trauma and grief 2-dorothy

7/29/2019 Trauma and Grief 2-Dorothy

1/20

OMEGA, Vol. 59(4) 305-323, 2009

THE PREVALENCE OF CHILDHOOD TRAUMATICGRIEFA COMPARISON OF VIOLENT/SUDDENAND EXPECTED LOSS

IRENE SEARLES M CCLATCHY

M. ELIZABETH VONK

University of Georgia, Athens

GREGORY PALARDY University of California, Riverside

ABSTRACT

The purpose of this study was to examine the prevalence of childhoodtraumatic grief (CTG) and posttraumatic stress disorder (PTSD) symptoms in

parentally bereaved children and compare scores between those who had losta parent to a sudden/violent death and those who had lost a parent to anexpected death. A sampleof 158 parentally bereaved children ages 716com- pleted the Extended Grief Inventory (EGI); 127 of those also completedthe UCLA PTSD Index. A large number of children were experiencing CTGsymptoms at moderate and severe levels. There was no significant differ-ence in EGI or UCLA PTSD Index scores between the two types of losses.Findings are discussed in relation to trauma theory, research on parentally bereaved children and implications for practice.

According to government records, close to two million children in the UnitedStates receive social security death benefits due to the death of a parent (SocialSecurity Administration (SSA, 2007). Children also experience deaths of other loved ones such as grandparents or siblings resulting in a significant number of

305 2009, Baywood Publishing Co., Inc.doi: 10.2190/OM.59.4.bhttp://baywood.com


2/20

children who are affected by the death of a loved one due to illness, naturaldisaster, or man-made trauma. Unattended grief symptoms may negatively affectchild development (Kaffman & Elizur, 1979), lead to anxious and withdrawn behaviors (Felner, Stolberg, & Cowen, 1975) or depression (Kranzler, Shaffer, &Wasserman, 1990; Lloyd, 1980). Unresolved grief, which involves grief symp-toms that prevent a person from completing various grief tasks, may also havegrave long-term consequences such as marital breakdown, adult depression, andother psychiatric problems (Florian & Mikulincer, 1997). A significantly largegroup of children (19%) show serious problems at 1 year after the loss of a parentand many continue to do so (21%) 2 years after the loss (Worden & Silverman,1996). Greater understanding of this group of children is needed to inform bothresearch and clinical practice.

CHILDREN, GRIEF AND TRAUMA

Traditional grief theory has guided much of the research with bereaved chil-dren. From this perspective, the child will adjust to his or her loss and be able tomove on by completing certain tasks, such as accepting that the loss has occurred,expressing feelings around the loss, and transforming the relationship into one of memories (Wolfelt, 1996; Worden, 1996).

Outcome studies of interventions for bereaved children based on traditionalgrief theory (Wolfelt, 1996; Worden, 1996) has produced inconclusive evidenceof effectiveness. While some children may benefit from support groups (Goldberg& Leyden, 1998; Samide & Stockton, 2002), others may not (Huss & Ritchie,1999; Schilling, Koh, Abramovitz, & Gilbert, 1992). Although most outcomestudies were not statistically controlled (i.e., did not have comparison or controlgroups), those that were controlled provide mixed results also (Adams, 1996;Graham, 1999; Sandler, Ayers, Wolchik, Tein, Kwok, Haine et al., 2003; Sandler,West, Baca, & Pillow, 1992). Dependence solely on grief theory to inform inter-ventions may help explain the varied results.

Traditional grief theory by itself may not fully explain what happens to a childwho loses a parent, especially if the loss is violent (Amick-McMullan, Kilpatrick,& Resnick, 1991; Sprang & McNeil, 1998). Indeed, researchers have found thatthe violent loss of a parent may cause post traumatic stress disorder (PTSD)symptoms in addition to general grief symptoms among surviving children (e.g.,Black, 1998; Pynoos, 1992).

The area of violent loss and its effect on children caught the attention of Pynoosand his colleagues in the mid 1980s. These researchers were interested in theinteraction between trauma and grief in children experiencing loss caused byhomicide (Pynoos, 1992; Pynoos & Eth, 1984), community violence (Murphy,Pynoos, James, & Osofsky, 1997; Pynoos & Nader, 1988), sniper attack (Nader,Pynoos, Fairbanks, & Frederick, 1990; Pynoos, Nader, Frederick, & Gonda,

306 / SEARLES M CCLATCHEY, VONK AND PALARDY


3/20

1987), and natural disaster (Pynoos, Goenjian, Tashjian, Karakashian, Manjikian,Manoukian et al., 1993). Other researchers also examined thepresence of grief andtrauma symptoms after a parents death due to homicide and suicide (Black, 1998;Pfeffer, Jiang, Kakuma, Hwang, & Metsch, 2002; Pfeffer, Karus, Siegel, & Jiang,2000). The researchers found that oftentimes trauma symptoms caused by theviolence of the death interfered with the grieving process in surviving children.Children who had experienced the homicide of a sibling or a parent demonstratedadelay in their grief process (Brosius, 2004; Eth & Pynoos, 1994). Intrusivethoughts about how the parent died seemed to interrupt the integration of thechilds grief tasks. The task of reminiscing, for example, would be interrupted bythoughts or images of the violent death (Eth & Pynoos, 1994). In addition, thePTSD symptom of numbing in children who had experienced the violent loss of a parent, prevented full expression of grief feelings. Therefore, it seemed evidentthat PTSD symptoms had to be addressed before the actual grieving process couldtake place: In this manner, PTSD symptoms can be at least partially resolved,allowing children to better tolerate memories of the deceased and move throughthe process of grieving the loss of their loved ones (Cohen, Mannarino, & Knud-sen, 2004, p. 1226).

In view of recent national traumatic events such as the September 11 disaster,the results from recent studies have supported previous findings that traumasymp-toms experienced after the violent loss of a parent may prevent children fromexpressing and processing their grief (Brown & Goodman, 2005; Cohen, Man-narino, Greenberg, Padlo, & Shipley, 2002). This phenomenon has been labeledChildhood Traumatic Grief (CTG). CTG is currently defined as:

a. a grief caused by a death that is either objectively or subjectively perceivedto be traumatic;

b. the child has significant posttraumatic stress disorder (PTSD) symptoms,including loss and change reminders that segue into trauma reminders that bring forth avoidance and numbing tactics; and

c. the PTSD symptoms prevent the child from completing the tasks of bereave-ment (Cohen et al., 2002).

