Handbook of Positive Psychology Phần 9 potx

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48
Positive Psychology for Children
Development, Prevention, and Promotion
Michael C. Roberts, Keri J. Brown, Rebecca J. Johnson, &
Janette Reinke
You have brains in your head
You have feet in your shoes
You can steer yourself
Any direction you choose.
—Dr. Seuss
Although the specialties of psychology deal-
ing with children recognize the serious prob-
lems encountered during their development,
much of the recent orientation involves moving
away from viewing the psychological and be-
havioral deficits resulting from a developmental
challenge. Instead, the focus increasingly has
become one of perceiving the competence of the
child and his or her family and enhancing
growth in psychological domains. The clinical
child, school, and pediatric psychology litera-
tures frequently address concepts of stress and
coping, generally accepting that coping is a pos-
itive response to the stress of a negative envi-
ronmental situation or life event such as a
chronic illness or parental divorce.
As noted by Siegel (1992), “individual-
differences factors can influence both a child’s
response to stress and his or her use of coping

strategies” (p. 4). He called for increased atten-
tion to the individual differences in children’s
behavioral, emotional, and physiological re-
sponsiveness to their environment. Siegel indi-
cated that each child may respond quite dif-
ferently to an environmental stressor. An
important aspect of coping is that the same
mechanisms of responding to stress are involved
in life events that are not as significant as di-
vorce or disease but are the daily hassles of hu-
man existence. For example, in pediatric psy-
chology, several resilience and coping models
have emerged to frame issues of children who
have a chronic illness such as diabetes, cystic
fibrosis, or sickle-cell disease. In much of the
earlier literature and still to some extent today,
coping or resilience concepts are thought of
only as responses to a stressor, usually a major
one, not as a positive behavioral style of ad-
justing, adapting, accommodating, and assimi-
lating to an ever-changing environment in a
child’s life. In a positive psychology orientation,
however, a comprehensive and inclusive concep-
tualization of coping views these adaptations as
664 PART IX. SPECIAL POPULATIONS AND SETTINGS
normal developmental events with much com-
mon origin and function. Additionally, there is
an increasing recognition that growth and en-
hancement to achieve physical and psychologi-
cal well-being occur through these adaptations.

Others have noted the need, particularly
working with adolescents, to examine the
strengths and positive assets of the develop-
mental stage rather than focusing on the mul-
titude of stressors and potential negative out-
comes (Johnson, Roberts, & Worell, 1999).
Johnson and Roberts (1999) recognized that
“looking at strengths rather than deficits, op-
portunities rather than risks, assets rather than
liabilities is slowly becoming an increasing pres-
ence in the psychotherapy, education, and par-
enting literature” (p. 5). Similarly, Dryfoos
(1998) reviewed the programs aimed at assisting
adolescents and concluded that successful ones
emphasized optimism and hope and were
growth-enhancing for the adolescents and their
families.
All too often, a “pathology model” has been
applied to studying how children develop. That
is, children with significant behavior disorders
pose major problems for parents, teachers, and
peers, such that their pathology gets the
greatest attention. More recent conceptualiza-
tions have focused attention on more “normal”
development for most children, but also to con-
sidering how pathology might be avoided
through early intervention and enhanced envi-
ronments for all children. Frequently the focus
has been on taking children with problems and
doing something to change them. Positive psy-

chology has something to offer this process, but
a larger application of positive psychology
would be to view it in terms of prevention and
promotion. Additionally, the pathology model
typically takes an adult-oriented perspective. By
assuming that the goal of all human develop-
ment and any intervention is intended to pro-
duce a fully functioning adult, only adult out-
comes are considered important. The positive
psychology alternative is to focus on the child
while a child is in development and attempt to
enhance functioning, competence, and overall
mental health at any particular time. Further-
more, psychological conceptualizations of pa-
thology have historically been formulated for
adults and then, in a downward extension,
applied to children and adolescents (Maddux,
Roberts, Sledden, & Wright, 1986). This ap-
plication, all too frequently, does not fit. Adult-
oriented theories and intervention techniques
“have never sufficed in other areas of mental
health intervention work with children re-
quires a developmental perspective which rec-
ognizes the process of continual change over
time in the psychology of children” (Roberts
& Peterson, 1984, p. 3). In our view, well-
formulated positive psychology literature takes
a developmental perspective.
In this chapter, we will describe the three ma-
jor conceptualizations of optimism, hope, and

quality of life as related to positive psychology
for children and adolescents. This examination
of the extant literature is descriptive and not
exhaustive, but it does illustrate the potential
utility of positive psychology in child develop-
ment. In the final section, we propose that in-
tegrating a positive psychology orientation with
a developmental perspective creates a catalyst
for prevention.
Optimism
Definition and Concepts
One conception of optimism defines it in terms
of explanatory style and how an individual
thinks about causality of an event. That is, an
optimist is defined as a person who sees defeat
as temporary, confined to a particular case, and
not his or her direct fault (Seligman, 1991). A
pessimist, on the other hand, believes bad
events will last a long time and undermine
everything he or she does, and that these events
were his or her fault. Thus, the way that a per-
son explains positive or negative events to him
or herself determines whether he or she is op-
timistic or pessimistic. This explanatory style is
evident in how an individual thinks about the
causes of events. A pessimist dwells on the most
catastrophic causes for the event, whereas an
optimist can see that there are other possible,
less catastrophic causes for the same event. For
example, two children may receive poor grades

on a test. The pessimistic child might say to
himself, “I’m stupid and can’t get anything
right,” whereas the optimistic child might say
to herself “I need to study a little harder next
time.” In summary, Seligman stated that the
way in which a person explains events has three
dimensions: permanent versus temporary, uni-
versal versus specific, and internal versus exter-
nal. These dimensions determine whether a
person is pessimistic or optimistic. This explan-
atory style can be acquired by children and
CHAPTER 48. POSITIVE PSYCHOLOGY FOR CHILDREN 665
adults and has been labeled learned optimism.
Seligman and his colleagues have studied the
concept of learned optimism with children as
well as adults.
Considerable research has been conducted on
the benefits of optimism and the costs of pes-
simism. Optimists tend to do better in school
and college than pessimists. Optimists also per-
form well at work and in sports. The physical
and mental health of optimists tends to be bet-
ter, and optimists may even live longer than
pessimists (Seligman, 1991). Optimists also
tend to cope with adverse situations in more
adaptive ways (Scheier & Carver, 1993). Ado-
lescents who are optimistic tend to be less angry
(Puskar, Sereika, Lamb, Tusaie-Mumford, &
McGuiness, 1999) and abuse substances less of-
ten (Carvajal, Clair, Nash, & Evans, 1998). Con-

versely, pessimists tend to give up more easily,
get depressed more often, have poorer health,
be more passive (Seligman, 1991), have more
failure in work and school, and have more social
problems (Peterson, 2000).
Seligman, Reivich, Jaycox, and Gillham
(1995) described four sources for the origins of
optimism. The first possible source is genetics
(Schulman, Keith, & Seligman, 1993; Seligman
et al., 1995). A second source is the child’s en-
vironment, in which parents seem to be a strong
influence on the level of optimism in their chil-
dren. Researchers have found that there is a
strong relationship between a mother’s explan-
atory style and that of her child (Seligman et
al., 1995). Children may imitate parents’ ex-
planatory style. A third source for optimism is
also an environmental influence, in the form of
criticism that a child receives from parents,
teachers, coaches, or other adults. If an adult
criticizes a rather permanent ability of a child
(e.g., “You just can’t learn this”), the child is
more likely to develop a pessimistic explanatory
style. A fourth way in which optimism develops
is through life experiences that promote either
mastery or helplessness. Life events such as di-
vorce, death in the family, or abuse can affect
how a child describes causes to him- or herself.
Events such as these tend to be permanent, and
many times the child is unable to stop or re-

