Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 4, 391–397

© 2015 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/tra0000031

Core Belief Challenge and Rumination as Predictors of PTSD and PTG Among Adolescent Survivors of the Wenchuan Earthquake Xiao Zhou and Xinchun Wu

Fang Fu

Beijing Normal University

Fudan University

Yuanyuan An This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Nanjing Normal University Middle school students in Wenchuan County (N ⫽ 354) were assessed 4.5 years after the Wenchuan earthquake to examine the effects of challenges to core beliefs, intrusive rumination, and deliberate rumination on posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG). The results indicated that intrusive rumination partly mediated the relationship between challenges to core beliefs and PTSD, whereas deliberate rumination partly mediated both the relationship between challenges to core beliefs and PTG, as well as the relationship between intrusive rumination and PTG. These findings suggest that challenges to core beliefs had a direct positive impact on both PTSD and PTG. Moreover, such challenges predicted PTSD through intrusive rumination and predicted PTG through deliberate rumination. Furthermore, intrusive rumination might cue individuals to engage in a more purposive deliberate rumination process. These results indicate that PTSD and PTG are influenced by different mechanisms and that PTSD and PTG represent 2 separate dimensions of experience following adversity. Keywords: core belief challenge, posttraumatic stress disorder, posttraumatic growth, intrusive rumination, deliberate rumination

PTG and PTSD occur in response to an initial traumatic event or a stressor that presents a challenge. This challenge can shatter core beliefs that comprise a person’s assumptive world (Janoff-Bulman, 1992; Linley & Joseph, 2004; Tedeschi & Calhoun, 2004). The assumptive world is a “general set of beliefs and assumptions about the world, that guide actions and help understand the causes and reasons for what happens” (Lindstrom, Cann, Calhoun, & Tedeschi, 2013; Tedeschi & Calhoun, 2004). After a trauma, an individual’s core beliefs are challenged and become unstable, uncontrollable, and unpredictable (Janoff-Bulman, 1992; Magwaza, 1999), and then considerable distress may emerge. However, such challenges can also force an individual to reexamine personal assumptions. During this process, there is an opportunity for considering the positive implications of a traumatic experience, which could result in PTG (Cann et al., 2010). Previous studies have indicated that challenges to core beliefs could lead to both PTSD and PTG (Connerty & Knott, 2013; Lilly & Pierce, 2013). However, the specific mechanism involved in this process has not been examined. According to the “shattered world” assumption (Janoff-Bulman, 2006), individuals need to engage in repeated thoughts about what happened between the initial challenge to core beliefs and the subsequent posttraumatic responses (Janoff-Bulman, 1992). However, some components of this repetitive thought process are risk factors for distress, whereas others are crucial for growth (Janoff-Bulman, 1992; Linley & Joseph, 2004). Thus, Cann et al. (2010) proposed a distinction between two types of repetitive thinking about an event: intrusive rumination and deliberate rumination. The former represents those thoughts that invade an individual’s cognitive world without his or her

The earthquake that occurred in Wenchuan, China, in 2008 caused widespread loss of life and property. Adolescent survivors of this earthquake experienced significant psychological reactions such as posttraumatic stress disorder (PTSD; Wang et al., 2012; Ying, Wu, Lin, & Chen, 2013). Nevertheless, some positive outcomes like posttraumatic growth (PTG) have also been reported (Jin, Xu, Liu, & Liu, 2014; Ying et al., 2014). PTG refers to positive changes, such as the feeling of strength and wisdom, placing increased value on friends and family, and finding a fresh appreciation for each new day, which result from experiencing a traumatic event (Calhoun & Tedeschi, 2006; Tedeschi & Calhoun, 1995). Research indicates that PTSD and PTG coexisted in adolescents after the Wenchuan earthquake (Lin et al., 2013; Yu et al., 2010), suggestive of the possibility that PTSD and PTG share developmental mechanisms. The aim of this study was to explore possible mechanisms of the development of PTSD and PTG among adolescent survivors of the Wenchuan earthquake.

