Childhood Traumatic Grief

Thanatology Academic (often scientific) study of death Circumstances surrounding person’s death Grief experiences Social attitudes towards death

Definition bereavement, grief, mourning Bereavement = objective experience of having a loved one die Grief = emotional, physiological, cognitive, behavioral reaction Mourning = cultural practices and expression of grief Stroebe, Hansson, Stroebe, & Schut (2001) Experienced by almost everyone

Discussion What is normal response to death of a loved one?

Types of grief in the literature (Cohen et al., 2002) Uncomplicated grief (adult) Complicated grief Child traumatic grief

Uncomplicated grief Normal process of grieving How long? Great variability Stage models of grief Tasks of grief for children Harvard Child Bereavement Study

Five stages of grief (Kuebler-Ross, 1969, 1973) Denial Anger Bargaining Depression Acceptance Also for children?

Yale Bereavement study(YBS) Maciejewski et al., 2007 N=233 (adults) Acceptance most common indicator Yearning strongest negative indicator Sequence of 5 grief indicators Disbelief Yearning Anger Depression acceptance Yearning = sehnsucht

Harvard Child Bereavement study (Worden, 1996; Silverman, Worden, 1992) N=125 (+70 controls) 6-17 years Smilansky Death Questionnaire (?) (Smilansky, 1981) Child Behavior Checklist (Achenbach, 1983) 74% lost father,26% lost mother

Four tasks of mourning William J. Worden (MGH) accepting reality of death experiencing pain of emotions adjusting to environment (with missing person) relocating person within one’s life and finding ways to memorize

Normative child bereavement (Goodman et al., 2004) Accepting reality/permanence Experiencing/coping with painful emotions Adjusting to changes resulting from death Develop new/deepening existing relations (to cope) Investing in new relationships/life affirming activities Maintaining attachment (reminiscing, remembering, memorialization) Making meaning (e.g. why person died) Continuing normal stages of development

Uncomplicated grief and clinical conditions (Cohen et al, 2006) ‘Bereavement’ in DSM-IV V62.82 Other (additional) conditions that may be a Focus of Clinical Attention Uncomplicated grief resembles Major Depressive Disorder (MDD) But: MDD not diagnosed in first 2 months after death

Unless person has: Guilt about things (other than actions taken/not taken at time of death) Thoughts of death (other than feeling s/he would be better off dead/should have died with deceased) Preoccupation with worthlessness Psychomotor retardation Prolonged/marked functional impairment Hallucinations (other than of death person)

Two theories of grief (Phyllis R. Silverman) Primary inner psychological phenomenon Negative feelings to be expunged quickly Grief as illness (?) Helpful to express/talk Life-cycle transition (Silverman, 2000) Time of loss and changes Help the mourner find ways of living in these changes Can’t simply put behind or “get over”

Discussion Inner psychological phenomenon vs. life-cycle transition Cultural influences?

(Adult) complicated Grief Grief accompanied by symptoms of separation distress (and trauma) (Prigerson et al., 1997, 1999) For adults term used interchangeably with ‘traumatic grief’ Death not objectively ‘traumatic’

Complicated Grief (CG) (Cohen et al., 2006) ‘Separation distress’ symptoms (3/4) Intrusive thoughts about deceased Yearning for deceased Searching for deceased Excessive loneliness since death

Complicated Grief (CG) (Cohen et al., 2006) ‘Traumatic distress’ symptoms (4/8) Purposelessness about the future Numbness, detachment or absence of emotional responsiveness Difficulty believing or acknowledging death Felling that life is empty/meaningless Feeling that part of oneself died Shattered world view Assuming symptoms of harmful behaviors of the deceased person Excessive irritability, bitterness or anger related to death Symptoms last at least 6 months Significant functional impairment

Some measures of CG Inventory of Complicated Grief (Prigerson et al., 1995) Texas Revised Inventory of Grief (Faschingbauer et al., 1987) Used with adults and adolescents (Melhem et al., 2004)

Inventory of Complicated Grief 19 item scale I think about person so much that it’s hard for me to do the things I normally do I feel I cannot accept the death of the person who died I feel myself longing for the person who died I feel drawn to places and things associated with the person who died I can’t help feeling angry about his/her death I feel disbelief over what happened I feel stunned or dazed over what happened Ever since he/she died, it is hard for me to trust people Ever since he/she died, I feel as if I have lost the ability to care about other people or I feel distant from people I care about I feel lonely a great deal of the time ever since he/she died ... Frequency: 0=never, 1=rarely, 2=sometimes, 3=often, 4=always)

Texas Revised Inventory of Grief 21-item scale Factor 1: traumatic grief Crying Yearning Numbness Preoccupation with deceased Functional impairment Poor adjustment to loss Factor 2: separation distress

Early days of PTSD Delayed-onset PTSD in Vietnam Vets = delayed grief reactions (Shatan, 1973)

Child Traumatic Grief (CTG) Early conceptions PTSD in children witnessing parents’ murder (Eth & Pynoos, 1985) Interference of trauma reactions with bereavement (Nader, 1997) Studied in Community violence (Saltzman et al., 2001) Bosnia (Layne et al., 2001)