According to the current theoretical understanding of CTG, the pain of the childsgrief cannot be resolved unless PTSD symptoms are processed first.

Notably Cohen et al.s (2002) definition of CTG allows for the loss to haveoccurred by any means as long as the loss is subjectively perceived as trau-

matic by the child. Moreover, there seems to be agreement among many grief experts that the loss of a parent by any means during childhood is a traumaticevent (e.g., Black, 1978; Krueger, 1983; Worden, 1996). Kaffman and Elizur (1996) write: . . . , the death of a parent at an early age is a serious traumaticevent. . . (p. 591). Thus, whether the parental loss is due to a sudden, single, andunexpected blow, classified as a Type I trauma (Terr, 1990, 1991), or to a

CHILDHOOD TRAUMATIC GRIEF / 307


4/20

long-standing and expected blow, classified as a Type II trauma (Terr, 1990,1991), CTG may follow.

Parental loss due to a protracted illness may be experienced by the child as aType II trauma for a number of reasons. The child who watches his or her parentdie from an expected illness is by most accounts losing his or her primary and mostimportant care-giving system (Bronfenbrenner, 1986). Further, the childs con-cern about his or her own personal well-being (Christ, 2000) could lead to power-ful feelings of fear and/or helplessness. These experiences partiallyfulfill DSM IVTR (APA, 2000) criteria for post traumatic stress disorder, for example.,

a. the person experienced, witnessed, or was confronted with one or moreevents that involved actual or threatened death or serious injury, or a threatto the physical integrity of self or others;

b. the persons response involved intense fear, helplessness, or horror (APA,2000, p. 467).

In addition, magical thinking, in which children assume the guilt or responsibilityfor the parents death, is a common phenomenon, especially among children aged8 and under (Christ, 2000), and may contribute to childrens perception that theycould have prevented the death. In adults, this belief has been shown to be relatedto higher rates of PTSD during the bereavement process (Marcey, 1996). It seemslikely, therefore, that any manner of death of a parent could be subjectively exper-ienced as traumatic, creating PTSD symptoms and, consequently, CTG symptomsin children.

A few studies have been identified that examine the interaction of grief andPTSD symptoms in children who have experienced the death of a parent to subjectively traumatic causes, such as cancer or other terminal illnesses. Pfeffer andher colleagues (2000) studied and compared depressive symptoms as well as behavior and competence in children who were bereaved of a parent due to cancer and suicide. In addition, an exploratory study examining PTSD symptoms in chil-dren who participated in a bereavement camp, found that childrens PTSD symp-toms were comparable for those children who had lost a parent to an unexpecteddeath and for those who had lost a parent to an expected death (McClatchey &Vonk, 2005). Related literature has examined the effects of gender and age on thedevelopment of PTSD symptoms among children bereaved by violent means or who witnessed violent death (Dyregrov, Kuterovac, & Barath, 1996; Winje &Ulvik, 1998).

In spite of theoretical understanding and nascent evidence that childrensresponse to loss caused by subjectively traumatic death of a parent may fit thedefinition of CTG, extant literature has focused on studies that examine CTGrelated to objectively traumatic deaths such as homicides, suicides, wars, andnatural disasters, etc. In one exception, Godder (2008) compared CTG symptomsof children bereaved of a parent on 9/11 to CTG symptomsof children bereaved of



5/20

a loved one to a non-traumatic event. However, this sample was small, and did notinvolve parental losses exclusively in the two groups.

Webb (1993) states that helping a child after the suicide of a parent isanalogous to providing temporary shelter following the total destruction of homeand community in a violent earthquake: We do what we can to pick up the pieces but life will never be the same (p. 152). Thus, losing a parent to suicide is anobjectively traumatic experience after which a child may develop CTG. Yet, the prevalence of PTSD symptoms and the development of CTG symptoms in paren-tally bereaved children who have experienced the death of a parent to an expecteddeath have been largely unexamined. The purpose of this study is to examine theoccurrence and interplay of grief and post traumatic stress disorder symptomsamong parentally bereaved children, both for those children who have been bereaved by a violent/sudden death and for those children who have been bereaved by an expected death, such as that due to chronic illness. As such, this studyaddresses the following research questions:

1. Do children who experience an expected death of a parent suffer fromChildhood Traumatic Grief to the same extent as those children who lose a parent to a sudden and/or violent death?

2. Do children who experience an expected death of a parent suffer from PTSDsymptoms to the same extent as those children who lose a parent to a suddenand/or violent death?

3. To what extent do parentally bereaved children experience CTG and PTSDsymptoms?

METHODS

Sample

Three weekend bereavement camps were held in April, May, and October of 2006 in a metropolitan area in the southeastern United States. A purposive samplewas used for this study which was part of a larger quasi-experimental study.

As presented in Table 1, the total sample of 158 children ranged in agefrom 6 to 16 ( M = 10.8, SD = 2.31). The length of time since death ranged

from 1 to 48 months with an average of 13.48 months ( SD = 12.54). Eighty-three(52.5%) of the children were female, 98 (62%) White, 50 (31.6%) African Amer-ican, 9 (5.7%) Latino, and 1 (0.6%) Asian. Sixty-two (39.2%) children had lost amother. Sixty-three (39.9%) children had lost a parent to an expected deathsuch as cancer, end-stage kidney and heart disease, and multiple sclerosis.Most of these deaths had occurred on hospice care. Sixty percent of the children



6/20

had lost a parent to a sudden or violent death, such as accidents, homicide, suicide,and heart attacks.

Instrumentation

Two standardized instruments were used in this study:

a. The University of California at Los Angeles Post-Traumatic Stress Disorder

Reaction Index for DSM-IV (Revision 1) (UCLA PTSD Index; Pynoos,Rodriguez, Steinberg, Stuber, & Frederick, 1998) to measure PTSD symp-toms; and

b. the Extended Grief Inventory (EGI) (Layne, Savjak, Saltzman, & Pynoos,2001) to measure CTG symptoms.


