Keys to emotional wellbeing and resilience in minors who have suffered trauma
Enrique Echeburúa(a and Pedro Javier Amor(b
a) Universidad del País Vasco (UPV/EHU)
b) Universidad Nacional de Educación a Distancia (UNED)
Ansiedad y Estrés, (2022), 28(3), 153-159
Received 13 August 2022
Accepted 13 October 2022
Available online 3 November 2022
Being a victim of a violent event in childhood carries a higher risk of developing emotional, behavioral and social problems. However, not all minors show serious negative consequences. Their degree of resilience will depend on previous emotional stability, degree of self-esteem, cognitive style and the type of experiences, as well as their ability to solve problems. Protective factors implicated in resilience include a stable family environment, helpful relationships with peers, and community support. There are certain adaptive coping strategies, such as striving to realistically solve everyday problems, adapting to the new reality, and actively forgetting or forgiving what happened. The greater or lesser use of certain cognitive emotional regulation strategies can also condition the recovery process or be linked to different trajectories of the victims in the face of potentially traumatic events. A positive indicator of the victim’s improvement is when the verbal expression of feelings is recovered and order is brought to the chaos of images and memories of the violent event. Further research is required in the near future, such as the influence of the age and gender of minors and the role of coping strategies and emotional regulation.
Claves del Bienestar Emocional y de la Resiliencia en Menores que han Sufrido un Trauma
Ansiedad y Estrés, (2022), 28(3), 153-159
Ser víctima de un suceso violento en la infancia conlleva un mayor riesgo en el desarrollo de problemas emocionales, de conducta y sociales. Sin embargo, no todos los menores muestran consecuencias negativas graves. La mayor o menor resiliencia va a depender del equilibrio emocional previo, del grado de autoestima, del estilo cognitivo y del tipo de experiencias habidas, así como de su capacidad de resolución de problemas. Entre los factores de protección implicados en la resiliencia figuran el entorno familiar estable y las relaciones de ayuda con los iguales y el apoyo del entorno comunitario. Hay ciertas estrategias de afrontamiento adaptativas, como esforzarse por solucionar los problemas cotidianos de una manera realista y adaptarse a la nueva realidad, olvidar de forma activa o perdonar lo ocurrido. El mayor o menor uso de determinadas estrategias de regulación emocional cognitiva puede asimismo condicionar el proceso de recuperación o estar vinculado a diferentes trayectorias de las víctimas ante sucesos potencialmente traumáticos. Un indicador positivo del proceso de mejoría de la víctima es cuando se recupera la expresión verbal de los sentimientos y se pone orden en el caos de las imágenes y recuerdos del suceso violento. Nuevas investigaciones son requeridas en un futuro próximo, como la influencia de la edad y del sexo de los menores y el papel de las estrategias de afrontamiento y de regulación emocional.
Indicadores de recuperación
Victims are people who suffer from intentional harm caused by other human beings. However, victimhood is not per se a clinical case (mental disorder), nor can victims necessarily be identified with a specific clinical picture if they present to the clinic (posttraumatic stress disorder, for example). Essentially, there are victims who, despite suffering deep emotional discomfort, do not suffer from psychopathological alterations while there are others who manifest a variety of different consequences (post-traumatic stress disorder, depression, anxiety disorders or personality alterations). Nor can a specific clinical profile be established based on the type of traumatic event. In other words, the psychopathology of a victim cannot be mapped according to the type of negative events suffered (Echeburúa & Corral, 2009). As far as minors are concerned, being the victim of a traumatic event in childhood or adolescence entails a greater risk of developing emotional, behavioral and social problems. However, not all minors show serious negative consequences. In fact, the effects derived from the victimization and the course of the symptoms can be very heterogeneous (Fergusson et al., 2013). Thus, there are minors at risk of victimization who have protective shock-absorbing factors that make them resistant to stress. Therefore, the psychological reaction of minors to a traumatic situation is related to the intensity and circumstances of the event, but also their age, history of previous aggression and available psychological resources, as well as the type of attachment they had during childhood (Amor & Echeburúa, 2015). The survival instinct manifests itself in the form of coping strategies that human beings use to deal with stressful events. It is, in fact, a set of skills and resources that the person acquires in the process of socialization to overcome difficulties and withstand the disappointments of daily life, without seriously diminishing their personal well-being. These survival skills will depend, among other things, on previous emotional stability, degree of self-esteem, personal cognitive style (more or less optimistic) and types of experiences had, as well as their ability to solve problems and the family and social support received (Echeburúa & Amor, 2019). The objective of this article is to classify the reactions of minors to traumatic events, to indicate the protection factors of the victims, to point out the facilitating variables of resilience and post-traumatic growth and to describe the adaptive coping strategies in the face of traumatic events, as well as the role played by cognitive emotional regulation in trauma recovery and an increase in the emotional well-being of the minor. Finally, some of the positive indicators of the minor’s recovery from the adversities of daily life are discussed.
