healing camp for bereaved children held in three different locations in the Southeastern United States. This purposive sample was chosen to examine predictors of PTG among bereaved youth and the impact of trauma-informed care on PTG in a preexperimental pretest–posttest study design. At the first camp session, 25 parents or guardians consented to have their children participate in the study; at the second camp session, 30; and at the third camp session, 30. Among these 85 campers, 5 did not want to participate and thus did not sign an assent form. In addition, due to the unexpected absence of graduate students to assist with the administration of the assessment instrument at the third camp session, a total of 65 campers of the 80 completed the PTGI for Children (PTGI-C; Cryder et al., 2006) instrument at pretest. Thirty-two of these campers (49% response rate) were available for posttesting 1 month later.

The 65 children and adolescents who completed the pretesting of the PTG instrument were equally divided between males and females (49.2% and 50.8%, respectively). Sixty-two percent were White, 35% Black, and 3% were Latino. Age ranged between 6 and 18 years, with a mean age of 11.3 years (standard deviation [SD] = 2.8). Time since loss ranged from 1 month to 48 months with a mean of 12.4 (SD = 13.4).

Among the participating campers, 46% had lost a father, 26% a mother, 9% a guardian grandparent, and close to 19% a sibling. Expected losses included cancer, liver and respiratory failure, end-stage heart disease, pneumonia, and multisystem failure. Sudden or unexpected losses included murder, suicide, heart attacks, pulmonary and other blood clots, drowning, car accidents, and complications during routine surgery. Sixty-five percent of the campers had experienced a loss to sudden or unexpected death.

Three percent of the guardians had less than high school education, 19% had some high school education or high school diplomas, and 50% had some college education or college degrees. The remaining guardians had some graduate education or graduate degrees (14%) or a vocational degree (14%). Annual income varied greatly. Twenty-two percent of the parent or guardians had an annual income below US$20,000; 59% had incomes between US$30,000 and US$60,000; the remaining families were more affluent with incomes between US$70,000 and above US$100,000 (see Table 1).

Table 1.

Gender, Race, Age, Type of Loss, Type of Death, Income, and Education of Surviving Parent or Guardian.

Demographics	n	%	Mean	SD	Range
Gender
Female	33	50.8
Male	32	49.2
Race
White	40	61.5
Black	23	35.4
Latino	2	3.1
Age	65	100	11.3	2.8	6–18
Months since loss	65	100	12.4	13.4	1–48
Type of loss
Mother	17	26.2
Father	30	46.2
Guardian grandparent	6	9.2
Sibling	12	18.5
Type of death
Expected	23	35.4
Sudden or violent	42	64.6
Income
<US$20,000	14	21.9
US$21,000–US$40,000	23	35.9
US$41,000–US$60,000	15	23.4
US$61,000–US$80,000	6	9.4
>US$81,000	6	9.4
Education
<HS	2	3.1
Some HS, diploma, GED	12	18.8
Some college or degree	32	50.1
Graduate or graduate degree	9	14.0
Vocational degree	9	14.0

Note. HS = high school; GED = general equivalency diploma; SD = standard deviation.

Table 2.

Regression Model: Predictors of Posttraumatic Growth.

Variable	N = 65
Variable	B	SE	p	F	R ²
Age	−0.476	0.353	.184	2.193	.245
Gender	0.037	1.878	.984
Race	−0.555	0.925	.551
Circumstances of death	−6.314	2.119	.004^a
Time	−0.023	0.076	.767
Income	0.713	0.874	.418
Education	−0.506	0.664	.450
Event severity	0.702	0.896	.437

Note. SE = standard error.

^aSignificant at α ≤ .01.

