Children’s Posttraumatic Growth in the Aftermath of the Covid-19 Pandemic in Austria: A Mixed Methods Study

On 5 May 2023, the WHO Director-General announced the position of the Emergency Committee members to transition to long-term management of the COVID-19 pandemic in view of the declining trend in COVID-19 deaths, the decrease in COVID-19 related hospitalisations and intensive care unit admissions, and the high levels of population immunity to SARS-CoV-2 (WHO, 2023). Nevertheless, the COVID-19 pandemic was a public health crisis that caused adverse psychological effects (e.g., anxiety, depressive and posttraumatic symptoms) particularly in children and adolescents as shown by numerous meta-analyses (e.g. Ma et al., 2021; Panda et al., 2021; Racine et al., 2021). Possible positive changes in terms of posttraumatic growth (PTG) (Calhoun & Tedeschi, 2006), which may occur after adverse events have been less prominent in psychological research. Therefore, the present study examined PTG in children from North Tyrol (Austria) and South Tyrol (Northern Italy) during the final phase of the COVID-19 pandemic.

Exposure to highly stressful or traumatic events can lead to the development of posttraumatic stress disorder (PTSD) in both children and adults. An epidemiological study providing estimates using the DSM-5 classification in a contemporary European cohort showed that 31.1% of children and adolescents experienced trauma, and 7.8% developed PTSD by the age of 18 years (Lewis et al., 2019). In addition to the negative consequences of traumatic events, studies have also reported positive outcomes, with 50.0% of children reporting an average response of some perceived change after Hurricane Katrina (Kilmer et al., 2009), and 39.79% of those experiencing posttraumatic stress (PTS) in the aftermath of COVID-19 reporting PTG (Bhushan et al., 2022). Both PTSD and PTG share event centrality—the extent to which the memory of the adversity becomes central to one’s identity (Groleau et al., 2013). The starting point for PTG is a “seismic event” that shatters a set of basic assumptions about oneself, others, and the world (Janoff-Bulman, 1992). This event serves as a major psychological challenge to an individual and consequently sets in motion ruminative processes that lead to an intra-individual positive transformation (Calhoun & Tedeschi, 2006). Tedeschi and Calhoun (1996) identified five areas of personal growth and developed the Posttraumatic Growth Inventory (PTGI) an instrument for measuring PTG: (1) ‘Relating to others’ denotes a heightened sense of interconnectedness with others, (2) ‘Personal strength’ signifies positive perceptions regarding one’s own strength and resilience, (3) ‘Appreciation of life’ signifies a shift in life priorities, (4) ‘New possibilities’ encompasses the identification of novel life pathways, and (5) ‘Spiritual change’ encompasses alterations in spiritual beliefs or practices, which may result in a more profound sense of spirituality. In 2017, the domain of spiritual change was expanded to cover spiritual-existential experiences across diverse cultural contexts. The corresponding questionnaire for adults is known as the PTGI-X (Tedeschi et al., 2017).

Further research has also demonstrated that individuals can undergo both positive and negative changes in the aftermath of a traumatic event (e.g. Taku et al., 2021). For instance, in a study conducted in Sierra Leone, participants who experienced the civil war reported on the one hand how cruel and vile people could be, on the other hand how caring and wonderful they were (Exenberger et al., 2022). In recent decades, there has been a significant body of research examining the relationship between psychological distress following an adverse event, often measured as PTSD, and possible positive outcomes, such as PTG. For instance, a meta-analysis (Liu, et al., 2017) indicated that there is a positive correlation between PTG and PTSD symptoms (especially hyperarousal) with a reported effect size of r = 0.22. The relation between posttraumatic symptoms and PTG has also been confirmed in children (Shakespeare-Finch & Lurie-Beck, 2014). In their meta-analysis on PTG and PTSD, Shakespeare-Finch and Lurie-Beck (2014) showed a linear relationship and a curvilinear relationship between the factors. Levine et al.’s (2008) research found that in a population of young people the highest level of growth was achieved by those adolescents who experienced moderate levels of PTSD. In order to provide a more comprehensive understanding of the phenomenon of positive and negative posttraumatic change, an equal number of additional items (25) were added to the original PTGI-X (Tedeschi et al., 2017) in order to simultaneously capture posttraumatic depreciation (PTD), or perceived negative changes within the same five domains. PTG and PTD are two independent, co-existent constructs of change that can occur in parallel after trauma reflecting the paradoxical nature of trauma and its impact on positive/negative disclosure (Taku et al., 2021).