verse the event.
In light of all the benefits of being optimistic
and the costs of being pessimistic, is it best for
a child to be optimistic all the time? Seligman
and other researchers have not advocated that
parents mold their children to be the more ex-
treme “Pollyanna.” Instead, Seligman et al.
(1995) noted that there are limits to optimism.
Children must see themselves in a realistic light
in order for them to successfully challenge their
automatic negative thoughts. Teaching children
to be realistic helps them perceive the begin-
nings of negative self-attribution (e.g., “I
flunked the test because I am stupid”) and chal-
lenge that thought, and also to see where they
might be able to overcome a fault (e.g., “I
flunked the test because I didn’t study enough.
Next time I’ll study harder”). Disputing auto-
matic thoughts only works when the thoughts
can be checked against reality.
Measurement
One assessment tool for measuring optimism in
children is the Children’s Attributional Style
Questionnaire (CASQ; Seligman et al., 1995).
This instrument is a 48-item forced-choice
questionnaire that assesses explanatory style for
both positive and negative hypothetical events.
The questions measure whether the child’s at-
tributions about positive or negative events are
stable or unstable, global or specific, and inter-

nal or external. Example items include: “You
get good grades: (A) School work is simple; or
(B) I am a hard worker.” The CASQ gives an
overall picture of the child’s explanatory style
and whether that style is positive or negative.
The book The Optimistic Child (1995), by Se-
ligman et al., contains an in-depth description
of the CASQ, including administration, scoring,
and interpretation. The Life Orientation Test
(Scheier & Carver, 1985) is a measure developed
for assessing optimism of adults and has been
used with adolescents (e.g., Carvajal et al., 1998;
Puskar et al., 1999)
Interventions
The Penn Prevention Program is an inter-
vention-oriented research project that has in-
vestigated the costs of pessimism in children
(Jaycox, Reivich, Gillham, & Seligman, 1994;
Gillham, Reivich, Jaycox, & Seligman, 1995).
The goal of this program has been to prevent
depressive symptoms in children at risk for this
pathology using a treatment that addresses the
child’s explanatory style and social-problem-
solving skills. The children in the prevention
group were taught to identify negative beliefs,
to evaluate those beliefs by examining evidence
for and against them, and to generate more re-
alistic alternatives. They were also taught to
666 PART IX. SPECIAL POPULATIONS AND SETTINGS
identify pessimistic explanations for events and

to generate alternative explanations that were
more optimistic. These children also learned so-
cial problem solving, as well as ways to cope
with parental conflict, and behavioral techniques
to enhance negotiations, assertiveness, and re-
laxation. The results of this project are encour-
aging. The researchers found that the children
who were in the prevention condition had half
the rate of depression as the control group. Im-
mediately after the prevention program, the
control group had more depressed symptoms
than the treated group. Also of considerable in-
terest is the finding that the benefits of the pro-
gram seemed to maintain over time. Children
who completed the prevention program in pre-
adolescence were able to deal with the chal-
lenges they faced in adolescence more effec-
tively and had less depression than children in
the control group. This study demonstrates the
importance of teaching children the skills of
learned optimism before they reach puberty,
but late enough in childhood for them to un-
derstand the concepts.
The study of optimism in children is fairly
new, and many areas have yet to be researched.
Results thus far seem to indicate that optimism
can be taught, and learned optimism can be
helpful in alleviating and even preventing some
of the problems of childhood and adolescence.
Optimism may be a very valuable tool that chil-

dren can use to negotiate the challenges and ad-
versity they are sure to face.
Hope
Definition and Concept
Snyder and his colleagues have defined hope as
a cognitive set involving an individual’s beliefs
in his or her capability to produce workable
routes to goals (waypower or pathways) and be-
liefs in his or her own ability to initiate and
sustain movement toward those goals (will-
power or agency; Snyder, 1994; Snyder et al.,
1991; Snyder, Hoza, et al., 1997). With this def-
inition they have suggested that hope is an
important construct in understanding how chil-
dren deal with stressors in their lives, avoid be-
coming mired down in problem behaviors, and
use past experiences to develop strategies for
working toward goals in an adaptive, effective
manner.
Hope is not correlated with intelligence, and
Snyder, Hoza, et al. (1997) have proposed that
most children have the intellectual capacity to
use hopeful, goal-directed thinking. Children’s
hope does appear to moderately predict cogni-
tive and school-related achievement. Boys and
girls have similar levels of hope. Children tend
to be biased somewhat positively in their per-
ceptions of the future, although it has been ar-
gued that this is typical and rather adaptive
(Snyder, Hoza, et al., 1997). This bias may be

appropriate to help children develop and sustain
positive outcome thoughts even if they are re-
alistically untenable, because it appears that
high-hope children do this as they successfully
deal with stressful events in childhood. The re-
search thus far indicates that, for most children,
hope is relatively high, and that even children
with comparatively low hope rarely indicate
that they have no hope, and they tend to have
hope in at least some of their thoughts (Snyder,
McDermott, Cook, & Rapoff, 1997). Measures
of children’s hope correlate positively with self-
reported competency, and children with higher
levels of hope report feeling more positively
about themselves and less depressed than chil-
dren with lower levels of hope. Snyder, Feld-
man, Taylor, Schroeder, and Adams (2000)
present some experimental evidence to support
the idea that self-esteem results from the de-
velopment of hope (through identification of
goals and pathways).
Measurement
A measure of children’s hope, the Children’s
Hope Scale (CHS), was developed by Snyder,
Hoza, et al. (1997). The guiding assumption be-
hind the development of the CHS and subse-
quent versions of the scale (Snyder, Hoza, et al.,
1997) was that the acquisition and usage of
goal-directed thinking are critical for effective
functioning in children and adolescents.

Therefore, the purpose of the measure is to
identify children who need nurturance and ed-
ucation in order to improve their hopeful think-
ing, especially during times of illness and stress
(Snyder, McDermott, et al., 1997). The scale
also identifies children who exhibit hope at high
levels and who can serve as models for other
children. Several versions of the CHS have been
designed for different age-groups and for dif-
ferent purposes. These versions include the
Young Children’s Hope Scale (YCHS) Story
CHAPTER 48. POSITIVE PSYCHOLOGY FOR CHILDREN 667
Form (aged 5–8 years); the Young Children’s
Hope Scale (YCHS) Self-Report Form (aged 5–
9 years); the Young Children’s Hope Scale
(YCHS) Observer Rating Form (for teachers,
parents, and other adults), the Children’s Hope
Scale (CHS) Self-Report Form (aged 9–16
years); and the Children’s Hope Scale (CHS)
Observer Rating Form. Adolescents aged 16 and
over can complete the Trait Hope Scale or the
State Hope Scale, which have been designed for
adults and also come with observer rating
forms.
Data collected during the development of the
original Children’s Hope Scale indicate that the
CHS demonstrates high test-retest reliability
for intervals up to 1 month (Snyder, Hoza, et
al., 1997). Research with the hope scales for
children has shown that the agency (willpower)

and pathways (waypower) subscales tend to cor-
relate .50 to .70. Snyder, McDermott, et al.
(1997) have labeled four different patterns of
scores that tend to describe children’s hope
based on the combination of their agency and
pathways subscores: small hope (low agency
and low pathways), half hope (one low and one
high), and high or large hope (high agency and
high pathways). It has been suggested that in-
terventions may be tailored to address either
low agency or low pathways, or both, but re-
search has not addressed this possibility (Sny-
der, McDermott, et al., 1997).
Increasingly more research has explored hope
in children. In particular, hope has been intro-
duced as a useful concept to examine in pediatric
populations, because children who are seriously
ill or injured are often required to cope with or
adjust to difficult conditions. In this section, we
will examine the handful of studies that have
investigated hope in children.
In the first study, Lewis and Kliewer (1996)
investigated the role that coping strategies play
in the relationship between hope and adjust-
ment in a group of children with sickle-cell dis-
ease (SCD). Results revealed that hope was neg-
atively related to anxiety, but that coping
strategies moderated this relationship. Specifi-
cally, hope was negatively related to anxiety
when active support and distraction coping

strategies were high. In other words, children
with SCD who had high levels of hope and who
reported using primarily active, support, and
distraction coping strategies reported less anxi-
ety. Hope did not appear to be associated with
a reduction in anxiety by affecting coping ef-
forts. Hope and coping were related to anxiety
but did not make unique contributions to func-
tional adjustment or depression once control
variables were considered. The authors con-
cluded that knowing both a child’s level of hope
and the types of coping behaviors he or she is
using may be important for understanding var-
iations in psychological adjustment, especially
when talking about a disorder like SCD, where
stress and anxiety can exacerbate physical con-
ditions.
In the second study, Barnum, Snyder, Rapoff,
Mani, and Thompson (1998) hypothesized that
high-hope thinking may serve a protective
function, allowing children to function effec-
tively in spite of obstacles and challenges in
their lives. They examined predictors of adjust-
ment in adolescents who suffered burns as chil-
dren and their matched controls. Variables that
were selected as possible predictors of adjust-
ment included social support, family environ-
ment, burn characteristics, demographics, and
hope. There were few differences between the
burn survivors and the comparison group. For

