Journal of Traumatic Stress

December 2017, 30, 583–592

Posttraumatic Stress Symptoms and Posttraumatic Growth in

Children and Adolescents Following an Earthquake: A Latent
Transition Analysis
Jieling Chen1,2 and Xinchun Wu1
1
Beijing Key Laboratory of Applied Experimental Psychology, School of Psychology, Beijing Normal University, Beijing, China
2
Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China

This study examined the transitions in classes of posttraumatic stress symptoms and posttraumatic growth in a sample of children and
adolescents (N = 757), between 8 and 20 months after the 2013 Ya’an earthquake in China. Using latent profile analysis, three classes of
symptoms (resilient, thriving, and struggling) were identified at 8 and 20 months after the earthquake. Latent transition analysis indicated
that the majority of survivors remained in the same class during the period, while others showed a transition between different classes over
time. The transition was mainly characterized by three paths: from struggling to resilient, and from thriving to either resilient or struggling.
Of the survivors who were classified as thriving at 8 months, those transitioning to the struggling class at 20 months were more likely
to experience higher levels of loss and injury compared with those transitioning to the resilient class (Cohen’s d = 0.72) or remaining
in the thriving class (Cohen’s d = 0.36) at 20 months postearthquake. Survivors who remained stable in the struggling class were older
than those who remained stable in the thriving class (Cohen’s d = 0.41) or those who moved from thriving at 8 months to resilient at
20 months after the earthquake (Cohen’s d = 0.39). It is recommended that clinicians consider the classes of posttraumatic stress symptoms
and posttraumatic growth, and the potential development paths and associated factors, when implementing interventions for children and
adolescents after a natural disaster.

It is estimated that millions of people worldwide were af-
fected by about 150 major natural disasters in 2015, including
earthquakes, floods, and drought (Huber, 2015). Children and
adolescents represent a significant proportion of those who
endure disasters. Posttraumatic stress symptoms (PTSS) such
as intrusion, avoidance, negative thoughts and feelings, and
hyperarousal (American Psychiatric Association, 2013), are
common among individuals who have been exposed to natural
disasters (Norris et al., 2002). Nevertheless, positive psycho-
logical changes, such as posttraumatic growth (PTG; Tedeschi
& Calhoun, 1996), have been documented in children and
adolescents who were exposed to natural disasters (Kilmer &
Gil-Rivas, 2010). Posttraumatic growth refers to positive psy-
chological changes as a result of the struggle that can arise from
This study was supported by the Major Project of Beijing Social Science
Fund, China (15ZDA11). We declare that we have no competing or potential
conflicts of interest. The authors thank the participating schools and students,
Qiuyan Chen, Xiaojiao Yuan, Xiao Zhou, and Min Zeng for their help with data
collection, and the reviewers for their constructive comments that improved
the manuscript.
Correspondence concerning this article should be addressed to Xinchun Wu,
19 Xinjiekouwai Street, Beijing, China, 100875; E-mail: xcwu@bnu.edu.cn
Copyright  C 2017 International Society for Traumatic Stress Studies. View
highly challenging events; such changes can include perceived
changes in self, a changed sense of relationships with others,
and a changed philosophy of life (Tedeschi & Calhoun, 1996).
Research on the association between PTSS and PTG has
revealed inconsistent findings (see Helgeson, Reynolds, &
Tomich, 2006, and Shakespeare-Finch & Lurie-Beck, 2014,
for review). Some studies have found a positive association
between PTSS and PTG (e.g., Kilmer et al., 2009; Saccinto,
Prati, Pietrantoni, & Pérez-Testor, 2013), whereas others have
reported that PTG is negatively associated with PTSS (e.g.,
Chen, Zhou, Zeng, & Wu, 2015; Linley, Joseph, & Goodfellow,
2008). Further, some studies have indicated that the association
between PTSS and PTG can be curvilinear (e.g., Levine, Laufer,
Hamama-Raz, Stein, & Solomon, 2008). Still others have pro-
posed that the two constructs are not necessarily related and
can coexist as two independent entities (e.g., Sleijpen, Haagen,
Mooren, & Kleber, 2016; Zoellner & Maercker, 2006).
The inconsistent findings across studies may be due to the
heterogeneity of the samples, the type or severity of the trau-
matic event, the measurement time point, or the tools used
(Zoellner & Maercker, 2006). Moreover, the presence of differ-
ent patterns of PTSS and PTG can contribute to the complex
relationship between PTSS and PTG. A recent study used la-

this article online at wileyonlinelibrary.com

tent profile analysis to investigate patterns of PTSS and PTG in
DOI: 10.1002/jts.22238 children and adolescents following a natural disaster (Chen &

