Childhood Traumatic Grief

Order Description

1.How is traumatic grief different than simple grief?

2.What are some ways that childhood traumatic grief may present differently than adult traumatic grief?
3. What are some common symptoms children express or signs when experiencing traumatic grief? (simple list of at least 5 examples)

Journal of Clinical Child and Adolescent Psychology
2004, Vol. 33, No. 4, 819-831
Copyright © 2004 by
Lawrence Erlbaum Associates, Inc.
OTHER ARTICLES
Treatment of Childhood Traumatic Grief
Judith A. Cohen and Anthony P. Mannarino
Department of Psychiatry, Allegheny General Hospital, Drexel University College of Medicine
Childhood traumatic grief (CTG) is a condition in which trauma symptoms impinge on
children’s ability to negotiate the normal grieving process. Clinical characteristics of
CTG and their implications for treatment are discussed, and data from a small number
of open-treatment studies oftraumatically bereaved children are reviewed. An empirically
derived treatment model for CTG is described; this model addresses both trauma
and grief symptoms and includes a parental treatment component. Future research directions
are also addressed.
Childhood traumatic grief (CTG) refers to a condition
in which a child or adolescent has lost a loved one in
circumstances that are objectively or subjectively traumatic
and in which trauma symptoms impinge on the
child’s ability to negotiate the normal grieving process.
(Throughout this article, the term child is used to refer to
children and adolescents.) This article describes our
current understanding of CTG, as well as the treatment
implications of these clinical features. Four treatment
studies have included traumatically bereaved children
or youth; data from these and other studies suggest important
components for treating CTG. An empirically
informed individual child and parent trauma- and grieffocused
cognitive-behavioral treatment (CBT) model
for CTG has been developed from this information and
is described here. Recommendations for future clinical
and research efforts are presented.
Grief, Mourning, Uncomplicated
Bereavement, and Complicated
Bereavement
Bereavement refers to the state of having lost a
loved one, regardless of the emotional reaction to that
Preparation of this article was funded in part by Grants SM54319
from the Substance Abuse and Mental Health Services Administration
and K02 MHO 1938 from the National Institute of Mental Health.
We thank Elissa Brown, Robin Goodman, Susan Padlo, Karen
Stubenbort, Tamra Greenberg, Carrie Seslow, and the Traumatic
Grief Task Force of the National Child Traumatic Stress Network for
their conceptual contributions to this article, and Ann Marie Kotlik
for assistance in its preparation.
Requests for reprints should be sent to Judith A. Cohen, Allegheny
General Hospital, Department of Psychiatry, Four Allegheny Center,
Eighth Floor, Pittsburgh, PA 15212. E-mail: [email protected]
loss; grief refers to the person’s reaction to the loss; and
mourning refers to the family, religious, and cultural
rituals through which bereavement and grief are expressed
(Stroebe, Hansson, Stroebe, & Schut, 2001).
The Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev. [DSM-IV-TR], American Psychiatric
Association, 2000) utilizes the term uncomplicated
bereavement to refer to the “typical” grieving
process through which children and adults adjust to the
death of a loved one (DSM-IV-TR). Uncomplicated
bereavement is described in The Diagnostic and Statistical
Manual of Mental Disorders (4th ed. [DSM-IV],
American Psychiatric Association, 1994) as having
much in common with depression (i.e., it is characterized
by great sadness, sleep and appetite problems,
lack of interest in normal activities, and difficulty concentrating).
Adult complicated bereavement is a condition
in which adult bereavement is complicated by separation
distress and trauma symptoms related to the
loss of the relationship (Prigerson, Shear, & Jacobs,
1997). In complicated bereavement, the traumatic nature
of the loss is due to the security-enhancing nature
of the relationship and the bereaved’s dependency on
that relationship. Distinctions between complicated
grief and CTG are discussed in detail elsewhere (Cohen,
Mannarino, Greenberg, Padlo, & Shipley, 2002).
Children’s understanding of death varies according
to developmental level; this has been discussed in detail
elsewhere (Black, 1998; Cohen et al., 2002;
Emswiler & Emswiler, 2000; Grollman, 1995; Webb,
2002a; Wolfelt, 1996). Uncomplicated bereavement in
children is also manifested in varying ways depending
on the family’s modeling and support of emotional expression,
religious and cultural beliefs, and mourning
rituals, as well as the child’s own cognitive and expressive
style.
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COHEN AND MANNARINO
Reconciliation is a term used to describe the process
of the child adjusting to and accepting the reality of life
without the loved one and reinvolving oneself in the activities
of living (Wolfelt, 1996). The following tasks
have been conceptualized as critical to the reconciliation
process (Wolfelt, 1996; Worden, 1996): accepting
the reality of the loss; fully experiencing the pain of
the loss; adjusting to an environment and self-identity
without the loved one, including integrating positive
aspects of the deceased into one’s own self-image; converting
the relationship from one of present interacting
to one of memory; finding meaning in the loved one’s
death; and experiencing the comfort of a continuing or
new supportive adult presence in the child’s life. These
tasks require the child to tolerate sustained thoughts
about the deceased loved one and the child’s past interactions
with the deceased; to remember the totality of
that person and tolerate regret or guilt about things left
unsaid or undone in that relationship; and to face and
bear the pain associated with the loss. It is important to
note that children can experience intensely painful normal
grief reactions, and these must be distinguished
from CTG. As discussed later, children with traumatic
grief are unable to complete these tasks of reconciliation
because reminiscing about the loved one typically
serves as a trauma reminder, with the subsequent development
of trauma symptoms.
Posttraumatic Stress Disorder (PTSD)
Symptoms in CTG
The trauma symptoms that children with CTG experience
are PTSD symptoms (i.e., reexperiencing of
the traumatic event that led to the loved one’s death;
avoidance of reminders of the traumatic event, the
death, and the loved one; and physiological hyperarousal).
In CTG, these PTSD symptoms are an indication
that the danger and trauma associated with the circumstances
of death are taking priority over the loss
itself in the child’s mind. PTSD symptoms occur in relation
to an event involving actual or threatened death
or serious injury or threat to the physical integrity of
the child or others, and include intense horror, fear, or
helplessness (DSM-IV-TR). The current concept of
CTG requires children to have significant PTSD symptoms
that impinge on normal grieving, although children
do not need to be diagnosed with PTSD to have
CTG (and could conversely have full-blown PTSD
without CTG). Many children react to traumatic events
with resilience, developing no or few PTSD symptoms.