Measurement

To measure PTG, the PTGI-C was used (Cryder et al., 2006). This instrument is a 21-question self-report instrument that was adapted from the PTGI (Tedeschi & Calhoun, 1996). It addresses five areas of PTG, namely, (a) new possibilities, (b) relating to others, (c) personal strength, (d) appreciation of life, and (e) spiritual change. Questions from the different domains include “I have new things that I like to do (like hobbies, toys, etc.),” “I learned that some people will be there for me and help me if something bad happens,” “l learned that I can handle my problems,” “I feel like each day is important,” and “My spiritual or religious beliefs are stronger now.” The respondents answer the questions using a scale from 1 to 4, with 1 = not at all true for me and 4 = very true for me. Furthermore, the respondents rate the severity of the event from A (about the worst thing that could happen) to D (not too bad). The Cronbach’s α for the PTGI-C in Cryder et al.’s study (2006) was .89. Cronbach’s α on the PTGI-C for the current sample was .80.

Procedures

Institutional review board at the university where the research was conducted gave appropriate approval for the study. The procedures of recruitment, data collection, and camp are described later.

Recruitment

Campers are recruited through the school system, and each camp accepts 50 campers who have lost a parent, guardian grandparent, or sibling within the past 4 years. Due to the high demand for this camp, repeat campers are not allowed; and therefore, none of the campers participating in this study had attended a previous camp session. The researcher sent an informational packet 2 weeks before camp about the research study and its purpose to parents and guardians of children and adolescents who had been accepted to participate in one of the three camp sessions. The researcher asked the parents and guardians to sign and bring a consent form to camp if they agreed for their children to participate in the study. On arrival, those children and adolescents with parental consent were informed about the study and asked whether they were willing to participate.

Data collection

Those campers who answered yes to the questions of participation were read an assent form in a private setting at camp and asked to sign it. Once assent was obtained from the campers, those campers who were in the 6 to 11 age-group were read the PTGI-C by a mental health graduate student unless they indicated that they wanted to read it themselves. Campers aged 12 to 18 years filled out their instruments on their own with a mental health graduate student on hand to answer any questions.

Campers who had completed the pretest of the PTGI-C at the start of camp were mailed a copy of the instrument 1 month after the camp with a self-addressed stamped envelope, along with a request to respond within 1 week. If no response had been received within the appointed time, a mental health professional attempted to contact campers by phone to read the instrument to the campers in an attempt to add more data to the data bank. Twenty-two of the 32 campers who completed the PTGI-C at posttest returned their instruments via the U.S. Postal Service, 10 completed the instrument via phone. Camp sessions were held in the spring and the fall shortly before summer and winter breaks. Therefore, posttesting was scheduled during breaks when many campers were out of town and were difficult to reach. Others had moved. These reasons and simply a decision not to further participate in the study may account for attrition.

Camp

The campers participated in a weekend long healing camp. At camp, the campers participated in six-group counseling sessions led by mental health professionals following a trauma-focused grief curriculum based on the five foci developed by Goenjian et al. (1997) and Pynoos, Steinberg, and Wraith (1995). In addition, cognitive behavioral trauma-focused grief interventions were used based on the work of Cohen et al. (2001). The trauma-informed curriculum has shown to decrease PTSD symptoms and complicated grief symptoms among bereaved children (Cohen, Mannarino, & Staron, 2006; McClatchey, Vonk, & Palardy, 2008). In between counseling sessions, the campers participated in other grief activities such as journaling, the making of memory pillows, a memorial service, and a balloon release. The older campers also watched and processed a grief-related play. The younger age-group watched and processed a grief-related puppetry show. In addition, time was spent on traditional camp activities such as, hiking, a ropes course, canoeing, and a talent show.

Results

All data obtained from the participating campers before and after camp were entered into IBM SPSS 20 (2011) for analysis.

Predictors of PTG

To answer the first research question about possible demographic and death-related predictors of PTG in this sample of bereaved youth, the PTGI-C scores of the 65 campers who filled out the PTGI-C at pretest were used. PTGI-C pretest scores were entered into a regression model as the dependent variable with age, race (Latino campers were not included in the analysis due to their low number), gender, time since loss, perceived trauma severity, circumstances of death, and guardian education and income as independent variables. Age, race, gender, time since loss, trauma severity, guardian education, and income were not predictors of PTG when all variables were entered simultaneously into the model, but circumstances of death was, with children who had experienced a sudden or unexpected death showing statistically significantly higher PTG scores (p < .01) (see Table 2). When the independent variables were entered as single variables in separate regression models, age also showed as a significant predictor (p < .05).

