Grief and Trauma in Children

An Evidence-Based Treatment Manual

Alison Salloum

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781134613922
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Grief and Trauma in Children provides easy-to-implement, ready-to-use therapy materials to help busy practitioners use grief and trauma interventions in real-world settings. All interventions in the book have been developed and researched with clinicians who faced challenging environments, including devastating natural disasters, and in communities where ongoing violence victimized children directly. Even in these stressful environments, clinicians found the interventions easy to implement, effective in helping children acquire coping skills, and effective in decreasing traumatic symptoms in order to proceed with grieving without impaired functioning.

Grief and Trauma in Children blends cognitive-behavioral therapy methods and narrative practices to present an integrated grief and trauma model that can be delivered individually, to a group of children, or to a family. The book uses the Draw, Discuss, Write, Witness (DDWW) method to help children explore narratives of resilience and build coping capacity, engage in restorative stories about what happened, and reconnect and reengage in meaningful ways that allow the child to enjoy life again and get back on-track developmentally. Grief and Trauma in Children also provides up-to-date research on childhood bereavement and trauma, a brief description of the theoretical framework of the Grief and Trauma Intervention (GTI) model, a description of session-by-session goals and activities, case examples with ways to address common challenges, and photocopiable tools for clinicians to easily implement the model, such as session agendas, fidelity checklists, handouts for parents, and activity sheets for children.

Chapter 1

Introduction

This chapter provides a brief overview of the latest research on children who experience both grief and traumatic stress, and lessons learned in the development of an evidence-based practice for children experiencing grief and trauma called Grief and Trauma Intervention (GTI) for Children. The theoretical framework of GTI for Children, specific methods used within the model, intervention goals, and the overall outline of the intervention are provided.

CURRENT RESEARCH ON CHILDHOOD BEREAVEMENT AND TRAUMA

While there is still much controversy and discussion in the field about what makes childhood grief complicated, prolonged, or traumatic (all terms with slightly different complexities and distinctions in the experience and expression of the child’s grief) (Nader & Salloum, 2011), we know that some bereaved children will experience a loss as traumatic. Therefore, it is important to understand how to work with children when both grief and trauma are present. Some researchers have described the term traumatic grief as meaning that the symptoms of traumatic stress (i.e., re-experiencing, avoidance, and arousal) impinge on a child’s ability to proceed with the typical grieving process (Brown et al., 2008; Cohen, Mannarino, Greenberg, Padlo & Shipley, 2002; Layne et al., 2009). For example, a child may have intrusive death images about how the person died, may avoid loss reminders (e.g., places where they used to go, photographs, or people telling stories about the deceased), and not want to go to sleep for fear of having a nightmare about how the person died.

Whether a child perceives a loss as traumatic seems to be more subjective and based on the child’s experience, than objectively related to categorization of cause of death. Factors such as the relationship to the deceased; the surviving parent’s support of the child (McClatchy, Vonk & Palardy, 2009); the child’s level of functioning and coping; beliefs about themselves and the world; and the presence or absence of a supportive, non-stressful environment (Brown, Sandler, Tein, Liu & Haine, 2007), more than the manner of death (i.e., violent, sudden, unanticipated), may lead to a child experiencing traumatic grief. A child does not have to witness death in order for it to be traumatic. For example, Melhem, Moritz, Walker, Shear, and Brent (2007) suggest that childhood complicated grief may occur even in the absence of direct exposure to the death or a traumatic life-threatening event, and the child may experience symptoms such as constant thoughts of the deceased, avoidance of death reminders, loss reminders, loss of security and control, and anger. The loss of a primary attachment figure may be traumatic for a young child even without regard to how the person died (Kaplow, Layne, Pynoos, Cohen & Lieberman, 2012).

Research has shown traumatic grief (Brown et al., 2008), complicated grief (Melhem et al., 2007), and prolonged grief (Spuij et al., 2012) to be distinct from, but associated with, posttraumatic stress disorder (PTSD) and depression. Some bereaved children may experience PTSD in the absence of traumatic grief such that “trauma and loss reminders remain separate; one does not automatically segue into the other, and positive memories of the deceased as well as the pain associated with the loss of the relationship, can therefore be experienced, tolerated, and mourned without interference of PTSD symptoms into this process” (Cohen et al., 2002, p. 316).

When posttraumatic stress and grief are present, there is a complex interplay between grief associated with the loss of the relationship and trauma associated with the death or surrounding circumstances (Raphael & Martinek, 1997; Rynearson, 2001). A child may be experiencing both separation distress due to the loss as well as traumatic stress related to the manner in which the person died or related traumatic elements surrounding the circumstances of the death. With separation distress there is a longing to be connected to the deceased; with trauma distress there is a pushing away from any reminders about what happened and these thoughts become intrusive. Indeed, “separation distress is intent on reestablishing a psychological and physical connection with the living presence, while trauma distress is intent on replaying and avoiding the dying presence” (Rynearson, 2001, p. 25).