Child Traumatic Grief (CTG) (Brown & Goodman, 2005) Objectively/subjectively perceive death as traumatic BUT usually objectively traumatic ‘natural cause’ if child experiences as horrifying/shocking (Cohen & Mannarino, 2004) Overwhelmed by trauma response Unable to accomplish normal grieving tasks

CTG (Cohen et al., 2006) Complicated (unresolved) grief symptoms i.e. yearning/search for deceased, difficulty accepting death + PTSD symptoms Including anger or bitterness related to death ALSO often accompanied by depressive symptoms

Measures Grief Screening Scale (Layne et al., 1998) 10 items (normal and traumatic grief) (Normal): “I feel that even though the person is gone, he/she is still an important part of my life” (Traumatic): “Unpleasant thoughts about how the person died get in the way of enjoying good memories of him/her” 3 subscales: (1) Positive Connection, (2) Complicated Grief, (3) Traumatic intrusion/avoidance Used following war trauma (Layne et al., 2001) and community violence (Saltzman et al., 2001) Extended Grief Inventory (Layne et al., 2001) More complex CTG construct, additional concepts (e.g. revenge), language suitable for school-age

Extended Grief Inventory (Layne et al., 2001) Suitable for ages 8-18 28-items (normal and traumatic grief) Agreement on 5-point Likert scale Three factors Traumatic grief “I don’t talk about the person who died because it is too painful to think about him/her” Positive Memory “I enjoy good memories of him/her” Ongoing Presence “I think that I see or hear him/her, or that I can feel his/her presence nearby”

Traumatic grief (23 items) “I can’t stop thinking about the person who died when I want to think about other things” “I don’t do positive things that I want or need to do because they remind me of the person who died” “I feel more irritable since he/she died” … Positive memory (3 items) “I feel that, even though the person is gone, he/she is still an important part of my life” “I enjoy thinking about him/her” Ongoing Presence (2 items) “I have pleasant or comforting dreams about the person who died”

Other measures Modified life event checklist (NSA, Rheingold et. al.) Traumatic Events NOT uncomplicated/complicated/traumatic grief Smilansky Death Questionnaire (HCBS, Worden & Silverman) Five concepts about death assessed: (1) irreversibility, (2) finality, (3) causality, (4) inevitability, and (5) old age NOT (uncomplicated)/complicated/traumatic grief Most studies combine death/grief measures with measures of mental health, etc. (e.g. CBCL, PTSD scales, etc.)

Distinguish CTG from other forms of grief CTG (i.e. presence of PTSD symptoms) increases risk of ongoing mental illness Uncomplicated grief does not Implications for intervention combined trauma- and grief-focused treatment (Cohen & Mannarino, 2004)

CTG reaction (Cohen & Mannarino, 2004) Thoughts/reminders of traumatic nature of death (e.g. sights, smells) actual loss (e.g. photos of person) changes resulting from death (e.g. moving to a new house) Trigger traumatic thoughts (?), images, or memories that interfere with pleasant/comforting memories of loved one

Three types of reminders (Pynoos, 1992) Trauma reminders Situations, people, places, sights, smells, etc. reminding of traumatic nature of death Loss reminders People, places, objects, situations, thoughts, or memories reminding child of deceased Change reminders Situations, people, places, or things reminding child of changes in living circumstance

Memory effects (Pynoos, 1992) Even positive reminiscing results in thoughts, memories, emotions related to traumatic nature of person’s death Unwanted intrusive thoughts? (D. Wegner) Impinge on ability to reminisce Necessary for uncomplicated bereavement

CTG reactions To manage the distress aroused by reminders, child engages in behaviors, such as avoidance (that further interfere with adjustment in a normative fashion BUT usually impossible to totally avoid (e.g. school) (Cohen & Mannarino, 2004)

Secondary adversities and pre-existing family stressors Additional losses Loss of home, health insurance, family income Leave school, peers, place of worship, other social support Hypothesized to further impact CTG reactions (Brown & Goodman, 2005; Cohen & Mannarino, 2004) BUT no empirical studies (yet)

CTG as a new mental health disorder Brown & Goodman (2005) suggest that CTG a new mental health disorder Must Distinguish from normal grief reactions Conceptual and empirical distinguish from other established psychiatric syndromes/disorders (e.g. PTSD, major depressive disorder)- these other disorders are also commonly associated with traumatic death

CTG as new disorder common first-year following death (e.g. Dowdney, 2000) Internalizing symptoms (depression and anxiety) Externalizing behavior Somatic complaints all PTSD symptoms of avoidance in CTG maybe better explained by dysphoria associated with depression Withdrawn due to anhedonia maybe actually avoiding situations for fear of exposure to reminders or going through period of sadness all supposed to underscores the need to consider CTG as new disorder Dysphoria = unpleasant, uncomfortable mood (depressed mood) Anhedonia =inability to experience pleasure from normally pleasurable life events

Discussion Do you think there is a need for CTG as new mental health disorder?

