Introduction
Because of the relationship between stressful experiences and health and mental health outcomes, multiple disciplines (eg, medicine, mental health, and public health) incorporate coping as a critical construct related to theory, assessment, and intervention when planning for, and responding to, the adverse circumstances associated with mass trauma. Evidence-based practice requires rigorous research that relies on clear conceptualization and measurement of key constructs of interest. Unfortunately, the conceptualization and measurement of coping in children and adolescents has been challenging both in general and within specific contexts. The current report selected coping instruments that have been utilized by researchers and clinicians in the context of disasters, terrorism, war, or other mass-casualty events or situations to form the basis of a review of studies assessing coping in children and adolescents affected by mass trauma. This review addresses coping in relation to child characteristics, event exposure, and clinical implications. Given the need to establish and improve the measurement of children’s coping in the context of mass trauma, recommendations are offered for the further development of instrumentation that reflects the complexity of coping within these contexts. Clinical implications regarding the current literature base using these measures are also considered.
Search Methodology and Results
A systematic search for publications assessing coping in children in the context of disasters, terrorism, war, and mass trauma was conducted in the fall of 2014. The review included studies published in refereed journals with an identifiable measure of coping that addressed children and/or adolescents affected by mass trauma. Search terms were chosen with the intent of identifying publications related to: (1) coping with collective trauma, disasters, mass trauma, terrorism, terrorist events, and/or war in children and/or adolescents; and (2) coping assessments, instruments, measures, scales, and/or tools used with children and/or adolescents. The following databases were searched: EBM Reviews (Ovid Technologies; New York, New York USA); EMBASE (Elsevier; Amsterdam, Netherlands); ERIC (EBSCO Information Services; Ipswich, Massachusetts USA); Medline (Medline Industries, Inc; Mundelein, Illinois USA); Ovid (Ovid Technologies; New York, New York USA); PILOTS (National Center for PTSD, US Department of Veteran Affairs; Washington, DC USA); PsycINFO (American Psychological Association; Washington DC, USA); and Social Work Abstracts (EBSCO Information Services; Ipswich, Massachusetts USA). The search was confined to materials on children and adolescents, aged 0 to 18 years, and to English language sources with no restriction on date of publication. The search yielded a total of 1,330 unduplicated titles. An updated search in the spring of 2015 yielded an additional 420 unduplicated titles. Throughout the process, titles, abstracts, and reference sections of publications were reviewed to identify additional materials that were not generated in the database searches. From the two searches, 228 publications specifically addressing coping in children and adolescents in the context of mass trauma were identified for more careful examination.
Criteria for inclusion in this review required the study instrument used to assess coping to have been subjected to factor analytic methods with the study sample. Restricting the selected publications to those that had performed principal component analysis (PCA), exploratory factor analysis (EFA), or confirmatory factor analysis (CFA) confined the current review to coping instruments that have demonstrated content validity. A total of 20 studies investigating 14 coping instruments and including factor or principal component analytic procedures were identified for this analysis. The studies which met the selection criteria and were included in this review are presented in Table 1.Reference Pfefferbaum, Nitiéma, Jacobs, Noffsinger, Wind and Allen 1 - Reference Duraković-Belko, Kulenović and Ðapić 30
Coping Instruments Used in Child Disaster, Terrorism, and War Studies
Abbreviations: BASC-2, Behavioral Assessment Scale for Children, Second Edition; CAC, Coping Activities Checklist; CFA, confirmatory factor analysis; COPE, Coping Orientation for Problem Experiences; CPTSRI, Child Posttraumatic Stress Reaction Index; EFA, exploratory factor analysis; GSI, Global Severity Index; GSS, Global Symptom Score; PCA, principal component analysis; PSSA, Personal Stress Symptom Assessment; PTS, posttraumatic stress; PTSD; posttraumatic stress disorder; RSQ, Responses to Stress Questionnaire; SSSCA, Social Support Scale for Children and Adolescents.