Table 1. Demographic Group Composition

Variable N Min Max Mean ( SD) Percent

Age

Agegroup

611

1217

Gender

Female

Male

Ethnicity

White

African Am

Latino

Asian

Type of Death

Sudden/Viol

Expected

Type of loss

Mother

Father

Time (months)

158

90

68

83

75

98

50

9

1

95

63

62

96

158

6

1

16

48

10.8

13.48

(2.31)

(12.5)

100

57.0

43.0

52.5

47.5

62.0

31.6

5.7

0.6

60.1

39.9

39.2

60.8

100


7/20

The UCLA PTSD Index is a screening tool used to assess exposure to trauma andPTSD symptoms in children ages 7-18. The instrument consists of three parts, butonly the third part, the frequency of occurrence of re-experiencing, avoidance, andarousal symptoms over the month prior to the administration of the scale, was usedfor this study. This third part is a 20-item paper-and-pencil self-report instrument onwhich the participanthas an option of five frequencies, ranging from 0 (none of thetime) to 4 (most of the time). Validity of previous versions of the UCLA PTSDIndex has been supported by many studies (Steinberg, Brymer, Decker, & Pynoos,2004) and the latest scale version used in this study has shown to have goodconvergent validity (0.70) with the PTSD Module of the Schedule for AffectiveDisorders and Schizophrenia for School-Age Children, Epidemiologic version(Steinberg et al., 2004). The UCLA PTSD Index also has good convergent validity(0.82) with the Child and Adolescent Version of the Clinician-administered PTSDScale. Researchers have demonstrated support for the internal consistency of thelatest scale version of the UCLA PTSD Index with a Cronbachs alpha of 0.90(Roussos, Goenjian, Steinberg, Sotiorpoulou, Kakaki, Kabakos et al., 2005). Atest-retest reliability coefficient of 0.84 was recently reported (Roussos et al.,2005). The scoring for this study was computed by summing the scores for eachsymptom (re-experiencing, avoidance, arousal). The total score for the combinedsymptoms was also acquired. The authors of the instrument do not provide a cutscore for the diagnosis of PTSD but it has been suggested that scores of 38 or above(of a total of 68 possible) may indicate a diagnosis (the work of Rodriguez,Steinberg, Saltzman and Pynoos as cited in Steinberg, et al., 2004). A diagnosis of PTSD was not, however, the purpose of this study.

The Extended Grief Inventory (EGI) (Layne et al., 2001) is a 28-item paper-and-pencil self-report measure. Items measure the frequency of grief reactionsexperienced during the past 30 days using a 5-point frequency scale ranging fromnever (0) to almost always (4). A factor analysis of the EGI by Brown andGoodman (2005) revealed three factors which were named:

a. traumatic grief (23 items); b. positive memory (3 items); andc. ongoing presence (2 items).

Brown and Goodmans study reported Cronbachs alpha reliabilities of .94 for theEGI-Traumatic Grief subscale and of .62 and .73 for the EGI-Ongoing Presenceand EGI-Positive Memories subscales, respectively (Brown & Goodman, 2005).

For the present study, the 23 items identified by Brown and Goodman as meas-uring traumatic grief were used to measure CTG symptoms. Scoring of the EGIwas done by summing the frequencies reported by the subjects for possible scores between 0 and 92. The EGI has no official clinical cut score. However, a score of 46 or above would indicate an average frequency score of 2 or higher on each of



8/20

the 23 items which is judged to be a clinically significant frequency (C. M. Layne, personal communication, September 5, 2006).

Procedures

After obtaining appropriate Institutional Review Board approval, an announce-ment for the camps was sent out to schools, hospices, hospitals, and depart-ments of family and children services, who referred children to camp. Other children were recruited by word of mouth and by the camps website. The campsessions were held by a non-profit organization established solely to provide bereavement camps to children and adolescents who have lost a parent, sibling, or other loved one to death.

Forty-nine children ages 616 who had lost a parent/guardian to death withinthe past 148 months were accepted to the April camp, 56 children to the Maycamp, and 58 children to the October camp. After appropriate consent from parents and after discarding tests not properly completed, 158 subjects remainedfor the study. All participating subjects completed the Extended Grief Inventory(EGI) (Layne et al., 2001) and UCLA PTSD Index (Pynoos et al., 1998) with theexception of 30 children from the October camp who did not complete the PTSDIndex. In summary, the researcher tested 158 children on the EGI and 127 on theUCLA PTSD Index.

Children attending the April and October camps whose parents had consentedfor them to participate in this study were read an assent form upon arrival to camp.If assenting to participate, children aged 11 and under were read the EGI and

UCLA PTSD Index. Children age 12 and older were asked to complete the EGIand UCLA PTSD Index on their own, with a mentalhealth professional on hand toanswer any questions. Campers attending the May camp, whose parents had con-sented for them to participate in the research, were contacted by telephone by amental health professional during the week prior to the camp. They were first readan assent form, then the instruments.

RESULTS

The internal consistency reliability for the total sample of this study ( N = 158),using Cronbachs alpha, was .918 for the EGI. The reliability for those childrenwho had experienced an expected loss was .928; 0.914 for those children who had

experienced a sudden/violent loss. The internal consistency reliability for the totalnumber of subjects of this study who completed the UCLA PTSD Index ( N = 127),using Cronbachs alpha, was 0.874. The reliability for those children who hadexperienced an expected loss was 0.878; 0.874 for those children who had experi-enced a sudden/violent loss. The coefficient alphas obtained show high levelsof internal consistency for both scales (Nunnally, 1978), with no significant



9/20

differences between those children who had been read the scales and those whohad filled the scales out themselves.