both groups, hope was the only significant pre-
dictor of externalizing behavior problem scores:
Higher hope scores predicted lower externaliz-
ing behavior scores. In addition, social support
and hope both significantly contributed to the
prediction of global self-worth. Barnum et al.
suggested that adolescents who report higher
levels of hope may think in ways that generate
positive solutions, and they may feel more ca-
pable of enacting a variety of behaviors to solve
problems, possibly reducing the need to act out
in problematic ways.
In a third study using the CHS, Hinton-
Nelson, Roberts, and Snyder (1996) gathered
information from junior high students attend-
ing a school in close proximity to a high crime
area in order to explore the relationship be-
tween stressful life experiences, hope, and per-
ceived vulnerability. In addition to measuring
the children’s hope, they also measured the
children’s exposure to violence and their per-
ceptions of their vulnerability to victimization.
Hinton-Nelson et al. hypothesized that children
who had been exposed to violence would have
lower levels of hope, but this was not the case.
The children in this study reported levels of
hope similar to that of other groups. Adoles-
cents who had witnessed violence around them
but had less personal or direct experience with
violence reported the highest levels of hope, and

668 PART IX. SPECIAL POPULATIONS AND SETTINGS
adolescents with higher hope perceived that
they would be less likely to die a violent death.
Adolescents with direct exposure to violence
tended to predict violent deaths for themselves.
The authors concluded that, while these young
people acknowledged the violence surrounding
them, they were able to sustain high hope as
long as they did not experience violence di-
rectly.
Intervention
A few preliminary projects are being reported
in which an intervention has been designed to
influence children’s hope. Snyder, McDermott,
et al. (1997) proposed that hopeful stories are
important for constructing and maintaining a
sense of hope in children. They viewed hopeful
stories as reflections of past experiences and ar-
gued that these stories are used to guide future
action. McDermott et al. (1996; and described in
McDermott & Hastings, 2000) discussed a pro-
gram in which schoolchildren (grades 1–6) were
read stories of high-hope children, and class-
room discussions addressed how these children
might incorporate hope into their own lives.
Modest positive changes were found on mea-
sures of hope. These authors noted that a more
comprehensive inclusion of teaching hope in the
classroom might have greater effect. Lopez
(2000) conducted another pilot project in a jun-

ior high school in which hopeful stories (e.g.,
from a Harry Potter book) were read. Children
were engaged in structured exercises, goal-
oriented discussions, and the assignment of a
“Hope Buddy” to discuss goals, pathways to
achieve goals, and ways to navigate around bar-
riers. Future research needs to examine the use-
fulness of hope-filled curriculum as an inter-
vention technique.
Other projects have examined whether psy-
chosocial interventions are associated with chil-
dren’s hope (but where hope was not the prime
target of the intervention). McNeal (1998) con-
ducted a study of children and adolescents’ hope
before and after they had been in psychological
treatment in a residential setting over 6 months.
He found that significantly higher levels of
hope were developed over that period. In an-
other study of hope with children in an inter-
vention program, Brown and Roberts (2000) as-
sessed hope in children who were participants
in a summer day camp after being identified as
being at risk for a number of psychosocial prob-
lems. In the 6-week camp, the children were
given intensive training in dance and perform-
ing arts. They also participated in group ses-
sions on a variety of psychosocial issues related
to their life experiences. During the day camp,
the participants wrote essays answering ques-
tions similar to those proposed by Snyder,

McDermott et al. (1997). The results during the
camp and afterward indicated that hope scores
increased significantly as a result of the 6-week
experience. Mean hope scores remained elevated
and stable at a 4-month follow-up. The study
could not isolate what contributed to the hope
changes, so the comprehensive camp experience
as a whole may be viewed as an intervention.
These types of intervention can indicate the vi-
ability of hope as a dependent measure indicat-
ing change as a result. Most important, these
studies into children’s hope demonstrate that
hope in children is an essential element of de-
velopment.
Quality of Life
Definition and Concept
The concept of quality of life (QOL) takes a
multidimensional view of well-being and in-
cludes physical, mental, spiritual, and social as-
pects (Institute for the Future, 2000). However,
QOL has not been well defined or consistently
utilized in the literature. Other terms, such as
psychological well-being or adjustment are also
used to represent constructs similar to QOL.
Walker and Rosser (1988) defined QOL as “a
concept encompassing a broad range of physical
and psychological characteristics and limitations
which describes an individual’s ability to func-
tion and derive satisfaction from doing so”
(p. xv). One QOL measure for pediatric cancer

patients includes five domains: disease and
treatment-related symptoms, physical function-
ing, social functioning, cognitive functioning,
and psychological functioning (Varni, Seid, &
Rode, 1999).
In addition to exploring QOL as a general
concept, research has examined health-related
quality of life (e.g., determination of whether
new and invasive treatments to increase chances
of survival are worthwhile given the deleterious
nature of the treatment side effects). Health-
related QOL reflects an individual’s personal
perceptions of his or her own well-being. For
example, a child with asthma may successfully
pass a pulmonary function test but may have
CHAPTER 48. POSITIVE PSYCHOLOGY FOR CHILDREN 669
fears of an attack and thus limit the physical
activities he or she is willing to try. Those in-
terested in the delegation of limited health re-
sources also have recognized the utility of mea-
suring health-related QOL. Measuring QOL in
the medical setting may assist health profes-
sionals in demonstrating to third-party payers
the effectiveness of particular interventions.
In addition to measuring QOL in health sit-
uations, QOL measures are used to assess im-
pact of health-related diseases and procedures
on one’s daily life. However, one of the most
frequently noted concerns is that the various
QOL measures lack theoretical foundations.

Much of the philosophy behind the measure-
ment of health-related QOL has been based on
the notion that the medical treatment itself is
the primary determinant of a patient’s QOL.
Varni (1983) suggested that this biomedical
model does not encompass all aspects of a pe-
diatric patient’s life or situation that might af-
fect his or her perceptions of QOL. Varni pro-
posed that, in addition to the traditional
biomedical model, a biobehavioral conceptuali-
zation should guide assessment. In this model,
a patient’s problem-solving skills and ongoing
level of symptom control are important. Kaplan,
Sallis, and Patterson (1993) proposed a biopsy-
chosocial model that emphasizes the important
roles of social, psychological, and biological fac-
tors in the conceptualization of health-related
QOL. To date, conceptualization and measure-
ment of health-related QOL in children has
lagged behind that of adults (Spieth & Harris,
1996).
Measurement
QOL measures were developed for adults, so
many of the measures cover domains not ap-
plicable to children (e.g., economic indepen-
dence, infertility) or base the psychometrics on
adult responses. Thus, there is little information
regarding the validity or reliability of these
measures for use with children. When assessing
a child’s QOL, age and development should be

considered. In addition, there is a lack of con-
sensus in the literature regarding who is the
best informant of a child’s health-related QOL.
Early measures did not take into account a
child’s perceptions, for example. Instead, par-
ents, teachers, nurses, and doctors provided sub-
jective information to define children’s QOL.
While some studies have suggested that proxy
informants are similar to a child’s own percep-
tions of his or her QOL, the majority of the
research provides limited evidence for concor-
dance between respondents (Vogels et al., 1998).
Additionally, considerable difference in ob-
server ratings provided by parents and teachers
and the children’s own self-ratings of health at-
titudes and behaviors has been reported (Pantell
& Lewis, 1987).
Using parents to rate QOL is a widely imple-
mented strategy in the literature, yet parents
may not report all important aspects of their
children’s well-being. For example, parents of
adolescents might underestimate the important
role of peers. Health personnel also may serve
as reporters for a child’s QOL. One advantage
of hospital staff is that these individuals can use
other patients as points of reference. However,
they may have limited knowledge regarding the
child’s functioning in other arenas of life, such
as at home, in school, or with peers. In addition,
they may overemphasize the importance of pos-