This article was published Online First March 16, 2015. Xiao Zhou and Xinchun Wu, School of Psychology, Institute of Developmental Psychology, Beijing Normal University; Fang Fu, School of Social Development and Public Policy, Fudan University; Yuanyuan An, School of Psychology, Nanjing Normal University. This research was supported by the Key Projects of Humanities and Social Sciences Key Research Base, Ministry of Education, China (Grant No. 11JJD190006). We sincerely appreciate the students and teachers who voluntarily devoted time and interest to our research. Correspondence concerning this article should be addressed to Xinchun Wu, School of Psychology, Beijing Normal University, 19 Xinjiekou Wai Street, Beijing, 100875, China. E-mail: [email protected] 391

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willingness, whereas the latter involves deliberate reexamining of and contemplation about the event. Persons engaging in intrusive rumination typically focus on negative aspects of traumatic events and fail to deal with issues of concern regarding such events, which in turn increases the frequency of PTSD symptoms (Affleck & Tennen, 1996; Cann, Calhoun, Tedeschi, & Solomon, 2010). Intrusive rumination also exposes people to traumatic cues, thereby encouraging further cognitive processing of traumatic events, which also result in PTG (Park & Fenster, 2004; Yanez, Stanton, Hoyt, Tennen, & Lechner, 2011). Therefore, we assumed that intrusive rumination would be positively related to both PTSD and PTG. Deliberate rumination is an equally important cognitive factor related to both distress and growth after trauma. Cognitive therapy and cognitive-behavior therapy studies of PTSD have emphasized that active thinking about traumatic events can change pathological thinking styles and reduce trauma-related fear and PTSD symptoms (Ehlers & Steil, 1995; Paunovic & Öst, 2001), and help trauma survivors reconstruct positive meanings in traumatic events, resulting in PTG (Cann et al., 2010; Taku, Calhoun, Cann, & Tedeschi, 2008). Thus, deliberate rumination can be conceptualized as a protective factor related to PTSD, which could also be conducive to PTG. Calhoun and Tedeschi’s (2006) model of PTG assumes that intrusive rumination provides cues that stimulate attempts to engage in more deliberate processing of experiences (Cann et al., 2011). Therefore, could there be a positive relationship between intrusive and deliberate rumination? The theoretically expected coexistence of PTSD and PTG has been verified by empirical studies (Lin et al., 2013; Tedeschi & Calhoun, 1996; Yu et al., 2010). However, it remains unclear whether these two reactions come about via similar or different cognitive mechanisms. Furthermore, though the relationship between rumination, challenges to core beliefs, and both PTSD and PTG has attracted much research, the predictive utility of such relationships has not been evaluated in adolescent survivors of natural disasters. Addressing this gap in knowledge would advance (a) contemporary efforts aimed at clarifying the relationship between PTSD and PTG (Solomon & Dekel, 2007) and (b) research on the role of cognitive factors, particularly rumination, in the developmental processes of both PTSD and PTG (Chan, Ho, Tedeschi, & Leung, 2011). Given this background, the present study examined how challenges to core beliefs, intrusive rumination, and deliberate rumination might be associated with both PTSD and PTG in adolescent survivors of the Wenchuan earthquake. The aim of the study was to examine possible roles played by different types of rumination in the relationship between challenges to core beliefs and PTSD, as well as PTG. Based on the shattered world assumption (JanoffBulman, 2006) and Calhoun and Tedeschi’s (2006) model of PTG, we proposed the following three hypotheses: Hypothesis 1: Challenges to core beliefs would positively predict both PTSD and PTG. Hypothesis 2: Intrusive and deliberate rumination would mediate the relationship between challenges to core beliefs and both PTSD and PTG.

Hypothesis 3: Deliberate rumination would mediate the relationships between intrusive rumination and both PTSD and PTG.