The mean total score in this sample ( N = 158) on the EGI was 41.79 ( SD =19.54) with a range from 3 to 89. Children who had experienced an expected parental loss showed a mean EGI score of 42.32 ( SD = 19.55) and those childrenwho had experienced a violent/sudden loss a mean of 41.44 ( SD = 19.62). A mul-tiple linear regression (MLR) model wasused to address the first research questionof whether type of death, that is, expected or unexpected, is associated with CTGsymptoms in parentally bereaved children as measured by the EGI. To control for extraneous variables, variables such as time since death (measured in months),gender, race, age and type of loss were included in the model. To investigate theeffect of age on the dependent variable, the subjects were divided into two groups:elementary school age children (age range 611, n = 90, M = 9.13, SD = 1.42) andmiddle and high-school children (age range 1216, n = 68, M = 13.01, SD = 1.06).The division into these age-groups has basis in both cognitive and psycho-socialdevelopment theories (Erikson, 1982; Piaget & Inhelder, 1969). The resultssuggest that CTG symptoms were not significantly related to type of deathexperienced by parentally bereaved children (95% CI = 6.81 to 6.86; power .73;effect size .52) when controlling for extraneous variables. Thus, children who hadexperienced an expected loss tended to have similar CTG symptoms as measured by the EGI as those children who had experienced a sudden/violent loss. Inaddition, extraneous variables such as time measured in months, gender, and typeof loss (mother or father) had no influence on the development of CTG symptoms.Using categorical measures of time, dividing time into the categories of 3, 6, 12,24, 36, and 48 months since the loss, similarly showed no time effect. However,African-American children had significantly higher CTG symptoms than Whitechildren ( p = .04) but Latino children did not score differently from White children( p = .90). (The only Asian child participating in this study was omitted from thisanalysis.) Likewise, elementary age school children had significantly higher CTGsymptoms than middle or high-school age children ( p = .04).

The mean total score of the sample ( N = 127) on the UCLA PTSD Index was27.02 ( SD = 13.93) ranging from 0 to 61. The mean score for those children whohad experienced an expected loss was 26.82 ( SD = 13.68) and for those childrenwho had experienced a sudden/violent loss 27.14 ( SD = 14.17). A similar MLR model to the one used to estimate CTG symptoms was used to address the secondresearch question whether type of death is associated with PTSD symptoms in parentally bereaved children. Similar to the findings for CTG symptoms, PTSD

symptoms were not significantly related to type of death in parentally bereavedchildren (95% CI = 4.37 to 6.50; power .95; effect size .49). MLR, running threeseparate models, was used to test for the three sub-symptoms of PTSD (i.e.,re-experiencing, avoidance, and arousal), and supported the hypothesis of nodifference between these symptoms experienced by children bereaved of a parent by a sudden/violent death versus an expected death. Again, time, gender, and type



10/20

of loss did not have a significant impact on PTSD scores, but African-Americanchildren scored significantly higher than White children on the UCLA PTSDIndex (total score p = .01), with the higher scores coming from the subscales of avoidance ( p = .01) and arousal ( p = .01). Latino children did not score differentlyfrom White children ( p = .57). (The Asian subject was again omitted from theanalysis.) Elementary age school children also scored significantly higher on theUCLA PTSD Index (total score p = .01) with the higher scores coming from allthree subscales: re-experiencing ( p = .01); avoidance ( p = .01); arousal ( p = .04).The results are presented in Table 2.

Using 46 as a cut score for moderate to severe levels of CTG symptoms (Layne,2006) 43.7% of the total sample( N = 158) scored at or above this level.Forty-three percent of the children who had experienced an expected loss scored above 46 asdid 44% of those who had experienced a sudden/violent loss. Using Cohen et al.s(2004) definition of 30 as a significant score of CTG symptoms, 71.5% scored ator above this marker. Seventy-three percent of the children in the group that hadexperienced an expected death scored at or above the significance level of 30;71%of the children who had experienced a sudden/violent loss scored at or above thissignificance level. Using dummy coding and chi-square analysis, it was revealedthat these differences in severity between children who had experienced asudden/violent loss and those who had experienced an expected death, were notstatistically significant ( p = .87 and p = .73 respectively).

Using a score of 38 on the UCLA PTSD Index to indicate the possibility of aPTSD diagnosis (the work of Rodriguez, Steinberg, Saltzman and Pynoos as citedin Steinberg et al., 2004), 24% who completed the UCLA PTSD Index ( N = 127)had scores of 38 or higher. Twenty percent of the participating children who hadlost a parent to an expected loss showed a level of PTSD symptoms at or above 38;the percentage for children who had experienced a sudden/violent loss of a parentwas 26. Again, this difference was not statistically significant ( p = .50).

DISCUSSION

This study examined the prevalence of Childhood Traumatic Grief (CTG) andPosttraumatic Stress Disorder (PTSD) symptoms among parentally bereaved chil-dren. The current research contrasts with previous studies of Childhood TraumaticGrief (CTG) and Posttraumatic Stress Disorder (PTSD) symptoms in bereavedchildren (Cohen et al., 2004; Cohen, Mannarino, & Staron, 2006; Goenjian,Karayan, Pynoos, Minassian, Najarian, Steinberg et al., 1997; Saltzman, Pynoos,

Steinberg, Aisenberg, & Layne, 2001) by examining children who had experi-enced sudden and/or violent loss of a parent in addition to children who had exper-ienced expected loss of a parent. The findings demonstrated that the incidence of CTG and PTSD symptoms, as measured by the EGI and UCLA PTSD Indexrespectively, did not differ in children who had experienced an expected loss of a parent compared with children who had experienced a violent or sudden loss.