583
584
Wu, 2017). Three classes were identified: resilient (low levels
of PTSS and PTG); thriving (low levels of PTSS and moderate
PTG); and stressed and growing (high levels of PTSS and mod-
erate PTG). Another study that examined PTG, psychological
distress (posttraumatic stress disorder [PTSD] and depression),
and coping in a group of women with breast cancer identified
four profiles of posttreatment adaptation: distress (high prob-
ability of negative coping, depression, PTSD, and low PTG);
resistant (high probability of nonclinical PTSD and depression,
low negative coping and PTG); struggling PTG (high probabil-
ity of PTSD, depression, negative coping, and high PTG); and
constructive PTG (high probability of nonclinical PTSD and de-
pression, low negative coping, and high PTG; Pat-Horenczyk
et al., 2016). The different classes may reflect different qualities
of adaptation, and the distribution of classes may vary across
the different natures of samples, types of traumatic events, and
time points, which could contribute to the inconsistent findings.
Research on psychological adjustment following a traumatic
event indicates that psychological health can develop over time
(e.g., Fan, Long, Zhou, Zheng, & Liu, 2015; Marshall, Frazier,
Frankfurt, & Kuijer, 2015; Self-Brown, Lai, Thompson,
McGill, & Kelley, 2013). For instance, a study examined the
trajectories of PTSS in a group of youths following 2005’s
Hurricane Katrina over two years. The findings suggest that
some youths (25%) recovered over time, while in others PTSS
remained stable either at high (4%) or low levels (71%; Self-
Brown et al., 2013). Other recent studies have examined the
trajectories of PTG over time (Danhauer et al., 2015; Marshall
et al., 2015). A study of adults after two major earthquakes
identified three trajectories of growth in relationships. They
differed only in levels of growth (low, moderate, and high), but
no significant change (slope) was observed over time (Marshall
et al., 2015).
Although these longitudinal studies shed some light on the
temporal course of PTSS or PTG following a traumatic event,
few of them have examined the development of psychological
adjustment based on an integrated assessment of both the nega-
tive and positive psychological outcomes. An exception is Pat-
Horenczyk et al.’s (2016) study, which used latent transition
analysis to analyze the transitions between different adapta-
tion profiles among women with breast cancer. They found that
while some profiles (resistant and distress) tended to have fairly
stable trajectories over time, others (struggling PTG and con-
structive PTG) were not as stable. Nonetheless, less is known
about how classes of PTSS and PTG develop over time in chil-
dren and adolescents after a natural disaster. The experience of
natural disaster can differ from cancer (the traumatic event used
in Pat-Horenczyk et al.’s 2016 study). Natural disaster can cause
a sudden huge destruction to an area, but the reconstruction of
the family and community postdisaster may provide opportuni-
ties for survivors to recover; in comparison, after the diagnosis
of cancer, the individuals would receive active treatment, in
which uncertainty about the disease and treatment may cause
variation in psychological adjustment. Moreover, Zoellner and
Maercker (2006) indicated the importance of studying the
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Chen & Wu
coexistence of PTSS and PTG using longitudinal research. They
suggested that self-perceived growth had both a constructive
side as well as a self-deceptive, illusory side. The constructive
component was suggested to be correlated with psychological
adjustment (e.g., fewer clinical symptoms), whereas the illu-
sory component may be adaptive; that is, it may not hinder the
individual from acknowledging and processing the trauma but
could help to make the struggle a bit more bearable, or it may
not be adaptive when it serves as a cognitive avoidance strategy
(e.g., denial) in the short term but have deteriorating effects on
long-term adjustment (Maercker & Zoellner, 2004). Therefore,
the current study investigated the development over time of the
coexistence of PTSS and PTG among a group of children and
adolescents following an earthquake disaster.
Another important consideration is to elucidate potential fac-
tors related to the transitions of the different PTSS and PTG pat-
terns. The effects of gender and age on psychological responses
following disaster have been explored. Being a girl was associ-
ated with greater risk for posttraumatic stress (Furr, Comer,
Edmunds, & Kendall, 2010; Trickey, Siddaway, Meiser-
Stedman, Serpell, & Field, 2012), as well as greater likelihood
of PTG (Vishnevsky, Cann, Calhoun, Tedeschi, & Demakis,
2010). Gender differences may be related to the tendency for
girls to engage in rumination (Vishnevsky et al., 2010). The ru-
minative activity of the trauma-related cues and negative moods
can elicit posttraumatic stress, but it may also encourage fur-
ther cognitive processing of the traumatic events, which leads
to PTG (Zhou & Wu, 2016). The role of age in posttraumatic
response can be complex, as younger children are relatively
vulnerable in some ways but protected in others in compari-
son to older adolescents (Masten & Narayan, 2012). On one
hand, younger children are more dependent on caregivers, and
a decline in the quality of caregiving can increase their vul-
nerability; but when the environment remains relatively stable
regardless of disaster (e.g., family environment), the children
can be protected from the negative effects of traumatic events.
The cognitive immaturity in younger children may lead them
to perceive the event as having been less frightening than an
older child would. On the other hand, adolescents have better
coping capacity and problem-solving skills in comparison with
younger children. In line with the complex task of characteriz-
ing “age effect,” the empirical findings have been mixed (e.g.,
Ayer et al., 2011; Fan et al., 2015; Furr et al., 2010; McDermott,
Lee, Judd, & Gibbon, 2005). Regarding PTG, mixed findings
have been observed in terms of the association between age
and PTG in children and adolescents (Meyerson, Grant, Carter,
& Kilmer, 2011). Nevertheless, it has been shown that both
children and adolescents have the ability to report their positive
growth experiences after they experience challenging events.
Disaster exposure, including both objective disaster expo-