Method Participants and Procedures Data were collected as part of a longitudinal study of psychological adjustment among child survivors of the Wenchuan earthquake. In the present study, 354 adolescent survivors were randomly selected from several classes of the only two high schools in the county of Wenchuan (mean age 16.98 years, SD ⫽ 1.64, age range 14 –20 years). There were 189 girls (53.5%). Participants consisted of members of the Han ethnic Group 68 (19.3%), Tibetan ethnic Group 99 (28.0%), locally resident Qiang people 179 (50.7%), and other ethnic categories 7 (2.0%). The Research Ethics Committee of Beijing Normal University and the principals of the participating schools approved this study. All students in the selected classes who attended school on the date of the survey were recruited to participate, with no exclusion criteria. Compensation was not provided for participation. The purpose of the study and the voluntary nature of participation were highlighted before the survey, and written informed-consent forms were provided to participants and their parents that emphasized the right of each participant to withdraw from the survey at any time. The researchers administered the questionnaire packets in a classroom setting without the presence of teachers. Participants were initially asked to provide demographic information including their sex, age, and ethnic group. They were then asked to complete the remaining measures described below that assessed challenges to core beliefs, rumination, PTG, and PTSD. After the questionnaire packets were completed, participants were told that school psychologists or teachers were available to provide any psychological/ counseling services they might need.

Measures Core Beliefs Inventory. Challenges to core beliefs were measured using a modified version of Core Beliefs Inventory (CBI; Zhou, Wu, An, & Chen, 2014). This is a 9-item measure assessing the degree to which a traumatic/stressful event causes people to reevaluate their assumptive worlds, including their beliefs about themselves, other people, the future, and the world after the trauma. The items in the scale are rated on a 6-point scale ranging from 0 (not at all) to 5 (to a very great degree). The original CBI was developed by Cann et al. (2010) and consisted of 9 items. Compared with the original scale, the revised CBI used in this study included certain revised items to enhance comprehension by adolescent survivors of the Wenchuan earthquake. The internal reliability of the modified CBI (␣ ⫽ .84) and fit indices obtained in confirmatory factor analysis (CFA) in this study, ␹2/df ⫽ 3.66, Comparative Fit Index (CFI) ⫽ 0.93, Tucker-Lewis Index (TLI) ⫽ 0.91, root mean square error of approximation (RMSEA) ⫽ 0.084, standardized root mean residual (SRMR) ⫽ 0.047, were both high. Event Related Rumination Inventory. The modified Event Related Rumination Inventory (ERRI) was used to measure intrusive and deliberate rumination (Zhou, Wu, An, Chen, & Long, 2014). This measure assesses intrusive (10 items) and deliberate

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CORE BELIEF CHALLENGE, RUMINATION PREDICT PTSD/PTG

rumination (10 items) that occurred over the past 2 weeks. The items are rated on a 6-point scale ranging from 0 (not at all) to 5 (always). The original ERRI was developed by Cann et al. (2011) and consisted of 20 items. Certain items of the original scale were revised to form the modified ERRI. In the present study, alpha coefficients for intrusive and deliberate rumination were 0.94 and 0.88, respectively. Moreover, CFA indicated good fit indices of the modified ERRI, ␹2/df ⫽ 2.36, CFI ⫽ 0.92, TLI ⫽ 0.91, RMSEA ⫽ 0.060, SRMR ⫽ 0.049. Posttraumatic Growth Inventory. Posttraumatic growth was measured using a modified version of the Posttraumatic Growth Inventory (PTGI; Zhou, Wu, An, Chen, & Long, 2014). The original PTGI was developed by Tedeschi and Calhoun (1996) and consists of the following five subscales: personal strength, new possibilities, relating to others, appreciation of life, and spiritual change. Each of the 21 items is scored on a 6-point scale ranging from 0 (no change) to 5 (very high degree of change). The PTGI has good internal consistency, as well as construct, convergent, and discriminate validity (Tedeschi & Calhoun, 1996). The revised PTGI includes three subscales with 22 items in total: perceived changes in self, a changed sense of relationship with others, and a changed philosophy of life. The modified scale used in this study had good reliability and construct validity for the sample of adolescent survivors of the Wenchuan earthquake. Moreover, the internal reliability of the modified inventory was good (␣ ⫽ .92), and the fit indices derived from CFA were acceptable, ␹2/df ⫽ 2.82, CFI ⫽ 0.90, TLI ⫽ 0.88, RMSEA ⫽ 0.072, SRMR ⫽ 0.051. The Child PTSD Symptom Scale. PTSD symptoms were assessed using the Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, & Treadwell, 2001) standardized for the Chinese population (Ying et al., 2014). This measure is a 17-item selfreport scale designed to assess the occurrence and frequency of PTSD symptoms according to the Diagnostic and Statistical Manual of Mental Disorders, in relation to the most distressing event experienced by an individual. In the present study, all of the items were translated into Chinese, with respondents rating the frequency of symptoms during the previous 2 weeks on 4-pointLikert scale ranging between 0 (not at all/only once) to 3 (almost always or 5 or more times a week). Subscale scores range from 0 –15 for intrusion symptoms, 0 –21 for avoidance symptoms, and 0 –15 for hyper-arousal symptoms. In the scale, summing the scores for the three symptom types generates the overall severity score. In this sample, the scale demonstrated good internal consistency (␣ ⫽ .90), and the fit indices for CFA were good, ␹2/df ⫽ 2.48, CFI ⫽ 0.91, TLI ⫽ 0.89, RMSEA ⫽ 0.065, SRMR ⫽ 0.057.