itive health outcomes versus social, psycholog-
ical, or spiritual outcomes.
Guyatt and colleagues (1997) suggested that
information should be obtained regarding per-
ceived QOL from the children themselves. Al-
though age-appropriate modifications are nec-
essary, self-report QOL information can be
reliably obtained from children as young as 7
(Feeny, Juniper, Ferry, Griffith, & Guyatt,
1998). Guyatt et al. noted that younger children
have difficulty recalling events that occurred
more than a week earlier. In addition, they
found that the feeling thermometer, a measure
often used to assess children’s QOL, seemed
more difficult for children to understand than
interview-administered questionnaires. They
suggested that feeling thermometers should
only be used with children at a reading level of
age 8 or grade 3.
One frequently used measure assesses both
child and parent perceptions of health-related
QOL. The Pediatric Cancer Quality of Life In-
ventory (PCQL) contains two parallel forms de-
signed to define health-related QOL in terms of
the impact of the disease and treatment on the
child’s physical, social, psychological, and cog-
nitive functioning and disease or treatment-
related symptoms as perceived by parent and
child patient (Varni et al., 1998). In addition to
issues of who is the best informant, a clinician

must decide between general and disease-
specific QOL measures. General measures of
QOL can be used in many other instances as
well, such as for children with low-incidence
670 PART IX. SPECIAL POPULATIONS AND SETTINGS
childhood diseases. Additionally, these general
measures allow for cross-condition compari-
sons. These measures include the Child Health
and Illness Profile—Adolescent Edition (Star-
field et al., 1995); Child Health Questionnaire
(Landgraf, Abetz, & Ware, 1996); Functional
Status II-R (Stein & Jessop, 1990); and Play
Performance Scale for Children (Mulhern, Fair-
cough, Friedman, & Leigh, 1990).
Disease-specific measures of QOL may be
more sensitive in determining the differential
effects of treatments within one illness domain.
Consequently, different QOL measures have
been developed for use with various childhood
conditions including pediatric cancer (Varni et
al., 1998), diabetes (Diabetes Control and Com-
plications Trial Research Group, 1988), asthma
(Mishoe et al., 1998; Townsend et al., 1991), and
children born with limb deficiencies (Pruitt,
Seid, Varni, & Setoguchi, 1999). These mea-
sures demonstrate some utility in detecting
changes in patients whose health status has
changed due to fluctuations of their disease or
as a result of treatment. In the case of children’s
asthma, a multidisciplinary team assesses QOL

in the domains of symptomatology, activity
limitations, and emotional functioning (Town-
send et al., 1991). The QOL measure for dia-
betes assesses disease impact as well as school
life and relationships with peers (Ingersoll &
Marrero, 1991). Most of the better measures ap-
pear to use this multidimensional approach to
assess not only physical symptoms but also
health status, psychological and adaptive func-
tioning, and family functioning.
Interventions
One purpose of studies examining QOL is to
add clinical relevance to the results of outcome
studies following medical or psychological in-
terventions. Drotar and colleagues (1998) sug-
gested that the use of health-related QOL mea-
sures could aid in the identification of children
with chronic illness who may need additional
psychological assessment and intervention. The
use of these measures early in the initial iden-
tification of an illness may help improve par-
ents’ ability to report information regarding
their child’s mental and physical health earlier
and more thoroughly. For example, for children
diagnosed with cancer, Boggs and Durning
(1998) reported using the Pediatric Oncology
Quality of Life Scale as a screening measure to
determine which children would be most likely
to benefit from psychological services. Another
purpose of QOL studies is to identify the chil-

dren who are experiencing health problems who
are less likely to adhere to a treatment protocol
(Drotar et al., 1998). For some children, the side
effects of a treatment regimen may be seen as
very aversive and may affect QOL. Information
collected through the use of QOL measures
may lead to additional support or intervention
for the child. Psychosocial interventions de-
signed to improve the adjustment and function-
ing of children undergoing medical treatment
may also impact reported QOL.
Related Concepts of Positive
Psychology
There are several psychological concepts related
to positive psychology in children in addition to
the concepts reviewed here. The movement in
pediatric psychology away from an exclusive fo-
cus on children’s deficits or pathology to a more
affirming and strength-building approach ex-
emplifies a positive psychology orientation
(whether acknowledged or not). Clinicians and
researchers are increasingly focused on enhanc-
ing and facilitating children’s development
whatever the setting or circumstances. In the
psychosocial care of children with cancer, Noll
and Kazak (1997) emphasized that while diag-
nosis and treatment “can be overwhelming,
they can be managed in positive ways that en-
courage families to continue to function in the
best possible fashion and facilitate personal

growth” (p. 263). They recommended that in
order to promote positive adaptations, certain
psychologically directed actions can be taken by
professionals, parents, and children themselves.
Other aspects related to enhancing the psycho-
social growth of children in medical settings in-
volve making changes in the hospital architec-
ture that welcome and support children and
families, training staff to recognize and facilitate
children’s needs and development at all times,
and following medical procedures that allow
children appropriate input and control regarding
what is done to them (Johnson, Jeppson, & Red-
burn, 1992).
Similarly, schools can be envisioned as set-
tings where children can experience empower-
ment and enhanced development rather than
places where the focus is on stresses and chal-
lenges (Donnelly, 1997; Schorr, 1997). For ex-
ample, Spivack and Shure have developed and
CHAPTER 48. POSITIVE PSYCHOLOGY FOR CHILDREN 671
tested a model of teaching children and teachers
to use interpersonal cognitive problem-solving
skills in interactions (Shure, 1996). These skills
enhance positive growth and development with-
out focusing on any of a child’s deficiencies.
Social support is also viewed as a potential
element of positive psychology for children fac-
ing the challenges of stressful events as well as
coping and adjusting in everyday living. Quitt-

ner (1992) noted that the accepted definition of
social support includes several aspects such as
“provision of direct assistance, information,
emotional concern, and affirmation” (p. 87). So-
cial support has not been fully conceptualized
within a positive psychology framework but re-
lates to it very well.
Faith is another aspect of positive psychology
that has not been given significant attention. As
noted by health researchers, “Spiritual factors
promote good health and contribute to the
state of wellness that characterizes health” (In-
stitute for the Future, 2000, p. 190). Additional
consideration of faith and religion in the lives
of children and adolescents may be an important
aspect of positive psychology research.
Developmental Perspective
Because positive psychology is a newly devel-
oping field of research and application, there re-
main a large number of issues for children and
adolescents that deserve greater attention. Al-
though it is encouraging to have any research,
the relative lack of empirical studies to review
in this chapter indicates that there is much to
be done. We strongly urge that positive psy-
chology theorists and researchers consider a de-
velopmental perspective rather than focusing
only on adults (and children as “smaller hu-
mans”) or give minimal attention to develop-
ment by considering childhood only as a period

preceding adulthood. Maddux et al. (1986) sug-
gested that two elements are important to a de-
velopmental approach. The first is a future ori-
entation in which any effort at intervention or
change is considered important because of its
relationship to improving future health status
(i.e., in adulthood). The second, and perhaps
most neglected, element in a developmental per-
spective requires that “each period of life receive
attention to the particular problems evident in
that period” (p. 25). Thus, there should be a fo-
cus on the health status of children while they
are children rather than recognizing children’s
importance only because the children will be-
come adults in the future. We think both ele-
ments are important in the positive psychology
movement, but we want to emphasize the latter
point. The uniqueness of children’s develop-
ment needs to be recognized in all theories,
measurements, and application of positive psy-
chology concepts.
Prevention and Promotion
Interlinked with the developmental perspective
is a view that childhood may be the optimal
time to promote healthy attitudes, behavior, ad-
justment, and prevention of problems (Roberts
& Peterson, 1984). Roberts (1991) stated, “Pre-
vention is basically taking action to avoid de-
velopment of a problem and/or identify prob-
lems early enough in their development to

minimize potential negative outcomes. Health
promotion refers to increasing individuals’ abil-
ities to adopt health-enhancing life styles”
(p. 95). Prevention and promotion efforts in
childhood attempt to improve the quality of life
for the child during childhood and for that
child’s later adulthood. As noted by Peterson
and Roberts (1986), prevention efforts often
take a developmental perspective and focus on
competency enhancement that “is likely to be
most effective when applied during the time of
greatest competency acquisition, which is dur-
ing childhood for many skills such as language,
social abilities, or self-efficacy beliefs” (p. 623).
Such enhancement of positive psychology
thinking, such as encouraging hope, would sim-
ilarly be most effective at these early stages of
human development.
Future Research Directions
Studies of the positive psychology topics of hope
and optimism, as examples, have typically util-
ized cross-sectional designs. Longitudinal mod-
els would elucidate the sequence of development
and what influences change over time. Interven-
tions and evaluations of programs to promote
hope or optimism are also prime areas for fur-
ther work. Interventions may enhance the posi-
tive frames for all children or for those with
special stresses. In the latter case, applications
may be necessary with children who have a