Recently, the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5; American Psychiatric Association (APA), 2013) released criteria for psychiatric disorders and provides guidance on how to diagnose in the presence of bereavement. However, as leading grief and trauma experts in the field suggest, classifications need to take into account the developmental age of the child. Further research is needed on the longitudinal course of childhood grief to help distinguish normal versus maladaptive bereavement and contributing factors (Kaplow et al., 2012). Nonetheless, the current DSM-5 classification can provide a clinician with ways to assess and describe the clinical presentation of a child experiencing grief and trauma.

According to the DSM-5, PTSD may occur when there is exposure to actual or threatened death. Indirect exposure, such as learning about the death or about someone who was threatened, must involve a close relative or friend and must occur due to violent or accidental means. Readers are referred to the DSM-5 (APA, 2013) for a detailed description of PTSD. Generally, PTSD symptoms are characterized by intrusive symptoms, persistent avoidance, negative changes in cognition and mood associated with the traumatic events, marked alterations in arousal that occur for more than one month, and significant impairment in functioning.

The DSM-5 recognizes that when the trauma involves a violent death, both “problematic bereavement and PTSD may be present” (APA, 2013, p. 276). In addition, if the bereaved person has characteristics of PTSD but does not meet full criteria for PTSD, the specification of “persistent complex bereavement disorder” may be used to describe the reason the person does not meet full criteria for PTSD. Persistent complex bereavement disorder is a proposed disorder but was not included as a disorder in the DSM-5 due to the need for additional research. This classification is considered for clinical purposes and for the field to gather further empirical data on how to best characterize bereavement that is persistent and complex and beyond what would be expected in normal bereavement. The proposed persistent complex bereavement disorder may provide a clinician with some descriptive characteristics of indicators that a bereaved child may need intervention. For example, intervention may be needed if after six months the child (1) continues to experience the following: preoccupation with the circumstances of the death and the deceased, intense sorrow, persistent longing for the deceased, persistent distress due to the death (e.g., emotional numbness, difficulty having positive memories of the deceased, anger, self-blame, excessive avoidance of reminders of the loss), and social and identity disruption (e.g., desire to die to be with the deceased, difficulty trusting others, feeling alone and detached, sense of meaninglessness about life, loss of sense of identity since the person died, lack of interests and planning for the future); and (2) these disturbances are outside the realm of cultural, developmental, and religious norms, and cause significant impairment. However, the timeframe and characteristics may vary greatly depending on the circumstances, the child, and the environmental context.

The proposed persistent complex bereavement disorder diagnosis is differentiated from normal childhood grief due to persistence of severe grief reactions for more than six months and significant impairment. The proposed disorder has the descriptor “with traumatic bereavement” for those bereaved due to homicide or suicide. With traumatic bereavement, there are persistent distressing preoccupations related to the death (e.g., about the last moments, suffering, mutilation, injury, or the manner in which the person died) that often occur in the context of loss reminders (APA, 2013).

According to the DSM-5, bereaved children who experience difficulty adjusting after the death may meet criteria for an adjustment disorder, although the symptoms cannot be due to “normal bereavement” (APA, 2013, p. 287). When assessing a bereaved person who may be experiencing a major depressive episode, the guideline is for the clinician to use clinical judgment while taking into account the person’s history and cultural bereavement norms to ascertain if the expression is a normal grief response (feelings of emptiness and loss, and pre-occupation with thoughts and memories of the person), or if the person’s presentation would be better classified as a major depressive episode (persistent depressed mood and pervasive unhappiness, misery, pessimistic ruminations, and thoughts of ending one’s own life).

The vast majority of bereaved children are resilient and fare quite well. Generally, resilience is a positive adaptation that occurs in the context of adversity, and, for many children, develops over time (Luthar, Cicchetti & Becker, 2000). Areas of resilience entail competencies within behavioral and emotional functioning, social competence, and academic performance, although how these domains differ based on age and at what thresholds is still to be determined (Walsh, Dawson & Mattingly, 2012). When a child is dealing with both grief and traumatic stress, it is expected that the child will be challenged. Indeed, being resilient after the traumatic death of someone close does not mean that there will be an absence of struggling, but rather, that there are protective factors that help the child to struggle well. As described by Walsh (2003), “resilience involves key processes over time that foster the ability to ‘struggle well’, surmount obstacles, and go on to live and love fully” (p. 3).

