childhood traumatic grief

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The concept of Childhood traumatic Grief involves a condition where a child’s trauma symptoms surrounding the loss of a parent prevent the child from processing his or her grief. The loss can be either what is objectively described as a traumatic death, such as a death caused by suicide, homicide, or accident, or a loss caused by what is subjectively interpreted by the child as a traumatic experience.

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PowerPoint Presentation

Rania Attia M.D.Grand Rounds5/29/13Childhood Traumatic GriefDeath of a loved one is one of the most common stressful life events for anyone. While searching for my grand rounds topic I encountered several patients of different ages that experienced the loss of a loved one. Also, given recent tragic events in the media such as bombings, school shootings and natural disasters, it is very difficult to shield children and teenagers from death and loss, even if they do not experience it directly. One of the reasons I chose Childhood Traumatic Grief as my grand rounds topic, is because it seems to be a new area of interest where childhood grief, loss and trauma meet.

The topic of traumatic grief, initially seemed to be a new field of interest for trauma researchers, but the more I looked into it, the more I found that since the 1900s researchers and clinicians noted that when someone important in a childs life died under traumatic circumstances, they were often unable to grieve normally. Later in 1995 Eth and Pynoos brought this topic to attention due to the potential convergence b/t grief and ptsd symptoms after working w. children who witnessed the murder of a parent.

The concept of Childhood traumatic Grief involves a condition where a childs trauma symptoms surrounding the loss of a parent prevent the child from processing his or her grief. The loss can be either what is objectively described as a traumatic death, such as a death caused by suicide, homicide, or accident, or a loss caused by what is subjectively interpreted by the child as a traumatic experience.

1Topic RelevanceTerminologyDevelopmental Perspective on GriefVariablesSymptoms of Childhood Traumatic GriefAssessmentTreatment

ObjectiveDuring the next half hour, I would like to talk about the following:

-Topic Relevance-Some of the terminology

-Developmental Perspective on Grief-In order to learn about traumatic grief, I think its important to discuss and define what normal grief looks like for a child or teenager.

-We will discuss other grief related variables such as: types of loss, family relationships and attachment, and how that plays a role in how children could potentially develop CTG

-Symptoms of CTG-we will review the core features of this proposed disorder

-Assessment-questions you may want to ask when you evaluate a child or teen after the loss of a loved one

-Treatment-there is a need for evidence based treatments but I will briefly review some of the proposed treatment modules in the current literature. I think this area of the lecture will be helpful for a brief review of issues to address when seeing children who experienced loss whether they have experienced the loss with associated trauma symptoms or not.

2ImportanceResearches have documented higher levels of trauma symptoms with concurrent grief reactions in youth exposed to war, violence and terrorism.

5% of children age 15 and younger have lost one or both parents (Steen, 1998)

Slightly more than half (51.9%) had experienced the sudden unexpected death of a close relative or friend by age 21

Childhood bereavement from parental death is associated with increased psychiatric problems in the first 2 years after death

Cerel et al 2006; Breslau et al 2004; Weller et al., 1991; Worden and Silverman, 1996; mentalhelp.net; Pfefferbaum, Call,et al., 2001; Pfefferbaum, Nixon, et al., 1999

-Researchers long ago documented higher levels of trauma symptoms associatedwith concurrent grief reactions after traumatic deaths. Many children who where exposed to war, violence or terrorism, who where grieving relationships to individuals who died under those traumatic circumstances, were more likely to have higher levels of posttraumatic stress symptoms.

-It is estimated that 5% of children age 15 and younger have lost one or bothparents (Steen, 1998). Close to two million children are currently on SocialSecurity Administration (SSA) survivors benefits due to the death of a parent(Social Security Administration [SSA], 2009).

-Slightly more than half (51.9%) had experienced the sudden unexpected death of a close relative or friend by age 21.

-Childhood bereavement from parental death is associated with increased psychiatric problems in the first 2 years after death. And in one study done by Taylor, Weens and colleagues in 2009 found that parents whose children lost a parent, reportedly had, higher of behavioral problems when compared to age-and gender-matched controls.

Also, just to mention when children lose a friend and where in bereavement, one study showed that when adolescents lost a close friend to suicide, 5% met full criteria for ptsd and endorsed more symptoms on the PTSD reaction index.