chronic illness or with those experiencing psy-
chological problems or disruptive life events,
672 PART IX. SPECIAL POPULATIONS AND SETTINGS
such as divorce, death, or relocation. Most im-
portant, because positive psychology seems in-
herently linked to preventive efforts to improve
children’s lives, these concepts need to be inte-
grated into prevention theory and programming.
Behavioral measures of positive psychology con-
cepts, such as hope, need to be developed and in-
tegrated into the theories. These behaviors can
then be used as affirmative outcome measures in
prevention and intervention programs.
More research needs to be done with children
with regard to happiness and positive well-
being. So far, outcome measures in the study of
optimism in children assess whether negative
states are present or absent. Instruments need
to be developed that also measure the positive
aspects that children possess, like happiness, in-
stead of just the absence of any negatives. An-
other area for future research is in pediatric
psychology. Does enhancing hope and teaching
children with a chronic illness the skills of
learned optimism improve the course of their
illness or the quality of their lives? Does a pos-
itive psychology approach help the family to
cope with the child’s illness?
Research is needed to determine more pre-
cisely when hope becomes a stable personality

trait and whether hope is stable during child-
hood and adolescence. Additional research
should determine what types of experiences are
related to high or low hope, and under what
circumstances children’s levels of hope may be
malleable to negative or positive circumstances.
Further research may explore what types of in-
terventions may help children to increase their
level of hope or optimism. McNeal (1998) and
Brown and Roberts (2000) found evidence sug-
gesting that children and adolescents reported
higher levels of hope after psychosocial inter-
ventions (but these interventions were not di-
rectly attempting to affect the children’s hope).
Pilot projects by Lopez (2000) and McDermott
et al. (1996) are promising investigations di-
rectly targeting changes in children’s hope.
Whether such changes in hope subsequently af-
fect other significant outcomes in children will
be important to measure. As suggested by Sny-
der et al. (2000), ensuring that children have
“hope coaches” early and consistently in their
lives seems important to the development of
hope. Books for parents and other caregivers
that teach hope coaching skills, such as Mc-
Dermott and Snyder, The Great Big Book of
Hope (2000), should be empirically evaluated to
assess their effectiveness.
Research is needed to examine whether other
types of psychotherapy or psychosocial inter-

ventions might affect children’s levels of hope
or learned optimism (or whether these variables
predict the influence of the psychological/be-
havioral interventions). Finally, future research
needs to address the relationship between hope,
coping, and adjustment. Studies need to exam-
ine whether preexisting levels of hope may in-
fluence the impact of life events on children’s
adjustment.
In their study of the effects of violence on
hope, Hinton-Nelson et al. (1996) suggested
that future research should investigate whether
hope and perceptions of the future differentiate
those young people who commit violent acts
from those who do not. They also suggested
that future research examine the relationship
between hope and resiliency.
Quality-of-life issues are important when one
is considering a multidimensional view of how
a child (or adult) perceives the world and his or
her functioning within it. Further refinement of
the conceptual bases and measurement tools is
clearly needed. Measurement of QOL in its
general and situation-specific forms will aid in
the conceptualization of how children develop
their perspectives on their lives, what they de-
fine as important, and how they rate what they
value. In its development the QOL concept de-
rived from a deficit view, for example, negative
life events diminish QOL. In newer conceptu-

alizations, measuring QOL perceptions in chil-
dren and adolescents may provide evidence of
the positive effects of even negative life events
(Cohen & Park, 1992). Thus, future research
should also examine the adaptive and resiliency
features in a child that may lead to greater sat-
isfaction and enhanced or increased QOL.
The many benefits of a positive psychology
orientation with children have been hinted at by
the research thus far. The full contribution will
be demonstrated through a better understand-
ing of children’s development and more effec-
tive interventions that also address prevention,
treatment of problems, and the promotion of
well-being.
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676
49
Aging Well
Outlook for the 21st Century
Gail M. Williamson

Getting old is something most people dread be-
cause they believe it portends the loss of func-
tional capacities and the enjoyable aspects of
life. But, as my grandfather often said in the
last years of his life, “Being old is better than
the only available alternative.” Thus, if we are
fortunate, we will age. Our best option, then, is
to remain as vital as we can for as long as pos-
sible. In the last two decades, there has been a
movement toward defining and fostering “suc-
cessful aging” that, to judge by recent profes-
sional and popular press publications, has lit-
erally exploded.
It is a credit to our society that we are more
concerned about old people than ever before. On
the other hand, there never have been as many
old people about whom to be concerned. An
even greater worry is that the number of older
Americans will increase dramatically in the next
10 years and beyond, as will their percentage of
the population. Indeed, this demographic shift
is the most salient explanation for the mush-
rooming interest in gerontological science.
History of Aging and Outlook for
the Future
The population is “graying.”
1
Put simply, peo-
ple are living longer. Life expectancy in 1900
was 47 years; today, it is closer to 76 years.

Over two thirds of people now live to at least
age 65 (a threefold increase from 1900). And the
fastest growing segment of the population is in
the over age 85 category—4% in 1900 to over
10% today (e.g., Rowe & Kahn, 1998; U.S. De-
partment of Health and Human Services
[DHHS], 1992; Volz, 2000). Moreover, the first
wave of the 76 million baby boomers born be-
tween 1946 and 1964 will approach traditional
retirement age in 2010 (Binstock, 1999). In 30
years, there will be twice as many people 65
years of age and older, and these oldsters will
constitute at least 20% of the total population
(e.g., Hobbs, 1996). By 2050, the number of
centenarians (those over age 100) in the United
States may be as high as 4.2 million (Volz,
2000).
CHAPTER 49. AGING WELL 677
Historically, attitudes about aging have been
fraught with mythical thinking, a shortsight-
edness we have yet to overcome. To give a few
examples, old people are viewed as sick, cogni-
tively inept, isolated, a financial drain on soci-
ety, and depressed by their circumstances (e.g.,
Center for the Advancement of Health [CAH],
1998; Palmore, 1990; Rowe & Kahn, 1998). Tra-
ditional attitudes and the projected increase in
elderly people within the next few years have
seduced scholars, commentators, and policy
makers into the doomsday philosophy that our

society is about to be overwhelmed by people
who are disabled, requiring constant care, and
not making worthwhile contributions. With
fewer children per capita than previous gener-
ations, a major concern is that when the baby
boomers age into disability, there will be fewer
adult children available to provide care, creating
a demand for formal care that may severely (if
not impossibly) tax the rest of societal re-
sources.
Are we, in fact, on the brink of geriatric Ar-
mageddon? As with any substantial demo-
graphic shift, there are problems to be ad-
dressed. The central purpose of this chapter,
however, is to summarize evidence that indi-
cates things are not as grim as they might ap-
pear, and, indeed, that there are offsetting par-
allel, positive arguments to these catastrophic
predictions. Many solutions revolve around ac-
tions that should be taken and, in some cases,
already are being taken at governmental and so-
cietal levels. But I also argue that aging individ-
uals and their immediate social networks can
solve many problems without resorting to pub-
lic assistance. The solution lies in changing their
behaviors so that they can continue to engage
in valued normal activities with each advancing
year. First, however, we need to take a realistic
look at today’s elders and what future genera-
tions can expect as they age.

