Toward the Rainbow After the Storm: Post-Traumatic Growth in Children Surviving Sexual Abuse

Abstract

Child Sexual Abuse (CSA) has been conceptualized as one of the severe forms of trauma in children with adverse multidimensional consequences throughout the lifetime of an individual. A vast literature exists to enumerate the short-term and long-term impact of CSA. However, recently, it has been observed that the impact of trauma may initially be profoundly negative but may not necessarily remain a negative experience throughout life. While trauma adversely challenges one’s basic beliefs about self, others, and the world, it may at times also enhance new ways of coping with it. These positive changes that co-exist with trauma have the potential to lead to psychological growth in the child. This productive process of growth in and after trauma is conceptualized as Post-Traumatic Growth (PTG), a concept compared to a metaphorical rainbow comprising the vitalities of life forces after the storm of emotional turmoil. The article introduces the concept of PTG, elaborates on its relevance in CSA, identifies some of the factors determining PTG in CSA, and lastly highlights the importance of taking it up for further understanding in clinical practices and research studies.

Introduction

Child Sexual Abuse (CSA) is one of the most severe forms of violence committed against children. Research studies over the years have gathered vast evidence indicating that the consequent psychological trauma is complex and multi-layered, leading to several short- and long-term impacts on the lives of survivors and their families, very often continuing into adulthood and in some cases transgenerational.^1,2 One of the recent comprehensive qualitative studies from India on assessing the impact of CSA indicated a multidimensional impact, consisting of six chief domains, that is, a child’s emotions, behavior, academics, cognitive functioning, biological functioning, social functioning, and psychopathology. ³ For many children, the adverse impact of CSA continues throughout life manifested as depression, anxiety, personality disorder, substance use, and sexual dysfunction. ⁴ However, it has been observed that not all child survivors of sexual abuse develop Post-Traumatic Stress Disorder (PTSD) or other forms of psychiatric disorders continuing till late in their lives. There seems to be a wide variability in trauma manifestation depending on the child’s meaning-making from these experiences, which determines the way CSA experiences are constructed and integrated into the child’s mind. Hence, contrary to popular assumptions, the impact of trauma might not be universally negative. ⁵ However, what is even interesting to note here is that a category of children who undergo the traumatic impact of abuse, as anyone else, takes their time recovering from it. Also, when they recover, they move way beyond the pre-trauma level of adaptation. Academicians and researchers have only recently started focusing on the spectrum of positive change experiences after trauma, called Post-Traumatic Growth (PTG). The term PTG refers to ways in which people are positively transformed by the experience of surviving significant adversity in their lives. ⁶

The present article will introduce the concept of PTG in detail and how it is relevant in the context of CSA.

PTG: Concept and Relevance

The origin of the concept of PTG is not new. For thousands of years, early philosophical inquiries and the literary work of novelists, poets, and religious leaders across various cultures have discussed in detail the extent to which suffering can induce growth. ⁷ For example, Hinduism promotes the ideology that suffering is an opportunity to progress along the spiritual path. Dr Victor Frankl, an Austrian neurologist, psychiatrist, and holocaust survivor, in his famous writing, Man’s Search for Meaning, ⁸ gives us a glimpse of PTG when he says, “In some ways suffering ceases to be suffering at the moment it finds a meaning.” Similarly, a polish psychiatrist, Kazimierz Dabrowski, ⁹ proposed that “personality development sometimes requires the disintegration of the personality structure, which can temporarily lead to psychological tension, self-doubt, anxiety, and depression”. However, Dabrowski believed that this process is essential for a deeper analysis of a person’s assumptions of the self and the world, leading to ultimately higher levels of growth and resilience. Because of the overwhelming evidence across cultures and domains of knowledge, it was clear that the frightening and confusing aftermath of trauma, where fundamental assumptions are severely challenged, can also be fertile grounds for an unexpected positive outcome in survivors, a phenomenon called PTG. Cahhoun and Tedeschi ¹⁰ conducted pioneer research on the conceptual understanding of the PTG, and they defined the terms as “positive psychological growth which is experienced because of struggle with highly challenging life circumstances.” They further defined that after surviving significant stress, individuals are often able to make gains in at least these five domains:“(i) personal strength, (ii) exploring new life possibilities, (iii) forming meaningful interpersonal relationships, (iv) gaining an appreciation for life, and (v) develop spirituality”. ¹¹ These gains necessarily don’t replace the emotional distress but rather act as an extension of one’s self which co-exists with it. Such co-existence over time reduces the emotional valence of the traumatic impact on an individual because the person now may not necessarily fall back on the negative impact of trauma but the positive changes as well. Such a transformation in suffering has now been documented in research as well where further evidence of PTG has been provided across a range of traumatic life experiences, being it life-threatening physical illnesses, the COVID-19 pandemic, bereavement, war-zone trauma in military personnel, or abuse.^12-16