11/20


T a b l e 2

. R e g r e s s i o n C o e f f i c i e n t s M o d e l 1 R e s u l t s f o r E G I a n d P T S D

O u t c o m e M o d e l s

C T G O u t c o m e

N =

1 5 8

P T S D O u t c o m e

N =

1 2 7

R e - e

x p e r i e n c e

N =

1 2 7

A v o i d a n c e

N =

1 2 7

A r o u s a l

N =

1 2 7

V a r i a b l e

B

( S E )

B

( S E )

B

( S E )

B

( S E )

B

( S E )

T i m e

M a l e

A f r i c a n A m e r i c a n

L a t i n o

M i d d l e / H S a g e

L o s s o f F a t h e r

S u d d e n / V i o l e n t L o s s

F R 2

. 1 0

3 . 0

7 . 0

2

. 9 1

6 . 8

3

3 . 3

9 . 0

2

1 . 8

6 . 0

8

( . 1 3 )

( 3 . 1

3 )

( 3 . 4

1 ) *

( 7 . 3

0 )

( 3 . 2

5 ) *

( 3 . 3

8 )

( 3 . 4

6 )

. 0 0

2 . 5

3

7 . 4

4

3 . 2

0

8 . 2

6

1 . 0

1

1 . 0

7

3 . 2

9 . 1

6

( . 1 0 )

( 2 . 4

2 )

( 2 . 5

4 ) * *

( 5 . 5

9 )

( 2 . 5

1 ) * *

( 2 . 7

3 )

( 2 . 7

5 )

. 0 1

1 . 2

0

1 . 2

0

. 9 2

3 . 1

0

1 . 2

9

1 . 1

1

3 . 4

1 . 1

7

( . 0 3 )

( . 8 4 )

( . 8 8 )

( 1 . 9

4 )

( . 8 7 ) * *

( . 9 5 )

( . 9 5 )

. 0 2

. 7 9

3 . 4

3

1 . 0

0

3 . 3

7

. 0 7

. 0 3

2 . 4

7 . 1

3

( . 0 5 )

( 1 . 1

5 )

( 1 . 2

0 ) * *

( 2 . 6

5 )

( 1 . 1

9 ) * *

( 1 . 3

0 )

( 1 . 3

0 )

. 0 1

. 5 5

2 . 8

2

1 . 2

7

1 . 7

9 . 3

4

. 0 7

2 . 4

5 . 1

3

( . 0 3 )

( . 8 3 )

( . 8 7 ) * *

( . 9 1 )

( . 8 6 ) *

( . 9 4 )

( . 9 4 )

N o t e :

* s i g n i f i c a n t a t t h e

. 0 5 a l p h a l e v e l ; * * s i g n i f i c a n t a t

t h e

. 0 1 a l p h a l e v e l .


12/20

Therefore, other factors may have played a role, such as the quality of therelationship with the deceased, availability of social supports, childs and/or surviving parents coping skills, or a surviving parents mental health (Nader,1997a, 1997b; Rollins, 1997). Moreover, regardless of the type of loss, a signi-ficant percent of the children suffered from PTSD and CTG symptoms. Theseresults suggest that both expected and unexpected losses can be expected to produce PTSD and CTG symptoms in a significant proportion of parentally bereaved children. Furthermore, the findings support a theoretical view that theloss of a parent may be a traumatic event for children regardless of the type of loss,evoking perceived threat and creation of fearfulness and helplessness.

The current study supports the results of a previous exploratory study(McClatchey & Vonk, 2005) that found severity of PTSD symptoms was unre-lated to type of loss in parentally bereaved children. In contrast to the previous pilot study, this study had a much larger sample and involved only children whowere parentally bereaved. The study also supports previous findings that timeoften does not mitigate PTSD symptoms (e. g. Green, Grace, Vary, Kramer,Gleser, & Leonard, 1994; Sack, Him, & Dickason, 1999; Terr, 1983).

The findings of this study differ from studies with adults in which those who hadexperienced sudden,unexpected losses were found to have statistically significantlyhigher levels of PTSD symptoms than those adults who had experienced anexpected loss (Lundin, 1984; Schut, de Keijser, van den Bout, & Dijkhuis, 1991).The current study indicated that the objective severity of an event may not be thedetermining factor of the severity of PTSD symptoms in children as previouslysuggested (Cohen, 1998). Instead, any type of parental death may be traumatic to achild (Kaffman & Elizur, 1996). The present results support earlier findings thatethnicity is related to the development of PTSD symptoms (Briere & Elliott,1998), but differ from McClatchey and Vonks (2005) pilot study that showed norace differences in PTSD symptoms. This may be due to the small sample size inthe 2005 study that did not have enough power to detect ethnic differences.

In addition, the large proportion of parentally bereaved children who experi-enced CTG symptoms in this study suggests that the phenomenon of CTG mayoccur more commonly than was thought previously. For example, Worden andSilverman(1996) show thepercentages of negatively affected children to be lower than reported in this study, but the researchers did not measure CTG specifically but rather social withdrawal, anxiety, social problems, self-esteem, and self-efficacy. Sandler and his colleagues report that the majority of parentally bereavedchildren handle their grief well (Brown, Sandler, Tein, Liu, & Haine, 2007), but

their studies do not include measures of CTG (Brown et al., 2007; Sandler et al.,2003; Sandler, 1992; Wolchik, Ma, Tein, Sandler, & Ayers, 2008). Instead theymeasure grief symptoms using a scale developed for adults and a scale of ruminative or intrusive grief thoughts with limited known support for its psychometric properties. Further, prevalence rates of risk factors are notgiven. In addition, Cohen and Mannarino (2004) have stated that . . . the



13/20

majority of children who lose loved ones under traumatic circumstances do notdevelop CTG, . . . (p. 822). These differing conclusions maybe due to differencesin measurements or methods, but nonetheless underscore the need to know moreabout prevalence of CTG.

Further, the current study suggests that African- American children exhibitCTG symptoms as measured by the EGI to a statistically significantly higher degree than White children. Though this was not the case with Latino children, notenough Latino children participated ( n = 9) in the current study to make com- parisons with this group meaningful. Ethnic differences in the prevalence of CTGsymptoms need further examination. In addition, the study showed elementaryschool children to have higher CTG symptoms than older children. The cause for this finding maylie in younger children being developmentallymore dependent ontheir parents and/or developmentally not able to understand the concept of death, but this finding needs further exploration.

Finally, the results of the current study differ from previous studies in relation tochilds age and gender. The results of this study, which showed younger childrenhaving significantly higher scores on the PTSD scale than older children, differ from the previous pilot study that found no difference due to age (McClatchey &Vonk, 2005); and from other studies that found higher levels of PTSD in older children (Dyregrov et al., 1996; Green, Korol, Grace, Vary, Leonard, Gleser et al.,1991). Contrary to previous studies that have reported higher levels of PTSDamong females (Dyregrov et al., 1996; Goenjian et al., 1997; Pynoos et al., 1993;Winje & Ulvik, 1998), no gender differences were found in this study.