-Therefore children and teens who experience the loss of an important person in their lives, as well as having such circumstances occur during a traumatic experience are at higher risk of developing severe and persisting mental health disorders.

3BereavementGriefComplicated Grief and Prolonged grief-DSM V Persistent Complex Bereavement disorderChildhood Traumatic GriefNader et al 2011; Storebe et al 2001

TerminologyWhen considering how children grieve, it becomes more complicated as you are also considering their developmental level and how this impacts how they express grief. Much of what we know about grief in children and teenagers is based off of literature and studies done on adults.

First off I just want to briefly clarify some terminology used in the literature:

As per Storebe and colleagues 2001 clarified the following definitions:

The terms bereavement, grief and mourning are often used interchangeably.

-Bereavement is defined as the objective experience of having a loved one die. Thus, bereavement is a universal event experienced by everyone.

-Grief is defined as the emotional, physiological, cognitive, and behavioral reactions to the death of someone significant. Again, grief is experienced by everyone who is in a bereaved state.

-Lastly, mourning is defined as the cultural practices and expressions of grief.

What I found in my search initially, was 3 separate entities of Complicated grief, Prolonged grief and then traumatic grief. From my understanding, The DSM V now has the term Persistent complex bereavement d/o which is now included in the appendix of the DSM V, as a area under investigation. This is proposed to be an umbrella term that includes complicated, prolonged and traumatic grief.

I believe the main feature b/t more complicated or prolonged forms of grief and traumatic grief, is the loss of the attachment figure. This loss is what causes persistent grief symptoms that impairs functioning rather than the actual trauma surrounding the event. But again, the subtle differences are still under investigation.

4Infants and ToddlersNo Cognitive understanding of deathExpect Person to returnSleep DisturbanceEating Pattern ChangesFussinessBowel and Bladder DisturbanceDifficulty being comforted

Nader et al 2011, Cohen et al 2002Death is temporary and reversibleDeath is sleepingMagical thinkingRegressive behaviorRe-enact death via playAggression

Developmental ConsiderationsPreschoolersFirst we will review normal bereavement from a developmental perspective.

**The clinical presentation of uncomplicated bereavement, aka normal grief varies greatly b/c it is based on developmental level! The variables according to developmental stage include understanding what death is, ways of expressing grief which may vary based on how parents model the grieving process (for instance not talking about the death), religious and cultural practices and cognitive and verbal abilities.

Also, complicated grief reactions may undermine development and functioning for children and adolescents, and it may persist for years if unresolved.

-Infants and Toddlers-(0-3): No Cognitive understanding of death, expect person to return. They typically react to separation from a primary care giver w. sleep disturbance, eating pattern changes, fussiness, bowel and bladder disturbance or difficulty being comforted (Cohen et al 2002). They may not understand the impact of death, however loss of a primary attachment figure can be experienced as traumatic in and of itself (cohen et al).

-Preschoolers (roughly ages 3-6)-Cannot typically understand the irreversible nature of death. They may believe death is just sleeping however may also engage in magical thinking in which they believe that they are powerful enough to influence what happened to their caregiver. Such as, I was a bad boy and now mommy isnt coming back. They will often ask questions about how the deceased is breathing in the coffin, how they look, what and how do they eat, which indicates trying to understand the concept of death.

Also, they may exhibit regressive behaviors, such as temper tantrums, thumb sucking, bedwetting or soiling themselves, or change in lang abilities. They may reenact the death in play and use this as a way of coping and expressing their feelings. This is to be distinguished from the play noted in children who experience PTSD symptoms. When children w. ptsd re-enact the traumatic event, the quality of the play tends to reflect the trauma. For instance, the play may be repetitive, uncreative, that produces no emotional relief or gradual resolution of traumatic themes. Children of this age may express that they would like to die and join their loved one, which is not to be confused w. being suicidal, though this needs to be assessed if there are true concerns for the childs safety.

5School Age Begin to understand that death is permanentMay not believe that death is universalAnxiety Depression and AngerSomatic complaintsFear the safety of loved ones

Nader et al 2011, Cohen et al 2002

Death is final and irreversibleCuriosity about deathInterest in religious or cultural aspects of deathGuiltFear dyingFeel different from other kidsDevelopmental ConsiderationsPreadolescent-Primary School Children or school aged children (roughly ages 5-9 years old)-Children around this age begin to understand that death is permanent. They start to see death as something tangible and physical for instance, ghosts, angels or spirits. Whats important is that many children around this age are still making sense of what exactly death is. For example, they may question how the deceased are in the ground and in heaven (if this is what is believed by the family and what child is told) at the same time. Intermittent anxiety, depression, anger and irritability are common around this age after the loss of a loved one. Also, its common to see a lot of somatic complaints. As their understanding of death evolves, one may also see that the child fears the loss of other primary care givers and worries about their own death.