Many minors faced with traumatic events have difficulties expressing their thoughts or labeling their emotions. Instead, they express themselves through their behaviors (American Psychiatric Association [APA], 2022). The degree to which minors can verbalize their thoughts and emotions depends on their age, degree of development, personality characteristics and the types of family and social relationships they maintain. In childhood, the symptoms experienced can be highly variable (sleep disturbances, changes in eating habits, irritability, generalized fears, guilt and shame, shocks, decreased self-esteem, etc.). Ultimately, all of them reflect an intense degree of emotional distress and difficulty adapting to daily life. Trauma can also manifest in the form of physical symptoms (nausea, upset stomach, headaches, etc.) or regressive behaviors in terms of language, personal autonomy or sphincter control. In some cases, there may even be profound social withdrawal, premature preoccupation with death, a variety of distressing dreams or unexpected emotional reactions. At other times, the symptoms reflect an extension of pre-existing traits, as is the case of nervous children who present symptoms of anxiety or sad children who show symptoms of depression (Echeburúa & Guerricaechevarría, 2021). Separation anxiety from loved ones can also manifest, causing exaggerated emotional dependency. The capacity for verbal expression increases with development and minors are not capable of providing a reliable chronology of events until they are 8 or 9 years old (Echeburúa, 2020). Trauma can manifest itself differently depending on gender. In general, boys have more difficulty expressing their emotions than girls. More specifically, anxious and depressive symptoms tend to predominate in girls; in boys, on the other hand, externalizing post-traumatic symptoms are more frequent, such as impulsiveness, aggressiveness, hyperactivity and inattention. School maladjustment and socialization difficulties may appear in both genders (Perry & Azad, 1999). In comparison with adults, emotional reactions in minors can be more global and intense, which implies a broader level of behavioral disorganization, but of shorter duration. Children experience trauma like adults, but have more difficulty assimilating what happened and expressing their emotions. Therefore, minors tend to blame themselves, directly or indirectly, for traumatic events with greater frequency than older people. However, the degree of recovery is usually greater than in adults (Echeburúa & Amor, 2014). In the long term, some children harbor feelings of violence and have a predisposition to violent behavior and revenge; others, in turn, will engage in risky behaviors that can endanger their physical integrity. This will depend, to a large extent, on the reaction of loved ones. The traumatization of the parents and the absence of an atmosphere of support and communication tend to aggravate the psychological development of a minor (Echeburúa & Amor, 2020). When a child becomes an adolescent, there may be a tendency to adopt radical changes in behavior and lifestyle, the result of an excessive desire for independence. Sometimes these are escapist attitudes, such as moving away from home, consuming alcohol and drugs, putting oneself in risky situations or showing an extreme interest in seeking new and exciting experiences. Regarding the evolution of some of the symptoms of posttraumatic stress disorder (PTSD), the clinical expression of flashbacks varies in the phases of growth and development and may appear differently than in adult life (APA, 2022). Thus, younger children may relive the traumatic event directly or symbolically through games or stories related to the trauma that are anxious, repetitive and rigid in nature (for example, a child acts out the violence he or she has observed with two dolls that fight and end up being thrown against the wall repeatedly) or show recurring horror dreams without recognizable content. They may also behave with intense emotional or physical reactions when exposed to internal or external memories related to the trauma. In turn, avoidance behaviors can be manifested, in the case of preschool children, through little involvement in exploratory activities; and in older children, through reduced participation in school or play activities. Likewise, minors can see their self-esteem affected, consider themselves unattractive to other people and limit their aspirations for the future. In short, in a more or less subtle way, efforts to avoid exposure to conversations, people, objects, situations or places that are reminiscent of the trauma are observed (De Young et al., 2011). Furthermore, the symptoms of hyperarousal usually present themselves fundamentally as sleep disturbances, high irritability, tantrums, a constant state of alertness to danger, concentration difficulties and increased activity levels. All of this can lead to negative alterations in cognition and frequent mood swings (Amor & Echeburúa, 2015). As for the psychopathological repercussions in adult life of childhood trauma, they are difficult to predict. In the first place, they only occur in approximately 20% of affected people. Secondly, in the event that they do occur, the specific psychopathological alterations vary from one case to another (Bonnano & Diminich, 2013) and they cannot be established based on the specific type of traumatic event experienced (sexual abuse, child abuse, loss of a father due to a terrorist act, etc.). Different types of childhood victimization can generate unpredictable emotional alterations in adult life (Echeburúa, 2020; Echeburúa & Amor, 2014).