Dimensions of Coping
Coping can be volitional and goal directed, or it can be involuntary. Voluntary coping includes a host of intentional activities, including efforts to mobilize social support. Involuntary responses to stress include temperamentally-based and conditioned reactions that may or may not be within the individual’s conscious awareness and are not under volitional control, such as emotional and physiological arousal, intrusive thoughts and rumination, and emotional numbing.Reference Papadatou, Giannopoulou, Bitsakou, Bellali, Talias and Tselepi 20 To date, there does not appear to be a uniform theory regarding the dimensions of child and adolescent coping. Moreover, the terminology to depict various elements of coping is inconsistent. Several dimensional categories have been used to describe coping styles in children and adolescents—problem-focused and emotion-focused coping, primary and secondary control coping (sometimes called assimilative and accommodative coping), and engagement and disengagement coping (also referred to as approach versus avoidant coping),Reference Lazarus and Folkman 31 most of which are considered voluntary coping efforts. Problem-focused coping refers to voluntary activities such as seeking information or attempting to change the circumstances in some way. Examples of emotion-focused coping include expressing emotions, seeking support, and avoiding anything related to the event. Primary control, or assimilative coping, is used by children to increase their sense of personal control either by changing events or by regulating their own emotions.Reference Lazarus and Folkman 31 Secondary control, or accommodative coping, is focused on adaptation through means such as acceptance or cognitive restructuring. Engagement coping entails problem solving or seeking support while disengagement, or passive coping, focuses away from the event or one’s reactions to it, through actions like withdrawal or denial.Reference Lazarus and Folkman 31
Reflecting the child coping literature in general, the studies examined for this report were also inconsistent in describing coping dimensions. A number of studies categorized coping dimensions as problem-focused and emotion-focused,Reference Zeidner 12 , Reference Hoffner and Haefner 26 , Reference Compas, Connor-Smith, Saltzman, Thomsen and Wadsworth 32 as primary and secondary control,Reference Papadatou, Giannopoulou, Bitsakou, Bellali, Talias and Tselepi 20 as engagement and disengagement,Reference Papadatou, Giannopoulou, Bitsakou, Bellali, Talias and Tselepi 20 or as active and passive coping.Reference Schiff 13 , Reference Ryan-Wenger 24 Active, avoidant, and support (or support seeking) copingReference Carver 5 , Reference Ayers, Sandler, West and Roosa 15 , Reference Cole, Bruschi and Tamang 33 and distractionReference Ayers, Sandler, West and Roosa 15 , Reference Cole, Bruschi and Tamang 33 were commonly referenced categories. Other studies simply referred to adaptive and maladaptive copingReference Moscardino, Scrimin, Capello, Altoé and Axia 6 and productive and non-productive coping.Reference Frydenberg and Lewis 3
Development and Psychometric Features of Coping Measures
Existing coping measures reflect a variety of theoretical and practical considerations. Recently, researchers have begun to incorporate sophisticated statistical procedures for optimal development and evaluation of coping instruments. A brief review of factor analytic approaches and their importance for the future of coping assessment is presented as a foundation to discussion of factor analytic findings of the coping construct in the literature reviewed.
Factor Analytic Methods for Instrument Validation
Although a theoretical framework defining the dimensions of a construct is essential in designing a tool to measure that construct, the postulated theory must be confirmed by data from the field. Indeed, a hypothesized model may not be supported by empirical data. In the specific case of coping, the construct may be influenced by age, gender, and/or culture, but with no universal model and requiring that researchers test the adequacy of the construct dimensions in each study population. Factor analytic techniques yield estimates of how well operationalized aspects of coping are represented within a measure and determine the adequacy of fit of previously-identified factor structures. Factor analysis is considered an excellent statistical procedure for demonstrating content validity of an instrument.Reference Langley and Jones 34
Three analytic methods have been utilized to identify or confirm the dimensions of coping as a construct: PCA, EFA, and CFA. Principal component analysis is a data reduction technique for a dataset with highly correlated variables that creates linear combinations of weighted observed variables to obtain uncorrelated variables known as principal components. Principal component analysis does not actually identify latent (unobserved) variables (eg, coping, resilience, or functioning), but instead combines the correlated items to form a set of uncorrelated variables that can be used to summarize the data. Principal component analysis accounts for the total variance of the variables being analyzed, that is, the variance that is unique to each variable as well as the variance common among those variables.
Exploratory factor analysis takes into account only the variance that is common among all of the variables. Exploratory factor analysis identifies latent variables or common factors, which cannot be measured directly, from a set of observed variables. This difference between PCA and EFA has led some authors to recommend the use of EFA instead of PCA for identifying latent constructs and the dimensions of a measurement tool.Reference Bryant 35 , Reference Costello and Osborne 36 In EFA, factors are assumed to be the underlying roots, or origin, of the measured variables, and these factors can be used to define subscales of the instrument. Principal component analysis may yield principal components that are similar to the factors obtained through an EFA, but the results of PCA and EFA may diverge when communalities are low or when the ratio number of observed variables by the number of factors is small.Reference Costello and Osborne 36 As an exploratory method, EFA does not constrain the observed variables to load to a specific underlying construct.