sure and subjective life threat, has been found to be a sig-
nificant factor related to PTSS. In a meta-analysis of studies
that included child and adolescent disaster survivors, aspects of
exposure, such as death toll and perception of threat, showed
medium-to-large associations with posttraumatic stress (Furr
 Latent Transitions in Posttraumatic Stress and Growth
et al., 2010). Tedeschi and Calhoun (2004) also suggested
that trauma exposure is associated with PTG. Exposure to a
traumatic event can threaten an individual’s basic assumptions
about the world and self (Janoff-Bulman, 2010), which may
serve as a catalyst for growth.
In addition to studies that have examined factors that con-
tribute to PTSS or PTG separately, a few studies have consid-
ered the factors that affect PTS and PTG simultaneously (e.g.,
Chen & Wu, 2017; Gul & Karanci, 2017). A recent study in a
Turkish community sample found that being female was related
to more PTSS, whereas younger age was associated with both
more PTSS and PTG (Gul & Karanci, 2017). Exposure-related
factors, including loss, injury, and subjective fear, were found to
be associated with membership in the various classes of PTSS
and PTG among children and adolescents (Chen & Wu, 2017).
The current study provided of an opportunity to further exam-
ine the factors relating to the coexistence of PTSS and PTG in
children and adolescents in the longitudinal course.
In the current study, we examined the development of classes
of PTSS and PTG in children and adolescents following a nat-
ural disaster. Study participants were children and adolescents
who had been exposed to the 2013 Ya’an earthquake. The re-
search questions were as follows: (1) what were the transition
paths between the classes of PTSS and PTG from an early to
later stage after the earthquake?, and (2) what were the char-
acteristics of the transition paths in terms of demographics and
disaster exposure severity? We assumed that there were indi-
vidual differences among the development of the classes of
PTSS and PTG; some individuals remained in the same class
while others showed transition between classes over time. How-
ever, given the limited evidence on the development of classes
of PTSS and PTG in children and adolescents after traumatic
events, we did not make assumptions about specific transition
paths; we explored the transition, as well as factors associated
with transition, in the study.
Method
Participants
Participants in the present study consisted of 757 child and
adolescent survivors of the 2013 Ya’an earthquake, the most
devastating earthquake to hit China since the Wenchuan earth-
quake of 2008. The Ya’an earthquake carried a magnitude of
Ms 7.0 and Mw 6.6. All 757 children and adolescents partici-
pated in two assessments, performed at 8 and 20 months after
the Ya’an earthquake.
Procedure
This study was approved by the Research Ethics Committee
of the School of Psychology at Beijing Normal University,
Beijing, China. Written informed consent was obtained from
the school leaders and class advisors. The research invitation
was delivered to the students in Grades 4 and 5 in the primary
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
585
school, and Grades 7, 8, 10, and 11 in the secondary school via
the help of teachers (e.g., class advisors). We did not survey
students in Grades 6, 9, and 12 due to the fact that those are
graduation years, and the students in those grades might have
been under additional stress (e.g., in preparation for entrance
exams). The students who were interested in the survey signed
written informed consent and completed self-reported ques-
tionnaires. Participation was voluntary, and the written consent
forms emphasized that we would protect the confidentiality of
each participant, and that each participant had the right to with-
draw from the survey at any time. In China, parental consent is
not required when a research project has been approved by local
education authorities and school administrators, and is addition-
ally deemed to provide a service to the students. In this research
project, the study results (general description of mental health
in the studied samples without personal information) and rec-
ommendations were provided to all of the participating schools.
Data collection was carried out by trained individuals with ei-
ther a bachelor’s degree or master’s degree in psychology.
The flow of the three assessments is shown in Supplemental
Figure 1, available online. The first assessment was conducted
in December 2013, approximately 8 months after the Ya’an
earthquake. A total of 928 children and adolescents, from one
primary and two secondary schools located in the rural Lushan
County (the earthquake’s epicenter), participated in the study.
According to records provided by the school counseling teacher,
none of the children or adolescents in the study exhibited major
psychosis (e.g., schizophrenia or organic mental disorders) or
had ever taken psychiatric medication prior to the earthquake.
At the second assessment, 14 months after the earthquake, 831
of the original students participated in the survey. At the third
assessment, 20 months after the earthquake, 727 of the stu-
dents who participated in the second assessment completed the
survey, and 30 additional students who did not participate in
the second assessment but had completed the first assessment
completed the survey, resulting in 757 of the original students
participating in the third assessment. In each follow-up survey,
students dropped out with the reason that they did not agree
to continue to participate. Attrition analysis was conducted be-
tween the survivors who participated in all three assessments
(n = 727), the survivors who only participated in the first and
third assessment (n = 30), and the survivors who did not partic-
ipate in the third assessment (n = 171). The survivors who did
not participate in the third assessment were significantly older
than those who only participated in the first and third assess-
ments and those who participated in all the three assessments,
while the latter two groups were not significantly different in
age. The three groups did not differ in gender, trauma severity,
PTSS, or PTG at the first assessment.
Measures
The Child PTSD Symptom Scale (CPSS) was used to as-
sess posttraumatic stress symptoms (Foa, Johnson, Feeny, &
Treadwell, 2001). It is an appropriate measure for children aged
586 Chen & Wu