Other children develop only transient PTSD
symptoms, which spontaneously remit over several
weeks. Still other children may develop generalized
fears, specific phobias, depressive symptoms, or behavior
problems in response to a frightening event
(Pine & Cohen, 2002). PTSD symptoms in CTG may
include recurrent upsetting recollections or dreams of
the traumatic event that led to the loved one’s death or a
sense of the event happening over again. Children often
have intense physiological reactivity or psychological
distress in response to reminders of the traumatic
cause of death (“trauma reminders”; Pynoos, 1992).
Avoidance or numbing symptoms may include efforts
to avoid thoughts, feelings, or conversations about
the death or people, places, or situations that remind
the child of the traumatic cause of death. Children with
CTG may also experience a diminished interest in normal
activities, feeling emotionally distant or detached
from others, a restricted affective range, or a sense of a
foreshortened future. Hyperarousal symptoms may include
sleep disturbance, irritability or angry outbursts,
decreased concentration, increased startle reaction, or
hypervigilance {DSM-IV-TR).
CTG
CTG (also called traumatic loss or traumatic bereavement)
is conceptualized as the encroachment of
trauma symptoms on the child’s ability to successfully
navigate the normal grieving process (Elder & Knowles,
2002; Layne, Pynoos, et al., 2001; Nader, 1997;
Pynoos, 1992; Rando, 1993; Webb, 2002b). In essence,
children with CTG cannot get their minds off of
the traumatic and threatening circumstances of the
death and thus the loss itself cannot be fully experienced
and the pain of the grief cannot recede. In CTG,
intrusive and disturbing trauma-related thoughts, images,
and memories may be triggered by at least
three types of reminders, described by Pynoos (1992).
Trauma reminders are situations, people, places,
sights, smells, or sounds that remind the child of the
traumatic nature of the death. For example, tall buildings
or hearing airplanes overhead may be trauma reminders
for children whose parents died in the September
11th terrorist attacks. Loss reminders are people,
places, objects, situations, thoughts, or memories that
remind the child of the deceased loved one. A parent’s
birthday or seeing pictures of their deceased parents
may be loss reminders for these children. Change reminders
are situations, people, places, or things that
remind the child of changes in living circumstances
caused by the traumatic death. Having to move to a
smaller house in a new neighborhood or having to
bring an uncle instead of a father to a father-son baseball
game may be change reminders for these children.
Essential Features of CTG
In CTG, trauma reminders, loss reminders, and
change reminders may all segue into memories,
thoughts, and images of the traumatic nature of the
loved one’s death, which leads to distressing, intrusive
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CHILDHOOD TRAUMATIC GRIEF TREATMENT
reexperiencing of this trauma and physiological hyperarousal.
For example, when a child whose brother has
died in a school shooting walks to that same school (a
trauma reminder), he may experience intrusive images
of his brother’s mutilated face, heart palpitations, irritability,
and terror (i.e., PTSD reexperiencing and hyperarousal
symptoms). The distress that such children
experience on exposure to trauma, loss, or change reminders
leads them to try to avoid such exposure to
minimize their distress. For example, the aforementioned
child may avoid walking to or attending that
school. Such avoidance may generalize to apparently
neutral or innocuous situations, people, places, or objects
(this child may refuse to walk in the neighborhood
where the school is located or refuse to attend any
school at all).
Such avoidance may allow these children to minimize
the intensity or frequency of exposure to trauma,
loss, and change reminders. However, when children
have lost a loved one, these reminders are typically
ubiquitous and usually impossible to totally avoid.
Some children may develop emotional numbing to
cope with those unavoidable or uncontrollable reminders.
Numbing may take the form of extreme detachment
or estrangement, in which the child feels different,
set apart and alienated from others, even those in
his or her own family or circle of friends who experienced
the same traumatic loss (Nader, 1997).
For children with traumatic grief, even positive
reminiscing (i.e., thinking about happy times with the
deceased) segues into thoughts, memories, and emotions
related to the traumatic nature of the person’s
death. This, in turn, sets off the cascade of reactions described
previously (i.e., reminiscing about the loved
one leads to thoughts of the horrible way in which the
person died), which leads to PTSD symptoms (reexperiencing,
hyperarousal, physiological hyperreactivity,
and intense psychological distress). These symptoms
prompt numbing, avoidance, or both, which in
turn interfere with the child’s ability to reminisce about
the loved one. Thus, in CTG, PTSD-like trauma symptoms
impinge on the child’s ability to reminisce about
the loved one and to achieve reconciliation, which is
necessary for the successful negotiation of normal (uncomplicated)
bereavement. As Pynoos (1992) stated,
“It is difficult for a child to reminisce … when an image
of… mutilation is what first comes to mind” (p. 7).
This is the essence of the current concept of CTG.
Associated Features of CTG
In addition to this impingement of traumatic symptoms
on children’s ability to negotiate the grieving process,
some children avoid acknowledging any similarities
between themselves and the deceased, for fear that
they will also share the fate of the deceased (dying in a
horrifying and premature manner; Nader, 1997; Pynoos,
1992). As noted previously, integrating some
positive aspects of the deceased into one’s own selfconcept
is a key task of reconciliation; thus, children
who are fearful of any identification with the deceased
may be unable to successfully reconcile themselves to
the loss of this person. Conversely, some children may
overidentify with the deceased, to the point of taking
the deceased’s name or only wearing objects of clothing
that used to belong to the deceased, as an attempt to
avoid accepting the reality of the death and thereby
avoid the pain accompanying uncomplicated bereavement
(Nader, 1997).
Children with traumatic grief may blame themselves
for the death of the loved one or experience survival
guilt, characterized by exaggerated guilt for being
safe and alive when others are not (Nader, 1997;
Pynoos & Nader, 1990). Some children may unrealistically
blame themselves for not being able to rescue or
save the deceased person and may develop rescue fantasies
in which they manage to do so. Revenge fantasies
may also occur, in which children imagine they are
punishing the real or perceived killer of their loved one
(Eth & Pynoos, 1985). Guilt and shame may also accompany
the death of a loved one in circumstances to
which society attaches a stigma, such as suicide, homicide
under “suspicious” circumstances (for example,
when the media report the death as occurring in the
context of a drug deal), a drunk-driving episode, or an
AIDS-related death (Eth & Pynoos, 1985; Nader,
1997). Unlike children whose loved ones died in circumstances
viewed as heroic (e.g., firefighters or police
officers who die in the line of duty), these children
typically do not receive an outpouring of public sympathy
or financial support. It is possible that the added
stigma or negative community judgment about the
manner of death may constitute a risk factor for developing
CTG.
Reactivity to ubiquitous and unavoidable trauma,
loss, and change reminders may result in more extreme
emotional numbing or avoidance in children with
CTG, whereas such reminders may be beneficial or
healing to children with uncomplicated bereavement.