As its name suggests, CFA, which is not a data reduction method, determines whether prior knowledge or theory about the relationship between latent constructs and observed variables is confirmed with the data collected from the study sample. In CFA, the observed variables are loaded into pre-defined latent constructs. The model’s fit is then evaluated with a good fit confirming the tested theory or knowledge. If the theory is not confirmed with the available data, the researcher may then choose to conduct an EFA to identify latent constructs.
Replicability of Factor Analytic Methods
As noted by Skinner and colleagues,Reference Fabrigar, Wegener, MacCallum and Strahan 37 EFA conducted on data from different samples may not yield the same coping constructs, raising the issue of replicability of the reported coping dimensions. Early in the process of instrument development, researchers should ensure reliability and replicability of their findings. For this purpose, EFA should be conducted with a sample size large enough to minimize the standard errors of the parameter estimates and to obtain reliable results. Elements that should be considered to determine the adequate sample size include the communalities of the variables (ie, the proportion of variation of variables that is explained by the common factors) and the ratio of the number of questionnaire items to the number of factors.Reference Skinner, Edge, Altman and Sherwood 38 Replicability of the extracted factors can be determined either with a fraction of the same study sample (internal replicability) or with data collected on a different sample (external replicability).Reference MacCallum, Widaman, Zhang and Hong 39 When conducting an internal replicability analysis, the study sample used for the EFA is divided into subsamples with one subsample used to identify the coping constructs and the remaining to determine whether identical factors are extracted.
Assessment of Measurement Invariance
Another important concern is whether an instrument can provide valid measures across different populations. Measurement invariance assessment is a technique used in CFA (and structural equation modeling) to determine whether respondents with the same true instrument scores will have the same observed scores regardless of their membership in a specific group (eg, gender, ethnicity, or culture).Reference Osborne and Fitzpatrick 40 , Reference Meredith 41 This ensures that a given measurement will yield valid scores if used in different populations and that observed between-group differences in scores are not artifacts of inconsistencies in the performance of the instrument when used in different populations. Strict measurement invariance as recommended by MeredithReference Osborne and Fitzpatrick 40 requires not only that the same factor structure holds across groups, but also that the factor loadings, intercepts, and residual variances of the multi-group CFA be equal across these groups.
Results of Factor Analyses of Children’s Coping in the Context of Mass Trauma
The coping mechanisms used by children and adolescents exposed to mass trauma have been explored using factor analytic techniques. This exploration assumes that some unobserved, underlying factors stimulate the coping strategies reported by the respondents (EFA), or that the reported strategies that are correlated can be combined to form a set of uncorrelated variables (PCA). Among the 20 studies selected for this review, six conducted EFA and seven conducted PCA of the coping measurement tool using data collected from the study participants. The number of identified coping dimensions varied from two to nine, with a three-factor solution being the most frequent (n=5). Ten (50.0%) of the studies reviewed for this report used CFA to verify the coping dimensions identified by specific measurement tools in previous studies. Nine of these ten studies confirmed in their sample the dimensions formerly identified by other studies using the instrument (Table 1).
Significant variability exists across instruments and studies in the number and content of the identified coping factors, and varying factors may emerge when the same measure is used with different populations. Few studies have identified a clear theoretical framework to guide instrument construction or to test the instrument across multiple populations with various forms of exposure to diverse types of mass trauma. Significant age differences have emerged in factor structures which are likely representative of developmental differences in coping.Reference Spirito, Stark and Williams 17 None of the studies reviewed has conducted a multi-group confirmatory factor analysis to evaluate factorial invariance of the coping instrument across sample subgroups (eg, age, gender, or ethnicity).
Coping Styles and Respondent Characteristics and Event Exposure
The reviewed studies revealed relationships between coping styles used by children and adolescents and age and/or development, gender, culture, and aspects of exposure to the traumatic event. Restricting the analysis to studies that conducted factor analysis of coping data collected from various study samples ensured that the coping dimensions or styles examined in the investigation were actually those used by the study participants.