Figure 1. Three-class latent profile analysis (LPA) results at 8 months (a) and 22 months (b) after the earthquake. PTSS = posttraumatic stress symptoms; PTG =
posttraumatic growth; CPSS = Child PTSD Symptom Scale, with a cut-off of 16 points for posttraumatic stress disorder (PTSD); PTGI = Posttraumatic Growth
Inventory, with a total score above 66 for a moderate level of PTG.

8 to 18 years. The CPSS was translated into Chinese and val-
idated in Chinese children and adolescents (Zhou, Wu, An, &
Chen, 2014). It includes 17 items that measure the occurrence
and frequency of PTSD symptoms as defined in the Diagnostic
and Statistical Manual of Mental Disorders (4th ed.; DSM-IV;
American Psychiatric Association, 1994). Participants rated the
frequency of experiencing symptoms in relation to the earth-
quake over the past two weeks on a 4-point Likert scale ranging
from 0 (not at all) to 3 (almost always). An overall score was
generated to indicate the level of PTSS. A cut-off of 16 points
for PTSD is recommended in children and adolescents (Nixon
et al., 2013). The CPSS was used at the three assessments, and
Cronbach’s alphas of the scale were .85 and .89 at the first and
third assessment, respectively.
The Posttraumatic Growth Inventory was used to assess
PTG. The original instrument was developed by Tedeschi and
Calhoun (1996) and was translated and revised to be used
with Chinese children and adolescents for the assessment
of positive changes following traumatic events (Zhou et al.,
2014). Based on the interview with the survivors on the
growth experience after the earthquake, one item (“A better
understanding on uncontrollable force in the unseen world”)
was added to assess the existential and spiritual change in
addition to the original two items in this aspect. Each of the
22 items was rated on a 6-point Likert scale ranging from
0 (not at all) to 5 (extremely). Higher total scores indicate more
positive changes following traumatic events. An overall score
above the 60th percentile is suggested to indicate moderate
PTG (Jin, Xu, & Liu, 2014); thus, in the current study, a
total score above 66 was considered to indicate a moderate
level of PTG. The Posttraumatic Growth Inventory was
assessed at the three assessments, and Cronbach’s alphas of
the scale were .90 and .94 at the first and third assessment,
respectively.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Latent Transitions in Posttraumatic Stress and Growth 587