It is possible that the timing of these symptoms is important
in differentiating children with traumatic grief
from those with early uncomplicated bereavement.
That is, developing trauma symptoms may be normative
for children in the immediate aftermath of a traumatic
death, but not after a month or longer. More empirical
research is needed to determine whether this is
the case.
CTG and the Cause of Death
In CTG, the cause of death is usually objectively
traumatic. In some instances, deaths from so-called
natural causes (cancer, heart attack, stroke, and so on)
may result in traumatic grief, if the child’s experience
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of the death was horrifying or shocking (e.g., if the
child directly witnessed the death, the death was accompanied
by what the child perceived as intense pain
or suffering, or if the deceased’s appearance at the time
of death was mutilated, disfigured, or otherwise horrifying
to the child). This should be differentiated from
normal grief reactions (i.e., pain, sadness, loneliness,
longing for the deceased), which are intensely experienced
but are unrelated to explicitly traumatic aspects
of the death.
It is important to recognize that developing CTG is
not normative for children who lose loved ones, even if
the cause of death is objectively traumatic. For example,
Pfefferbaum and her colleagues (1999) found that,
although loss of a loved one and the closeness of the relationship
to the deceased were correlated with higher
levels of PTSD, the majority of children who lost loved
ones in the Oklahoma City bombing in 1995 did not report
elevated PTSD symptoms or functional impairment
7 weeks after the bombing. Brent, Perper, and
Moritz (1993) and Brent et al. (1995) demonstrated
similar findings with regard to close friends of adolescents
who committed suicide; only 5% of these adolescents
reported persistent PTSD symptoms. Additionally,
siblings of adolescent suicide completers did
not demonstrate an increased incidence of PTSD
symptoms compared to a control group that was not exposed
to suicide, despite having a prolonged elevation
of grief symptoms (Brent, Moritz, Bridge, Perper, &
Canobbio, 1996a, 1996b). Thus, it appears that the majority
of children who lose loved ones under traumatic
circumstances do not develop CTG, and development
of persistent PTSD symptoms that intrude on children’s
ability to grieve should not be viewed as normative
for such children.
Secondary Adversities
Following a familial death, children may experience
secondary adversities such as the loss of home, health
insurance, or family income. If the family has to relocate,
children may also have to leave their school,
peers, place of worship, and other social supports. In
these situations, children and parents have to adjust not
only to the loss of the loved one, but also to these additional
losses. These adversities, as well as preexisting
family stressors, likely impact on children’s likelihood
of developing CTG.
Assessment of CTG
The assessment of CTG entails evaluation of the
child’s and family’s past and current functioning, the
child’s experience of the loved one’s death, the child’s
PTSD symptoms (including identification of the
child’s personal trauma, loss, and change reminders),
and the impingement of these symptoms on the child’s
ability to negotiate the normal grieving tasks of reconciliation.
A detailed description of the assessment of
CTG has been described elsewhere (Cohen et al.,
2002). A factor analysis of the Expanded Grief Inventory
(Layne, Savjak, Saltzman, & Pynoos, 2001),
which has been used to assess CTG, is described elsewhere
(Brown & Goodman, in press). Instruments to
assess the child’s experience of the death have been developed
and are currently undergoing field testing by
the National Child Traumatic Stress Network’s Traumatic
Grief Task Force (Brown, Handel, Cohen, &
Amaya-Jackson, 2003).
Implications for Treatment
The previous discussion suggests that optimal treatment
for CTG should include both trauma- and grieffocused
treatment components. In the case of PTSD
and other trauma-related symptoms, in which there are
known efficacious treatments (Cohen, in press), these
treatments should be adapted for use with CTG. In the
absence of empirical studies, grief-focused treatments
that are believed to assist children in the tasks of reconciliation
(Wolfelt, 1996; Worden, 1996) also should be
included in the treatment.
Treatment Studies for CTG
There have been a small number of open-treatment
studies for adolescents and young adults with CTG, all
using group-treatment approaches. One has been delivered
in school setfings (Layne, Pynoos, et al., 2001).
This treatment protocol includes five foci: traumatic experiences,
reminders of trauma and loss, bereavement
and the interplay of trauma and grief, posttrauma adversity,
and developmental progression. Layne, Pynoos, et
al. (2001) utilized this treatment model to treat 15- to
19-year-old Bosnian youth {N = 55) who survived the
civil war in their country and documented that youth
who received both the trauma-focused and the grief-focused
treatment modules experienced significant improvement
in PTSD and depressive and traumatic grief
symptoms. Youth who only received the trauma-focused
treatment modules (due to circumstances unforeseen
at the start of the study) experienced significant improvement
in PTSD and depressive symptoms
comparable to the group receiving full treatment. Their
improvement in traumatic grief symptoms, although
sfiU statistically significant, was significantly less than
that of the group receiving all five treatment modules.
These findings support the contention that including
both trauma- and grief-focused components may be essential
for resolving CTG symptoms.
Saltzman, Pynoos, Layne, Steinberg, and Aisenberg
(2001) also used this school-based group approach to
treat symptomatic 11- to 14-year-old students (A’^ 26)
who had experienced community violence in Los An-
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CHILDHOOD TRAUMATIC GRIEF TREATMENT
geles. Of these youths, all of whom had known of violent
deaths in their communities, 7 had experienced the
traumatic loss of a loved one. The study demonstrated
significant pre- to posttreatment improvement in PTSD
as well as improvement in participants’ grade point averages
at school, an important indicator of adaptive
functioning. The 7 youths who had experienced loss of
a loved one also demonstrated a significant decrease in
traumatic grief symptoms.
Salloum, Avery, and McCain (2001) used a different
treatment model in an open group treatment study
for 45 adolescent survivors of homicide victims. This
10-week treatment included psychoeducation about
grief, facilitation of expressing grief-related thoughts
and feelings, coping skills, safety enhancement, management
of anger and thoughts of revenge, accessing
support systems, spirituality, and identifying future
goals. The study documented that participants experienced
significant decreases in PTSD symptoms from
pre- to posttreatment as measured by the University of
California-Los Angeles PTSD Reaction Index (Steinberg,
Brymer, Decker, & Pynoos, 2004).
Pfeffer, Jiang, Kakuma, Hwang, and Metsch (2002)
randomly assigned 102 children ages 6 to 15 years old
bereaved by the suicide of a parent or sibling to a
manualized group treatment or a no-treatment control
group. The treatment consisted of 10 sessions and included
psychoeducation about death, grief, suicide,
and prevention of suicidal urges; problem-solving
skills; feeling identification and expression; identification
of positive aspects of the deceased while avoiding
suicidal urges or hopelessness; managing traumatic
thoughts; dealing with stigmatization; encouraging
new supportive relationships; and enhancing optimism.