Age and Developmental Stage
The choice of coping strategy used by children may differ according to their age or developmental level.Reference Wu, Li and Zumbo 42 While the number of studies is limited, extant research supports an increase in cognitive coping strategies with ageReference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 , Reference Baráth 25 , Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 as cognitive functions mature. BaráthReference Ryan-Wenger 24 found that cognitive development influenced coping more than gender, with younger children more likely to use passive, self-focused coping strategies such as crying or staying alone. Earlier research conducted by Boehnke and colleaguesReference Schiff 13 found that passive strategies, which are used in situations in which the individual has no options for action or active coping, decreased with age, while seeking factual information increased with age. Weisenberg and colleaguesReference Hoffner and Haefner 26 concluded that adolescents used more effective emotion-based techniques than younger children. Punamäki and PuhakkaReference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 reported that older children (12 to 13 years of age) had a broader range of coping techniques than younger children (10 to 11 years of age), and that older children used both more emotional and cognitive coping strategies. Hoffner and HaefnerReference Baráth 25 also found an increase in the use of cognitive coping with age in a sample of 80 American children (ages eight to 12 years) exposed to the televised news coverage of the 1991 Persian Gulf War. Younger children relied more on social support for coping than their older counterparts, but the trend was not statistically significant.Reference Baráth 25 In a sample of 185 Palestinian children assessed before and during the 1987-1991 Intifada, Punamäki and PuhakkaReference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 observed that the use of cognitive coping processes (including intellectualization, wishful and magical thinking, denial of emotions, and verbal hostility toward Israeli soldiers) as well as avoidant distraction (including passivity and helplessness, distraction, and feeling overwhelmed by stress) increased with age.
Age also may influence how caregivers respond to children’s coping needs. Following Hurricane Andrew (Florida, USA; 1992), third graders reported receiving more emotional processing help than did the fourth and fifth graders.Reference Stratta, Capanna and Dell’Osso 8 Gender differences also may play a role in these developmental differences. In a cross-sectional study of political violence, older girls were more likely to report coping through active fighting compared to younger girls, while the opposite trend was found for boys.Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27
Gender
While not all studies found gender differences in children’s use of active, avoidant, and/or emotion-focused coping strategies,Reference Zeidner 11 , Reference Vigna, Hernandez, Kelley and Gresham 18 , Reference Ryan-Wenger 24 some studies revealed an association between the coping strategies used by youth based upon gender. For example, relative to boys, girls showed a greater use of active coping, such as community and social engagement,Reference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 and more primary control strategies, such as problem-solving and emotional regulation.Reference Wadsworth, Gudmundsen and Raviv 22 , Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 In contrast, boys reported using more non-productive, avoidant strategies,Reference Frydenberg and Lewis 3 and less-active coping techniques.Reference Schiff 13 , Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 The finding that boys used more non-productive coping than girls may be explained partially by societal expectations of gender roles with boys expected to show more strength and resilience than girls. This expectation may condition boys to refrain from seeking social support.Reference Frydenberg and Lewis 3 In a sample of Israeli children exposed to threat of Scud missile bombardment during the first Persian Gulf War, Weisenberg and colleaguesReference Hoffner and Haefner 26 found that girls had sought reassurance more than boys. Moreover, societal expectations may lead parents to provide less psychosocial support to boys than to girls after a traumatic experience. As an illustration, in a sample of children previously exposed to Hurricane Andrew, girls reported more social support received from their parents than boys.Reference Vigna, Hernandez, Kelley and Gresham 18
Culture
There are cross-cultural differences in the coping mechanisms used by children. For example, in a study exploring how children from different cultures might react to difficult situations, Cole, Bruschi, and TamangReference Compas, Connor-Smith, Saltzman, Thomsen and Wadsworth 32 observed that children in the United States used more problem-focused strategies than Tamang and Brahman children in Nepal, while Tamang and Brahman children used more emotion-focused coping than their US counterparts.
It should be emphasized that with the exception of Wadsworth and colleagues,Reference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 none of the studies included in this review assessed measurement invariance of the instrument used to measure coping. Wadsworth and colleaguesReference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 found the Responses to Stress Questionnaire to adequately measure coping in adolescents and young adults. Hence, it is unclear whether the observed associations of specific coping dimensions with age, gender, and culture are real or reflect inconsistencies in the performance of the measurement scales across subgroups within samples.