The Earthquake Exposure Questionnaire was used to assess Table 1

the severity of disaster exposure (Ying et al., 2014). It included Sample Characteristics
three major categories of disaster exposure: injury and loss,
Variable Mean SD
house damage, and subjective fear. Injury and loss was assessed
Age, years 12.71 2.78
with 20 items (e.g., “Was the participant trapped or injured in
n %
the earthquake?”; “Did the participant have a parent, teacher,
classmate, friend, other relative, or other person with him or her Gender
who was trapped or injured or died during the earthquake?”). Female 405 53.5
House damage was assessed with two items (e.g., “What was the Male 352 46.5
impact of the earthquake on the participant’s house and school Educational level
building?”). Subjective fear was assessed with eight items (e.g., Primary school (Grade 4 to 6 at T1) 295 39.0
“Was the participant worried about parent, teacher, classmate or Junior Middle school (Grade 7 or 8 at T1) 263 34.7
himself/herself dying or being injured during the earthquake?”). Senior Middle school (Grade 10 or 11 at T1) 199 26.3
Items regarding house damage were rated on a 4-point scale Disaster exposure
including 0 (no damage), 1 (mild damage), 2 (severe damage), Trapped in earthquake 58 7.7
or 3 (totally collapsed). Other items in the questionnaire were Injured in earthquake 104 13.7
rated in a 1 = yes or 0 = no format. Sum scores for injury Death of parent(s) 4 0.5
and loss, house damage, and subjective fear were calculated Death of teacher 1 0.1
respectively. The Earthquake Exposure Questionnaire was used Death of classmate(s) 100 13.2
in the first assessment. Death of relative(s) or friend(s) 99 13.1
House damage (severe or total) 500 66.1
Data Analysis Worried about dying 468 61.8
Worried about being injured 477 63.0
To identify the latent classes of PTSS and PTG at 8 and 20 Worried the earthquake happen again 622 82.2
months after the earthquake, separate latent profile analyses
Note. T1 = time 1 (8 months after the earthquake).
(LPA) were run with the specification of a one- to four-class
model. Missing data were handled with full information max-
imum likelihood (FIML). Statistical fit indices were used to of variances was not assumed. The software packages Mplus
determine the optimal number of latent classes: lower Bayesian 7.1.1 and SPSS 21.0 were used for the analyses.
information criterion (BIC) and adjusted Bayesian information
criterion (ABIC) values, significant Lo-Mendell-Rubin likeli-
hood adjusted test (LRT) and bootstrap likelihood ratio test Results
(BLRT). Based on Nagin’s (2005) recommendation, beyond
fit statistics we chose the most parsimonious model that cap- Sample Characteristics
tured the distinct and substantive features of the data; that is, Of the total sample, 104 participants (13.7%) were injured
consisting of conceptually different patterns. in the earthquake, and houses of 500 participants (66.1%)
Latent transition analysis (LTA), a longitudinal extension of were destroyed in the earthquake. Furthermore, 468 partic-
LPA, was used to analyze the changes in latent class member- ipants (61.8%) reported that they worried about dying dur-
ship over time. We followed the three-step specification method ing the earthquake, and 622 participants (82.2%) worried the
to estimate the effects (Asparouhov & Muthén, 2014; Nylund- earthquake would happen again (see Table 1 for more sample
Gibson, Grimm, Quirk, & Furlong, 2014). In step 1, two LPA characteristics).
models at two time points (C1 and C2 ) were estimated in paral-
lel, but independent of each other, while holding measurement
Descriptive Statistics
invariant. In step 2, while holding the parameters fixed to the
results from step 1, the most likely class variables, N1 and The mean PTSS severity scores were 13.18 (SD = 7.82) and
N2 , and their log ratios were calculated. In step 3, N1 and N2 12.96 (SD = 8.69) at 8 and 20 months after the earthquake,
were used as indicators of C1 and C2 with parameters fixed respectively (see Table 2). Within-subject analysis of variance
at the log ratios from step 2. A final model, which contained revealed that the means of PTSS severity at 8 and 20 months
the regression of C2 on C1 , was run to estimate the transition did not differ significantly. Overall, the means of PTSS severity
probabilities describing the changes of classes. Then analy- were lower than the cut-off point of 16, indicating a mild to
sis of variance (ANOVA) was conducted to examine whether moderate level of PTSS in general. In particular, 243 (32.1%)
the various transition paths differed in terms of demograph- and 261 (34.5%) participants of the total sample (n = 757) re-
ics and disaster exposure. A Bonferroni post hoc test was ported a score of PTSS higher than the cut-off point of 16 at 8
conducted when homogeneity of variances was assumed; a and 20 months after the earthquake, respectively. The mean lev-
Games-Howell post hoc test was conducted when homogeneity els of PTG were 61.79 (SD = 20.59) and 57.08 (SD = 24.08)