Evidence in support of new diagnostic category (for DSM) Traumatic grief symptoms independent of Depression and PTSD symptoms Melhem et al. (2004) Bonanno et al. (2007) Proposed Criteria for Traumatic Grief (Jacobs et al., 2000)

Proposed Criteria for Traumatic Grief (Jacobs et al., 2000) Criterion A Person experienced death of significant other Response involves intrusive, distressing preoccupation with deceased (e.g., yearning, longing, or searching)

Proposed Criteria for Traumatic Grief (Jacobs et al., 2000) Criterion B (following symptoms marked and persistent) [number?] Frequent efforts to avoid reminders of deceased (e.g. thoughts, feelings, activities, people, places) Purposelessness or feelings of futility about the future Subjective sense of numbness, detachment, or absence of emotional responsiveness Feeling stunned, dazed, or shocked Difficulty acknowledging the death (e.g. disbelief) Feeling that life is empty or meaningless Difficulty imagining a fulfilling life without the deceased Feeling that part of oneself has died Shattered worldview (e.g., lost sense of security, trust, or control) Assumes symptoms or harmful behaviors of, or related to, the deceased person Excessive irritability, bitterness, or anger related to the death futility+=sinnlosigkeit

Proposed Criteria for Traumatic Grief (Jacobs et al., 2000) Criterion C Duration of disturbance (symptoms listed) is at least two months Criterion D Disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

Complicated Grief Disorder Horowitz et al. (1997) proposed criteria for ‘Complicated Grief Disorder’ Some differences: symptoms E.g., includes interference with sleep (reflecting hyper arousal) BUT may be not indicative of traumatic grief (Jacobson et al., 2000) Duration One-month, 14-months after death

Other symptoms and disorders Somatization (esp. children) (physical complaints without a disease or physical basis) (Worden, 1996) Serous illness and accidents Cancer, cardiac disorders Substance use Suicidal ideation (Jacobs et al., 2000)

Prevalence (uncomplicated grief) Over course of lifetime almost everyone (normal grief?) In children and adolescents 40% of college students report death of peer More than 2 mio. children and adolescents in the US per year (Rheingold et al., 2003)

Data from the National survey of adolescents (NSA) Normal loss/grief (not traumatic?) N=4,023 adolescents aged 12 to 17 years Prevalence of past-year deaths (48.2%) 36.1% death of family member 20.3% death of close friend 8.1% both family member + friend not associated with mental health problems)

Data from the National survey of adolescents (NSA) Demographic factors Females, lower SES, African American increased risk of death of family member Girls, older, lower SES, minority increased risk of death of friend Mental health problems Death of family member: not related Death of close friend: related to depression, PTSD and substance abuse (BUT after controlling for demographics and victimization history only substance abuse)

Prevalence of Complicated/traumatic grief To date no empirical studies CTG not normative (Cohen & Mannarino, 2004) Even if death objectively traumatic Oklahoma City bombing (Pfefferbaum et al., 1999) Adolescent suicide of friend (Brent et al., 1993, 1995 Only minority (~5%) prolonged symptoms

BUT immediately after death/trauma Bereaved trauma survivors report higher levels of PTSD symptoms, arousal and worry Depression changes in home environment physical health complaints (Pfefferbaum et al., 1999) BUT no measure of complicated/traumatic grief

Factors possibly affecting response to trauma/death Closer emotional proximity = more symptomatic Family member > friend > acquaintance (Pfefferbaum et al., 2000, 1999) Other factors Physical proximity Secondary adversities Poor pre-trauma/death functioning Poor coping strategies (e.g. La Greca, Silverman & Wasserstein, 1998)

Problems/ confusion appears to be some confusion in the literature over whether what’s traumatic Death/loss itself Nature of death E.g. violent death Reactions to loss Symptoms, disorder/illness (e.g., PTSD) Some think any loss in children is traumatic (Silverman, personal communication)

Problems/ confusion Problems Culturally dependent Age dependent Developmental theories (e.g. Pigaet, Bowlby, Vygotsky, Bronfenbrenner) mentioned, but still poorly researched

Development and grief Children’s understanding of death (Corr & Corr, 1996) Irreversibility, Finality, inevitability, and causality, (noncorporeal continuation) Influenced by variables such as Age Experience cognitive development (Cuddy-Casey et al., 1997)

Developing understanding of death Prior to age 3 years Sense an absence and miss a familiar person Unlikely to understand difference between temporary absence Before age 5 May talk about death, but may still expect person to come back Most children do not realize that everyone will die By ages 9 or 10 Understanding death as final, irreversible, and inescapable (e.g. Worden, 1996)

Discussion Would you expect different grief reactions in young children? Do you think a very young child (not fully understanding death) suffers more or less?

Developing understanding of death Cultural differences (Schonfeld & Smilansky, 1989) Israeli children performed higher than Americans on Irreversibility and finality Influence on (traumatic) grief reactions?

Grief and spirituality Religion/spirituality discussed as helpful coping strategy (e.g., Weaver et al., 2003; Hays & Hendrix, 2008) BUT empirical research still needed Developmental implications (e.g. Harris & Astuti, 2006)

Video on CTG (NCTSN) http://www.nctsn.org/nctsn_assets/acp/ctg/nctsnnew3.htm