This study documented that the treatment group
experienced significantly greater improvement in anxiety
and depression, but not in PTSD symptoms, compared
to the no-treatment group.
Unlike the Layne, Pynoos, et al. (2001) group-treatment
model, neither of the last two treatment models
included a specific measure of CTG, nor did either include
interventions aimed directly at desensitizing participants
to traumatic memories. Interestingly, PTSD
symptoms improved in one study (Salloum et al.,
2001) but not the other (Pfeffer et al., 2002). The reason
for this difference is unclear but may be related to
the fact that, unlike homicide, suicide is an intentional
act committed by the victim. This may result in greater
ambivalence toward the deceased, which may result in
increased avoidance and difficulty in resolving PTSD
symptoms.
Inclusion of Parents in Treatment
of CTG
None of these studies included a parental treatment
component, either because they were treating older
youth or because treatments were delivered in the
school setting, where parents would not typically be
available for participation. However, there are important
reasons to consider including parents in treatments
for children suffering from CTG. Epidemiologic studies
have indicated that lack of parental and other social
support is a risk factor for developing psychopathological
symptoms following trauma exposure (reviewed
in Pine & Cohen, 2002). Parents of children
with CTG are typically bereaved themselves (i.e., the
deceased loved one was their spouse, partner, or child)
and may have their own trauma or traumatic grief
symptoms. Therapeutic interventions may optimize
the ability of these parents to be emotionally available
and supportive to their children. This may be particularly
true as parents can serve as models for their children
in accomplishing the tasks of reconciliation or, in
the presence of parental PTSD or traumatic grief, may
conversely model avoidance of these tasks. Several
treatment studies of children traumatized by sexual
abuse have indicated that both parent emotional distress
related to the child’s trauma and lower levels of
parental support for the child predicted poorer treatment
outcome for these children (Cohen & Mannarino,
1996b, 2000). Debhnger, Lippman, and Steer (1996)
also found that sexually abused children whose parents
received treatment experienced significantly greater
improvement in self-reported depressive symptoms
than children whose parents did not receive treatment,
even if the child did not receive treatment. It remains to
be determined whether parental distress mediates child
outcome in CTG. Even if this is not the case, it still may
be beneficial to include a parental treatment component
in treatment models for CTG. This may be particularly
beneficial for those treatments that target
children and younger adolescents, who are more dependent
on parents as a primary source of support than
older adolescents.
Development of the CBT
for CTG Model
We direct a child psychiatric outpatient treatment
clinic for traumatized children, the Allegheny General
Hospital Center for Traumatic Stress in Children and
Adolescents, located in an academically affiliated urban
hospital. Much of the program’s early efforts had
been devoted to developing and empirically testing
individual psychosocial treatments for sexually abused
children and their nonoffending parents. These studies
demonstrated that trauma-focused CBT treatment
(TF-CBT) was efficacious in decreasing a variety of
psychological difficulties in these children (Cohen &
Mannarino, 1996a, 1998). These interventions were
also used successfully in the Center for Traumatic
Stress in Children and Adolescents with children who
had been exposed to a variety of other types of trau-
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matic events. A recent multisite study, which indicated
that the TF-CBT model was superior to child-centered
supportive therapy in decreasing PTSD, anxiety, depression,
and shame in 229 sexually abused children,
documented that 70% of the children also had experienced
either the sudden death or terminal illness of a
loved one (Cohen, Deblinger, Mannarino, & Steer, in
press). Although this study did not specifically assess
CTG, experiencing a traumatic loss did not predict differential
treatment response to TF-CBT.
Following the crash of U.S. Air Flight 427 outside
of Pittsburgh in 1994, the clinic had the opportunity to
provide treatment to several children and parents who
had lost loved ones in the disaster. This led to the development
of a group-focused treatment for CTG (Cohen
et al., 2001; Stubenbort, Donnelly, & Cohen, 2001).
Based on the success of TF-CBT interventions in decreasing
PTSD, depressive, anxiety, and behavioral
symptoms in our randomized treatment trials, and the
presumption that children with CTG would have to resolve
some of their trauma symptoms prior to addressing
their grief, we incorporated TF-CBT interventions
into the early stages of an individual-treatment model
for CTG. One advantage of individual treatment over
the group approach is that the Center for Traumatic
Stress in Children and Adolescents typically sees children
bereaved by different events rather than a community-
level tragedy. Individual treatment allows each
child to develop his or her own trauma narrative and
does not expose other children to the possibility of
vicarious traumatization (through hearing other children’s
horrifying experiences).
Also included in the model adapted from TF-CBT
were child grief-focused interventions, which had garnered
preliminary empirical support in children who
had lost a parent to homicide (Salloum et al., 2001) or
cancer (Schut, Stroebe, van der Bout, & Terheggen,
2001). This treatment model was being manualized
when the September 11, 2001, terrorist attacks occurred.
Almost simultaneously, the National Child
Traumatic Stress Network was funded by Substance
House and Mental Health Services Administration,
and its Traumatic Grief Task Force was formed to develop
a coordinated response to children impacted by
the terrorist acts of September 11 th. This convergence
of events allowed us to benefit from the suggestions of
numerous therapists and researchers in New York City
and nationally and to complete the treatment manual
(Cohen et al., 2001), which was made available in November
2001. This individual treatment model is currently
being empirically evaluated in an open trial at
our clinic and in a randomized controlled trial in New
York City (Brown & Goodman, 2002).
The CBT for CTG treatment model includes 12-16
treatment sessions. It is used for children and adolescents
(ages 6 to 17 years) who have significant CTG
symptoms. The therapist provides individual treatment
to the child and parent in 8-12 of these sessions,
whereas the remaining 4 are used for joint parent-child
treatment sessions. If multiple siblings are treated,
each child has individual sessions, whereas the parent
receives one session per week to address issues for
both or all children in the family. Although the treatment
is manualized, therapist creativity and flexibility
are critical for optimally individualizing how the treatment
is implemented. Specific components of this
treatment model are divided into trauma-focused and
grief-focused segments, which are listed in Table 1;
however, in practice, therapy often flows between
trauma and grief elements according to the individual
child’s and parent’s needs as well as external circumstances
that may impact on the child’s symptoms.
Because the goals of this treatment are to decrease
symptoms of CTG, PTSD, and other emotional and behavioral
problems, initial and follow-up assessments in
this model include the use of standardized instruments.