We must recognize that some children experiencing grief and trauma may struggle, but not well. Approximately 5 to 20 percent of bereaved children will develop psychiatric problems and these problems may not manifest right after the death (Cerel, Fristad, Verducci, Weller & Weller, 2006; Dowdney, 2000; Melhem, Porta, Shamseddeen, Payne & Brent, 2012; Silverman & Worden, 1992; Worden & Silverman, 1996). There may be risk factors or a combination of risk factors that contribute to the child experiencing significant and persistent distress or psychiatric problems after the death of a loved one (see Table 1.1 for a list of potential risk factors). Neurobiological factors such as changes to brain development (Perry, 2009) and stress hormones such as cortisol (Hagan, Luecken, Sandler & Tein, 2010; Kaplow et al., 2013) are likely to interact with these risk factors and place some children at greater risk.

Most theories of bereavement recognize that, due to the complexities of unique situations and capacities, bereaved individuals tend to go through stages of grief or to oscillate between phases rather than go through specified tasks or milestones in an orderly fashion. From a developmental perspective, we also know that children may go through different periods of grieving or have different adjustments to address as they develop over time. For example, Worden argues that the tasks of mourning apply to children but that they must be viewed in the context of the child’s development as these tasks may need to be negotiated as the child matures. Worden’s four tasks of mourning are “to accept the reality of the loss … to experience the pain or emotional aspects of the loss … to adjust to an environment in which the deceased is missing … to relocate the dead person within one’s life and find ways to memorialize the person” (Worden, 1996, pp. 14–15). Recognizing the process of grief over time, Stroebe and Schut (1999) proposed a dual process model which allows for oscillation between loss-oriented aspects (grief associated with the loss) and restoration-oriented aspects (coping with changes) and confronting and avoiding stressors associated with each. The dual process model aligns with GTI for Children in that the intervention oscillates between helping the child to express their thoughts and feelings about the loss and identifying and promoting coping strategies. GTI for Children addresses trauma and loss in an integrative way and provides choices for children so they sometimes can focus more on the loss or at other times during the intervention they can focus more on the trauma. The clinician also helps the child to confront aspects of the trauma and loss experience which the child may be avoiding in an effort to help decrease symptoms and improve functioning.

Table 1.1 Risk Factors for Children Experiencing Grief and Trauma

Perceived life threat and fear

Association that death is due to action or no action of others

Closeness of the relationship with the deceased

Past exposure to trauma and loss

Time since death

Degree of overall sadness in the home

Witnessing dying, especially when there is physical distress or gruesome images

Pre-existing psychiatric disorder of the child and/or parent and comorbid psychological problems

Negative life events following the death

Child’s self-esteem and belief system

Child’s sense of competence

Family environment and stressors such as financial hardship

Lack of parental support and warmth to the child

Caregiver’s low functioning and emotional reaction to the death, depression, and posttraumatic stress

Sources: Brown et al., 2008; Brown et al., 2007; Cerel et al., 2006; Melhem et al., 2007; Melhem et al., 2012; Stoppelbein & Greening, 2000; Trickey, Siddaway, Meiser-Stedman, Serpell & Field, 2012

Children may oscillate between wanting to focus on the loss and needing to engage in activities to distract them from reminders. In a qualitative study with youth bereaved due to the death of a parent, findings suggest that youth wanted to be able to express their loss but also wanted to remain engaged in fun activities (Brewer & Sparkes, 2011). This study offers several key factors about interventions helpful for bereaved children: (1) having a non-judgmental environment where the youth can express a range of emotions from anger and fear to sadness to enjoyment; (2) being active and engaging in physical activity can serve as distraction for some and a way to release or channel intense feelings; (3) maintaining a positive connection with the surviving parent or guardian and also with the deceased person; (4) having experiences to feel a sense of competence and meaning in one’s life; (5) having social support and a connection with others who understand what it is like to be grieving; (6) realizing it is okay to have fun and also to engage in humor and laughter; and (7) feeling a sense of transcendence where the youth experiences gratitude and appreciation of life as well as a positive vision of his/her own future (Brewer & Sparkes, 2011). These themes are important to keep in mind when providing interventions to children experiencing grief and trauma.

DEVELOPMENT OF AN EVIDENCE-BASED GRIEF AND TRAUMA INTERVENTION (GTI) FOR CHILDREN

Grief and Trauma Intervention (GTI) for Children is considered an evidence-based practice. GTI for Children is listed on the National Registry of Evidence-based Programs and Practices (see www.nrepp.samhsa.gov/ViewIntervention.aspx?id=259) which is sponsored by the United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration.

To date, there have been four studies on GTI for Children. Lessons learned from each study as well as the outcome data were used to refine and develop the model. Continuous feedback between practice and research helped shape the model into an empirically-based intervention. As the mode...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Overview
• Acknowledgments
• 1 Introduction
• 2 Getting Ready to Implement GTI for Children
• 3 Practitioner Support
• 4 Screening and Evaluating
• 5 Parents and Other Important Adults
• 6 GTI for Children Sessions
• 7 GTI for Children in Action
• 8 In-Session Guidance
• 9 Treatment Adherence
• Appendix: GTI for Children Activity Sheets
• Index