Are Old People Sick People?
An important truth, albeit persistently denied
by much of the population, is that most adults
over age 65 are remarkably healthy. Rates of
disability, even among the very old (i.e., those
over age 95), are steadily declining. Only 5.2%
of older adults live in nursing homes and sim-
ilar facilities, a drop of 1.1% since 1982 (CAH,
1998). In 1994, 73% of adults 78 to 84 years of
age reported no disabling conditions, and among
the “oldest old” (i.e., those over age 85), fully
40% had no functional disabilities (Manton,
Stallard, & Corder, 1995).
Along with increasingly widespread public
knowledge and acceptance of the behavioral as-
pects of chronic illness, advances in medical
technology forecast an even rosier old age for
baby boomers and subsequent generations
(DHHS, 1992). Although no solution is in
sight for the fact that, with age, physiological
systems slow down and become less efficient
(Birren & Birren, 1990), older adults are quite
skilled in making gradual lifestyle changes to
accommodate diminishing physical abilities
(Williamson & Dooley, 2001). Through medi-
cal and psychological research, we also know
that “nature is remarkably forgiving” (CAH,
1998). In other words, it is never too late to be-
gin a healthful lifestyle. For example, regard-
less of age, duration of smoking, and magni-

tude of tobacco consumption, after 5 years of
abstinence, ex-smokers have about the same
risk for heart disease as those who never
smoked. The same is true for a variety of other
risk factors, including obesity and a sedentary
lifestyle.
Are Old People Cognitively Deficient?
As with physiological functions, in the “nor-
mal” course of events, cognitive abilities slow
down with increasing age (Horn & Hofer, 1992;
Schaie, 1996). The “use it or lose it” adage
about sexual functioning, however, applies to
learning and memory abilities as well. Short of
organic disorders (e.g., Alzheimer’s disease) that
increase with age (e.g., Gatz & Smyer, 1992),
older adults in cognitively challenging environ-
ments show minimal, if any, declines in think-
ing and learning abilities. Similar to any other
age group, when elderly people are less men-
tally challenged, their cognitive performance
declines (e.g., CAH, 1998; Lawton & Nahemow,
1973). Although older adults may routinely en-
counter such challenges less frequently than the
college students to whom they typically are
compared (Williamson & Dooley, 2001), under
the right conditions, they can learn new
things—and learn them quite well (e.g., Schaie,
1996; also see Volz, 2000, for a review). More-
over, whether people believe they can learn and
remember is crucial (Cavanaugh, 1996). The

lesson here is that aging adults bear some re-
sponsibility for making sure that they engage
in cognitively challenging activities (West,
Crook, & Barron, 1992).
678 PART IX. SPECIAL POPULATIONS AND SETTINGS
What about future generations? Being able to
use current and emerging technologies should
improve cognitive capacities of seniors, but
those who make the effort to gain technological
expertise will benefit most from these advances.
The first step may involve no more than learn-
ing to use an ATM machine, but that effort can
promote subsequent skills (Rogers, Fisk, Mead,
Walker, & Cabrera, 1996). In addition, “neu-
robic exercises” both preserve and improve
brain and memory functions (Katz, Rubin, &
Suter, 1999). Routine activities that require lit-
tle cognitive effort can exacerbate cognitive de-
cline. Accordingly, Katz and colleagues recom-
mend seeking offbeat and, simultaneously, fun
experiences—not because they are difficult but
because they are different.
Are Old People Isolated and Lonely?
Rowe and Kahn (1998) assert that “the com-
mon view of old age as a prolonged period of
demanding support from an ever-diminishing
number of overworked providers is wrong”
(pp. 159–160). Citing evidence from the Mac-
Arthur Foundation Study of Aging in America,
these researchers argue that social networks

remain remarkably stable in size throughout
the life span, with the number of close rela-
tionships among noninstitutionalized older
adults equaling those of younger people. Some
elders are isolated and lonely, but people fail to
realize that the same is true for other age
groups as well. Network losses do occur over
the life span through death, relocation, and re-
tirement, but even among very old people, new
social relationships are formed to replace lost
ones.
What does the future bode for the baby
boomers? Will they, with fewer offspring, be
lonelier and more isolated than previous gen-
erations? Probably not. They should be just as
capable of dealing with changes in network size
as are today’s elders. In addition, they will have
the advantages afforded by technology and cy-
berspace. With their computer competencies,
the majority of aging baby boomers will use
e-mail to stay in touch with family members
and friends. Furthermore, we already have ev-
idence that they are more likely than their
younger counterparts to access Internet infor-
mation and support from a wide spectrum of
people who share their needs and concerns (Ki-
yak & Hooyman, 1999).
Do Old People Drain Society’s
Resources?
According to the CAH report (1998), the com-

mon belief that old people drain society’s re-
sources is based on the assumption that “every-
body who works for pay is pulling his or her
weight, and those who do not are a burden”
(p. 5). Contrary to past attitudes, the benefits el-
ders receive are being scrutinized as potentially
wasted and taking away from “more needy”
groups and the overall economic well-being
(Hendricks, Hatch, & Cutler, 1999). How accu-
rate is the “emerging social construction of older
Americans as ‘greedy geezers’ who are advan-
taged relative to younger age groups and who do
not deserve such a large slice of the government
pie” (Hendricks et al., 1999, p. 15; also see Hew-
itt, 1997; Steckenrider & Parrott, 1998)?
Evidence does not support such sweeping in-
terpretations. First, lumping older adults into a
homogeneous group is inappropriate. They vary
as widely as their younger counterparts in
health, financial security, and willingness to ac-
cept public support. Second, senior citizen ben-
efits depend on social status and past work ex-
perience, favoring high-income earners with a
continuous work history, that is, white middle-
class men (Hendricks et al., 1999). The stereo-
type of these “advantaged” oldsters is used to
justify reforms aimed at decreasing old-age ben-
efits for all elders. Let us look at the actual sce-
nario. The standard for living at or below the
poverty level changes between age 64 and age

65; people 64 and younger qualify for poverty
benefits with less income than do those 65 and
older. Today, 12% of people over age 65 live in
governmentally defined poverty (U.S. Senate
Special Committee on Aging, 1997). Without
Social Security, this percentage would increase
to 50% or more (Moon & Mulvey, 1996). Thus,
cuts in Social Security would hit hardest those
who need it most.
Moreover, older adults do not drain societal
resources. They may not engage in work for
pay, but “paid” work tends to be overvalued in
our society (e.g., CAH, 1998). By contrast, un-
paid (e.g., in the home, volunteer efforts) and
underpaid (e.g., working in fast-food restau-
rants and bagging groceries) activities contrib-
ute a great deal to the social enterprise. In fact,
when given the opportunity, large numbers of
seniors are eager to do volunteer work and take
on low-paying part-time jobs.
CHAPTER 49. AGING WELL 679
The baby boomers and subsequent genera-
tions should be more advantaged in the work
domain relative to the current cohort of old-
sters. Attitudes about older workers are chang-
ing. More important, because of post–baby
boom declines in birth rates, as the baby boom-
ers age, the number of employable adults will
decrease relative to the number of new jobs
(DHHS, 1992; Kiyak & Hooyman, 1999). Fol-

lowing the law of supply and demand, older
workers will be more valued and sought-after,
and those who do not feel ready to retire are
less likely to be compelled to do so. Many policy
makers advocate raising the normal retirement
age to 70. The reasoning is that, in terms of
health and life expectancy, age 70 today is
roughly the equivalent of age 65 in the 1930s
when Social Security was established (e.g.,
Chen, 1994). Indeed, changing health status and
attitudes have led to age 65 no longer being
considered “old” (Kiyak & Hooyman, 1999).
Although most individuals who have adequate
(or better) financial resources will retire at the
usual time or follow the trend toward early re-
tirement (e.g., Quinn & Burkhauser, 1990),
physically healthy elders will be able to choose
to continue working either because they want
to or because they feel the need to supplement
their retirement benefits.
But the critical prerequisite for continuing to
live as one pleases is good health. What about
older adults who both are physically unable to
continue working for pay and do not have the
financial resources to live in a satisfactory fash-
ion without working—that is, those whose pri-
mary, perhaps only, source of income is Social
Security? Recognizing the needs of these people
in an ever-aging population has fostered nu-
merous governmental initiatives (U.S. Depart-