The Expanded Grief Inventory and the University of
California-Los Angeles PTSD Reaction Index are
used, along with instruments that measure depression,
anxiety, and behavior problems in children and PTSD
and depression in the parents who participate in the
treatment (see Table 1).
Trauma-Focused Components
The trauma-focused components of this treatment
model include the following interventions, which are
listed in Table 1: affective expression skills; stress management
skills; improving affective modulation, problem
solving, and social skills through use of the cognitive
triangle; creating the child’s trauma narrative;
cognitive processing; and joint parent-child sessions.
Affective expression skills optimize children’s and
parents’ ability and comfort with accurately identifying
and appropriately expressing a wide range of emo-
Table 1. Trauma-Focused Versus Grief-Focused
Interventions
Trauma-Focused Interventions
Affective expression skills
Stress management skills
Cognitive triangle
Creating the child’s trauma narrative
Cognitive processing
Joint parent-child sessions
Grief-Focused Interventions
Talking about death; psychoeducation
Mourning the loss
Addressing ambivalent feelings about the deceased
Preserving positive memories
Redefining the relationship
Committing to other relationships
Making meaning of the traumatic loss
Joint parent-child sessions
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CHILDHOOD TRAUMATIC GRIEF TREATMENT
tions, including those they may perceive as “negative”
(e.g., anger, fear) and therefore unacceptable. A variety
of techniques or games may be used to facilitate feeling
identification and expression; some of these are reviewed
by Hall, Kaduson, and Schaefer (2002). Very
young children may enjoy interventions that employ
drawing or puppets to express feelings, such as Color
Your Life (O’Connor, 1983); elementary school age
children often enjoy games they can “win,” such as
Emotional Bingo (Western Psychological Services,
1998). Older children and adolescents may prefer more
complex games such as The Stamp Game (Black,
1984), in which they identify and quantify how much
of several emotions they would feel in various circumstances.
Other feeling-identification activities may include
making a feeling mask (representing “outside”
feelings that others observe and “inside” feelings that
are not shown to others), having adolescents use lyrics
of popular music to exemplify different feelings, or allowing
them to create their own rap songs to express a
variety of emotions. The parallel parent session encourages
parents to discuss a range of feelings they
have about the traumatic death and also introduces several
behavior management techniques, including the
use of praise, active ignoring, effective time-out, and
contingency management procedures. When clinically
appropriate, parents can also be encouraged to discuss
the child’s reaction to the loved one’s death with the
child’s teachers to assist in the child’s recovery.
Stress management skills assist the child and parent
in handling physiological hyperarousal symptoms
such as difficulty falling asleep, increased startle, and
hypervigilance in innocuous situations. They also give
children and parents an increased sense of control over
these responses. Stress management techniques include
deep breathing, progressive muscle relaxation,
thought stopping, and positive self-talk. These skills
are taught to both children and parents; parents may assist
younger children in practicing them at bedtime or
in other appropriate situations or remind older children
or teens to utilize them when they are experiencing
high levels of stress. For children or parents who do not
respond positively to these relaxation techniques, the
therapist may ask how they relax or unwind (e.g., listen
to music, play sports, dance, knit). The therapist can
then encourage the child or parent to use these activities
when they are under stress or to experiment with
other activities or techniques that bring about a similar
sense of being relaxed.
Improving affective modulation, problem solving,
and social skills through use of the cognitive triangle
introduces children and parents to the relations among
thoughts, feelings, and behavior. Understanding these
relations allows children to recognize that many of
their negative feelings, problematic social interactions,
and behavioral difficulties result from thoughts that are
inaccurate or unhelpful. Modifying cognitions to be
more accurate and helpful assists children in modulating
upsetting affective states, interacting more
positively with peers, and selecting optimal behavioral
strategies in challenging situations. For example, if a
child walks into a classroom and another child turns
away and does not speak to him, the first child might
think “she doesn’t like me” (thought). This may lead
the child to feel sad, hurt, or angry (feelings). If he felt
sad or hurt, that child might cry, turn away or isolate
himself, whereas if he felt angry, he might confront or
fight with the other child (behaviors). On the other
hand, if this child thought “she must be shy” (alternative
thought), he might feel sympathetic or generous
toward the other child (new feelings). This might lead
the child to initiate a conversation with the other child
(new behavior). Learning about these relations hopefully
assist children and parents in examining and
modifying their thoughts to have less upsetting feelings
and more productive behaviors. Practicing this
with everyday (i.e., not related to the traumatic death)
situations may be preferred at this early point in treatment.
Parents and children may want to write down
times between sessions when they felt upset or angry
and try to identify whether a thought was contributing
to that feeling. They can then consider whether that
thought was accurate and helpful and, if not, try to
identify more accurate or helpful thoughts to feel
better. It is important for the therapist to note, however,
that some negative feelings might be helpful to children
or parents (e.g., anger at the murderer of their
loved one might give them the determination to testify
at trial and see that justice is served); in such a situation,
the person is benefiting from the feeling and will
not have a reason to change it.
Creating the child’s trauma narrative typically
takes two to three sessions and encourages the child to
gradually face increasingly painful and frightening aspects
of the event that led to the death of their loved
one. The goals of this component are to gradually desensitize
the child to thoughts and reminders of the
traumatic aspects of the death, to decrease avoidance
of the more horrifying aspects of the experience, to
help contextualize these events in the greater schema
of his or her own life and the world, and to identify cognitive
distortions about the death. The therapist may introduce
this component by reading with the child one
of several commercially available books about traumatic
deaths that are written from a child’s viewpoint.
Then the therapist may ask whether the child would
like to create a personal book about what happened
when the child’s loved one died. Children may opt to
draw a series of pictures, a poem, a comic strip, or a
song instead of creating a book. The narrative should
include not only “what happened” but also the child’s
thoughts, feelings, and body sensations throughout the
experience. This is typically accomplished by the child
rereading aloud what he or she has already written and
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adding additional information on each subsequent
reading. At some point the therapist should encourage
the child to include the “worst moment” of the traumatic
death in the narrative. Through such repetition
and by gradually adding more painful or avoided aspects
to the narrative, children become more comfortable
with talking and thinking about the totality of the
experience, with the result that they have less need to
avoid such thoughts or discussions. The therapist also
assists in this process by modeling competent coping,
by hearing the child’s story without becoming emotionally
distraught, angry, or fearful and reassuring the
child that hearing this story is not unbearable.
As children create their trauma narratives, therapists
ask permission to share these with parents and
typically do so during the parallel parent sessions.
