Introduction
Stress and coping research is shifting from focusing exclusively on the negative effects of chronic conditions (CCs) to an emphasis on ways in which these conditions promote positive life changes [
1]. Benefit finding (BF), defined as individual differences in perceiving positive life changes resulting from adversity and negative life stressors [
1,
2], herein emerged as a key construct and gained increasing attention in the context of CCs [
3]. Positive life changes may manifest themselves in domains including intrapersonal benefits (e.g., feeling stronger and wiser), interpersonal benefits (e.g., feeling closer with friends and family), and changes in priorities and goals (e.g., reordering goals and emphasis of enjoyment in life) [
4]. There is first meta-analytic evidence that BF in response to several health stressors is associated with lower levels of depression and global distress as well as more positive well-being [
2]. While BF was studied among adults with various CCs [
1,
2], studies among youth are lacking [
5].
CCs are highly prevalent in youth [
6] and constitute an additional challenge in their life. Transdiagnostic characteristics of CCs, namely chronicity, functional impairments, physical disability, or pain, and the need for extensive (permanent) health care, can interfere with the mastery of common developmental tasks (e.g., forming friendships, establishing first romantic relationships, school transitions or striving for autonomy and emancipation from parents) [
7,
8]. So far, studies on BF in youth are limited to populations with cancer [
9‐
11] and type 1 diabetes [
12‐
14]. However, only one measure for BF was psychometrically evaluated for children and adolescents with cancer [
11]. The Benefit Finding Scale for Children (BFSC) was adapted by pediatric clinicians from scales developed for adult patients with cancer [
11]. Conducting a principal component analysis (PCA), the authors identified a single component, which accounted for 41% of the variance, and showed that the BFSC had an adequate internal consistency. Further studies on children and adolescents with cancer supported the reliability and construct validity of the BFSC (e.g., [
10]).
However, it is crucial to ensure the measure provides appropriate psychometric properties when introduced to new populations [
15], namely youth facing various CCs. To the best of our knowledge, this is the first study validating a BF measure for a sample of youth facing different CCs, simultaneously providing the first age-appropriate, German version. The study aimed at examining the factor structure of the BFSC, using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Moreover, we examined the scale’s construct validity by focusing on associations with positive intra- and interpersonal resources and coping strategies. Convergent constructs were selected based on previous reported correlates of BF, such as optimism, self-esteem, self-efficacy, empathy, acceptance, social support, and support seeking [
2,
11,
16]. Discriminant constructs were chosen based on theoretical considerations. We hypothesized BF to be unrelated to measures of negative emotional reactions and passive coping strategies [
17] such as cognitive avoidance, wishful thinking, and distancing oneself from the CC. Finally, we tested the BFSC against a measure of health-related quality of life (hrQoL) as an independent criterion (concurrent validity).
Discussion
The purpose of this study was to provide a German version of the BFSC [
11] and to examine its psychometric properties among youth with various CCs. Previous studies have observed a one-dimensional factor structure of the BFSC in English-speaking [
11] and Dutch-speaking [
10] samples of children and adolescents with cancer. Our results are consistent with this literature: Using EFA, we found that all ten items of the German BFSC loaded onto the same latent dimension. Furthermore, using CFA in a second subsample, we were able to confirm that this one-dimensional model had an adequate fit following modification. Although the overall pattern of loadings was meaningful, item 4 showed only fair factor loadings, which, however, was following previous validation studies. To ensure comparability with the original study, we did not exclude this item from further analyses.
In addition, the results of our study uphold the internal consistency and construct validity of the BFSC. The BFSC showed positive correlations with a wide range of convergent constructs, while there were no significant correlations with discriminant constructs, including avoidance, wishful thinking, distance, and emotional reaction. However, it should be acknowledged that the associations between BF and acceptance, social support, and distance were not consistent across subsamples. Replicating the findings of the original study [
11], the BFSC was not significantly related to hrQoL. This result highlights the notion that positive experiences (e.g., “Having had my illness has helped me to deal better with my problems”) do not simply imply an absence of negative experiences (e.g., “Does your condition get you down”) but that both rather represent independent and co-occurring dimensions. Future studies should consider alternative criteria for validation by including measures of positive well-being and satisfaction with life.
While previous studies reported no sex differences between females and males [
10,
11], we observed higher scores for females, but only in our second subsample. Indeed, there is meta-analytic evidence indicating that females engage in more positive reappraisal and more positive self-talk than males [
43]. This indicates that female youth might perceive higher levels of benefit in response to their CC than male youth. Studies with adequately sized samples of females and males are warranted to clarify whether BFSC scores are invariant across participant sex. Contrary to previous studies, we found that BF was positively associated with age, but not with time since diagnosis. This finding might indicate that it depends more on the developmental level and skills and does not “naturally” increase over time when coping with the disease. However, given the fact that participants of previous studies were considerably younger with mean ages around 12 years [
10,
11], conclusions about the role of age and time since diagnosis should be drawn with caution. Longitudinal studies over the course of the disease including different age groups are needed to investigate BF in youth from a developmental perspective. Moreover, in line with prior work [
9], our findings of CFA sample suggest that youth with CCs who report a higher subjective disease severity might be more likely to utilize BF strategies, possibly representing relevant resources of adaptive coping [
44]. However, there is evidence questioning the linearity of the relation between BF and disease severity [
5]. Considering research on stress-related growth, it appears there may be an inverted “U” relation, suggesting that BF experiences may be highest at moderate levels of disease severity [
5]. Finally, our findings of the CFA sample indicate that youth with CCs who report higher subjective social status might be more likely to use BF strategies compared to those with lower subjective social status. While there was no significant metanalytical association between BF and socioeconomic status [
2], other studies even highlight the utility of BF as a coping strategy amongst lower social status populations [
45] and youth with CCs [
46]. However, while previous studies only examined the association of BF with objective social status [
9,
11], our study adds first insights into the link between BF and subjective social status. Evidence from prospective data indicates that subjective social status might be a more influential predictor for health status and change in health status than objective social status [
47]. Further studies including both objective and subjective indicators of social status are warranted to clarify the role of subjective measures of social status in CC.
Overall, the present study had several strengths, namely the very good data quality and the sufficient sample size. Our study covered a broad age range and a wide range of underlying chronic diseases, enhancing the generalizability of our results. It should be further stressed that a methodological sound approach with an EFA-to-CFA strategy was applied, thereby overcoming the limitations of previous studies using a PCA, which is inappropriate for the identification of latent constructs and factor structures of a set of variables [
48]. By focusing on intra- and interpersonal resources and coping strategies, our study provides initial evidence for potentially relevant starting points for diagnostic comparisons and transdiagnostic programs promoting BF in youth with different CCs.
Several limitations must be acknowledged. First, the recruitment strategy may have resulted in a selection bias towards generally lower levels of distress, as youth with higher levels of distress might be less likely to participate in online surveys. Second, as part of the CFA, model modifications were conducted to improve the model fit. Although modifications were based on theoretical considerations, they should be viewed as tentative until cross-validated on an independent sample [
49]. Third, the cross-sectional design of our study precluded the assessment of test-retest reliability or stability of BF over time. To further strengthen the psychometric basis for the BFSC, studies with adequately-sized samples are needed to verify whether BFSC scores are invariant across group membership (e.g., sex group and diagnostic group) and measurement occasion [
50]. Finally, future studies should examine whether benefit finding predicts positive adaptive outcomes, not only directly but incrementally over and above established constructs, such as emotion regulation (e.g., positive reappraisal), to further ensure the validity of BF.
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