There are three types of variables that are involved in the development of resistance in children (Table 1): positive personality factors (self-esteem, optimism, empathy, positive emotional regulation and daily living skills), stable family environment (cohesion and good family relationship, stable care by parental figures) and supportive relationships with peers, school, extended family members, and the community (Schaefer et al., 2018; Zolkoski & Bullock, 2012). The resistance of minors to the traumatic situation increases when they receive clear explanations from their parents and when they are emotionally supported by them. Likewise, the reestablishment of daily life (times for meals and sleep, school attendance, resumption of hobbies, etc.) in an atmosphere of serenity and normalization contributes to the psychological recovery of the child, who needs to regain confidence, the feeling of autonomy and the ability to exercise some control over themself and over their environment (Cyrulnik, 2015). In turn, stress-resistant children are characterized by emotional control, adequate self-esteem, confidence in their own resources, rewarding hobbies, a stimulating social life, a rich inner world and a positive attitude towards life. All this makes it possible to draw on the available resources to adequately deal with the negative events experienced, overcome adversity and learn from painful experiences without giving up their life goals. This type of personality works as a buffer or as a protective vaccine that tends to weaken the stress response (Echeburúa, 2021; Frankl, 2016).
Resilience and post-traumatic growth in minor
As can be seen in everyday life, there are minors who are resistant to the appearance of clinical symptoms after experiencing a traumatic event. This does not mean that they do not suffer from subclinical pain or that they do not have unpleasant memories, but that, despite this, they are able to cope with daily life and can enjoy other positive experiences (O’Dougherty et al., 2013). In this sense, resilience (resistance to stress and adversity) is the ability of the human being to recover from a serious setback. It is the dynamic process of positive readjustment to challenging or traumatic life events, without the person succumbing to their harmful effects. Resilience involves the presence of two components: a) a resistance to adversity; and b) a return to daily life with proper functioning and with a plan for the future (Echeburúa, 2021; Grych et al., 2015). Likewise, resilient coping has to do with the presence of strengths in emotional regulation skills and in prosocial skills (Bonanno & Mancini, 2012). The psychological pillars of resilience are self-esteem, emotional self-regulation, positive thinking and the will to live (Barudy & Dantagnan, 2011; Echeburúa, 2018). The greater or lesser resilience of a person is strongly correlated with the type of attachment they have experienced in childhood. Specifically, attachment figures in childhood perform two essential functions in development: they become a base of security and a port of refuge. Therefore, people with a secure attachment style develop adequate self-esteem, generate a pattern of positive expectations regarding interpersonal relationships (intimacy, basic trust in others, sociability, emotional autonomy, etc.) and are more resistant to traumatic events. On the contrary, people with an insecure attachment style (for example, of the anxious-ambivalent or avoidant type) are more vulnerable to the adversities of daily life (Muela et al., 2016). However, while these early years of a child’s life are critical, children can overcome a bad start. In other words, an unhappy childhood is not doomed to lead to an unhappy life, nor does a happy childhood, which is a good starting point, guarantee a happy adult life (Cyrulnik, 2015).