Event Exposure
There appears to be a dose-response relationship between the intensity of the stressor and coping as measured by a coping questionnaire. For example, Punamäki and PuhakkaReference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 found the coping styles of a sample of Palestinian children to differ with intensity of political violence—greater intensity of exposure was associated with more problem restructuring and less fighting or hostile confrontation. Greater political violence stress among Israeli adolescents exposed to terror attacks was associated with use of more problem-focused, emotion-focused, and avoidant coping.Reference Carver, Scheier and Weintraub 10
The type of exposure to the traumatic event also may be associated with the coping style used. For instance, Tatar and AmramReference Frydenberg and Lewis 3 reported a positive correlation between the use of productive coping and being at the site of a terrorist attack without being injured and a negative correlation between use of these strategies and greater contact with media reports covering terrorism. Of course, the interaction of participant characteristics can result in a more complex picture of coping. Moscardino and colleaguesReference Carver 5 found that the use of active coping and avoidant coping by adolescents who survived the 2004 Beslan terrorist attack differed according to their gender, and to whether they had been taken hostage during the attack (direct exposure) or were present at the site of the attack but not taken hostage (indirect exposure). Boys who were exposed directly to the attack used active coping more than directly exposed girls, whereas indirectly exposed boys used active coping less than indirectly exposed girls.Reference Carver 5 Hoffner and HaefnerReference Baráth 25 investigated the coping mechanisms of children who watched televised news coverage of the first Persian Gulf War and found children used cognitive coping more than social support.
Clinical Outcomes and Coping
Assessing coping is of interest to clinicians in how these strategies relate to impaired functioning, adaptation, and resilience. Unfortunately, the variability and complexity of coping styles without consideration of an overarching theoretical framework makes it challenging for practitioners to discern how best to use information on coping to develop, deliver, and modify interventions for youth after a mass-trauma event. To determine the effectiveness of coping strategies, some studies have assessed the relationship between coping methods and clinical outcomes identifying certain coping strategies as associated with positive/adaptive outcomes. In general, adaptive coping strategies (eg, active coping) are less frequently associated with distress symptoms compared to strategies targeting emotional distress reactions (eg, emotion-focused coping). For instance, in a sample of Israeli adolescents exposed to terror attacks, ZeidnerReference Carver, Scheier and Weintraub 10 reported an association of emotion-focused coping with negative mood, posttraumatic stress (PTS) reactions, and somatic symptoms; avoidant coping was associated with negative mood and somatic symptoms; and problem-focused coping was associated with none of these distress symptoms. Problem restructuring and behavioral coping strategies also were associated with fewer psychosocial difficulties in Palestinian children exposed to the First Intifada.Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 Following Hurricane Andrew, more severe levels of posttraumatic stress disorder (PTSD) symptoms in grade school children positively correlated with more emotional processing, greater distraction coping, and less adult support of rules and routines.Reference Stratta, Capanna and Dell’Osso 8 West German adolescents facing nuclear threat who used a defensive style of coping tended to report more personal anxieties.Reference Schiff 13
Despite a growing research base promoting active coping strategies and cautioning against the use of emotion-focused or avoidant coping, other studies reflect the need for a more sophisticated understanding of coping dimensions. In response to Scud missile attacks, children later assessed with PTSD tended to use more checking behaviors and requests for reassurance while utilizing less verbal distraction.Reference Hoffner and Haefner 26 Surprisingly, greater use of problem-focused coping and less emotion-focused coping also were associated with more severe postwar stress reactions, perhaps because it is not effective to use problem-focused strategies in situations that cannot be changed.Reference Hoffner and Haefner 26 In a sample of African-American children exposed to Hurricane Katrina (Louisiana USA; 2005), internalized negative coping was associated with greater depression, anxiety, and social stress; however, problem-avoidant coping was not associated with any of the assessed negative outcomes.Reference Spirito, Stark and Williams 17 SchiffReference Zeidner 12 found that both emotion-focused and problem-solving coping were related to higher PTSD symptoms and speculated that perhaps problem-solving coping was not as helpful when teens faced an ongoing terror threat. Similar results were reported by Stratta and colleaguesReference Pat-Horenczyk, Qasrawi and Lesack 7 who found a positive association between emotional coping and PTSD symptoms in a sample of adolescents exposed to the 2009 earthquake in L’Aquila (Italy). SchiffReference Zeidner 12 also noted that religiosity buffered terrorism exposure, underscoring the importance of context when addressing coping.