-Pre-pubertal (preadolescent phase) children(9-12): At this age, children should be better able to understand more abstract ideas about death, for instance, that death is final and everyone will die, while the body may be buried, the soul or spirit may live on (provided this is what is believed by caregivers and passed on-this may vary based on religious and cultural back ground). The child may still have some remnants of magical thinking, believing that something they did could have stopped their loved one from dying.

6Developmental ConsiderationsAdolescent:Increasing capacity for abstract reasoning and understanding complexity of deathExistential life crisisInvincibleResent results of loss (demands on family)Sadness and lonelinessReject adultsNormal mood swings=exacerbate griefIdealize deceased and demonize survivor

Nader et al 2011, Cohen et al 2002

-Adolescents: 12 y/o and on. Teenagers have an increasing capacity for abstract reasoning and understanding the complexity of death. They may struggle w. existential life crisis and wonder; why did this happen to us?, why am I here?. Because of their more advanced cognitive process and ability to understand death, they may become profoundly sad, lonely, angry, and irritable at times. They may feel they are invincible, particularly when it comes to death and this can manifest as more risk taking behaviors to protest their loss and test their own mortality. Also, they may resent sequalae of loss (demands on family), reject adults, normal mood swing can exacerbate grief, idealize deceased and demonize survivor

One thing that I have to mention when looking into the literature about grief and traumatic grief, it is difficult to find a time line as to what can be considered normal or not. I believe the consensus is that children normally grieve in spurts and that this is a reflection of their developing brains.

7Multiple factors influence a youths grief reactionsChild VariablesEnvironmental VariablesAttachment to caregiversSupport outside of the family

Brown et al.,2008; Crenshaw, 2007; Webb, 2002; Nader et al 2011; Salinder et al 2004

VariablesMultiple factors influence a youths grief reactions

-Child Variables: such as resilience, h/o psychiatric disorders, gender, ethnicity, adaptive functioning (e.g., avoidance, problem solving, coping), cognitive processing, and history of stressors.

-In terms of Environmental Factors- parenting styles-is it child centered, home conditions, who lives in the home and whether it is stable is important. What many studies have voiced, is that children tend to mirror their caregivers response to grief whether dealing with it in a more direct way or not dealing with at all.

-Attachment-In 1969/1982 Bowlby found that when a young child was separated from their primary caregiver for a long period of time, they went through a series of protest, despair and detachment. It is very important to note that a childs relationship with the deceased parent and surviving family members can be quite indicative of whether they develop a complicated grieving style.

-Support: support from others, outside of the family, such as school and friends for example, have shown to be an important protective factor for trauma and grief.

8 Type of LossNature of the loss will increase the chances of having a Traumatic Grief experience.

Youth exposed to the same type of loss may have different reactions, and youth exposed to different types of loss may have similar reactions

Loss of parent from terminal illness can also be considered traumatic

No Clear Consensus

Shapiro, 2008; Nader et al, 2011Many studies have indicated that nature of the loss will increase the chances of having a prolonged, complicated or possibly traumatic grief experience. Studies done in 2009 cited studies that indicated that people who lost loved ones from suicide or murder had an increase in trauma symptoms when grief was reported.

Youth exposed to the same type of loss may have different reactions, and youth exposed to different types of loss may have similar reactions (Shapiro, 2008). So overall, people may grieve very differently, though we know that there is some overlap when it comes to normal grief.

There is also some argument that despite the ability to anticipate a death as the result of illness, for example, due to cancer; there may be added stressors such as the strain on resources and the problems of having attention diverted away from other family and personal concerns (e.g., undermining of child-centered parenting, disruptions to normal concentration).

Still there is no consensus as to what type of loss or rather, what circumstances are considered traumatic. Saldinger, Cain, and Porterfield (2003) examined qualitative data from 58 school-aged children of parents with terminal illnesses and concluded that such experiences may constitute a traumatic experience. Some argue that from a childs perspective any loss of a parent or loved one can be considered traumatic.