The degree of resilience is quite stable throughout life. For this reason, resilient people who suffer a traumatic event tend to maintain a positive state of mind, beyond the intense but temporary pain that an event of this type can cause them. That is, they do not lose their personal ability to make sense of their current experiences and or their hopes for the future (Matsui & Taku, 2016). Resilience has to do with the person’s past (attachment and experiences in early childhood), but also with the present and the future. Thus, two types of resilience can be distinguished (Rojas Marcos, 2010): a) Primary resilience. This refers to the result of receiving affection and stimulation from parents and having a secure attachment (good treatment) (especially between 0-3 years), which increases the self-esteem of minors and makes them resistant to adversity. Neurologically, good treatment modulates brain development and tends to create healthy neural networks. b) Secondary resilience. If a traumatic event has occurred, the victim can recover, regardless of the treatment received in childhood, if the family and community group is supportive of the person and can contribute to their personal reconstruction. In short, resilience is related to aspects prior to the traumatic event (personality characteristics, type of childhood attachment, absence of previous victimization), but also to circumstances after the event, such as the type of psychological resources employed or the family, social or judicial support received (Echeburúa & Amor, 2019; Zolkoski & Bullock, 2012). In turn, post-traumatic growth is conceptually different from resilience (Levine et al., 2009; Vloet et al., 2017) and goes beyond it. Resilience allows people to recover emotionally after suffering a misfortune, but post-traumatic growth is something else: the traumatic experience is overcome, but the person is also psychologically renewed. These minors who, in their struggle to overcome adversity and post-traumatic symptoms, discover healthy traits of their personality that they were unaware of, reconfigure their hierarchy of values and find valuable new meaning in life. While resilience refers to the recovery of one’s previous life, posttraumatic growth implies a positive process of psychological transformation (Andrades et al., 2021; Calhoun & Tedeschi, 2014; Rojas Marcos, 2010). Ultimately, post-traumatic growth (the ability to emerge stronger or experience positive changes as a result of the crisis) involves a profound process of transformation: a) a feeling of greater strength and self-confidence; b) improvement in personal relationships and the need to share and express feelings; c) development of new interests and rediscovery of the value of small details of daily life; and d) positive reappraisal of life experiences (Cyrulnik, 2015) (Table 2). In short, a child’s experience of a traumatic event can make them more sensitive and vulnerable to subsequent negative events or, on the contrary, help them develop mature coping styles to deal with life’s setbacks. In fact, many victims of a traumatic event transform their tragedy into creative energy and enrich their lives with useful and rewarding social activities (Cyrulnik, 2015).
Adaptive coping strategies
Beyond the immediate resources that a minor uses when they suffer a traumatic event (vent emotionally, seek social and family support, concentrate on studies, return to daily life, eat and sleep properly or distract themselves with their usual hobbies), there are certain coping strategies that facilitate overcoming the emotional damage suffered (Tielman et al., 2017). Psychological resources are variable from one minor to another. What is useful to some is not necessarily useful to others. But, in general, there are some characteristics that are frequently repeated: a drive to solve everyday problems in a realistic way and the flexibility to adapt to the new reality; a positive outlook on reality that seeks to find good even in negative experiences; a tendency to lean on friends and family in difficult times; an acceptance of oneself as you are, with your own qualities and limitations; a lack of focus on one’s own world and an interest in what is happening in the wider world (nature or art); and a habit of engaging in rewarding activities. Others are not so universal but can be very useful: a spiritual life that provides religious consolation; or the capacity for enthusiasm and sense of humor, which can “melt” stress (Kaplan et al., 2016). Also, although it may seem paradoxical, active forgetting, i.e. cognitive avoidance, is among the adaptive strategies, as long as the traumatic thoughts do not emerge in an intrusive way. Forgetting can be an involuntary mental action that consists of failing to remember previously acquired information. The fading over time of the memories of past experiences (including negative ones) has an adaptive nature because it allows the inclusion of new memories related to the most recent experiences (Echeburúa & Amor, 2019). Intense emotional experiences are more difficult to erase. In these cases, the active forgetting of traumatic events loaded with pain or negative emotions (shame, hatred, or guilt) can be a natural protective reaction to maintain emotional balance. The objective of active forgetting is to emotionally modulate the memory and put aside the reproaches and the desire for revenge that occur during voluntary recall of the events. This means that the child actively strives to focus attention on present stimuli and future expectations, so as not to allow painful memories to surface (Enright & Fitzigibbons, 2000).