Gender may also need to be considered when evaluating the effectiveness of coping skills. Wadsworth and colleaguesReference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 found that girls used more emotion-focused coping, which was related to better functioning for them while boys used more disengagement, which was linked to worse functioning only in girls. Moscardino and colleaguesReference Carver 5 highlighted the need to consider both gender and exposure when examining outcomes in youth 18 months following a hostage crisis. For directly exposed adolescents, avoidant coping was linked to worse psychological outcomes for both genders, but this relationship was found only for girls among indirectly exposed students who usually attended the school but were not present or taken hostage on the day of the attack. The effectiveness of coping styles in alleviating psychosocial problems also varied according to the intensity of political violence. Problem restructuring, active fighting, and behavioral coping were linked to fewer psychosocial difficulties during, but not before, the First Intifada.Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27
Clinicians must remember that these statistical relationships merely are associations without directionality. Also, most of the studies on coping strategies and PTS outcomes are cross-sectional, with no evidence of the temporal sequence among the disaster-related symptoms. Vernberg and colleaguesReference Vigna, Hernandez, Kelley and Gresham 18 found all four coping variables analyzed (positive coping, blame-anger, wishful thinking, and social withdrawal) after Hurricane Andrew were related to PTSD symptoms leading the authors to argue that a high level of distress may result in children using a greater variety of coping strategies. Moreover, the extent to which items used to measure coping styles are the same as, or similar to, those measuring emotional outcomes (eg, avoidant coping versus avoidance subscale of a PTS symptoms scale) may influence results demonstrating correlations between some coping factors and outcomes. Hence, it is possible that some observed associations between coping strategies and disaster-related symptoms just indicate correlations among similar or close constructs.
Considerations for the Assessment of Disaster Coping
The literature has raised both theoretical and practical issues related to coping in children in the context of mass trauma. These considerations center on identifying appropriate informants and the appropriate content to query.
Self-report Measures and Other Informants
Self-report screening measures are valued for their relatively quick and direct administration, making them especially useful in the acute aftermath of a mass-trauma event when rapid decision making regarding limited resources is needed.Reference Skinner and Zimmer-Gembeck 43 Children can provide accurate indications of their internal statesReference Saylor and Deroma 44 and are the most direct and objective source of subjective information (eg, symptoms and coping efforts) following exposure to mass trauma.Reference Balaban 45 Vernberg and colleaguesReference Vigna, Hernandez, Kelley and Gresham 18 suggested that parents and teachers, likely struggling with their own stress due to an event, may be less reliable than children themselves in reporting their children’s distress. Yule and WilliamsReference Finch and Daugherty 46 elaborated further noting that children exposed to trauma did not always share their concerns with their parents to protect the parents from additional distress. Thus, certain response biases may interfere with an accurate appraisal of child coping. Children may distort their responses intentionally or unintentionally. For example, in an effort to present themselves in the best possible light, children may not acknowledge the use of ineffective or socially undesirable coping strategies (eg, denial and wishful thinking).Reference Lazarus and Folkman 31 Also, self-reports that are retrospective in nature may be biased by poor recall and by some degree of natural resolution of event-related problems.Reference Lazarus and Folkman 31
Most researchers agree on the importance of gathering data from multiple sources to obtain the most comprehensive appraisal of children’s reactions and functioning.Reference Skinner and Zimmer-Gembeck 43 , Reference Yule and Williams 47 - Reference La Greca, Silverman, Vernberg and Prinstein 49 Research indicates that although the most accurate information about children’s personal experiences, perceptions, and internal emotions is provided by the children themselves, parents best report children’s external behaviors and teachers are adept at identifying variations among peers.Reference La Greca, Silverman, Vernberg and Prinstein 49 In spite of efforts to utilize brief instrumentation, gathering information from multiple informants using multiple methods in a community grappling with the devastating effects of mass trauma presents tremendous challenges. It is this information that practitioners need to build understanding and intervene effectively.