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
588 Chen & Wu

Table 2 At 8 months after the earthquake, the majority of the survivors

Descriptive Statistics for the Main Study Measures (56.9%) were grouped in the thriving class, which showed a
mild level of PTSS and moderate level of PTG (see Figure 1).
Variable Mean SD
A resilient class, accounting for 21.1% of the total sample,
8-month PTSD 13.18 7.82 was identified, which showed mild PTSS and PTG. The re-
8-month PTG 61.79 20.59 mainder (21.9%) of survivors were in the struggling class, who
22-month PTSD 12.96 8.69 showed PTSS exceeding the cut-off of 16 points on the CPSS
22-month PTG 57.08 24.08 and exhibiting a moderate level of PTG. Similar to 8 months
Loss and injury 2.83 2.26 after the earthquake, resilient, thriving, struggling classes were
Home damage 5.89 0.99 identified among the survivors 20 months after the earthquake.
Subjective fear 6.74 2.55 The largest category was thriving (72.0%), followed by the
struggling (16.0%), and resilient (12.0%) classes.
Note. Scale range: PTSD (0 to 51); PTG (0 to 110); loss and injury (0 to 20);
home damage (0 to 6); subjective fear (0 to 8). PTSD = posttraumatic stress
disorder; PTG = posttraumatic growth. Latent Transition Analysis
The LTA was conducted to examine the transition across classes
over time. The measurement parameters were constrained to be
at 8 and 20 months after the earthquake, respectively, which invariant across time. Using the three-step specification method,
indicated a mild to moderate level of PTG in the current sam- an LTA model was constructed and estimated. Regarding the
ple. Additionally, within-subject analysis of variance revealed transition probabilities (see Table 4), the earthquake survivors
that overall PTG decreased significantly from 8 months to 20 had a high probability of remaining in the same class at 20
months after the earthquake. months: .88, .80, and .74 for the resilient, thriving, and strug-
gling classes, respectively. For those participants who were
classified as thriving at 8 months, there was a .12 probability
Latent Profile Analysis
of transitioning to the resilient class and a .08 probability of
To identify the patterns of PTSS and PTG at 8 and 20 months transitioning to the struggling class at 20 months. For those
after the earthquake, separate LPAs were employed to estimate who were classified as struggling at 8 months, there was a 0.21
the one- to four-class models (see Table 3). At 8 months after probability of transitioning to the resilient class at 20 months.
the earthquake, the three-class and four-class models showed After determining the transitions, a bivariate analysis was
lower BIC and ABIC values and significant BLRT and LRT. conducted to examine whether the various transition paths dif-
However, the four-class model did not capture the distinct and fered in terms of demographics (gender and age) and disaster
conceptually different features of data from those captured in exposure (loss and injury, home damage, and subjective fear).
the three-class model. Thus, according to the parsimony prin- Because the sample size in three transition paths (from resilient
ciple, the three-class model was chosen. At 20 months after to thriving, from resilient to struggling, and from struggling
the earthquake, the three-class model was chosen due to the to thriving) were smaller than 10 per group, they were not in-
relatively lower BIC, ABIC, results of LRT tests, and ease of cluded in the bivariate analysis. We compared the six transition
interpretability. paths (see Table 5). Results indicated that the transition paths

