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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

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  • Academic (often scientific) study of death
  • Circumstances surrounding person’s death
  • Grief experiences
  • Social attitudes towards death
definition bereavement grief mourning
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
  • What is normal response to death of a loved one?
types of grief in the literature cohen et al 2002
Types of grief in the literature(Cohen et al., 2002)
  • Uncomplicated grief
  • (adult) Complicated grief
  • Child traumatic grief
uncomplicated 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
Five stages of grief (Kuebler-Ross, 1969, 1973)
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
    • Also for children?
yale bereavement study ybs maciejewski et al 2007
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
harvard child bereavement study worden 1996 silverman worden 1992
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
Four tasks of mourningWilliam 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
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
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
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”
  • Inner psychological phenomenon vs. life-cycle transition
    • Cultural influences?
adult complicated grief
(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
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 20061
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
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
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
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
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
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
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
  • 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
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
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
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
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
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
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
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
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
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
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

  • Do you think there is a need for CTG as new mental health disorder?
evidence in support of new diagnostic category for dsm
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
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 20001
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
proposed criteria for traumatic grief jacobs et al 20002
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
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
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
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
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 nsa1
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
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
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
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
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 confusion1
Problems/ confusion
  • Problems
    • Culturally dependent
    • Age dependent
    • Developmental theories (e.g. Pigaet, Bowlby, Vygotsky, Bronfenbrenner) mentioned, but still poorly researched
development and grief
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
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)

  • 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 death1
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
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
Video on CTG(NCTSN)