ment of Housing and Urban Development,
1999; also see Hendricks et al., 1999).
The point to be made here revolves around
personal choice. People who feel in control, who
can make choices about the important aspects of
their lives, are both physically healthier and less
depressed than those who perceive that they
lack personal control (e.g., Peterson, Seligman,
& Vaillant, 1988; Taylor, 1983; Taylor &
Brown, 1988).
Are Old People Depressed?
Despite Rowe and Kahn’s (1998) allegation that
“depression is terribly prevalent in older
people” (p. 106), the evidence is to the contrary.
In fact, clinically diagnosable depression is less
prevalent in older than younger adults (e.g.,
Rybash, Roodin, & Hoyer, 1995; Schulz &
Ewen, 1993). Indeed, elders often cope more ef-
fectively with stressful life events than do
younger adults (McCrae, 1989). Over the life
course, through life experiences and successes in
coping with a variety of stressors, the typical
adult builds adaptive attitudes and beliefs that
generalize to coping with new stressors (see
Williamson & Dooley, 2001). Regardless of age,
people are motivated to exercise personal con-
trol over the important aspects of their lives
(Schulz & Heckhausen, 1996). Solving the
problems that go along with getting older (e.g.,
death of a spouse, declines in health status),

however, simply may not be possible. Conse-
quently, those who adapt well will shift their
focus from actively trying to change the situa-
tion to managing stress-related emotional re-
actions by, for example, accepting the situation
and continuing to function as normally as pos-
sible.
Personal control often is limited by social and
cultural expectations about appropriate roles for
specific segments of the population. Today’s
trend toward less stigmatization of older adults
should offer seniors more choices. Other soci-
etal changes will add impetus to this movement.
For example, economic prosperity has created
financial security for many current and future
older Americans, enabling them to exercise con-
trol over how they spend their retirement years.
The construct of personal control constitutes an
important part of the foundation underlying the
model described in the next sections.
The Activity Restriction Model of
Depressed Affect
Activity restriction is the inability to continue
normal activities (e.g., self-care, care of others,
doing household chores, going shopping, visit-
ing friends, working on hobbies, and maintain-
ing friendships) that often follows stressful life
events such as debilitating illness (e.g., William-
son & Schulz, 1992). According to the Activity
Restriction Model of Depressed Affect, major

life stressors lead to poorer mental health out-
comes because they disrupt normal activities
(e.g., Williamson, 1998). In other words, activ-
ity restriction mediates the association between
680 PART IX. SPECIAL POPULATIONS AND SETTINGS
stress and mental health (Walters & William-
son, 1999; Williamson, 2000; Williamson &
Dooley, 2001; Williamson & Schulz, 1992,
1995; Williamson, Schulz, Bridges, & Behan,
1994; Williamson & Shaffer, 2000; Williamson,
Shaffer, & Schulz, 1998; Williamson, Shaffer,
and the Family Relationships in Late Life Proj-
ect, 2000).
Individual Differences in Activity
Restriction
Stressful life circumstances are not the only
contributors to activity restriction. Rather, in-
dividual differences are important factors as
well. Age is one of the ways that individuals
differ. For example, older adults tolerate similar
levels of pain better than do younger adults
(Cassileth et al., 1984; Foley, 1985), a phenom-
enon most commonly attributed to the in-
creased exposure to pain and disabling condi-
tions that older people experience. Indeed, my
colleagues and I have found that experience,
rather than chronological age, matters more in
terms of predicting those who will restrict their
activities in the wake of stressful events (Wal-
ters & Williamson, 1999; Williamson & Schulz,

1995; Williamson et al., 1998). In other words,
old age does not necessarily foster activity re-
striction or depression.
Another potentially important contributor to
coping with stress is financial resources. Inade-
quate income interferes with normal activities
(Merluzzi & Martinez Sanchez, 1997). More-
over, if financial resources are merely perceived
as being less than adequate, activities are more
restricted (see Williamson, 1998, for a review).
Thus, when life becomes stressful, an under-
standable first line of defense may be to cut back
on normal activities that involve spending
money, for example, shopping, recreation, and
hobbies (Williamson & Dooley, 2001).
Aside from demographic factors, aspects of
the individual’s personality also contribute to
activity restriction. Some people cope in mal-
adaptive ways across all situations throughout
their lives. In contrast, there are those who are
dispositionally inclined to face the situation, ra-
tionally evaluate possible solutions, seek help
and information as appropriate, and, if all else
fails, accept that the problem has occurred, deal
with their emotional reactions (perhaps with
help from others), and make every effort to re-
sume life as usual.
As an example of how personality can affect
adjustment, consider public self-consciousness
as it relates to activity restriction and depression

when an illness condition results in bodily dis-
figurement. Public self-consciousness is the sta-
ble tendency to be highly concerned about as-
pects of the self that are evident to others and
from which others form impressions (Scheier &
Carver, 1985). People high in this trait worry a
great deal about their personal appearance and
actively avoid disapproval and rejection from
others. As would be expected, limb amputation
and breast cancer patients who are high in pub-
lic self-consciousness restrict their public activ-
ities (e.g., shopping, visiting friends) and expe-
rience more depression than their counterparts
who are low in public self-consciousness (Wil-
liamson, 1995, 2000). Moreover, highly self-
conscious individuals also restrict nonpublic ac-
tivities such as household chores (Williamson,
1995). Thus, it appears that giving up activities
conducted in the presence of others may gen-
eralize to acts conducted in private, thereby fos-
tering an unnecessary “spread” of the disability.
Reminiscent of findings in the self-presentation
literature on anticipatory excuse-making (Sny-
der, Higgins, & Stucky, 1983), when confront-
ing stressful life events, some people may forgo
their usual activities because they have a justi-
fication for doing so (e.g., Parmelee, Katz, &
Lawton, 1991). But this is not an adaptive strat-
egy (Snyder & Higgins, 1988; Williamson &
Dooley, 2001). Even after controlling for a wide

variety of other factors, activity restriction re-
mains the most proximal predictor of depression
(e.g., Williamson, 1998).
Another important individual difference is
social support resources. People with stronger
social support networks cope better with all
types of stressful life events (Mutran, Reitzes,
Mossey, & Fernandez, 1995; Oxman & Hull,
1997), and routine activities are facilitated by
social support (Williamson et al., 1994). Social
support, however, appears to be a function of
personality variables that, in turn, influence ac-
tivity restriction (e.g., Williamson & Dooley,
2001). Those with more socially desirable or
more socially proactive characteristics also have
more supportive social ties and less activity re-
striction. Comparable benefits are seen in people
who merely perceive that social support is avail-
able if it is needed, and the benefits of perceiv-
ing that one has supportive others remain after
controlling for demographics (e.g., age, financial
resources), illness severity, and personality vari-
CHAPTER 49. AGING WELL 681
ables such as public self-consciousness (Wil-
liamson, 2000).
Summary of Current Research Findings
The forecast for our aging population is that,
more than ever before, older adults will be
physically, cognitively, psychologically, and so-
cially healthy. Still, substantial numbers of the

elderly population will be disabled, socially iso-
lated, and depressed. From accumulating evi-
dence, it is now clear that people consistently
become depressed in the wake of stressful life
events largely because those events disrupt their
ability to go about life as usual (see Williamson,
1998, 2000, for reviews), and that illness sever-
ity, younger age (or lack of experience), inade-
quate income, less social support, and higher
public self-consciousness contribute to this ef-
fect (e.g., Walters & Williamson, 1999; Wil-
liamson, 1998, 2000; Williamson & Schulz,
1992, 1995; Williamson et al., 1998).
In their acclaimed book, Successful Aging,
Rowe and Kahn (1998) propose that there are
three components of successful aging: (a) avoid-
ing disease, (b) engagement with life, and (c)
maintaining high cognitive and physical func-
tion. They further propose that each of these
factors is “to some extent independent of the
others” (p. 38). My colleagues and I do not dis-
agree with this categorization of contributors to
successful aging. However, we argue that these
factors are less inclusive and independent than
Rowe and Kahn suggest. Not only do numerous
other factors influence how well one ages, but
also Rowe and Kahn’s three components can be
subsumed by the construct of maintaining a
lifestyle that involves normal, valued, and ben-
eficial activities.