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were estimated freely. CFA revealed a good fit, ␹2(314) ⫽ 649.410, CFI ⫽ 0.910, TLI ⫽ 0.900, RMSEA [90% CI] ⫽ 0.055 [0.049, 0.061], SRMR ⫽ 0.059. There was a significant fit difference between the two models, ⌬␹2(1) ⫽ 214.948, p ⬍ 0.001. These results indicated that the second model was acceptable and further indicated that PTSD and intrusive rumination are indeed two separate constructs. Descriptive analyses were conducted for all measures that were administered. Moreover, Pearson’s correlations were calculated to examine the associations among the major variables. Statistical analyses were conducted using Mplus 6.0 software (Muthén & Muthén, 2010). Missing data were handled by using full information maximum likelihood estimates (FIML) in structural models, because compared with conventional methods of dealing with missing data, such as listwise deletion, and pairwise deletion, the results of FIML are less biased and more reliable (Muthén, Kaplan, & Hollis, 1987). Thus, the present structural equation model (SEM) analysis was based on the total sample of 354 individuals. In addition, in order to evaluate the model fit, we used chi-square values; the CFI, TLI, the RMSEA, and the SRMR. A nonsignificant chi-square indicates good model-data fit. The general cutoffs for accepting a model are equal to or greater than 0.90 for CFI and TLI, and equal to or less than 0.08 for the RMSEA and SRMR (Wen, Hau, & Marsh, 2004). We built SEMs to examine the effects of challenges to core beliefs, intrusive rumination, and deliberate rumination on PTSD and PTG. SEM models have two basic elements: A measurement component (measurement model) and a structural component (structural model). Although both measurement and structural components can be evaluated simultaneously in SEM, Anderson and Gerbing (1988) strongly recommended that measurement model fit be evaluated first before proceeding to the evaluation of the full model (measurement and structural models together). There is little reason for proceeding to evaluate relationships among constructs (the structural model) if the measurement model is inadequate (Hays, Marshall, Wang, & Sherbourne, 1994). Thus, we first assessed the measurement model (see Figure 1), and then assessed the structural model. Next, according to mediating effects test procedures (Wen, Chang, Hau, & Liu, 2004), we applied an SEM approach to assess the following two SEM models: (1) a direct effect model (M1, see Figure 2) with structural paths from challenges to core beliefs to