9Reconciliation 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; Worden, 1996ReconciliationIdeally, Bereaved children should move on to this phase. Reconciliation-Defined 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 re-involving oneself in the activities of living

10Childhood Mourning1. Accept2. Experience pain3. Adjust to new identity4. New Relationships5. Convert to memory6. Find Meaning7. Supportive adultWorden Et al 1996; mom-psych.com; Goodman 2004

So the thought is that in order to reach reconciliation, the child should be able to go through the following stages of mourning.

Wolfelt and Worden et al (1996), Brown and Goodman 2005, described the following tasks of childhood mourning:

accepting the reality and permanence of the death(2) To experience and cope with painful emotional reactions to the death(3) adjusting to changes in their lives and identity that result from the death,(4) developing new relationships or deepening existing relationships to help them cope with the death (5) Convert to memory-its important that the child is able to tolerate keeping an appropriate attachment to the person who died through such activities as reminiscing, remembering, and memorialization, (6) Making or finding meaning of the death, which can include coming to an understanding of why the person died, and (7) experiencing the comfort of a continuing or new supportive adult presence in the child's life.

Then there is also mention of another task which is continuing through the normal developmental stages of childhood and adolescence (Goodman et al., 2004).

The child needs to be able to tolerate prolonged thoughts about the deceased, including specific memories, and also tolerate the uncomfortable feelings about the death and loss.

Now, children w. traumatic grief, are unable to complete these tasks for reconciliation.11Childhood 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.

Cohen et al 2004/2007; Brown Goodman 2005

Childhood Traumatic Grief-The current literature defines childhood traumatic grief as 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.

To not have to experience these extremely uncomfortable and terrifying experiences, the child may develop avoidance and or numbing strategies (Cohen et al) If a child experiences trauma symptoms when the thought of their loved one comes up, they will not be able to process the loss.

12Trauma Reminders---avoidance/numbing

Loss reminders--avoidance/numbing

Change reminders-avoidance/numbing

Pynos et al 1992; Cohen et al 2001; Childhood Traumatic GriefCohen et al mentions that these reminders are important in understanding CTG:

Trauma reminders include situations, places, people, smells, sights or sounds that remind the child of the traumatic nature of the death

Loss reminders-thoughts memories, objects, places or people who remind the child of the deceased person

Change reminders-situations, people places, or things that remind the child of changes in living situations caused by the traumatic death For instance a child who lost their mother in a car accident, can have intrusive re-experiencing symptoms when he hears cars blow horn at each other. He may also experience hyper-arousal when he sees mothers picture or spending time w. his relatives, who he now lives with, which is change reminder.

To not have to experience these extremely uncomfortable and terrifying experiences, the child may develop avoidance and or numbing strategies (cohen et al).

-Avoidance allows the child to decrease the frequency of the exposure to trauma, loss and change reminders. Though some of the studies argue that some avoidance behaviors, when mourning a loss, can be protective, prolonged avoidance can interfere w. integrating and adjustment (Nader et al 2011).

-Emotional numbing allows child to minimize the pain. It may make the child feel estranged, isolated; even when their family members also experienced the loss.

13Avoidance IdentificationOver identificationExaggerated self blaming and guilt

Pynos et al 1990, Nader 1997, Cohen 2001

Nader et al 1997; Pynoos 1992: Cohen et al 2001Childhood Traumatic GriefOther features of CTG include:

-Avoidance identification-children may avoid being associated with the deceased for fear they may also die or share the same fateThis can interfere with integrating positive aspects of the child with their deceased loved one which is a very important part of normal grief

-Generalize their exaggerated fears-something along the lines of thinking all of my loved ones will die and leave me, therefore a child may refuse or avoid other attachments to adult figures, which is also an important part of reconciliation and normal grief.

-Over identification-which is when a child w. CTG will take on many aspects of the deceased, for instance taking the deceased name, wearing their clothes. This is seen as an attempt to avoid accepting the loss of their loved one and avoiding the pain associated w that loss.

-Exaggerated self blaming and guilt-blame for not being able to rescue their loved one etc. There can also experience guilt and shame associated with stigma of the death, for instance, if a parent dies from suicide or AIDs.