There are some limitations to this study. Since the study used a purposive sample, questions about the generalizability of the results are raised. It is possible thatthose parents who were having more issues with their bereaved children weremore likely to register their children for a bereavement camp. Another concern isrelated to measurement. The EGI is a newly developed instrument and its psycho-metric properties have not been fully investigated. Questions exist about child-hood traumatic grief as a construct, as do questions of similarities and differences between traumatic and complicated grief (Malkinson, Rubin, & Witztum, 2000;Melhem, Day, Shear, Day, Reynolds, & Brent, 2004; Webb, 2004). Further, whilethis study included children who had lost a parent to an expected death, studies onthe psychometric properties of the EGI have included only children who haveexperienced Type I traumas. Factor analyses including various types of losses aswell as a broader, more diverse sample may provide more information about thereliability and validity of the instrument as well as answer questions about the

scales cultural sensitivity.This study leavessome obvious implications for further research. A randomizedsample with a more diverse racial and geographic sample would increase the gen-eralizability of the results. The prevalence of CTG among parentally bereavedchildren also deserves further investigation. Theroles of gender, ethnicity, and agein the development of childhood traumatic grief and posttraumatic stress disorder



14/20

symptoms need additional examination. It may also be of interest to examinereasons why these demographics may affect CTG and PTSD. This study does not pinpoint what causes PTSD and CTG symptoms in some parentally bereaved chil-dren but not in others. Perceived social supports have been identified as a possiblefactor (Godder, 2008) but further analyses of social supports and such variablessuch as quality of relationship with deceased parent, coping skills of child and/or parent, etc., may begin to provide answers to such a question.

This study showed that childhood traumatic grief as measured by the EGI wasequally present in children who had experienced an expected loss and in those whohad experienced a sudden/violent loss. As such, an expected loss of a parent seemsto fitTerrs (1991) definition of a Type II trauma, indicating that watching a parentdie slowly from protracted illness such as cancer constitutes long-standing andanticipated blows to the child. Though Terrs work has been criticized (McNally,2003; Roediger & Bergman, 1998), the findings in this study nevertheless supportthe development of PTSD symptoms, and thereby CTG symptoms, in any paren-tally bereaved child regardless of the mode of loss. The role of trauma in the loss of a parent, therefore, warrants further examination.

The findings of the current study provide several important implications for practice. As was seen in this study, a large number of parentally bereaved childrenmay be suffering from CTG symptoms at levels of clinical concern, whether theloss is due to expected or sudden/violent death. This strongly suggests that it isimportant for professionals who work with parentally bereaved children to assesstheir clients for CTG and PTSD symptoms in order to provide appropriate inter-ventions and achieve positive treatment results. Both assessment and treatment of parentally bereaved children may need to diverge from the current focus on grief alone and begin to incorporate a focus on trauma. Clinicians would benefit from becoming aware of the growing understanding of the process and interplay of grief and PTSD symptoms. By first addressing the intrusive thoughts about how the parent died, the child may be better able to attend to and resolve his or her grief (Black, 1998; Brosius, 2004; Eth & Pynoos, 1994). To neglect either phenomenonmay lead to unaddressed symptoms in bereaved children, which unfortunatelymay persist into adulthood.

REFERENCES

Adams, K. N. (1996). Bereavement counseling groups with elementary school students.Univ Microfilms International.

Amick-McMullan, A., Kilpatrick, D. G., & Resnick, H. S. (1991). Homicide as a risk factor for PTSD among surviving family members. Behavior Modification, 15 (4), 545.

American Psychiatric Association (APA). (2000). Diagnostic and statistical manual for mental disorders (DSM-IV-TR). (DSM-IV-TR 4th ed.). Washington, DC: Author.

Black, D. (1978). The bereaved child. Journal of Child Psychology & Psychiatry, 19 (3),287-292.



15/20

Black, D. (1998). Working with the effects of traumatic bereavement by uxoricide (spousekilling) on young childrens attachment behaviour. International Journal of Psychiatryin Clinical Practice, 2 (4), 245-249.

Briere, J., & Elliott, M. N. (1998). Clinical utility of the Impact of Event Scale:Psychometrics in the general population. Assessment, 5 (2), 171-180.

Bronfenbrenner, U. (1986). Ecology of the family as a context for human development:Research perspectives. Developmental Psychology, 22 (6), 723-742.

Brosius, K. K. (2004). Children who have lost their siblings due to homicide: A phenom-enological study. Univ Microfilms International.

Brown, A. C., Sandler, I., Tein, J., Liu, X., & Haine, R. (2007). Implications of parentalsuicide and violent death for promotion of resilience of parentally-bereaved children. Death Studies, 31 (4), 301-335.

Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: An exploration of the

construct in children bereaved on September 11. Journal of Clinical Child & Ado-lescent Psychology, 34 (2), 248-259.

Christ, G. H. (2000). Impact of development on childrens mourning. Cancer Practice,8(2), 72-81.

Cohen, J. (1998). Practice parameters for the assessment and treatment of children andadolescents with posttraumatic stress disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 37 (10 Suppl.), 4S-26S.

Cohen, J., & Mannarino, A. P. (2004). Treatment of childhood traumatic grief. Journal of Clinical Child and Adolescent Psychology, 33 (4), 819-831.

Cohen, J., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley, C. (2002). Childhood trau-matic grief: Concepts and controversies. Trauma Violence & Abuse, 3 (4),307-327.

Cohen, J., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: A pilot study. Journal of the American Academy of Child & Adolescent Psychiatry,43(10), 1225-1233.

Cohen, J., Mannarino, A. P., & Staron, V. R. (2006). A pilot study of modified cognitive- behavorial therapy for childhood traumatic grief (CBT-CTG). Journal of the American Academy of Child & Adolescent Psychiatry, 45 (12), 1465-1473.

Dyregrov, A., Kuterovac, G., & Barath, A. (1996). Factor analysis of the impact of eventscale with children in war. Scandinavian Journal of Psychology, 37, 339-350.