Our first counterargument is that avoiding
disease is largely a function of routine activities.
Temperance in detrimental behaviors (e.g.,
smoking, drinking alcohol, eating a high-fat
diet) is related to better physical health, less dis-
ability, and greater longevity (e.g., Cohen, Tyr-
rell, Russell, Jarvis, & Smith, 1993; McGinnis
& Foege, 1993). Second, “engagement with life”
(Rowe & Kahn, 1998) is virtually synonymous
with continuing valued personal activities. Peo-
ple who feel engaged with life are those who
engage in personally meaningful activities, but
what qualifies as meaningful will vary according
to each person’s history. In the Activity Restric-
tion Model, it is postulated that continuing to
be involved in personally relevant activities
(whether intellectual, physical, or social) is what
matters most.
Finally, Rowe and Kahn (1998) advocate
maintaining high cognitive and physical func-
tioning as the third key to aging successfully.
When a person is confronted with seemingly
overwhelming life events, the telling factor may
well be the extent to which at least a semblance
of normal activities can continue. What does
this mean when, for example, disability pre-
cludes playing several sets of tennis every day?
If this activity was driven by love of the sport,
then the aging tennis addict can still participate
by watching matches or, even better, by coach-

ing others in the finer aspects of playing the
game.
Interventions to Increase Activity and
Decrease Depression
In the Activity Restriction Model, coping with
stress is posited to be a complex, multifaceted
process that is influenced by numerous factors.
Stressors vary in nature across the life span,
with those faced by older adults being at least
as threatening as those confronted by young
adults. Because physical and psychological stress
differ (e.g., in terms of controllability) with in-
creasing age, however, coping successfully may
require replacing previously adaptive strategies
with ones better suited to the demands of ad-
vancing age. Therefore, interventions may re-
quire convincing elders to shift from problem-
focused to emotion-focused coping mechanisms
(see Stanton, Parsa, & Austenfeld, this volume).
By acknowledging that depressed affect is a
function of restricted normal activities, we can
design interventions that reduce both activity
restriction and depression. Simply encouraging
older adults to engage in more of their normal
activities, however, probably is not the best
strategy. Rather, efforts to increase activity
might take three (and probably several more)
forms. First, therapists should carefully consider
the (likely multiple) reasons that activities have
become restricted and design their interventions

accordingly. Second, they should target the in-
dividuals most at risk for poor adaptation.
Third, identifying manageable activities and
available resources means that programs can be
implemented to engage aging adults in pastimes
that not only meet their specific interests and
needs but also fit their functional capacities.
682 PART IX. SPECIAL POPULATIONS AND SETTINGS
As with younger adults, older adults’ finan-
cial resources vary widely, but higher costs for
insurance and health care in late life can sap
the resources of even the most financially pre-
pared seniors. Still, there are substantial indi-
vidual differences in how financial circum-
stances impact activity restriction (Williamson,
1998). Those with low incomes do not neces-
sarily see their financial resources as inade-
quate; likewise, people with higher incomes do
not uniformly report that their financial re-
sources are adequate (Williamson & Shaffer,
2000). Thus, perceptions of income adequacy
appear to matter more than actual dollar
amounts. Either way, older adults can be di-
rected toward the community-based and inex-
pensive social and recreational resources that
are available to them.
In addition to evaluating demographic char-
acteristics such as age and financial resources, it
is important to assess relevant personality di-
mensions. Although most personality traits are

quite stable across the life span (Costa & Mc-
Crae, 1993; McCrae & Costa, 1986) and, con-
sequently, should be difficult to change, iden-
tifying the traits that predispose people to
restrict their normal activities can help deter-
mine those who are at risk for poor adaptation.
For example, when an illness involves body
disfigurement (e.g., limb amputation or breast
cancer surgery), patients high in public self-
consciousness can be targeted for interventions
to improve self-esteem and sense of efficacy
such as hope enhancement (see Snyder, Rand,
& Sigmon, this volume), training in adaptive
coping skills, and support groups.
Other personality traits also warrant consid-
eration. For instance, people low in optimism
do not cope effectively or adjust well to stress
(Carver et al., 1993) and may be vulnerable to
activity restriction. High levels of neuroticism
are related to a maladaptive coping style (Mc-
Crae & Costa, 1986) that may include forgoing
pleasurable activities. When faced with disrup-
tive life events, individuals who are less agent-
ically oriented and do not have a strong sense
of mastery will have more difficulty finding
ways to avoid restricting their rewarding activ-
ities (e.g., Femia, Zarit, & Johansson, 1997;
Herzog, Franks, Markus, & Holmberg, 1998).
In addition, those who are low in the disposi-
tional predilection to hope for positive

outcomes are less likely to conceptualize ways
to continue (or replace) valued activities or to
persist in their efforts to do so, particularly
when pathways to achieving these goals are
blocked (e.g., Snyder, 1998). Although research
in this area is in its infancy, personality factors
should not be ignored—particularly when the
goal is to identify those who are at risk for re-
stricting their usual activities, are adapting
poorly to stress, and are in need of early inter-
vention.
Social support, like personality traits and ex-
perience with illness, interacts with health-
related variables to influence normal activities.
With stronger social support networks, activity
restriction is less likely (Williamson et al.,
1994). For example, disabled elders will attend
church and visit friends more often if other peo-
ple help with walking, transportation, and
words of encouragement. Maintaining usual ac-
tivities in the face of stress, in turn, reduces the
possibility of negative emotional responses and
further decrements in health and functioning.
Thus, identifying community-residing older
adults with deficits in social support is a good
starting point for intervention. Before interven-
ing, however, we need to specify which aspects
of social support are absent or most distressing
and target treatment accordingly (Oxman &
Hull, 1997). Some older people may be de-

pressed simply because they do not have
enough social interaction. Others may have
concrete needs for assistance that are not being
met (e.g., getting out of bed or grocery shop-
ping). Still others may be exposed to exploita-
tive or abusive social contacts (Cohen & McKay,
1983; Suls, 1982; Williamson et al., 2000; Wort-
man, 1984).
Directions for Future Research
The Activity Restriction Model of Depressed
Affect, like other models of stress and coping
(e.g., Lazarus & Folkman, 1984), implies that
the causal path is unidirectional—that is, that
stress causes activity restriction, which, in turn,
causes negative affect. Without doubt, this is an
inadequate representation. Consider pain and
depression as an example. According to unidi-
rectional models, depression is an outcome of
an inability to adjust to chronic pain. Yet sub-
stantial research suggests that depression fosters
higher levels of reported pain (e.g., Lefebvre,
1981; Mathew, Weinman, & Mirabi, 1981; Par-
melee et al., 1991). Similarly, the Activity Re-
striction Model of Depressed Affect can be
turned on its head such that, as clinicians have
684 PART IX. SPECIAL POPULATIONS AND SETTINGS
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50

Positive Growth Following Acquired
Physical Disability
Timothy R. Elliott, Monica Kurylo, & Patricia Rivera
People acquire physical disabilities through ag-
ing and a multitude of mishaps, diseases, and
infections. Although clinicians have offered
many different explanations for the diverse psy-
chological reactions that occur in the wake of
physical disabilities, few have applied scientific
tools to study these behaviors, and fewer still
have presented heuristic and testable theoretical
explanations. Moreover, most observers have
overlooked the potentially valuable experience
of acquiring a physical disability. Writers have
given only scant attention to positive growth
and optimal living with chronic health prob-
lems, as well as the related searches for mean-
ing, purpose, and fulfillment.
In this chapter, we first will review the his-
torical perspectives regarding adjustment to the
onset of physical disability. We then will pre-
sent a model for understanding such adjustment,
along with supporting evidence. Finally, we will
discuss relevant measures and intervention
practices that merit use in practice and research
and will propose directions for future study.
Historical Perspectives
In most conceptualizations of psychological ad-
justment following the onset of physical disa-
bility, researchers have focused primarily on the

negative emotional reactions; rarely have they
mentioned the potential for psychological
growth. For many years, the prevailing models
of adjustment were Freudian ones in which peo-
ple were presumed to pass through predictable
stages in reaction to severe loss (Grzesiak & Hi-
cock, 1994). With the losses accompanying the
disability, the individual was posited to sustain
a severe blow, and only with the passage of time
could the ego permit recognition of that loss.
Thus, a person purportedly would manifest de-
nial to defend against the anxiety precipitated
by the disability and thereafter would gradually
progress through depression, anger, and bar-
gaining phases until the ego could rationally ac-
cept the permanence and severity of the
disability (Mueller, 1962). Thus, optimal ad-
justment was conceptualized as the final accep-
tance of the reality of permanent disability.
In contrast to this rather fatalistic perspective,
students of Kurt Lewin (1939) observed great
variation in reactions to physical disability.
They recognized that many people manage the
negative implications of the disability by shift-
ing their values so as to experience increased
personal worth (Barker, Wright, Meyerson, &
Gonick, 1953; Dembo, Leviton, & Wright, 1956;
Meyerson, 1948). Additionally, these research-