When children resist this idea, it is rarely due to confidentiality
concerns; more typically, children worry that
hearing the narrative will upset their parents. Therapists
reassure children that even though reading the
narrative might naturally be upsetting to parents at
first, their parents are eager to hear what their children
are writing and will be able to handle it. (If, based on a
parent’s severe functional impairment, the therapist believes
that the parent will not be able to tolerate exposure
to the child’s narrative, alternative interventions
should be used.) This prepares the family for the joint
sessions, when children and parents directly communicate
about the traumatic events that led to the loved
one’s death.
Cognitive processing of the traumatic aspects of the
death allows children and parents to examine and modify
cognitive distortions they may have about the death
or its aftermath, which often contribute to difficult feelings
and avoidant behaviors. Children and parents may
have distorted ideas of their own responsibility in the
death (i.e., that they could or should have done something
to prevent it from happening). They also may develop
distorted ideas about future safety or dangerousness
of other people and the world around them. Some
may lose faith in the social contract that provides for
the punishment of those who hurt others (for example,
if the murderer of the loved one is not caught or convicted).
The therapist assists children and parents in
identifying these thoughts and examining whether they
are accurate (true) and helpful (contributing to healing
rather than maintaining unrealistic self-blame, fear, or
anger). For example, retaliatory or revenge fantasies
may present underlying unrealistic feelings of guilt for
not preventing the death; alternatively, they may represent
the child’s realistic regret about his or her own
powerlessness to protect others from death.
Some of the techniques used in this regard are
overgeneralization, progressive logical questioning,
and the best-friend role play. For example, if the child
says, “I can’t feel safe again,” the therapist might
overgeneralize (i.e., take the statement to a ridiculous
extreme that the child must realize is not true) by saying,
“So there is nothing you can ever do to keep
yourself safe at all?” The therapist may assist the child
in recognizing that this extreme is not accurate through
the use of progressive logical questioning, for example,
by saying, “So when you cross the street you just
have to close your eyes and pray, cause you can’t look
both ways?” When the child corrects this (“Of course I
can look before I cross the street”), the therapist can
say “Oh, so there are some ways that you can feel safe
now,” and from there continue to help the child recognize
the many ways in which he or she can stay and feel
safe and pinpoint the specific situations in which the
child does not feel safe. Then the child and therapist
(and parent, during joint sessions) can problem-solve
about how to help the child feel safe in these specific
situations.
The best-friend role play is helpful for children and
parents who are having difficulty finding alternative
thoughts to their current inaccurate or unhelpful ones.
The therapist plays the role of the child, and the child
plays the role of his or her own real-life best friend. The
therapist (playing the child) then expresses thoughts
similar to what the child has expressed in therapy, for
example, “I should have known a drunk driver would
be on the road that night and warned my father not to
go out. This was all my fault.” The child, playing the
best friend, will typically try to comfort the “child,” by
saying things such as “It wasn’t your fault, you couldn’t
have known, you’re not a mind reader” (which is often
what the child has heard from others but has been
unable to internally believe). The therapist persists in
these distortions (“But it was my father, I just should
have somehow known, if I only would have known he
would still be alive”). This often prompts children to
come up with more creative ways of convincing the
child that he or she is not responsible (“Even if you had
told him not to go out, he wouldn’t have listened to you
cause you’re a kid and he was the grown up”). The therapist
gradually comes around to the best friend’s viewpoint
and adds to this, if the child seems receptive
(“Yeah, I guess you’re right, even if I would have
known and told him, he would have thought I was being
silly. It is kinda silly to think you can predict the future,
huh?”). This technique is often helpful for parents
as well.
Revenge fantasies express children’s anger at the
real or perceived perpetrator of the loved one’s death,
as well as their wishes to see justice served and thus
maintain their belief in the social contract. Helping
children identify and acknowledge these underlying
themes can be achieved by the aforementioned processing
techniques (i.e., exploring what would happen
if the child actually tried to carry out these fantasies,
that this could endanger him or her and might not succeed,
that it is hard to see the perpetrator live when the
loved one is dead, that this is unfair and makes the child
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CHILDHOOD TRAUMATIC GRIEF TREATMENT
angry). Alternative strategies for resolving anger and
reinstating the social contract can then be developed
(e.g., testifying in court, taking social action to prevent
future similar deaths, and so on).
One of the goals of both creating the trauma narrative
and cognitive processing is to place the traumatic
death into the greater context of children’s whole lives.
Specifically, some children overidentify with the role
of a helpless victim or a bereaved child and overlook
the ways in which they have not been changed by the
death. It is hoped that, in combination with the grief
component focusing on making meaning of the traumatic
death, these interventions will result in the traumatic
death being a difficult and painful experience
that children have gotten through and grown from,
rather than the defining moment of these children’s
identity.
Joint parent-child sessions are typically included at
this point in treatment to allow children and parents the
opportunity to openly discuss the traumatic nature of
the loved one’s death with each other. Due to the centrality
of avoidance in CTG, these children will likely
have been unable to communicate sucb thoughts and
feelings previously and have not felt comfortable in
asking parents questions about this experience. In
these sessions children and parents are encouraged to
ask and answer such questions, both to address specific
concerns and to enhance open communication. When
children read their trauma narratives to their parents in
these sessions, they benefit from seeing their parents’
ability to tolerate hearing details about the trauma and
death, as well as from parental praise of the difficult
task they have accomplished in creating the narrative.
They are able to experience their parents’ genuine
pride and amazement that their children have come so
far so quickly. This parental support is a crucial factor
in children feeling that they have “permission” to
grieve and move on from the loss of the loved one in the
second part of treatment.
Grief-Focused Components
Grief-focused components of this treatment model
include talking about death, mourning the loss, addressing
ambivalent feelings about the deceased, preserving
positive memories, redefining the relationship
and committing to present and new relationships, making
meaning of traumatic loss, and joint parent-child
sessions (see Table 1).
Because family, religious, and cultural traditions
and rituals are central to bereavement and the manner
in which children and parents mourn, it is important for
the therapist to inquire and learn about these early in
the grief-focused portion of treatment (often these have
already been discussed earlier in treatment). Respect
for these traditions and values is essential; however.
therapists should not automatically assume that they
are knowledgeable about a particular family’s bereavement
practices or beliefs based on that family’s religion
or ethnicity. The therapist should ask directly
what children and parents believe happens after death,
where or in what state they believe the deceased is currently,
and whether they believe the manner of death
negatively affected this. For example, some children
believe a mutilated (i.e., not whole) body cannot be admitted
to heaven; other families believe that death from
suicide or drugs dooms the deceased to hell; some cultures
place more credence than others in the meaning
or predictive power of dreams about the deceased.