Impact of Camp Intervention on PTG

To answer the research question whether trauma-informed care would increase PTG among bereaved youth, a paired samples t test was conducted. Mean pretest score of the PTGI-C was 57.00 (SD = 12.77), and mean posttest score of the PTGI-C was 68.28 (SD = 10.28; see Table 3). This change in the PTGI-C scores was statistically significant (p < .05).

Table 3.

Impact of Trauma-Informed Care on Posttraumatic Growth.

	Paired samples statistics
	Mean	N	SD	SE mean
Pair 1 PTGI-C pretest	57.00	32	12.77	4.03
PTGI-C posttest	68.28	32	10.28	1.82
	Paired samples test
	Mean	SD	SE mean	95% CI of the difference	T	df	Significant (two-tailed)
Pair 1 PTGI-C pretest–PTGI-C posttest	−11.28	24.14	4.27	[−19.98, −2.58]	−2.64	31	.013^a

Note. SD = standard deviation; SE = standard error; CI = confidence interval; PTG = posttraumatic growth; PTGI-C = Posttraumatic Growth Inventory for Children.

^aSignificant at α ≤ .05.

The researcher wanted to examine whether the group of participants who were available for posttesting was different from the group of participants who dropped out of the study. χ² was used to compare gender, race, circumstances of death (sudden or unexpected or expected), guardian education, and family income. No significant differences were shown in these areas between the two groups. To compare pretest scores, age, and time since loss between those who participated in the posttesting and those who dropped out, independent samples t test was used. No significant differences in pretest scores or age were found. However, those who dropped out of the study at posttesting had experienced their loss significantly closer to camp than those who did not drop out (p < .02).

Discussion

This research examined predictors of PTG and the impact of trauma-informed care on PTG among youth who had lost a parent, guardian grandparent, or sibling. This is to the researcher’s knowledge the first study to look at how a program based on the trauma-informed care impacts PTG. The results indicate that such trauma-informed care may positively impact PTG. In the current sample, children and adolescents exhibited statistically significantly higher PTG scores as measured by the PTGI-C after participating in the camp experience.

The analysis of data also showed that gender was not a predictor of PTG scores, which correspond with earlier findings among parentally bereaved youth (Wolchik et al., 2009) as well as other youth (Hafstad et al., 2011; Milam et al., 2004; Tedeschi et al., 2007; Yu et al., 2010). In contrast, the study results do not match results from other studies where gender is a predictor (Kimhi et al., 2009; Laufer et al., 2009; Laufer & Solomon; 2006). However, these studies were not among bereaved youth. Ethnicity did not show as a predictor in this study, which corresponds with Wolchik et al.’s (2009) study results of parentally bereaved children as well as those of Currier et al. (2009) and Milam et al. (2004). However, the current results do not match findings of Milam et al. (2005) or Phipps et al. (2007) where ethnicity is a predictor. The current sample may be too small to detect differences in these demographic variables.

Age was a predictor when used as a single variable. Due to developmental stage, younger children may be more dependent on the deceased and experience a bigger struggle and thus more PTG. Yet, age does not appear as a predictor of PTG among other bereaved youth (Wolchik et al., 2009) or several other youth (Cryder et al., 2006; Hafstad et al., 2011; Kilmer & Gil-Rivas, 2010; Tedeschi et al., 2007). On the other hand, age was a predictor among predominantly Hispanic youth (Milam et al., 2004). The discrepancies in findings underscore the need for further examination of age as a factor of PTG in bereaved youth as well as other traumatized youth.