Erikson, E. H. (1982). The Life Cycle Completed . New York: Norton.Eth, S., & Pynoos, R. S. (1994). Children who witness the homicide of a parent. Psychiatry:

Interpersonal & Biological Processes, 57 (4), 287-306.Felner, R. D., Stolberg, A., & Cowen, E. L. (1975). Crisis events and school mental health

referral patterns of young children. Journal of Consulting & Clinical Psychology,43(3), 305-310.

Florian, V., & Mikulincer, M. (1997). Fear of personal death in adulthood: The impact of early and recent losses. Death Studies, 21 (1), 1-24.

Godder, G. (2008). Parental death and trauma from the attacks on the World Trade Center

and psychological functioning in 8 to 12 year old children: Ph. D. dissertation, NewYork University, United StatesNew York. Retrieved August 6, 2008 from Disser-tations & Theses: A & I database. (Publication No. AAT 3308296).

Goenjian, A., Karayan, I., Pynoos, R. S., Minassian, D., Najarian, L. M., Steinberg, A. M.,et al. (1997). Outcome of pyschotherapy among early adolescents after trauma. Ame-rican Journal of Psychiatry, 154 (4), 536-542.



16/20

Goldberg, F. R., & Leyden, H. D. (1998). Left and left out: Teaching children to grievethrough a rehabilitation curriculum. Professional School Counseling, 2 (2), 123-127.

Graham, H. M. (1999). Help or hindrance? An examination of the effectiveness of chil-drens grief support groups. Dissertation Abstracts International 60(06) , 2227A.

Green, B. L., Korol, M. G., Grace, M. G., Vary, M. G., Leonard, A. C. Gleser, G. C. et al.,(1991). Children and disaster: Age, gender, and parental effets on PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 30 , 945-951.

Green, B. L., Grace, M. C., Vary, M. F., Kramer, T. L., Gleser, G. C., & Leonard, A. C.(1994). Children of disaster in the second decade: A 17-year follow-up of BuffaloCreek survivors. Journal of the American Academy of Child & Adolescent Psychiatry,33, 71-79.

Huss, S. N., & Ritchie, M. (1999). Effectiveness of a group for parentally bereaved chil-dren. Journal for Specialists in Group Work, 24 (2), 186-196.

Kaffman, M., & Elizur, E. (1979). Childrens bereavement reactions following death of thefather. International Journal of Family Therapy, 1 (3), 203-229.

Kaffman, M.,& Elizur,E. (1996). Bereavement as a significant stressor in children. In C. R.Pfeffer (Ed.), Severe stress and mental disturbance in children. (pp. 591): AmericanPsychiatric Press.

Kranzler, E. M., Shaffer, D., & Wasserman, G. (1990). Early childhood bereavement. Journal of the American Academy of Child & Adolescent Psychiatry, 29 (4),513-520.

Krueger, D. W. (1983). Childhood parent loss: Developmental impact and adult psycho- pathology. American Journal of Psychotherapy, 37 (4), 582-592.

Layne, C. M. (2006). Extended grief inventory cut score discussion. Personal commun-ication September 5, 2006.

Layne, C. M., Savjak, N., Saltzman, W. R., & Pynoos, R. S. (2001). Extended Grief Inventory . University of California at Los Angeles and Brigham Young University.

Lloyd, C. (1980). Life events and depressive disorder reviewed: I. Events as predisposingfactors. Archives of General Psychiatry, 37 (5), 529-539.Lundin, T. (1984). Morbidity following sudden and unexpected bereavement. British

Journal of Psychiatry, 144, 84-88.Malkinson, R., Rubin, S. S., & Witztum, E. (2000). Loss, bereavement, and trauma: An

overview. In R. Malkinson, S. S. Rubin & E. Witztum (Eds.), Traumatic and nontrau-matic loss and bereavement (pp. 5-40). Madison, Connecticut: Psychosocial Press.

Marcey, M. M. (1996). A comparison of the long-term effects of bereavement after four types of death: Anticipated death, sudden death, drunk driver crash, and homicide. Dissertation Abstracts International Section B: The Sciences & Engineering,56 (11-B), 6399.

McClatchey, R. S., & Vonk, M. E. (2005). An exploratory study of post-traumatic stressdisorder symptoms among bereaved children. Omega: Journal of Death and Dying,51(4), 281-296.

McNally, R. J. (2003). Remembering trauma. Cambridge, MA: Belknap Press/HarvardUniversity Press.Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., III, & Brent, D. (2004).

Traumatic grief among adolescents exposed to a peers suicide. American Journal of Psychiatry, 161 (8), 1411-1416.



17/20

Murphy, L.,Pynoos, R. S., James,C. B.,& Osofsky, J. D. (1997). The trauma/grief-focusedgroup psychotherapy module of an elementary school-based violence prevention/-intervention program. In J. D. Osofsky (Ed.), Children in a violent society. (pp. 223). New York: Guilford Press.

Nader, K. (1997a). Childhood traumatic loss: The interaction of trauma and grief. In C. R.Figley, B. E. Bride & N. Mazza (Eds.), Death and trauma: The traumatology of griev-ing. (pp. 17-41). Washington, D.C.: Taylor & Francis.

Nader, K. (1997b). Treating traumatic grief in systems. In C. R. Figley, B. E. Bride & N.Mazza (Eds.), Death and trauma: The traumatology of grieving (pp. 159-192). Wash-ington, D.C.: Taylor & Francis.

Nader, K., Pynoos, R. S., Fairbanks, L., & Frederick, C. (1990). Childrens PTSD reactionsone year after a sniper attack at their school. American Journal of Psychiatry, 147 (11),1526-1530.

Nunnally, J. C. (1978). Psychometric Theory (2nd ed.). New York: McGraw-Hill.Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., & Metsch, M. (2002). Group intervention

for children bereaved by the suicide of a relative. Journal of American Academy of Child and Adolescent Psychiatry, 41 (5), 505-513.

Pfeffer, C. R., Karus, D., Siegel, K., & Jiang, H. (2000). Child survivors of parental deathfrom cancer or suicide: Depressiveand behavioraloutcomes. Psychooncology, 9 , 1-10.