In turn, the ability to forgive can be a fundamental ingredient in the recovery of young victims of trauma. It is not possible to change their past, but it is possible to modify their perspective and their attitude towards events in order to reinterpret their meaning in a more positive way, freeing their mind from harmful thoughts and reinforcing more liberating decisions (Rocha et al., 2017). In this way, forgiveness can have positive psychological effects: not living haunted by a traumatic past, improving health (for example, sleep and relaxation) and regaining inner peace. Getting rid of resentment helps to get rid of a burden that can be unbearable. Dissociation of anger and vindictive desires from the memory facilitates the well-being of the minor since it relieves emotional pain and allows them to focus on the future (Kaleta & Mróz, 2018). At the same time, it is easier to grant forgiveness when the offender shows remorse, recognizes the damage caused, sincerely apologizes for the damage caused and carries out some type of reparation. Minors present individual differences in terms of their ability to forgive, which is greater when they have had family modeling in this regard and when they have an optimistic cognitive style, emotional stability prior to the event, and good family and social support (Mullet, 2012).
Cognitive emotional regulation strategies
Cognitive emotional regulation strategies are cognitive responses that arise to try to modify the magnitude and/or type of emotional experience in the face of events that generate emotional discomfort. Certain cognitive emotional regulation strategies can also affect the recovery process or be linked to different trajectories of victims of potentially traumatic events (Crespo & Fernández-Lansac, 2016). Thus, a type of cognitive emotional coping that is more adaptive is when minors who have been traumatized accept what happened as something that cannot be changed. What they do in these cases is put what happened into perspective within their life trajectory, reevaluate the possible positive aspects that exist and focus attention on the planning of their current and future lives. The recovery of minors with this type of coping is much more likely to be successful (Kevers et al., 2016). In fact, there is a close relationship between post-traumatic growth and the use of adaptive cognitive emotional regulation strategies (Calhoun & Tedeschi, 2014; Matsui & Taku, 2016). However, a traumatic event is overcome more successfully if the person can flexibly use these coping strategies in response to the demands of the stressful situation. In fact, rumination, considered a priori as less adaptive than other strategies, could be decisive for post-traumatic growth to occur. Specifically, “deliberate rumination” (as opposed to intrusive rumination) involves an attempt to resignify the event or reconcile the trauma with the person’s view of the world (Calhoun & Tedeschi, 2006; García et al., 2018). Furthermore, positive cognitive emotional regulation can hardly arise in isolation. The ability to verbalize emotions and the solidarity of other people is an essential condition for any minor injured by trauma to regain confidence in themselves and in the human condition (Rojas Marcos, 2010).
Positive indicators of recovery
The reactions to a traumatic event and the medium and longterm recovery capacity of victims who have suffered an event that threatens their life or their psychological integrity are highly variable from one case to another (Medina, 2015). As has already been pointed out, many children can experience positive changes at different points throughout the recovery process (Calhoun & Tedeschi, 2014; McElheran et al., 2012). A positive indicator of the victim’s improvement is when the verbal expression of feelings is restored, and order is brought to the chaos of images and memories of the violent event suffered. The reappearance of gestural expressions of affection, such as smiles, or physical expressions, such as hugs or kisses, is a sign of recovery, as is the reacquisition of normal sleep patterns, involvement in daily leisure activities and the establishment of new goals, dreams or plans for the future. The memory of what happened is present, but it does not cause them distress or prevent them from being involved in other types of rewarding activities or relationships (Echeburúa & Amor, 2019). It is sometimes possible to transform resentment or pain into positive energy when the minor has a family, school and social support network or resorts to spirituality or contact with nature in search of psychological support and calm, which allows them to give meaning to the experience. Managing to adapt to the requirements of daily life (studies, family life, social relationships, etc.) and getting involved in rewarding projects, such as hobbies or travel, also denote a positive recovery process. In short, the evolution of recovery depends, among other aspects, on the coping and emotional regulation strategies used to overcome the trauma. Specifically, the prognosis is more positive when the victim, instead of adopting negative strategies (such as focusing on the memories of the traumatic events or feeling guilty or resentful about what happened) or using them in a rigid way, confronts the problem in a cognitively and emotionally adaptive way (Echeburúa & Amor, 2019). Some practical recommendations are summarized in Table 3.
