Stability and Change in Posttraumatic distress: A 7 Year Follow–up Study of Mothers and Young Children Exposed to Cumulative Trauma
April 17, 2017
What are the new insights on resilience of children and families living under continual threat?
Resilience has been coined as “ordinary magic” (Masten, 2001), but the age-old question remains as to why some people bounce back in the face of trauma, while others experience debilitating distress. Recently, the field of resilience research has emphasized the importance of understanding temporal aspects of resilience and the centrality of resources acquired over time to sustain resilience (Bonanno et al., 2015; Hobfoll et al., 2015). Sustaining resilience over time is especially important in situations of continual trauma, in which trauma accumulates over time. In situations of cumulative trauma, an individual experiences increases in allostatic load, reflected in rising physical and emotional difficulties resulting from the continual need to remain in survival mode when under threat (McEwen, 1998; Brom, 2014). For young children, these detriments to physical and mental health may be particularly damaging. The concept of emergent resilience (Bonanno et al., 2013) suggests that situations of chronic stress may be more taxing than situations of acute stress, but, over time, families that can flexibly adapt will be able to regain equilibrium (Pat-Horenczyk et al, 2013). For young children, parental resilience and ability for emotion regulation is especially important in fostering resilience and mitigating distress (Pat-Horenczyk et al, 2015)
What did the follow-up study on traumatized children and mothers reveal?
The study investigated the consistency of responses to cumulative trauma; stability and change in posttraumatic distress and resistance (no evidence of clinical symptoms). 140 Israeli mother/child dyads exposed to continual rocket attacks over approximately seven years were assessed at two time points; when the children were 2-4 years old (Time 1) and 9-11 years old (Time 2). Mothers completed self-report assessments of trauma exposure, posttraumatic and depressive symptoms (PDS, CES-D), and children’s behavioral symptoms (CBCL). We devised four longitudinal courses to characterize responses over time: Resilient (resistance at Time 1 and Time 2; i.e., stability of resistance); Recovered (clinical distress at Time 1 and resistance at Time 2; i.e., positive change); Developed Symptoms (resistance at Time 1 and clinical distress at Time 2; i.e., negative change); and Chronic Distress (clinical distress at Time 1 and Time 2; i.e., stability of distress). The results demonstrated more stability than change in the frequencies of resistance at both times of measurement and that resilient longitudinal course was the most common longitudinal course for both mothers and children. Maternal posttraumatic symptoms predicted the Recovered and Chronic Distress longitudinal courses of the children.
In situations of continuous trauma, how can resilience be sustained over time?
The question of what sustains resilience over time is still a challenge for researchers and clinicians. Most theories of resilience suggest that it is not just one, but a combination of many factors that contribute to sustained resilience including personal strengths, use of adaptive coping and regulatory strategies, and both family and community support. The current study suggests that parental resilience is especially important in mitigating the distress of young children. This goes beyond parental support, as a parent may be supportive yet still exhibit symptoms of distress. Parental functioning is a crucial component in sustaining a child’s resilience over time.
Do the responses of children mirror those of their mothers?
Previous research supports the idea that parental responses influence those of their children; the current study demonstrates that this continues over time, even as responses change. Chronically distressed children have higher rates of consistently symptomatic mothers, whereas children that are resistant to distress (resilient) have mothers that report consistently low rates of distress symptoms. Further, recovery in children over time is often mirrored by a decrease in maternal distress symptoms, while development of symptoms in children is parallel to increases in maternal reports of distress symptoms. In the current study, maternal posttraumatic and depressive symptoms at the first point of assessment predicted the identification of recovered children, and severity of posttraumatic symptoms predicted the identification of chronically distressed children.
What are the implications for interventions for traumatized children?
High rates of both sustained resilience as well as sustained distress suggest that responses to cumulative trauma are more likely to be stable over time; those who are resilient are likely to remain resilient, and those who are distressed are likely to remain distressed, despite the provision of psychosocial and community services. Changes in responses over time, especially in young children, may be related to changes in the response of their mother, as reflected in the term relational PTSD. It would be useful for clinicians to develop special screening and treatment methods for individuals exposed to repeated trauma and prolonged distress. It will also be important for future research to identify differentiating factors between chronically distressed and recovered mothers, as well as between resilient mothers and those who develop systems. In these respective pairings of trajectories, mothers both report similar clinical characteristics at their first assessment, but follow divergent trajectories over time. Identifying the factors that facilitate such turning points may help clinicians recognize warning signs and tailor treatments appropriately. Overall, the response of a developing child to continuous trauma is highly dependent and entwined with the response of his or her mother, and successful interventions should treat both mothers and children in a dyadic mode.
How can we reconcile high rates of distress and resilience?
This study offers additional evidence that distress and resilience can and do co-exist, and highlights the need to focus on both symptom reduction and resilience building to strengthen the coping and growth of traumatized children and families and enhance their wellbeing in all circumstances and contexts.
Pat-Horenczyk, R., Cohen, S., Ziv, Y., Achituv, M., Brickman, S., Blanchard, T. and Brom, D. (2017), Stability and Change in Posttraumatic Distress: A 7-Year Follow-Up Study of Mothers and Young Children Exposed to Cumulative Trauma. Journal of Traumatic Stress. 30(2): 115-121 doi:10.1002/jts.22177
Dr. Ruth Pat-Horenczyk is a clinical psychologist, an Associate Professor at the School of Social Work and Social Welfare at the Hebrew University of Jerusalem and the Director of the Child and Adolescent Clinical Services at the Israel Center for the Treatment of Psychotrauma in Jerusalem. Her research focuses on risk and protective factors for childhood PTSD, preparedness and resilience, relational trauma and posttraumatic growth. Prof Pat-Horenczyk co-edited the book “Treating Traumatized Children: Risk, Resilience and Recovery” (Routledge, 2009), and “Helping Children Cope with Trauma: Individual, Family and Community Perspective. (Routledge, 2014).
Sophie Brickman, B.A.,
is a research assistant at Brandeis University. Her research focuses on emotion regulation, responses to trauma and posttraumatic growth.
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