Such beliefs may have a profound effect on children’s
and parents’ grieving process; therapists must recognize
that challenging culturally bound belief systems is
rarely therapeutic. On the other hand, some beliefs
may not be consistent with those held by the child’s religion
or culture and may be responsive to reinterpretation
by religious leaders or community elders (e.g., a
religious leader may reassure a child that souls with
mutilated bodies can indeed be admitted to heaven).
Talking about death in general may be helpful for
many children who may have not to this point been
able or willing to ask questions about death due to their
traumatic grief symptoms. Initially, this discussion
may consist of neutral questions about death, rather
than about children’s specific losses. For example,
many children enjoy playing the Good-Bye Game
(Childswork/Childsplay), in which cards with questions
about death, funeral, cremation, heaven, and so
on are drawn and children get points for answering (S.
Padlo, personal communication, March 2003). This
activity sets the stage for openly talking and asking
questions about death.
Mourning the loss requires children to acknowledge
what they have lost (a task that children with CTG may
not have been able to do prior to completing the trauma-
focused interventions earlier in treatment). Children
have lost both the interactive relationship they had
(the special and everyday things they did with the deceased
person) and the things they may have shared
with that person in the future but now will never have
the chance to (such as confirmation or Bar Mitzvah,
high school graduation, wedding, and so on). Parents
have additionally lost (if their partner or spouse died)
having the other parent present to raise their children
together or (if their child died) the chance to see that
child grow into an adult. These losses are excruciatingly
painful to many people, and children and parents
may naturally experience ongoing pain in facing these
losses. It is not the goal of this brief treatment model to
totally resolve these; such losses may be associated
with lifelong pain. The goal is to begin the process of
acknowledging what has been lost and to help the person
at least intermittently face the pain as it is experienced,
rather than to attempt to consistently or perma-
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COHEN AND MANNARINO
nently avoid it. (Therapists should recognize that in
certain circumstances avoidance is a positive coping
response and may at times be an essential component
of normal grieving.) To assist the child in talking about
the deceased person, it may be helpful to write that person’s
name on a blank sheet of paper, with one letter for
each horizontal line. Then the therapist can ask the
child to fill in one word or phrase for each letter of the
person’s name that describes an important characteristic
of the person who died (S. Padlo, personal communication,
March 2003). For example, one child whose
brother Daniel died completed this task as follows:
Donut-lover
Allowed me to use his Nintendo games
Never impatient with me
Intelligent, helped me with math
Extremely funny—told the best jokes
Liked to play baseball
This allows children to gradually start talking about the
deceased person in a manner and to an extent that is
comfortable. Once children are able to talk about more
details about the deceased, they may be willing to
make lists of “Things I Miss” about the deceased, including
everyday and special activities they shared,
places they went together, shared rituals (e.g., bedtime,
Christmas morning), and so on. Children may also
want to list specific future plans they had made with the
deceased that will now need to be modified (e.g.,
a planned family vacation, father coaching a child’s
sports team, siblings going to the same school together
in the coming school year, and so on).
At this point children and parents may want to start
thinking about how these plans can be modified to
cause them the least amount of distress (i.e., coping
with future trauma and loss reminders while recognizing
that there will be sadness when doing these activities
in the absence of the deceased). In the parallel parent
session, therapists may share the losses children
named, as well as encourage parents to name and talk
about their own losses. Issues such as how to raise children
alone, how to interact with other couples as a single
parent, dealing with in-laws, parental sexuality after
loss of a partner, and changed religious beliefs or
attitudes may be appropriate foci for parents who have
lost a partner (Elissa Brown, personal communication,
October 2003). If secondary adversities (loss of home,
income, and so on) have resulted from the deceased’s
death, this may be an appropriate time to explore with
parents how this has negatively impacted the child and
family and how the therapist might be helpful in minimizing
the adverse impact on the child (this may involve
assisting the family in accessing community resources,
with which the therapist should have adequate
familiarity).
Addressing ambivalent feelings about the deceased
allows children and parents to acknowledge that the
deceased, like everyone else, had flaws and less likeable
qualities without diminishing either the tragedy of
his or her death or how much he or she was loved. It
may be that there were unresolved confiicts between
the child or parent and the deceased at the time of
death, which now cannot be resolved face-to-face.
There may have even been mistreatment, such as domestic
violence or child abuse, perpetrated by the deceased
toward other family members. These issues
need to be honestly addressed rather than denied or
hidden for the true totality of the deceased person to be
acknowledged, reminisced about, and grieved.
Addressing ambivalent feelings toward the deceased
may be a particularly important intervention for
those whose loved ones died in circumstances that are
associated with stigma or negative judgments from the
larger society, for example, deaths from suicide, drug
overdose, or AIDS. Children and parents may be angry
about or ashamed of how the loved one died and may
feel isolated from those who do not know the manner
of death or ostracized by those who do. Having the opportunity
to openly acknowledge these feelings in therapy
without being judged often allows children and
parents to express their positive feelings about the deceased
(which they may feel constrained from doing
publicly for fear that this will be viewed as condoning
the behaviors that led to the death), to thereby reminisce
about the totality of the person whom they have
lost and thus to start the process of grieving the loss. If
ambivalent feelings for the deceased are present, some
children may want to add to their earlier list of Things I
Miss another list of “Things I Will NOT Miss” about
the deceased (their bad temper, hitting me, calling me
mean names, and so on).
Some children choose to write a letter to the deceased
person and then write the letter they think the
deceased would write back to them in response. (Therapists
must be sure that younger children understand
that the deceased is not living in a distant location to
which the letter is being sent.) Such techniques can assist
children and parents in acknowledging and accepting
their true feelings, both positive and negative, toward
the deceased and thus allow them to begin
grieving the total person they have lost.
Preserving positive memories of the deceased is often
a prerequisite to giving oneself permission to commit
to existing and new relationships. At this point in
treatment, children (who previously may have preferred
to avoid mementos, pictures, and other reminders
of the deceased) are encouraged to look through
these and create a memory box, scrapbook, or other
collection of memories, in which they display or save
fond memories of the deceased person. Some children
may prefer to do this through fill-in-the-blank sheets
that the therapist and child can custom design for the
828
CHILDHOOD TRAUMATIC GRIEF TREATMENT
deceased person (e.g., “What was the funniest thing
your loved one ever did?” “What was his or her favorite
piece of clothing?” “What was the best Halloween costume
he or she ever wore?” “What was the best gift he
or she ever gave you?”). Other children may choose to
design their own tangible memorial of the deceased,
such as a mural, collage, or photo album. Children
should be encouraged to invite other family members
to assist them in collecting and remembering things to
include in this memorial; this may also help parents
who are themselves reluctant to look through the deceased’s
belongings but willing to do this for their children’s
benefit.