Interestingly, however, most of PTG evidence comes from research on adults as it is assumed that adults have well-formed schemas, which are essential to later bringing seismic challenges to it for its reconfiguration. ¹⁷ Should we assume that PTG is not relevant for children? Various academicians and researchers pondered the question because children are at a tender age where they are still building the foundations of their perspective of self, others, and the world. If the trauma memories are not processed adequately, a host of irrational beliefs can be easily internalized, leading to adverse consequences till adulthood. It has been hypothesized that trauma would impact children adversely because the disruption in the assumptive world of children is less firmly entrenched than that of adults.^18,19

Moreover, on the other hand, children’s schemas are also much more open and available to adaptive inputs than adults’. ¹⁸ Some supportive investigations suggest that children as young as 7 to 10 years old spontaneously reported evidence of PTG on open-ended questions illustrating growth. ²⁰ Thus, it is essential not only to reconstruct the irrational beliefs associated with trauma memories in children but also to construct some growth narratives.

However, many researchers have questioned children’s capacity to engage in the cognitive and affective processes necessary to yield profound changes as discussed above.^21,22 Although it has been postulated that PTG requires a great degree of cognitive sophistication and a capacity to weigh the losses and gains after difficulties, the process is complex and unclear in children. ²¹ Moreover, another factor worth consideration here is the children’s cognitive and affective capacity at the time of trauma as well as the time at which they can formulate their experiences and express them to others. ²³ Since a linear relationship cannot be assumed between PTG and growth in children surviving trauma, it is only reasonable to assume that following traumatic incidents, children vary widely in their responses depending on their differential capacity to understand, process, and internalize their experiences. ²⁴ Let us examine some of these factors in the next section.

Factors Determining PTG in CSA

One of the earliest models of PTG on children identified seven interrelated domains that impact a child’s ability to experience PTG after experiencing trauma. These were “(i) child’s pre-trauma beliefs, characteristics, and functioning; (ii) caregiver’s post-trauma responsiveness; (iii) trauma exposure; (iv) relationships and support; (v) appraisals, ruminations, and cognitive processing; (vi) cognitive resources; and (vii) self-system functioning”. ²² Though the model postulates a very comprehensive understanding of the key elements of PTG, it still needs to be examined further in studies and remains at a nascent stage of conceptualization. A more recent study by McElheran and colleagues ²⁵ added factors that could determine PTG in children with trauma. The proposed factors can be chiefly categorized as those relating to the child, their caregivers, and the trauma event itself. Let’s examine the sub-component of each of them in detail in this section.

Factors Related to Child

Age and cognitive maturity to find possible meaning in trauma have been repeatedly associated with PTG. ²⁶ Similarly, gender plays an important part where it has been observed that sociocultural factors favor girls seeking social support more than boys, hence experiencing higher growth rates. ²¹ Also, children who identified with a particular religious school and received peer support reported more PTG.^26-28 Further, in terms of attachment style, it has been postulated that securely attached children would be better able to expect and access appropriate social support post-trauma compared to those with avoidant or ambivalent attachment patterns.^21,26

Lastly, the child must recognize and express positive and negative emotions regarding the experience.^21,29 Especially, positive self-efficacy is a crucial factor in the discussion. Kilmer ²¹ found that children with adequate capacity for self-reflection and competency beliefs about themselves and the future were more likely to deal with trauma and sustain positive changes throughout. Wyman ³⁰ proposed that the expectation of control over an event outcome and recovery process is crucial for meaningful adaptive PTG processing. Kilmer ²¹ further laid out the pathway of realistic control expectations as operating through other cognitive elements such as productive rumination, coping competency beliefs, and hope for the future.

