Childhood Traumatic Grief

1
Childhood Traumatic Grief
2
Thanatology

• Academic (often scientific) study of death
• Circumstances surrounding persons death
• Grief experiences
• Social attitudes towards death

3
Definitionbereavement, 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

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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

• N233 (adults)
• Acceptance most common indicator
• Yearning strongest negative indicator
• Sequence of 5 grief indicators
• Disbelief
• Yearning
• Anger
• Depression
• acceptance

9
Harvard Child Bereavement study(Worden, 1996
Silverman, Worden, 1992)

• N125 (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 mourningWilliam J. Worden (MGH)

• accepting reality of death
• experiencing pain of emotions
• adjusting to environment (with missing person)
• relocating person within ones 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

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• 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
• Cant 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

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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

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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)

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Inventory of Complicated Grief

• 19 item scale
• I think about person so much that its 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 cant 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 0never, 1rarely, 2sometimes,
  3often, 4always)

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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

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

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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)

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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

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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

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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 dont 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

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• Traumatic grief (23 items)
• I cant stop thinking about the person who died
  when I want to think about other things
• I dont 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

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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.)

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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
  persons 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

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

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?)
• N4,023 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 gt friend gt 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 whats 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

• Childrens 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)

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Video on CTG(NCTSN)

• http//www.nctsn.org/nctsn_assets/acp/ctg/nctsnnew
  3.htm