Table 3
Fit Indices for Latent Profile Analysis (LPA) Models with 1 to 4 Classes
Class AIC BIC ABIC BLRT (p value) LRT (p value)
8 months
1 11961.87 11980.39 11967.69 — —
2 11895.10 11927.50 11905.27 <.001 <.001
3 11839.34 11885.63 11853.88 <.001 <.001
4 11821.83 11882.01 11840.73 <.001 .008
20 months
1 12328.22 12346.73 12334.03 — —
2 12263.69 12296.09 12273.87 <.001 .006
3 12211.82 12258.12 12226.36 <.001 <.001
4 12189.95 12250.13 12208.85 <.001 .090
Note. AIC = Akaike information criterion; BIC = Bayesian information criterion; ABIC = adjusted Bayesian information criterion; BLRT = bootstrapped likelihood
ratio test; LRT = Lo-Mendell-Rubin adjusted likelihood test.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Latent Transitions in Posttraumatic Stress and Growth
Table 4
Latent Transition Probabilities Between 8 and 20 Months After
the Ya’an Earthquake Based on the Unconditional Latent Tran-
sition Analysis Model
20 months
Resilient Thriving Struggling
8 months Probability SE Probability SE Probability SE
Resilient .88** .09 .05 .05 .07
Thriving .12** .03 .80** .03 .08**
Struggling .21** .06 .05 .07 .74**
**p < .01.
significantly differed in gender distribution, age, loss and injury,
and subjective fear (Table 5). Post hoc tests revealed that sur-
vivors who moved from the thriving class to the resilient class
were more likely to be boys. Survivors who remained stable in
the struggling class were older than those who remained stable
in the thriving class (Cohen’s d = 0.41) or those who moved
from thriving at 8 months to resilient at 20 months after the
earthquake (Cohen’s d = 0.39). Survivors who remained sta-
ble in the struggling class reported having experienced higher
levels of loss and injury than those who remained stable in the
resilient class (Cohen’s d = 0.72) or thriving class (Cohen’s
d = 0.36). Survivors who moved from thriving to struggling
also experienced higher levels loss and injury than those who
remained stable in the resilient class (Cohen’s d = 0.84) or
thriving class (Cohen’s d = 0.50), as well as those who moved
from the thriving class to the resilient class (Cohen’s d = 0.48).
Survivors who remained stable in the resilient class reported
having experienced the lowest levels of subjective fear of the
sample (Cohen’s d ranged from 0.63 to 0.98), and those who
remained stable in the thriving class had lower levels of subjec-
tive fear when compared with survivors who remained stable
in the struggling class (Cohen’s d = 0.33).
Discussion
This study examined the classes of PTSS and PTG in a sample of
children and adolescents following the 2013 Ya’an earthquake
in China, and explored the transitions across classes from 8 to
20 months after the earthquake. Three classes were identified
both at a relatively early stage and at a later stage after the
earthquake: resilient, thriving, and struggling. Survivors tended
to remain in the same class over time, especially survivors who
were found to be originally in the resilient class. The transitions
found were mainly characterized by three paths: from struggling
at 8 months to resilient at 20 months, and from thriving at
8 months to either the resilient or struggling at 20 months.
In line with the findings from previous studies (Chen &
Wu, 2017; Pat-Horenczyk et al., 2016), distinct classes of post-
disaster adjustment based on PTSS and PTG were identified.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
589
More than half of child and adolescent survivors were classi-
fied in a class with mild PTSS and a moderate level of PTG,
which was referred to as the thriving class, indicating that the
survivors in this group went beyond the original level of psy-
chosocial functioning and grew vigorously (O’Leary & Ick-
ovics, 1994). The individuals classified in the resilient class
showed mild PTSS and PTG. The resilient survivors repre-
sented low levels of distress and a lack of clinical posttraumatic
symptomatology after a challenging traumatic event (Bonanno,
.06 Westphal, & Mancini, 2011). The findings indicated that the
.03 absence of psychopathology did not necessarily imply the pres-
.08 ence of growth. The individuals classified in the struggling class
exhibited moderate PTSS and PTG, indicating that they were
undergoing a struggling process, where PTSS and PTG coex-
isted, following the traumatic experience (Tedeschi & Calhoun,
2004). On the other hand, we did not distinguish a class with
high PTSS but a mild level of PTG, similar to the “distress”
class in Pat-Horenczyk et al.’s (2016) study. One possible rea-
son is related to the different types of trauma experienced by
the different samples. The participants in the Pat-Horenczyk
et al. (2016) study were female adults with breast cancer. The
life-threatening disease and demanding treatment impaired the
patients’ health and functioning after the diagnosis, even when
there were no longer signs of the disease (Institute of Medicine,
2008), which could lead to significant distress and hinder the
development of growth for some individuals.
Regarding the transition between classes during the 2-year
period after the earthquake, the majority of survivors (73.1%)
remained stable in the same class while others showed change
over time. Among those survivors who were classified as being
in the resilient class at 8 months after the earthquake, approx-
imately 90% were estimated to stay in the resilient class at
20 months after the earthquake. The stability of the resilient
class supported the views that resilience was inferred as a sta-
ble construct (Bonanno et al., 2011); this manifested itself in
adaptation during the course from an early to a later stage fol-
lowing the disaster. Children and adolescents in the thriving
and struggling classes showed different transition paths later,
including the thriving stable, thriving resilient, thriving strug-
gling, struggling stable, and struggling resilient paths.
Individuals who were assessed to have moderate PTG but
who showed different transition paths can be explained from
the Janus-face model developed by Zoellner and Maercker
(2006). The self-reported moderate PTG may vary in extent
of the illusory and constructive components in different indi-
viduals, which is related to the different transition paths over
time. For instance, in survivors transitioning from thriving to
struggling, PTG at an early stage may reflect illusory, self-
deceptive growth, which may serve as a cognitive avoidance
strategy (e.g., denial) to reduce the distress in the short term,
but may have deteriorating effects on long-term adjustment
(Maercker & Zoellner, 2004). On the other hand, in survivors
transitioning from struggling to resilient, PTG at an early stage
may reflect constructive growth, which relieves the distress in
the long term. Thus, given the complexity of the various forms
590 Chen & Wu

Table 5
Demographic and Disaster Exposure Correlates of Transition Paths
A. B. C. D. E. F.
Resilient Stable Thriving- Thriving Stable Thriving- Struggling- Struggling
(n = 69) Resilient (n = 378) Struggling Resilient Stable
(n = 96) (n = 73) (n = 27) (n = 107)
Gender n % n % n % n % n % n % χ2 df
Girl 33 47.8 32 33.3 213 56.3 44 60.3 15 55.6 63 58.9 4.17** 5
Boy 36 52.2 64 66.7 165 43.7 29 39.7 12 44.4 44 41.1
M SD M SD M SD M SD M SD M SD F df Post hoca
Age 12.93 2.36 12.43 2.93 12.42 2.71 12.96 2.77 13.04 2.95 13.57 2.93 3.36** 5, 744 B,C<F
Disaster exposure
Loss and injury 1.87 1.85 2.64 2.24 2.64 1.99 3.84 2.71 3.52 2.90 3.43 2.43 8.56** 5, 744 A<C<D,F; B<D
Home damage 3.78 .92 3.99 .97 3.85 .99 4.04 .92 3.74 1.13 3.99 1.00 1.19 5, 744
Subjective fear 4.99 3.05 6.78 2.41 6.76 2.49 7.07 2.33 7.00 2.77 7.52 2.04 9.41** 5, 744 A<B,C,D,E,F; C<F
Note. a Bonferroni post hoc tests were conducted when homogeneity of variances was assumed; Games-Howell post hoc tests were conducted when homogeneity of
variances was not assumed.
*p < .05. **p< .01