Factors Related to Caregivers

Caregivers play a crucial role in helping the child understand traumatic events, making their impact apparent, and carefully offering coping and growth narratives that foster adaptive schemata changes.^11,18,21 Researchers have identified for a very long that warm and nurturing caregiving mitigates the impact of trauma.^31,32 In PTG literature, a significant link has been identified between perceived support and children’s PTG. ²¹ In the context of CSA if there is an absence of logical understanding of why the incident occurred, the child may soon develop an irrational belief that they caused it and everything is their fault. ³³ The self-blame, guilt, and shame can go a long way in leading to various forms of psychopathology. Hence, a warm, responsive caregiver may contribute to PTG by helping the child build correct narratives and a healthy self-system.

Factors Related to Traumatic Incidents

It has been found that traumatic events that come as shock, last for a longer duration, and are of higher intensity tend to interfere with the recovery process. ²⁵ Another relevant factor is the time since trauma which has been proposed to directly impact the child’s developmental capacity to answer the cognitions around “why me”? Suppose the impact of trauma coincides with the appropriate capacity of the child to engage in productive rumination of trauma memories. In that case, a child’s ruminative thinking can likely become more productive and conscious, yielding a deeper and more meaningful consolidation of new perspectives into the existing notions of the self, others, and the world.^21,25

Beyond the factors mentioned above, it is essential to remember that PTG phenomena may vary across cultures and their varying spiritual and religious values (e.g., notions of suffering, recovery, the path of recovery, etc.). Each culture has a norm of meaning-making during challenging times. The norms may further diversify in each family where parents and children have a specific way of expressing stress, problem-solving, and coping. Understanding the significant cultural and, further, the community’s family values, thus remains a unique factor determining PTG.

Research and Clinical Implications

The understanding generated on the negative impact of trauma on children is clear and has been well addressed in research and clinical literature. However, there is a need to move beyond trauma management to begin talking about growth as a step toward ensuring comprehensive intervention for the child. Unfortunately, understanding of the PTG in children with sexual trauma remains predominantly hypothetical and is chiefly derived from theoretical understandings. Research investigations on PTG in children are scarce and need further investigations. It would be very relevant to explore PTG pathways in CSA, identifying various domains of growth in children, identifying the individual varying factors determining growth, and how actively it can be fostered during the interventions.

Regarding clinical applicability, fostering PTG when planning trauma interventions seems to be one of the primary applicability. The understanding generated so far on PTG in sexual trauma can keep the clinical practices well-informed. For instance, working on building a secure and trusting relationship with children, building their cognitive resources to process trauma, supporting their adaptive coping, and helping them accept and adjust to the new reality. All of these help children build a healthy narrative of what happened, building growth narratives of their belief system, especially the positive changes that may be consistent with PTG. The notion of facilitating PTG may not necessarily mean a manualized technique of some step-by-step approach to intervention. It can be as simple as creating an environment for the child that supports PTG.

In that vein, it is worth mentioning that some findings in child literature suggest that factors leading to PTG may well be beyond the professional’s contribution to it. ³⁴ Put simply, when working with children with trauma, one cannot lose sight of the context within which recovery occurs. Because trauma has the potential to impact multiple levels of a child’s socio-cultural environment, the intervention must be comprehensive. Thus, involving the caregiver-child dyad is significant when working on a child’s adaptation post-trauma. Clinicians can also support caregivers in how they can optimally support their children. Sessions with primary caregivers or other supporting sources would be significant.

Whenever a child presents with trauma and is referred for trauma intervention, it can be beneficial to assess them for both the difficulties and relevant competencies required to foster PTG to move toward comprehensive planning of the trauma intervention. Clinical practices that consider PTG as an outcome can go a long way in speeding up the recovery time, enabling children to develop healthy socio-emotional functioning that can be sustained throughout life. Thus, there is a need to move beyond trauma symptom management only toward the child’s holistic growth.

As a concluding thought, it is important to remember that just as every child may not experience PTSD, every child may also not experience PTG. Hence, questioning the possible benefits of trauma, especially in a sensitive context of sexual trauma, should be avoided at the outset.^34,35 Furthermore, it is crucial never to push or sell the notion of growth too early when handling CSA. ³⁵ Instead, PTG should be nudged where the child has recovered and is willing to move forward. However, the opposite is not valid, that is, if the child does not move toward PTG, it does not mean they lack something or something is wrong with them. ³⁶ Thus, PTG should be explored as an additional intervention outcome that is consistent with building a child’s internal resources, supporting active coping, and making sense of the world or people around after trauma, instead of being a pre-requisite for recovery.