Similar to adults, PTG in children is analysed with the Revised Posttraumatic Growth Inventory for Children (PTGI-C-R, Kilmer et al., 2009), which consists of ten items reflecting the five factors of PTG. In general, several quantitative studies have highlighted the unique features of PTG in specific cultures. However, the factor structures of the PTGI-C-R deviated from the original PTGI-C-R. Andrades et al. (2016), and Exenberger et al. (2018) identified two domains in Chile (earthquake and tsunami) and India (2004 Tsunami) respectively. Other researchers have found that PTG is measured best as a unitary construct (China/Sichuan Earthquake: Lau et al., 2015), and Farahani et al. (2021) found no desirable psychometric properties for the PTGI-C-R in Iranian children with cancer. A recurrent theme in discourse pertains to the question of whether children possess the cognitive capacity to experience growth in terms of simultaneously recognising both losses and gains (Kilmer & Gil-Rivas, 2010). Despite this, systematic reviews (Ferris & O’Brien, 2022; Meyerson et al., 2011) demonstrate that children’s responses to trauma are closely related to their cognitive, behavioural, and emotional development. Children have been shown to experience growth following different traumatic events. As children mature, they acquire the capacity to regulate their emotions, retrieve information from memory and express themselves verbally—all of which are prerequisites for experiencing personal growth (Salmon & Bryant, 2002). Ferries and O´Brien (2022) explored factors related to the development of PTG in children and adolescents exposed to different types of trauma experiences (e.g., medical trauma, war- and terror-related trauma and environmental trauma) in five different countries (US, Israel, China, Japan and Norway). The presence of posttraumatic stress symptoms, particularly intrusiveness, and cognitive factors, such as positive reappraisal and deliberate rumination, were found to be associated with PTG. However, inconsistent findings across studies have been reported regarding the impact of age, gender/sex, social support, and parental factors (Ferries & O´Brien, 2022). The COVID-19 pandemic has been described as a “seismic psychological event” (Janoff-Bulman, 1992) by numerous scholars. For example, a study conducted with children in North- and South-Tyrol identified a high-risk group who reported symptoms of clinically significant trauma symptoms and COVID-19-related fears (Kohlböck et al., 2023). However, several studies demonstrate that the COVID-19 pandemic may not only cause significant distress in young people, but may also promote PTG (e.g., Ulset & von Soest, 2022) or stress related growth (SRG) (Vaughn et al., 2009). The construct of SRG is defined as “experience of deriving benefits from encountering stressful circumstances” (Vaughn et al., 2009, p. 131), and is measured by an abbreviated Stress-Related Growth Scale. This scale comprises the following factors (a) cognitive/affective growth, (b) religious growth, and (c) social growth (Vaughn et al., 2009). Individuals who experience SRG have been shown to possess a heightened sense of meaning, an augmented mastery of coping mechanisms, a broadened perspective, and the development of novel personal resources (Park, 2013; Park & Fenster, 2004). The aspects of the COVID-19 pandemic and the perceptions of growth can also be contemplated within the framework of meaning-making and its impact on the adjustment to stressful life events over time. The meaning-making model (Park, 2010), posits that the process of finding meaning in a stressful event is a form of cognitive adjustment, whereby individuals adjust their appraised meanings, goals, plans and desires to align with their global beliefs and goals (Joseph & Linley, 2005). Such positive changes have been evidenced by qualitative studies on a global scale (Bhushan et al., 2022; Kazemi et al., 2023; Yu et al., 2021; Zhen & Zhou, 2022; Zhen et al., 2022) and quantitative studies (Feraco et al., 2022; Kohlböck et al., 2023; Waters et al., 2021). Wenter et al. (2022) utilised a mixed-methods parents’ perspective study design (N = 2691) and identified five themes of positive change in their children aged 3 to 13 years in open-ended survey questions. These themes corresponded to Tedeschi and Calhoun’s (1996) PTG factors. In this study PTG was associated with better mental health outcomes, i.e. less internalising problems, aggressive behaviour, posttraumatic stress symptoms and better health-related quality of life. Ulset and von Soest (2022) showed that there is a complex interplay between predictors of PTG and the ongoing COVID-19 pandemic by revealing that good mental health was associated with higher levels of PTG only in groups who are typically at higher risk of negative outcomes. In terms of prevalence, Ulset and von Soest (2022) found that 9.6% of Norwegian junior and senior high school students reported moderate to high PTG, while Feraco et al. (2022) found that 68% of Italian students (11–18 years old) experienced at least moderate PTG, and Wenter et al. (2022) found that Austrian and Italian parents reported signs of PTG in almost all children (3–13 years old) in March 2020 and in three quarters of children in December 2021. A Polish study by Senejko et al. (2022) reported in their survey conducted in April 2020 that three of the four dimensions of PTG, (changes in relationships, greater appreciation of everyday life and spiritual change) were observed under pandemic conditions, while changes in self-perception were not. Furthermore, research by Ulset and von Soest (2022) and Senejko et al. (2022) has indicated that females appear to undergo more PTG than males during the threat of the COVID-19 pandemic. A number of variables have been identified as contributing to PTG in children and adolescents during the pandemic. These include adaptability prior to the COVID-19 pandemic (Feraco et al., 2022), life satisfaction, parental care, concerns regarding the pandemic and immigrant status (Ulset & von Soest, 2022). Furthermore, extroversion and stress levels (Senejko et al., 2022) as well as “pandemic” threats (threats to life, family and lifestyle), were associated with higher PTG during COVID-19 lockdown. Ulset and von Seost (2022) also indicated that there appears to be a complex association between mental health variables, social relationships with peers, gender differences, age, socioeconomic status and PTG in adolescents.