14Death of loved one perceived as traumaticPresence of significant PTSD symptomsImpingement on childs ability to complete bereavement

Pynos et al 1990, Nader 1997, Cohen 2001

Childhood Traumatic GriefOverall the current consensus regarding diagnostic criteria that was proposed for CTG are the following:

Death of childs loved one in circumstances that where objectively or subjectively perceived to be traumatic

Presence of significant ptsd symptoms, including that loss and change reminders segue into trauma reminders, which in turn, trigger the use of avoidant or numbing strategies

The impingement of these ptsd symptoms on the childs ability to complete the tasks of bereavement

15Children may grieve throughout their developmentOnly their persistence and intensity may distinguish them from normal reactions.

Cohen et al 2007; Layne et al 2001

Cohen et al; Nader et al 2011; Himebauch et al., 2008AssessmentXxxx Before discussing recommended assessment for CTG as well as grief in general, I want to again, point out how difficult it is to determine the nature of grief in a child (normal vs abnormal).

Unlike adults, children may grieve in spurts and cangrieve again when new developmental stages enhance their understanding of death or thenature of a death (Himebauch et al., 2008).

It is important to note that some of the symptoms of CTG are the same as symptoms of normal grief, which makes them difficult to distinguish. Only their persistence and intensity may distinguish them from normal reactions.

16What is the childs current and previous functioning?

The death

Childs PTSD symptoms

Variety of measures under exploration i.e. EGI-Extended Grief Inventory

Cohen et al 2007; Layne et al 2001AssessmentIt is necessary to evaluate the following issues:

-Current or previous functioning: Its important to understand the childs previous function, such as school performance, how the family functioned prior to death, developmental stage, temperament, past adjustment, psychiatric status, past experience w. death.

-The death-Here you want to understand the childs relationship to the deceased, circumstances of the death, how they learned of the death, emotional state of significant others present during the death and reaction during funerals etc. What was the childs experience during the time surrounding the death? What do they recall? And did the child participate in bereavement rituals. What does the child believe happens when someone dies? What does the family believe?

-PTSD symptoms-PTSD as a dx is a separate issues we are talking about symptoms only here. According to the current literature, a child does not have to have ptsd to have CTG, they just have to have symptoms.

-Impingement of ptsd symptoms on Mourning-This is difficult. To tease these symptoms out, you have to ask very specific questions but even so, I would imagine it is difficult to differentiate.

-Questions you might try: Understand if reminders of the loss of their loved one immediately segues into trauma symptomsfor instance-Do you find that when you remember happy times with your mother, this leads you to start having thoughts about the way she died or make you very scared?-does the child cry at the thought of missing their loved one or b/c horrifying images of how they died, real or imagined suffering make these thoughts overwhelming and this is what makes them cry?-Are thoughts of the deceased interfering with regular thoughts?-Does the child avoid the hearing the deceased name, seeing pictures?

There are a variety of measures under exploration for assessing TGI: Extended Grief Inventory (EGI). Was designed by Layne and colleagues in 2001 and it includes a range of items designed to assess the classical model of CTG, additional concepts (e.g., revenge), and normative grief reactions.

17Studies:Cohen and Mannarino 2004Layne et al 2001Saltzman and Pynoos et al 2001Salloum and Vincent 2001Pfeffer and colleagues 2002

Cohen 2004; 2011; Layne 2001; Saltzman 2001 Treatment for CTGWithout intervention, traumatic grief has the potential for long lasting consequences.

There are quite a few studies examining tx of CTG. Ive listed them above but the major one I would like to high light is Cohen and Mannarino in 2004.

Cohen and Mannarino who developed a trauma focused CBT treatment protocol for CTG in 2001 also published an open pilot study in 2004, which explored effectiveness of tf cbt for ctg pts that focused on individual therapy and parallel parent therapy, which had not been explored in prior studies. Twenty-two children and their primary caretakers received a manual-based 16-week treatment with sequential trauma- and grief-focused interventions. Children experienced significant improvements in CTG, posttraumatic stress disorder (PTSD), depressive, anxiety, and behavioral problems, with PTSD symptoms improving only during the trauma-focused treatment components and CTG improving during both trauma- and grief-focused components. Participating parents also experienced significant improvement in PTSD and depressive symptoms. The timing of improvements in CTG and PTSD symptoms lends support to providing sequential trauma- and grief-focused interventions and to the concept that CTG is related to but distinct from PTSD. The results also suggest the benefit of individual treatment for CTG and for including parents in the treatment of CTG.