General and Context-specific Coping Measures
Coping measures can be categorized broadly as either general or context-specific. General coping measures (eg, Adolescent Coping Orientation for Problem Experiences [A-COPE]) assess children’s coping styles across stressors, whereas some measures (eg, How I Coped Under Pressure Scale [HICUPS]) instruct participants to rate items according to their reactions to a specific stressor. Some general measures have been adapted to assess situation-specific coping.Reference Boehnke, Macpherson, Meador and Petri 14 Investigations of general coping styles typically include broad outcome measures of overall adjustment and do not consider the process of coping within a discrete stressful situation or event.Reference Boehnke, Macpherson, Meador and Petri 14 As Compas and colleaguesReference Lazarus and Folkman 31 noted, in inquiries of general coping as compared with a specific or unspecified situation, the use of a self-selected stressor undermines the validity of the measurement. Perhaps the most common method of assessing coping, asking children to report on their coping “in general,” ignores potentially important contextual factors.Reference Lazarus and Folkman 31 Lazarus and FolkmanReference Pfefferbaum and North 50 emphasized coping in response to specific stressors and asserted that general, or “trait,” measures of coping oversimplify the coping process and are of limited value in explaining and predicting one’s actions in a specific context. Thus, measures that address situation-specific coping are likely to be more appropriate in predicting outcomes directly associated with a mass-trauma event because they are grounded in transactional theory which views the person and the environment in a “dynamic, mutually reciprocal, bidirectional relationship.”Reference Pfefferbaum and North 50 (p293)
To address general and specific approaches to the assessment of coping, Ayers and colleaguesReference Boehnke, Macpherson, Meador and Petri 14 developed a situation-specific coping instrument, HICUPS, to complement their measure of general coping style, the Children’s Coping Strategies Checklist (CCSC).Reference Lazarus and Folkman 51 Simultaneous use of the CCSC and HICUPS allows for a direct examination of the suitability of a general (ie, trait) or context-specific (ie, state) version among young disaster victims. One child disaster study evaluated the use of both general and context-specific forms of the measure.Reference Ayers and Sandler 52 Lengua and colleaguesReference Ayers and Sandler 52 did not use both the CCSC and HICUPS, but revised the instructions on the CCSC to assess coping specific to the September 11th attacks (New York USA; 2001) to obtain information about children’s “dispositional” and “situational” coping strategies. Using prospective data on pre-attack stress load, appraisal, and coping responses, these researchers found that children’s pre-event dispositional coping and their event-specific situational coping both affected their September 11th PTS symptoms.Reference Ayers and Sandler 52 Dispositional coping directly influenced the initiation of situation-specific coping strategies and the development of positive or negative stress outcomes. Despite the recommendation to include both specific and global measures of coping,Reference Lengua, Long and Meltzoff 53 researchers have continued to utilize inquiries of coping in response to unspecified stressors. It is hopeful that a trend toward using measures of situational coping is emerging, as many of the studies reviewed in this report investigated context-specific coping rather than general coping.
Implications for and Challenges in Clinical Application
In their review of child and adolescent coping, Compas and colleaguesReference Lazarus and Folkman 31 identified two practical applications of coping research: (1) understanding coping strategies as mediators and moderators between stress and adaptive developmental trajectories; and (2) informing interventions designed to prevent psychopathology by finding ways to enhance effective coping. Skinner and colleaguesReference Fabrigar, Wegener, MacCallum and Strahan 37 analyzed 100 coping category systems and found little overlap or consistency in categories of coping strategies used. The authors noted that this lack of consensus has impeded research progress; it also delays the practical use of these data in the field.Reference Fabrigar, Wegener, MacCallum and Strahan 37 The current review revealed the many inconsistent coping dimensions and the difficulty bridging multiple studies. Though the current review examined a much more restricted sample of measures and contexts, a similar breadth of coping constructs emerged.
The inconsistencies in the coping dimensions explored make it difficult to integrate findings across studies in a meaningful way. Two initial challenges exist for professionals in using the coping literature. First, they must try to aggregate findings of studies that use different measures to examine a variety of coping dimensions and strategies. Second, they need to determine if the results are consistent across different populations of youth and in different contexts. As an illustration, the Kidcope has the advantages of being brief and having been used in previous disaster studies, yet Vigna and colleaguesReference Spirito, Stark and Williams 17 found that the proposed factor structure for the Kidcope did not fit the data they collected from hurricane-exposed, low-income, African American adolescents. These investigators also failed to find a relationship between the coping style, measured by the Kidcope, and personal adjustment.Reference Spirito, Stark and Williams 17 The current review revealed some support for promoting active coping strategies to enhance post-disaster functioning,Reference Carver, Scheier and Weintraub 10 , Reference Weisenberg, Schwarzwald, Waysman, Solomon and Klingman 27 but it also uncovered specific situations in which emotion-focused coping seemed advantageous.Reference Hoffner and Haefner 26 , Reference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 For example, in one study, because there was nothing that could be done about the threat of missile attacks on children in sealed rooms, problem solving was associated with more stress;Reference Hoffner and Haefner 26 in another study, emotion-focused coping was advantageous only for girls, perhaps because girls are likely to seek social contact during times of stress.Reference Connor-Smith, Compas, Wadsworth, Thomsen and Saltzman 21 As researchers learn more about coping across different populations and contexts, the interpretation is not as simple as promoting active coping and discouraging avoidant strategies.Reference Carver 5 , Reference Spirito, Stark and Williams 17 The interactions of many variables in different contexts are complex and require a more holistic interpretation of coping strategies.Reference Carver 5 , Reference Spirito, Stark and Williams 17 It is challenging to draw conclusions across these different studies, but these diverse and sometimes seemingly contradictory findings add to the developing, complex landscape that is the current state of knowledge related to coping across diverse dispositions, populations, exposures, and contexts.