Piaget, J., & Inhelder, B. . (1969). The psychology of the child . New York: Basic Books.Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care,

11 (1), 2-10.Pynoos, R. S., & Eth, E. S. (1984). The child as witness to homicide. Journal of Social

Issues, 40 (2), 87.Pynoos,R. S., Goenjian, A., Tashjian, M.,Karakashian, M.,Manjikian, R., Manoukian, G.,

et al. (1993). Post-traumatic stress reactions in children after the 1988 Armenian earth-quake. British Journal of Psychiatry, 163 (2), 239-247.

Pynoos, R. S., & Nader, K. (1988). Psychological first aid and treatment approach for children exposed to community violence: Research implications. Journal of TraumaticStress, 1 (4), 445-473.

Pynoos, R. S., Nader, K., Frederick, C., & Gonda, L. (1987). Grief reactions in school agechildren following a sniper attack at school. Israel Journal of Psychiatry & Related Sciences, 24 (1), 53-63.

Pynoos, R. S., Rodriguez, N., Steinberg, A. M., Stuber, M., & Frederick, C. (1998). TheUCLA PTSD Reaction Index for DSM IV (Revision 1) . Los Angeles: UCLA TraumaPsychiatry Program.

Roediger, H. L., & Bergman, E. T. (1998). The controversy over recovered memories. Psy-chology, Public Policy, and Law, 4 (4), 1091-1109.

Rollins, J. A. (1997). Minimizing the impact of community violence on child witnesses.Critical Care: Nursing Clinics of North America, 9 (2), 211-220.

Roussos, A., Goenjian, A., Steinberg, A. M., Sotiropoulou, C., Kakaki, M., Kabakos, C.,

et al. (2005). Posttraumatic stress and depressive reactions among children andadolescents after the 1999 earthquake in Ano Liosia, Greece. American Journal of Psychiatry, 162 (3), 530-537.

Sack, W. H., Him, C., & Dickason, D. (1999). Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children. Journal of the American Academy of Child & Adolescent Psychiatry, 38 , 1173-1179.



18/20

Saltzman, W. R., Pynoos, R. S., Steinberg, A. M., Aisenberg, E., & Layne, C. M. (2001).Trauma- and grief-focused intervention for adolescents exposed to communityviolence: Results of a school-based screening and group treatment protocol. Group Dynamics: Theory, Research, and Practice, 5 (4), 291-303.

Samide, L. L., & Stockton, R. (2002). Letting go of grief: Bereavement groups for childrenin the school setting. Journal for Specialists in Group Work, 27 (2), 192-204.

Sandler, I. N., Ayers, T. S., Wolchik, S. A., Tein, J.-Y., Kwok, O.-M., Haine, R. A., et al.(2003). The Family Bereavement Program: Efficacy evaluation of a theory-based pre-vention program for parentally bereaved children and adolescents. Journal of Consul-ting & Clinical Psychology, 71 (3), 587-600.

Sandler, I. N., West, S. G., Baca, L., &Pillow, D. R. (1992). Linking empirically based the-ory and evaluation: The Family Bereavement Program. American Journal of Com-munity Psychology, 20 (4), 491-521.

Schilling, R. F., Koh, N., Abramovitz, R., & Gilbert, L. (1992). Bereavement groups for inner-city children. Research on Social Work Practice, 2 (3), 405-419.

Schut, H. A. W., de Keijser, J. D., Van Den Bout, J., & Dijkhuis, J. H. (1991).Post-traumatic stress symptoms in the first years of conjugal bereavement. Anxiety Research, 4, 225-234.

Sprang, G., & McNeil, J. (1998). Post-homicide reactions: Grief, mourning and post-traumatic stress disorder following a drunk driving fatality. Omega: Journal of Death & Dying, 37 (1), 41-58.

Social Security Administration (SSA). (2007). Beneficiary data: Social Security Admin-istration. Washington, DC: Author.

Steinberg, A. M., Brymer, M. J., Decker, K. B., & Pynoos, R. S. (2004). The University of California at Los Angeles post-traumatic stress disorder reaction index. Current Psy-chiatry Reports, 6, 96-100.

Terr, L. C. (1983). Chowchilla revisited: The effects of psychic trauma four years after a

school-bus kidnapping. American Journal of Psychiatry, 140, 1543-1550.Terr, L. C. (1990). Too scared to cry: Psychic trauma in childhood . New York: Har- per & Row.

Terr, L. C. (1991). Childhood traumas: an outline and overview. American Journal of Psy-chiatry, 148 (1), 10-20.

Webb, N. B. (1993). Suicidal death of mother: Cases of silence and stigma. In N. B. Webb(Ed.), Helping bereaved children: A handbook for practitioners (pp. 137-155). NewYork: Guilford Press.

Webb, N. B. (2004). The impact of traumatic stress and loss on children and families. In N.B. Webb (Ed.), Mass trauma and violence: Helping families and children cope (pp.3-22). New York: Guilford Press.

Winje, D., & Ulvik, A. (1998). Long-term outcome of trauma in children: The psy-chological consequences of a bus accident. Journal of Child Psychol Psychiatry, 39 (5),635-642.

Wolchik, S., Ma, Y., Tein, J., Sandler, I., & Ayers, T. (2008). Parentally bereaved chil-drens grief: Self-system beliefs as mediators of the relations between grief andstressors and caregiver-child relationship quality. Death Studies, 32, 597-620.

Wolfelt, A. D. (1996). Healing the bereaved child: Grief gardening, growth through grief and other touchstones for caregivers. Fort Collins, CO: Companion.



19/20

Worden, J. W. (1996). Children and grief.When a parent dies . NewYork: Guilford Press.Worden, J. W., & Silverman, P. R. (1996). Parental death and the adjustment of school-age

children. Omega: Journal of Death and Dying, 33 (2), 91-102.

Direct reprint requests to:

Irene Searles McClatcheySchool of Social Work University of Georgia3377 Ridgewood Road, NWAtlanta, GA 30327e-mail: [email protected]



20/20

trauma and grief 2-dorothy

Documents