Many of these studies have quite a bit of limitations, including smaller sample sizes, non randomized trials, some have no placebo group, and large drop out rate.

So, despite the limitations I just mentioned, the idea is to treat both trauma and grief and by doing so, and allowing at least partial resolution of the trauma symptoms, this makes way for allowing the grieving processes to move forward.

18Trauma-Focused Interventions Affective expression skills Stress management skills Cognitive triangle Creating the child's trauma narrative Cognitive processingJoint parent-child sessions

Grief-Focused Interventions

Cohen et al 2004Talking about death; psychoeducationMourning the lossAddressing ambivalent feelings about the deceased Preserving positive memoriesRedefining the relationshipCommitting to other relationshipsMaking meaning of the traumatic lossJoint parent-child sessions

Treatment of CTGHere we have a brief overview of TF-CBT modules for Childhood traumatic grief.

-Judith Cohen who seems to be at the forefront of much of the current CTG literature developed a TF-CBT model for the tx for CTG (2001).

Here is the overall structure of TF-CBT for CTG patients. It consists of 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.

19Trauma Focused Interventions:Affective Expression SkillsStress management skillsUsing Cognitive triangleTrauma narrativeCognitive processingJoint parent-child sessions

Cohen et al 2004Treatment of CTGTrauma/Grief Focused CBT: Well start with the trauma focused interventions-

-Affective Expression Skills: This helps children and teenagers identify and express emotions related to traumatic events. So for instance creating a feeling mask (whereby they decorate the outside of the mask to express external emotions and the inside of the mask is used to express internal emotions).

-Stress management skills-Here, the therapist guides the child and parent separately to work on ways of managing hyper arousal symptoms associated w. trauma. These may include, deep breathing, thought stopping, progressive muscle relaxation. Also, exploring ways the child unwinds may also be helpful.

-Use of the Cognitive Triangle: This part of the treatment helps children and parents to understand and possibly modify thoughts that are unhelpful. So the example that is used is

So for instance, if a child walks into a room and sees another child put his head on the desk, that child may have an automatic thought that, that person doesnt like me and feel bad (feeling) and then go off and sit alone (action). However by altering the cognitive triangle w. changing the thought first, maybe that child is having a bad day, instead he or she feels empathy and then tries to become friends.

So the aim is to modify unhelpful thoughts to more helpful thoughts and feelings.

Creating the trauma narrative: this usually takes 2-3 sessions and is a way to process the trauma, allowing for the child to face what happened to them and or their loved one. Some of the goals here would be to gradually, make it easier for the child to face thoughts, and reminders of the traumatic aspects of death, decrease avoidance of the more scary aspects of the experience, to help put the event into context of their own life and to identify cognitive distortions about the death.

Ways to gradually start doing this would be to read a book with the child about traumatic deaths from a childs view point, also, they could create a story, a poem, a comic strip or a song for their loved one. The narrative should include not only "what happened" but also the childs thoughts, feelings, and body sensations throughout theexperience.

Cognitive Processing: This part of the tx, helps children process some of the cognitive distortions they have relating to the death and the aftermath. Many children may have ideas that may not be accurate after traumatic loss of a loved one such as feeling unsafe, feeling responsible for their loved ones death. Its this step that helps kids by challenging these cognitive distortions relating to the actual death.

The skills that can be used to help with cognitive processing are overgeneralization, best friend role play or progressive logical questioning. So for instance, if a child makes a statement such as Im not safe anywhere. Then this can be challenged by the therapist saying things like, so when you cross the street, you just close your eyes and pray youll be safe. Or you can play, best friend role play. So if a child feels to blame for a death, the child can play the role of his/her bf and therapist can be the pt. Pt will thereby learn to comfort and come up with alternative resolutions to the cognitive distortion.

-Joint parent-child sessions: allow children and parents the opportunity to openly discuss the traumatic nature of the loved one's death with each other. 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.

One of the goals of both creating the trauma narrative and cognitive processing is to place the traumaticdeath into the greater context of children's whole lives. Specifically, some children over-identify 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.