In summary, the findings from quantitative studies conducted to date demonstrate that children undergo personal growth, as measured by the PTGI-C-R, following a stressful or traumatic event. Despite the fact that the factor structure of the PTGI-C-R varies in certain countries, the PTG phenomenon is evident in young people.

To achieve a more nuanced understanding of the PTG phenomenon in children in the context of the post-pandemic era, this study employs a convergent parallel mixed methods design as outlined by Creswell and Plano Clark (2011). First, the quantitative data was utilised to ascertain the factor structure of the German version of the PTGI-C-R. Second, an examination was conducted to determine the prevalence of PTG and the association among the growth scores, posttraumatic stress scores, and age, while also exploring gender differences in experienced growth. We assumed that (1) children experience growth up to an average degree, (2) PTG and posttraumatic stress symptoms are positively correlated, (3) older children experience more PTG, and (4) that there is no association between PTG and gender. The qualitative data provided emergent themes to validate the quantitative survey findings, and explored the experience or non-experience of PTG in depth as well as possible PTD experiences. Utilising this mixed-methods approach, we wanted to merge quantitative and qualitative data to delineate PTG in Austrian and North Italian children.

The present study aimed to analyse PTG as well as PTD in North and South Tyrolean children during the final phases of the COVID- 19 pandemic. The quantitative findings revealed that the factor structure of the German PTGI-C-R deviates from the original factor structure according to Kilmer et al. (2009). The qualitative findings showed that four themes of PTG (personal development, new possibilities, appreciation, and relationships) corresponded to the original PTG dimensions according to Tedeschi and Calhoun (1996), whereas the children did not mention any spiritual change. However, a new theme “adjustment to new circumstances” emerged. In the following, the findings will be discussed in turn.

This mixed methods study explored experiences of positive changes following the COVID-19 crisis from the perspective of children. The results of the quantitative strand of the study demonstrated that children experienced positive changes in the aftermath of the crisis, albeit to a minor extent. Nevertheless, the crisis has clearly engendered positive changes in several respects, and the qualitative data allow a more detailed insight into the children's growth experiences.

The findings demonstrate a close correlation between PTG, resilience, and the tenets of positive psychology. Children draw on clearly defined sources and factors of resilience, such as the regulation of emotions, empathy, or support from others (e.g., Grotberg, 2001; Masten & Motti-Stefanidi, 2020). These resilience factors appear to be consolidated through their utilisation, suggesting that post-pandemic it is possible to speak of personal development and change. Furthermore, the child’s behaviour is characterised by his/her openness and curiosity with regard to changes in everyday life in general, and specifically due to the containment measures. The children do not only mourn the past during the pandemic, but also perceive new possibilities and opportunities for themselves. At this point the relation between personality traits such as openness to new experiences, curiosity and optimism becomes clear (Tedeschi & Calhoun, 1996). This adaptability is further evidenced by the children's ability to swiftly adjust to new rules and conventions, a novel growth facet identified in the present sample. The children perceived the coronavirus containment measures (especially the lockdowns) as a slowdown and reduction in their everyday activities. On the one hand they suffered from these restrictions interfering with their daily routines, on the other hand, they resorted to behaviours such as gratitude, humour, and autotelic experiences (flow experiences, Tse et al., 2021) which, according to representatives of positive psychology (e.g., Seligman, 2018), promote well-being.

In conclusion, the findings of the present study demonstrate that the children surveyed exhibited a holistic perception of the crisis with its negative and possible positive aspects. A more comprehensive understanding of the children’s strengths and possible benefits gained from their stressful experiences, beyond the assessment of the negative sequelae of trauma, facilitates the development of well-targeted plans for supporting the individual child. In other words, caregivers or professionals can acquire a holistic and balanced view of the child, facilitating the development of positive factors and fostering PTG (Tedeschi & Kilmer, 2005). The notion of encouraging a holistic perspective on traumatic experiences, which entails the recognition of positive aspects within a negative context, has been shown to facilitate a shift in thinking towards an Eastern mindset, characterised by cyclical reasoning (Ji et al., 2001). It is noteworthy that the children in this study did not face life-threatening circumstances, in contrast to the Indian children in Bhushan et al.'s (2022) study, who were confronted with situations that could be considered life-threatening. Nevertheless, it can be hypothesised that the promotion of resilience and well-being during both crisis and during non-crisis times may contribute to PTG.