While studies on the effectiveness of coping have shown links between better psychological adjustment and particular strategies, the direction of this relationship is not always clear.Reference Lazarus and Folkman 31 This was true for the studies reviewed here. The research currently cannot tell clinicians if a particular coping style leads to a better outcome or, if as Tatar and AmramReference Frydenberg and Lewis 3 suggest, youth reduce the use of less-productive coping strategies when they feel better. When the use of coping and symptoms are measured concurrently, the direction of the relationship cannot be determined.Reference Stratta, Capanna and Dell’Osso 8 Indeed, this measurement situation is common in mass-trauma research where the very things that are needed to advance coping research, such as replicability and experimental design, create challenges for researchers. In assessing the contribution this research makes to the larger body of literature, researchers must be mindful that mass-trauma research often uses an exploratory approach, which while useful, leaves much to be desired.Reference Knapp, Stark, Kurkjian and Spirito 54
Conclusions and Future Research Directions
This report provides a comprehensive review of measurement tools that have been used to assess coping in children and adolescents exposed to natural disasters, terrorist attacks, war, and other mass-trauma events. In his guidelines for the assessment of children in disasters, BalabanReference Saylor and Deroma 44 identified several features that enhance the usefulness of assessments tools, including: (1) brevity (ie, administered in 60 minutes or less); (2) standardized questionnaire format; (3) ability to be administered by non-clinicians; (4) established for use in disaster or emergency contexts; and (5) accompanied by published psychometric data. While each of these features of instrumentation for assessment is logical within the context of development and mass trauma, it is clear that much work is needed to create reliable and valid measures of coping with mass trauma that incorporate clear, theoretical underpinnings and multidimensional models that include a hierarchy of coping strategies in relation to intention and efficacy over time. Given the possibility that reported coping dimensions of an instrument may not replicate in another study sample, it is good practice to conduct a CFA testing for the postulated coping dimensions before proceeding with further analyses of the data collected with the coping measurement tool. If the predefined dimensions are not confirmed, researchers may perform an EFA to identify the coping dimensions specific to their study sample while ensuring replicability of their results. Also, the field will benefit from assessing measurement invariance of the coping scales to ensure that these tools are measuring the same constructs equally across different populations.
Using a multilevel, theoretical conceptualization of coping will advance the understanding of coping and the creation of effective assessment tools and interventions used in mass trauma. This conceptualization can help move the field beyond viewing coping as a simplistic, stable individual characteristic that fails to reflect the child’s development, gender, culture, and other key diverse aspects of the process. Braun-Lewensohn’sReference Pfefferbaum, Weems and Scott 55 recent integrated coping model represents movement toward more comprehensive models. Critical to instrument development will be the differentiation of measures needed based on demographic characteristics, exposure, time since the event, and context. Echoing Schwarzer and Schwarzer,Reference Braun-Lewensohn 56 this will require longitudinal assessment using multilevel instruments analyzed with advanced statistical modeling techniques consistent with the complexity of coping. As steps toward developing a more comprehensive conceptualization of coping, the research would benefit from increased attention to individual child factors, such as how temperament or disposition interacts with coping strategies,Reference Lazarus and Folkman 31 and the inclusion of bio-behavioral measures, such as involuntary stress responses.Reference Wadsworth, Gudmundsen and Raviv 22 Additional factors including social support and the role of cognitive appraisal are also rich areas where more disaster-related research in coping is needed.
