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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

Childhood traumatic grief

  • 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

Childhood traumatic grief

  • 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”

Childhood traumatic grief

  • 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)