1. Childhood Traumatic Grief

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

3. 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

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

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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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”

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

16. (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’

17. 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

18. 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

19. 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)

20. 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)

21. 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

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

23. 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)

24. 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

25. 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

26. 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

27. 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”

28. 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”

29. 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.)

30. 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)

31. 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

32. 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

33. 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

34. 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)

35. 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)

36. 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

37. 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

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

39. 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)

40. 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)

41. 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

42. 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

43. 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

44. 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)

45. 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)

46. 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)

47. 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)

48. 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

49. 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

50. 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)

51. 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)

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

53. 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)

54. 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)

55. 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?

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

57. 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)

58. Video on CTG (NCTSN)