20Treatment of CTGGrief Focused ComponentsTalking about deathMourning the lossAddressing ambivalent feelings about the deceasedPreserving positive memoriesRedefining the relationshipCommitting to other relationshipsMaking meaning of the traumatic lossJoint parent-child sessions

Cohen et al 2004; Brown 2003

So the Grief Focused components are helpful not just in tx TF CBT for CTG, but I think it gives us very helpful ways of talking to kids about death in a general way since its such a difficult topic.

So The Grief Focused Components include:

Talking about death-The idea is to openly discuss the death. There is a game called, 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.

Mourning the loss-It is not the goal of this brief treatment model to totally resolve the loss b/c this could take a life time. The goal in this area is to begin the process of acknowledging what has been lost and to help the person at least try and face the loss, rather than to attempt to avoid it. There are a # of exercises that can be used for this task. So for instance, the child can spell out the deceased name and assign a positive descriptive word for each letter of the persons name. Or make a things I miss list.

----For the parent, according to Cohen and Colleagues, 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 an appropriate focus for parents who have lost a partner (Elissa Brown, personal communication, October 2003).

Addressing ambivalent feelings about the deceased-This allows the child to address unpleasant feels and validates the unpleasant feelings. This makes it ok for the child to possibly have negative feelings about the deceased. The deceased may have had undesirable qualities on top of positive qualities as well. This could be particularly important if the childs loved one died due to circumstances that could be viewed as negative by society, i.e. suicide, overdose or AIDs.

"Things I Will NOT Miss" or a child can write a letter to the deceased. The idea is to accept both positive and negative feelings toward the deceased.

Preserving positive memories- so, this is described as almost a prerequisite to giving oneself permission to commit to other and possibly new relationships. Suggestions for this exercise could be creating a memory book, story or picture album commemorating their loved one.

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 sense of closure may be particularly difficult if there is no body (as was the case for many victims of the September 11th attacks).

There have been some literature on attending funerals for children. Many argue that this may allow a sense of relief for the child. Pick and choose what you allow the children to see.

Redefining the relationship- This helps the child accept that the relationship with the deceased has changed from one of present reality to one of memory. So one exercise that I really liked was the balloon exercise. The suggestion was that the child draws two balloons, one attached to the ground and another flying freely in the air. The child could identify the things that are lost of their loved ones relationship in the floating balloon. At the same time, the balloon that is still anchored can be used to identify what they are gaining in relationships can be symbolized by the balloon that is still anchored. This can begin the painful process of letting go of the relationship with the deceased while recognizing the good things that are still in the childs life.

Committing to other relationships-It is important to recognize and openly discuss potential barriers to committing to new relationships. Children or even parents could feel guilty about moving on, especially if one is a little farther along in the grieving process.

Making meaning of the traumatic loss-assists children in integrating this experience into a larger vision of themselves and the world around them. Asking questions such as, how has this loss changed you. The aim or hope is that at some point the child may be able to identify how difficult its been but that they have grown or gone through a lot. Older children and adults could try to may find meaning by trying to put time and energy into preventing this happens to someone else, i.e. they could volunteer for cancer organization.

Joint parent-child 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.

21SummaryCTG: Trauma + GriefDeath and loss increases risk of mental Health DisordersDevelopmental level complicates expression of griefReconciliation and MourningVariables to grief expressionAssessmentCTG studies are limited- current literatures suggests that TFCBT with Trauma and Grief Modules

In Summary-

-CTG is defined as the impingement of trauma symptoms on the grieving process.

-Children and teens who experience the loss of an important person in their lives, as well as having such circumstances occur during a traumatic experience are at higher risk of developing mental health disorders.

-Developmental Perspective-consensus is that children normally grieve in spurts and that this is a reflection of their developing brains. Also, its important to note that expression of grief varies based on developmental level, making it even more difficult to understand traumatic grief.

-Reconciliation and Mourning

-Variables to grief expression: here we discussed how several variables such as child resilience, attachment to care giver, nature of death, hx of trauma and relationship w. surviving caregiver can influence grief expression.

-Assessment should include how the child understands death, how they learned of the death, assessing trauma symptoms, current and previous functioning, and how the family has death with the death.

-Its important to remember that Childhood traumatic grief is still in the works and studies are limited but the current literatures suggests that TF-CBT with Trauma and Grief focused Modules are the standard treatment for children and teens who meet dx of CTG.

22Thank youAcknowledge:Paden Bhutia M.D.Wendy Klapper Phd

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