Intrusive symptoms 0.67***

Data Analysis Before examining relationships among the major variables, CFA was conducted to explore whether PTSD and rumination indeed represented separate constructs, despite certain conceptual overlap between intrusive rumination and the intrusive symptom cluster of PTSD. First, we developed a model consisting of one latent variable that included all items assessing PTSD and intrusive rumination. This model indicated a poor fit, ␹2(315) ⫽ 864.358, CFI ⫽ 0.853, TLI ⫽ 0.836, RMSEA [90% CI] ⫽ 0.070 [0.065, 0.076], SRMR ⫽ 0.068. Therefore, we developed another model that included two latent variables: PTSD and intrusive rumination. Factor loadings of the items on their respective latent variables

PTSD

0.86*** 0.84***

Avoidance symptoms

Hyperarousal symptoms

0.15** Perceived changes in self 0.92***

PTG

0.86***

Changed sense of relationships

0.80***

Changed philosophy of life

Figure 1. Measurement model.

ZHOU, WU, FU, AND AN

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PTSD 0.38***

Core Beliefs Challenge

0.00

Table 1 Means, Standard Deviations, and Correlations Among Core Belief Challenge, Intrusive Rumination, Deliberate Rumination, PTSD, and PTG

0.63***

1

PTG

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Figure 2.

Direct effect model (M1).

PTSD and PTG, such that PTSD and PTG were assumed to be related, based on the observation that they coexisted in trauma survivors (Tedeschi & Calhoun, 1996), and (2) based on M1 and the model of PTG proposed by Calhoun and Tedeschi (2006), we inserted mediators (e.g., intrusive and deliberate rumination) between challenges to core beliefs and PTSD/PTG and added one path from intrusive rumination to deliberate rumination, to establish a multiple indirect effects model (M2, see Figure 3). Moreover, to test for the significance of this indirect effect on M2, we conducted bias-corrected bootstrap tests with a 95% confidence interval (MacKinnon, Lockwood, & Williams, 2004).

Results Descriptive Statistics and Correlations Among Measures For illustrative purposes, we report the prevalence rate for PTSD in the present sample. Participants with CPSS scores above 11 were identified as having PTSD. According to this criterion, the prevalence rate of PTSD in this study was 58.8%. The descriptive statistic and correlations for all the measures are presented in Table 1. Correlations among these measures were positive and significant, ranging from 0.10 – 0.56.

SEM Analyses Phase 1: Results of the measurement modeling. We built a measurement model that included two latent variables: PTSD and PTG. The PTSD latent variable was evaluated using scores for the CPSS intrusion, avoidance, and hyperarousal subscales (Foa et al., 2001), whereas the PTG latent variable was evaluated using perceived changes in self, a changed sense of relationship with others, and a changed philosophy of life (Zhou, Wu, An, & Chen, 2014; Zhou, Wu, An, Chen, & Long, 2014). In this measurement model (see Figure 1), correlations were specified between PTSD and

Intrusive Rumination 0.72***

0.24***

PTSD 0.23***

Core Beliefs Challenge

-0.09 0.37** 0.51***

0.41***

Deliberate Rumination

0.07

0.02

PTG 0.18**

Figure 3. Multiple indirect effects model (M2).

1. 2. 3. 4. 5.

Core belief challenge Intrusive rumination Deliberate rumination PTSD PTG

1 0.23ⴱⴱⴱ 0.50ⴱⴱⴱ 0.33ⴱⴱⴱ 0.56ⴱⴱⴱ

2

3

4

1 0.47ⴱⴱⴱ 1 0.65ⴱⴱⴱ 0.37ⴱⴱⴱ 1 0.10† 0.38ⴱⴱⴱ 0.15ⴱⴱ

M ⫾ SD 19.34 ⫾ 9.27 5.71 ⫾ 4.61 9.19 ⫾ 5.46 13.13 ⫾ 7.73 59.13 ⫾ 19.51

Note. PTSD ⫽ posttraumatic stress disorder; PTG ⫽ posttraumatic growth. † p ⫽ .068. ⴱⴱⴱ p ⬍ .001.