The details of a traumatic event determine the damage caused to the victim by the first blow. But it is the significance that this person places on the event, as well as the family and social support received, which can explain the more or less devastating effects of the second blow, which is what really causes the trauma. A traumatic event overwhelms a minor only when it exceeds their threshold for trauma (Esbec, 2000; Trujillo, 2002). Young victims exhibit extremely variable reactions to traumatic events. Knowing the response of a minor in the face of previous negative events helps to predict future behavior. In this way, it is possible to find out if a minor is resistant to stress or, at the opposite extreme, if they experience emotional collapse in the face of minor setbacks (Amor & Echeburúa, 2015). The scope of psychological damage is mediated by the seriousness of the event, the figure of the aggressor, the damage or degree of risk suffered, the vulnerability of the victim, the possible influence of other concurrent problems (at the family and school level, for example) or past problems (history of poly-victimization or re-victimization), the existing social support and the available psychological coping resources. These factors influence the victim’s resistance to stress. In turn, all the risk and protective factors interact in variable ways in each case and result in the individual differences that are observed among the victims of the same traumatic event (Medina, 2015; Pereda et al., 2015). In general, the younger the person affected by a traumatic event is, the more severe their symptoms will be because they have less perception of control over their life. Children are very vulnerable to the destruction of their self-esteem, which runs parallel to the humiliation felt. However, future psychopathological outcomes in adult life are less frequent than might be expected and, in any case, much more difficult to predict (Echeburúa & Farmyard, 2009). In fact, around a third of minors who have been victims of a traumatic event are resilient and successfully overcome the victimization experience without developing psychopathological symptoms. In short, the experience of a violent event during early life can sensitize a person and make them more vulnerable to subsequent negative events or, on the contrary, help them develop mature emotional and cognitive coping styles to face the setbacks that life may bring them in the future. In these cases, resilience involves a natural and unique symbiosis of flexibility, resistance, adaptation, and recovery that improves the individual (Echeburúa, 2021; Rutter, 2007). Another possible trajectory derived from coping with the traumatic event that goes beyond resilience is post-traumatic growth (Calhoun & Tedeschi, 2006; 2014). There are minors who, after an adverse experience that results in post-traumatic symptoms, go through a positive process of transformation (Calhoun & Tedeschi, 2014; Yuan et al., 2021). This process usually affects one’s strength and self-confidence, interpersonal relationships, the development of new interests, a positive reassessment of past life experiences, and can even produce changes in their hierarchy of values and philosophy of life (Cyrulnik, 2015). Although resilience and post-traumatic growth are both salutogenic constructs, they are conceptually different (Vloet et al., 2017) and may even be inversely related (Levine et al., 2009), expanding the debate on the true nature of the concept of post-traumatic growth. This approach requires future research. Trauma does not heal on its own. The ability to resume living life without getting bogged down in trauma requires the assistance of a facilitating environment, of a close person who provides support and affection to the minor. The transitory expressions of sadness or stress associated with a traumatic event can be adaptive and have a therapeutic impact, since, in addition to being a form of outlet and relief, they provoke encouraging responses of support, empathy and solidarity in other people (Zhou et al., 2018). In summary, some young victims of violent events, like sexual assaults or terrorist attacks, are marked for life and blinded by resentment, bitterness or simply discouragement, destined to lead a dull life without hope. Others, after an intense psychological reaction, are able to cope with the pain, to partially readapt to the situation and attend to their immediate needs. Finally, there are others who draw strength from the weakness of pain, focus on the positive aspects of reality and do not limit themselves to surviving, but manage to live more fully, embarking on exciting future projects (Bonanno & Mancini, 2012; Masten & Narayan, 2012; Zhen & Zhou, 2022). There are some lines of research that hold promise for the near future, such as investigations into the influence of age, the sex of the minors and the time elapsed since the adverse event on resilience and post-traumatic growth. Likewise, it is convenient to analyze the different trajectories that are followed in the face of different traumatic events, the impact of revictimization and polyvictimization on the recovery capacity of minors and the precise determination of the type of attachment in the coping and emotional regulation strategies developed.
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