of PTG and the relationship between PTG and PTS in different
individuals, it is suggested that individuals could benefit from
clarifying the pattern of psychological adjustment and the na-
ture of growth experience, especially at a relatively early stage,
in different individual cases. Nevertheless, the explanation of
the transitions based on the components of PTG and their as-
sociations with psychological adjustment is preliminary, and
further research is recommended to include the role of coping
(e.g., avoidance and approach), which is an important factor in
understanding the form and function of PTG as suggested by
the Janus-face model (Maercker & Zoellner, 2004).
In addition, some factors were indicated to influence the tran-
sition between classes over time. The children and adolescents
transitioning from the thriving class to the resilient class were
more likely to be boys. Cognitive processing is thought to play
a key role in the development of growth following a traumatic
event (Tedeschi & Calhoun, 2004; Zoellner & Maercker, 2006).
Boys tend to engage less in cognitive activity (e.g., rumination)
than girls (Jose & Brown, 2008), which may be related to
the decline in PTG over time for boys. The individuals who
remained stable in the struggling class tended to be older,
especially when compared with those who remained stable in
the thriving class. This supports previous findings that levels of
PTSS increase with age among children and adolescents (e.g.,
Ayer et al., 2011; Fan et al., 2015). One possible explanation
is that the development of cognitive maturity in adolescents is
related to a greater capacity for understanding the event and
its consequences, and a greater tendency to retain and retrieve
disorganized memories (Masten & Narayan, 2012), that elicited
the PTSS. Additionally, it has been suggested that older adoles-
cents have a greater ability to identify and verbalize symptoms
compared with younger children (Contractor et al., 2013). On
the other hand, few survivors in this study experienced parental
loss due to the earthquake, which may have protected them
from the negative effects of the disaster, especially among the
younger children who were more dependent on caregiving from
family.
Regarding disaster exposure, the survivors who remained sta-
ble in the resilient class reported that they were less impacted
by the earthquake disaster, and experienced lower levels of loss
and injury, and subjective fear, from the earthquake in compari-
son to other individuals who reported moderate to high levels of
psychological reactions after the earthquake. This is consistent
with the notion that the resilient outcome is related to reduced
trauma exposure (Bonanno et al., 2011). The survivors who ex-
hibited chronic PTSS (“struggling stable”) and elevated PTSS
(“thriving struggling”) reported that they experienced higher
levels of loss and injury than the survivors in the transition
paths characterized by low levels of PTSS (thriving stable and
thriving resilient). It is suggested that loss and injury can in-
crease the risk for developing and maintaining PTSS, because
the loss and injury experience in the earthquake may pose sig-
nificant challenges for postdisaster recovery for children and
adolescents. Finally, the survivors who remained stable in the
struggling class perceived lower levels of subjective fear than
those who remained stable in the thriving class. This supports
previous literature that suggested that perception of threat was
a risk factor for posttraumatic stress (Furr et al., 2010).
The LTA model that analyzed transitions over three time
points and the LTA model that analyzed transitions between
the first and third time points yielded six conceptually similar
transition patterns. This accounted for more than 98% of the
total sample in both models.
The current study had some limitations. First, nearly 20%
of the survivors did not participate in the follow-up surveys.
Survivors who did not participate tended to be older and
in senior middle school. To address the potential impact of
attrition on the transition between classes, we conducted a
multigroup LTA and found that the transition probability
estimates did not differ significantly between the middle school
and primary school groups. Second, few of the participants in
the current study had suffered from the loss of a significant
family member (e.g., father or mother) due to the earthquake.
Thus, the findings may not generalize to the child and

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Latent Transitions in Posttraumatic Stress and Growth
adolescent survivors who experienced the disaster and suffered
from loss of significant family members as well. Last, for the
LTA, the current study sample size was still limited to support
the analysis of covariates in the LTA model. Although we
conducted the bivariate analysis to examine the characteristics
of different transition paths, it is preferable to use a larger
sample size and include the potential factors that may predict
the transitions across the classes over time.
Despite these limitations, the current study has several
strengths. It extended the scope of previous research on the
development and trajectory of PTSS and PTG, which have
generally studied one phenomenon as either PTSS or PTG. It
further addressed the coexistence of negative and positive facets
of psychological adjustment in individuals, and studied the de-
velopment of classes from an early stage to a later stage after
a natural disaster. We suggest that clinicians should consider
the classes of posttraumatic stress and PTG, their potential de-
velopmental paths, and associated factors when implementing
interventions for children and adolescents after a natural disas-
ter. Further investigation is suggested to examine more potential
factors influencing the transitions over time, as well as to distin-
guish the transitions between younger individuals and adults.
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