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Childhood Traumatic Grief


Childhood Traumatic Grief CTG reactions To manage the distress aroused by reminders, child engages in behaviors, such as avoidance (that further interfere with ... – PowerPoint PPT presentation

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Title: Childhood Traumatic Grief

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

Definitionbereavement, grief, mourning
  • Bereavement objective experience of having a
    loved one die
  • Grief emotional, physiological, cognitive,
    behavioral reaction
  • Mourning cultural practices and expression of
  • 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.,
  • 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.,
  • N233 (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)
  • N125 (70 controls)
  • 6-17 years
  • Smilansky Death Questionnaire (?) (Smilansky,
  • Child Behavior Checklist (Achenbach, 1983)
  • 74 lost father,26 lost mother

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

Normative child bereavement(Goodman et al.,
  • Accepting reality/permanence
  • Experiencing/coping with painful emotions
  • Adjusting to changes resulting from death
  • Develop new/deepening existing relations (to
  • Investing in new relationships/life affirming
  • Maintaining attachment (reminiscing, remembering,
  • 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

  • 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
  • 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
  • Cant simply put behind or get over

  • Inner psychological phenomenon vs. life-cycle
  • Cultural influences?

(Adult) complicated Grief
  • Grief accompanied by symptoms of separation
    distress (and trauma) (Prigerson et al., 1997,
  • 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
  • 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.,
  • Texas Revised Inventory of Grief (Faschingbauer
    et al., 1987)
  • Used with adults and adolescents (Melhem et al.,

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)

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,
  • Objectively/subjectively perceive death as
  • BUT usually objectively traumatic
  • natural cause if child experiences as
  • (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

  • 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
  • (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
  • 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 dont talk about the person
    who died because it is too painful to think about
  • Positive Memory I enjoy good memories of
  • Ongoing Presence I think that I see or hear
    him/her, or that I can feel his/her presence

  • 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
  • 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.
  • Traumatic Events
  • NOT uncomplicated/complicated/traumatic grief
  • Smilansky Death Questionnaire (HCBS, Worden
  • 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
    persons 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.
  • (Cohen Mannarino, 2004)

Secondary adversities and pre-existing family
  • 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,
  • 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)
  • 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,
  • Purposelessness or feelings of futility about the
  • Subjective sense of numbness, detachment, or
    absence of emotional responsiveness
  • Feeling stunned, dazed, or shocked
  • Difficulty acknowledging the death (e.g.
  • 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., 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
  • 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
  • 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)

Data from the National survey of adolescents
  • 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,
  • 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
  • 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)

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)

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

Development and grief
  • Childrens understanding of death (Corr Corr,
  • 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
  • By ages 9 or 10
  • Understanding death as final, irreversible, and
  • (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 death
  • Cultural differences (Schonfeld Smilansky,
  • Israeli children performed higher than Americans
  • Irreversibility and finality
  • Influence on (traumatic) grief reactions?

Grief and spirituality
  • Religion/spirituality discussed as helpful coping
  • (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//