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Childhood Traumatic Grief

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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Childhood Traumatic Grief

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  1. Childhood Traumatic Grief

  2. Thanatology • Academic (often scientific) study of death • Circumstances surrounding person’s 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

  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

  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 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

  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

  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?) • 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)

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