Particularly following a traumatic death, it is uncommon
for children to be included in the planning of
the funeral or burial rites. Children may at this point in
treatment elect to plan their own memorial service, in
which they can select the tributes to and memories of
the deceased to be included. This may provide some
closure that the initial funeral was unable to provide to
children with CTG. This sense of closure may be particularly
elusive if no corpse or remains of the deceased
were found (as was the case for many victims of the
September Uth attacks). Body reconstructive techniques
may assist these children in this regard (Layne,
Pynoos, et al., 2001; Pynoos, 1992).
Redefining the relationship is an important step for
children and parents to be able to move ahead in their
normal development. It requires children and parents
to accept that the relationship with the deceased has
changed from one of interaction to one of memory.
This is particularly crucial for children who are still in
the process of moving through progressive developmental
stages and who need relationships with others
who are also growing and changing (unlike the deceased
who can no longer grow or change). One technique
that may help children to operationalize this
change is by drawing one balloon anchored to the
ground with another floating up in the sky. Children are
asked to name all of the things they have lost in the relationship
in the floating balloon (e.g., doing things together)
and all the things they still have in the relationship
in the anchored balloon (e.g., memories of times
together). This can begin the painful process of letting
go of the interactive relationship with the deceased.
Committing to present and new relationships may be
easier if the therapist acknowledges that none of these
will be exactly like the relationship with the deceased,
and therefore none of these relationships can or intend to
“replace” the deceased person’s place in the child’s life
or memory. However, the therapist can help the child to
see that other people may be able to fill some of the roles
that the deceased played in the child’s life. For example,
an uncle may take the father’s place as the new coach of
the child’s baseball team, or a neighbor child can walk to
school with the child in place of the child’s sister. The
therapist can help the child see that all of these people together
will never be the same as having the deceased person
back, but it will be better than having no one to fill
any of these roles. Children may be assisted in committing
to new relationships by naming different needs or
roles that the deceased fulfilled for them and then identifying
other people in their lives who potentially could
fill one role or another. Children should be encouraged
to “audition” such people in these roles and see who is
the best fit for each.
It is important to recognize and openly discuss potential
barriers to committing to new relationships.
These may include a fear of being disloyal to the deceased
or a fear that the deceased will fade from memory.
Children may fear their parents will be angry if
they are able to be happy again, especially if children
are further along in the grieving process than the parent.
The therapist will need to address this concern
with parents who are in this situation and identify ways
in which the parent can encourage the child to enjoy
present and new relationships even if the parent is not
yet personally ready to do this. (In some cases, the parent
may be ready to explore new relationships, i.e.,
start dating after the death of a spouse, but the child
may object to this as disloyalty to the deceased parent.)
This would also be an appropriate focus for this treatment
component.
Making meaning of the traumatic loss assists children
in integrating this experience into a larger vision
of themselves and the world around them. Ideally, children
will recognize that adjusting to the traumatic
death has not only been a frightening and painful process,
but also one in which they have grown and become
stronger in some way. Children may be encouraged
to identify these aspects of the process through
answering questions such as “How has this experience
changed you?”; “What would you tell other children
who have just had a traumatic loss?”; “What would you
tell another child who is afraid of going to therapy for
this?”; and so on. Most children respond that it has
been very hard but it has been worth it because they
learned how strong they are, they became more aware
of how much their family members love them, they
came to understand how many good and caring people
there are in the world, and so on. Older children and
parents may find meaning in trying to prevent other
people from having to experience what they did or by
helping other people who are going through similar
circumstances. For example, children who lost a loved
one in a drunk-driving accident may join Students
Against Drunk Driving to spread the word about the
dangers of this activity; parents who lost a child to
community violence may become a victim advocate at
a community program.
Following the U.S. Air Flight 427 disaster, surviving
family members formed the Flight 427 Air Disaster
Support League, which advocated for more prompt
and open communication from airline officials follow-
829
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ing such disasters and continues to provide peer support
to families immediately following air disasters
throughout the world (Stubenbort et al., 2001). Many
parents and children have expressed the sentiment that
these activities have helped them to find meaning in the
death of their loved ones and in their own lives and to
heal from their own loss.
Joint parent-child grief sessions allow the family to
openly express their feelings of loss, to reminisce
fondly together about the deceased loved one, and to
prepare for trauma and loss reminders that will occur in
the future. It also allows parents and children to predict
that sad feelings will be inevitable at certain times and
to give themselves and each other permission to have
and express to each other such feelings. It also gives
children and parents the opportunity to see how far
they have come from the beginning of treatment and to
optimize their ability to communicate openly about
difficult topics in the future. Ideally, by the end of this
treatment, the parent will be the person the child is
most comfortable turning to in the future for support
and help in dealing with painful or difficult feelings,
whether or not they are related to the traumatic death.
Empirical Support for the CBT for
CTG Model
The above model has recently been tested in an
open treatment study, which evaluated both overall improvement
and the timing of symptomatic change (Cohen,
Mannarino, & Knudsen, in press). This study indicated
that children experienced significant
improvement in PTSD symptoms, which occurred
only during the first 8 (trauma-focused) treatment sessions;
and in CTG symptoms, which occurred during
both the first 8 and second 8 (grief-focused) interventions.
This suggests both that CTG is distinct from
PTSD, and that including both trauma- and grief-focused
interventions is optimal for children with CTG.
This study additionally indicated that children experienced
significant improvement in depression, anxiety,
and behavioral symptoms, and that participating parents
experienced significant improvement in their own
depression and PTSD symptoms (Cohen et al., in
press). This sends preliminary support to the CBT for
CTG treatment model described above.
Summary
CTG is a condition in which children are “stuck” on
the traumatic or dangerous circumstances of a loved
one’s death. Thoughts about the deceased segue into
thoughts and memories of the terrifying circumstances
of the death. This leads to avoidance of trauma and loss
reminders and an inability to reminisce about the deceased
person. Thus, trauma symptoms intrude and
impinge on the child’s ability to negotiate the normal
grieving process. CTG is not the norm among children
who have lost loved ones in traumatic circumstances.
Preliminary studies have indicated that group traumaand
grief-focused interventions provided in school settings
are helpful in decreasing CTG and PTSD symptoms
in youth exposed to war and community violence.
An individual-treatment model for treating CTG in
children that includes parents in treatment is currently
being empirically tested in open and randomized controlled
treatment trials; this article describes key
trauma- and grief-focused components of this treatment
model. Additional research is needed to determine
whether the current concept of CTG is supported
by epidemiologic data and whether current treatment
models are effective for decreasing symptoms and optimizing
adaptive functioning in children with CTG.
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Received November 5, 2003
Accepted March 25, 2004
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