PTG. Factor loadings of the manifest indicators on their respective latent variables were estimated freely. Results indicated that the measurement model fit the data well, ␹2(8) ⫽ 23.22, CFI ⫽ 0.986, TLI ⫽ 0.973, RMSEA [90% CI] ⫽ 0.073 [0.040, 0.109], SRMR ⫽ 0.042. These results also indicated that the measurement model was sound and that it was appropriate to conduct further analysis of the SEM. Phase 2: Structural model results. In this phase, we formulated two structural models by using the measurement model described above. First, we built a direct effects model (M1; see Figure 2), which demonstrated that challenges to core belief had direct effects on PTSD and PTG. The model fit the data well, ␹2(9) ⫽ 18.97, CFI ⫽ 0.992, TLI ⫽ 0.981, RMSEA [90% CI] ⫽ 0.056 [0.019, 0.091], SRMR ⫽ 0.029. Path analysis revealed that challenges to core belief had significant direct effects on both PTSD and PTG, with no significant relationship between PTSD and PTG. Second, based on the direct effects model, we added intrusive and deliberate rumination to the relationship between challenges to core belief and PTSD and PTG. Moreover, based on Calhoun and Tedeschi’s (2006) model of PTG and the present correlation data, we added a path from intrusive rumination to deliberate rumination and established a multiple indirect effects model (M2, see Figure 3). This model showed a good fit, ␹2(17) ⫽ 36.07, CFI ⫽ 0.989, TLI ⫽ 0.976, RMSEA [90% CI] ⫽ 0.056 [0.030, 0.082], SRMR ⫽ 0.029. These results indicated that M2 was an acceptable model. To evaluate the significance levels of indirect effects in M2, we conducted bias-corrected bootstrap tests with a 95% confidence interval (MacKinnon et al., 2004). Table 2 shows the biascorrected bootstrap test results, indicating that challenges to core beliefs had an effect on PTSD through intrusive rumination, but not on PTG, which indicated that intrusive rumination partly mediated the relationship between challenges to core beliefs and PTSD, but not the relationship between challenges to core belief and PTG. On the other hand, challenges to core beliefs affected PTG through deliberate rumination, but not PTSD, which indicated that deliberate rumination partly mediated the relationship between challenges to core beliefs and PTG, but played no such role in the relationship between challenges to core beliefs and PTSD. In addition, there were multiple mediating effects by which challenges to core beliefs affected PTG through deliberate rumination following intrusive rumination. More importantly, the present study found that there was no relationship between PTSD and PTG.

CORE BELIEF CHALLENGE, RUMINATION PREDICT PTSD/PTG

Table 2 Bias-Corrected Bootstrap Text on Mediating Effects 90% CI

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Paths Direct paths CBI-PTSD CBI-PTG Indirect paths CBI-IR-PTSD CBI-IR-PTG CBI-DR-PTSD CBI-DR-PTG CBI-IR-DR-PTSD CBI-IR-DR-PTG

␤ 0.23ⴱⴱ 0.51ⴱⴱⴱ 0.17ⴱⴱⴱ ⫺0.02 0.007 0.08ⴱ 0.001 0.02ⴱ

Low

High

0.11 0.43

0.36 0.59

0.10 ⫺0.04 ⫺0.05 0.03 ⫺0.008 0.003

0.24 0.05 0.01 0.13 0.01 0.029

Note. CI ⫽ confidence interval; CBI ⫽ core beliefs challenge; PTSD ⫽ posttraumatic stress disorder; PTG ⫽ posttraumatic growth; IR ⫽ intrusive rumination; DR ⫽ deliberate rumination. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