In this study, time was not a predictor, which does not match previous results among bereaved children and adolescents (Wolchik et al., 2009), or findings among some other youth (Alisic et al., 2008; Currier et al., 2009), but does parallel findings by Barakat et al. (2006) and Phipps et al. (2007). In addition, family income, guardian education, and subjective trauma severity did not predict PTG among this study’s participants. These findings contradict study results where subjective trauma severity has been shown to be significantly related to PTG (Hafstad et al., 2011; Kilmer et al., 2009; Laufer & Solomon, 2006) but correspond with findings that socioeconomic status is not related to PTG (Currier et al., 2009; Phipps et al., 2007). Circumstance of death, that is, sudden or unexpected loss versus expected loss, was a predictor of PTG in this sample with children who had experienced a sudden or unexpected loss reporting higher PTG scores. Thus, the objective trauma severity was a predictor. Differences in sample sizes and composition of samples may explain the discrepancies in findings between this study and previous studies (Kilmer et al., 2009).

Limitations

This study, although it shows promising results for trauma-informed care in increasing PTG among youth who have experienced the death of a parent, guardian grandparent, or sibling, has several limitations. For one, the sample size is small. In addition, the preexperimental design has several threats to internal validity, such as history and instrumentation. The instrument was administered differently at posttesting (by mail or phone) than at pretesting. Maturation may also have been a threat, although this may be less of a threat considering that only 1 month passed between the two testing occasions. Dropout is an additional threat—as noted the participants who dropped out were different from those who did not, by having experienced their losses closer in time to the camp sessions than those who participated at posttesting. It may be that those who dropped out felt uncomfortable completing the posttest and that their participation in posttesting would have altered the results of this study.

In addition, this study did not measure PTSD symptoms, which have been positively related to PTG in several studies (Hafstad et al., 2011; Kilmer & Gil-Rivas, 2010; Yu et al., 2010). It is not known whether the campers in this study were experiencing PTSD symptoms or not, which raises several questions. Did the majority of the campers experience PTSD symptoms? Did only a few campers experience PTSD symptoms, indicating that PTSD symptoms are not a prerequisite for PTG?

Moreover, even if participation in the camp experience did create the increase in PTG among the participating youth, it is impossible to say that it was the trauma-informed care that was the force behind the change. The increased PTG scores may simply have been the results of the power of meeting with other bereaved children, which has shown to be an important factor to help bereaved youth (Brewer & Sparkes, 2011).

What is more, the study results cannot be generalized—the sample is small, comes from a southeastern area of the United States, and a purposive sample was used. The participants chose to take part in a bereavement camp, and their struggles may have led to a referral to camp.

It is also possible that the PTGI-C may not have been the ideal instrument. This instrument has been revised—PTGI-C-R (Kilmer et al., 2009). The revised 10-item instrument with good psychometric properties may be easier for young children to complete.

Implications, Future Research, and Practice

Despite the limitations of this study, its results have implications for future research and practice. This is a pilot study that indicates that trauma-informed care may positively impact PTG among bereaved children. A follow-up study with a larger and more ethnically diverse sample as well as a more rigorous design that controls for most threats to internal validity is warranted. It would also be advisable to use a different instrument such as the PTGI-C-R and to add a measurement for PTSD.

Other findings in this study also suggest that further research needs to be done. Age, gender, and race were not predictors of PTG in this study but have been in some others. Subjective trauma severity was not a predictor in this study, but objective trauma severity was. These results conflict with other studies and, therefore, predictors of PTG merit further study.

In regard to implications for practice, the results suggest that to assist bereaved children in the most meaningful way, trauma-informed care needs to be considered in order to help them grow from the experience and in order to be able to appreciate life again after the trauma of losing a parent, guardian grandparent, or sibling.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Irene S. McClatchey is an associate professor and director of the MSW Program at Kennesaw State University. Her teaching and research center around death, dying, and bereavement. She is the founder of Camp MAGIK, a healing camp for bereaved children and adolescents serving 230 campers and their families each year.

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