Discussion In this study, we constructed a multiple indirect effects model to examine the relationships among challenges to core beliefs, rumination, PTSD, and PTG in a sample of adolescent survivors of the Wenchuan earthquake. The direct positive effects of challenges to adolescents’ core beliefs on both PTSD and PTG suggested that such challenges were associated with significant distress as well as growth. The results supported Janoff-Bulman’s (2006) shattered world assumption. A response to core beliefs being challenged by trauma might reasonably entail cyclical struggles to process the experience. Struggles such as reexperiencing, arousal, and avoidance/numbing can aggravate PTSD symptoms (Creamer, Burgess, & Pattison, 1992; Horowitz, 1997); however, other attempts to reorder and redefine life goals and priorities may lead to increased satisfaction with life and relationships, and enhance individual strength and spirituality, and as a result lead to PTG (Calhoun & Tedeschi, 2001; Tedeschi & Calhoun, 1995). Consistent with the shattered world assumption (Janoff-Bulman, 2006) and previous studies (Birrer & Michael, 2011; Ehring, Frank, & Ehlers, 2008), this study also found that challenges to adolescents’ core beliefs positively affected PTSD through intrusive rumination. Challenges to core beliefs could have forced adolescents to think repeatedly about the traumatic event and its effects in a catastrophic way (Paunovic & Öst, 2001). People may then perceive threats, accompanied by other negative emotions and symptoms of reexperiencing. Such a process is likely to motivate people to engage in dysfunctional behaviors, such as avoidance, that maintains, or increases the disorder (Mayou, Ehlers, & Bryant, 2002). The present study not only supported but also extended the shattered world assumption (Janoff-Bulman, 2006) by indicating that adolescents’ intrusive rumination activated by challenges to core beliefs had an indirect positive effect on PTG only through deliberate rumination. As internal cues elicited by intrusive rumination might also provide material for deliberate rumination (Cann et al., 2011; Nightingale, Sher, & Hansen, 2010), people have an opportunity to entertain thoughts concerning positive implications of traumatic experiences (Affleck & Tennen, 1996; Cann et al., 2010; Taku et al., 2008). Overall, the findings of this study

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suggested that the effect of adolescent survivors’ intrusive rumination had not only a direct negative effect, but also an indirect positive effect on trauma survivors’ posttraumatic reactions. Consistent with previous studies (Affleck & Tennen, 1996; Cann et al., 2010; Taku et al., 2008) and Calhoun and Tedeschi’s (2006) model of PTG, one of the findings of this study supported the idea that adolescents’ deliberate rumination activated by challenges to core beliefs has a positive effect on their PTG. However, the other finding of the present study was different from previous studies (Ehlers & Steil, 1995; Paunovic & Öst, 2001) in that it indicated a nonsignificant association between adolescents’ deliberate rumination and PTSD. The deliberate rumination of traumatized adolescents might represent their continuing struggle and the process of understanding the trauma that they have experienced (Taku et al., 2008). During this process, adolescents might not be cognitively overwhelmed by trauma-related cues and may not be symptomatic of PTSD. Challenges to core beliefs can lead to both PTSD and PTG, with intrusive rumination playing a role in the former and deliberate rumination playing a role in the latter. These findings support the suggestion by Chan et al. (2011) that the pathways to PTSD and PTG are different. Corroborating this suggestion, the current study demonstrated that there were certain predictive factors that have an initial effect on both PTSD and PTG, but that these two outcomes later diverge, progressing to manifest via different developmental processes. These results indicate that PTSD and PTG are separate, independent dimensions of experiences that follow adversity (Linley & Joseph, 2004). Although most of the theoretically derived predictions of this study were supported by the results, several major design and measurement limitations of this study must be acknowledged. One limitation is the cross-sectional design of this study that does not allow us to infer causality or a temporal sequence. A second limitation is that the study was conducted with a sample of adolescent survivors after the Wenchuan earthquake in China, and therefore generalizations to people with other traumatic experiences must be made with caution. Even with these limitations to our knowledge, however, this study is among the first to examine cognitive differences in processing between PTSD and PTG. Furthermore, the study contributes new knowledge to previous theoretical and empirical research on the relationship between PTSD and PTG by suggesting that PTSD and PTG can independently coexist in traumatized adolescents. From the perspectives of intervention and health-enhancement, this study has important implications for adolescent survivors of the Wenchuan earthquake. Substantial growth can still occur even in the face of distressing symptoms, and treating the latter should not impede the former. This study suggests that clinical efforts should focus on the enhancement of deliberate rumination, even as intrusive rumination is reduced.

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Received March 28, 2014 Revision received January 5, 2015 Accepted January 15, 2015 䡲