Posted by: faithful | July 7, 2007

Cognitive therapy and childhood traumatic grief

WHAT IS CHILDHOOD TRAUMATIC GRIEF?
Childhood Traumatic Grief is a condition that we are just starting to understand. Some children whose loved ones die under sudden, horrifying, frightening circumstances may develop this condition in which children get “stuck” on the way the person died and are unable to go forward with typical grieving tasks. Children whose loved ones die under expected medical conditions such as cancer can also develop traumatic grief if the children’s perceptions of the death were that it was shocking, unexpected or terrifying.
WHAT ARE THE TYPICAL TASKS OF CHILDHOOD GRIEF?
In the usual course of greiving the loss of someone they love, children typically have to accomplish several steps. These include the following tasks:
1. Experiencing the deep and intense pain of the loss of the person who died.2. Accepting the permanence of the loss (this will vary according to the child’s developmental level — very young children will not be able to understand this in the same way that older children will).

3. Reminiscing about and accepting the totality of the person who died (not just the bad parts, not just the good parts, but all of these parts together).

4. Preserving positive memories of the person who died and integrating some of these into the child’s own concept of herself or himself.

5. Converting the relationship from one of interaction to one of memory.

6. Reinvesting in new relationships.

Children going through these steps after the death of a loved one, and especially those experiencing the ongoing pain and loneliness associated with losing someone you love so deeply, are experiencing typical childhood grief. This is also called “uncomplicated childhood bereavement.”

The differences between grief, bereavement and mourning are not that important for most people. When we use these words, they mean slightly different things.

Grief refers to the intense pain people feel when someone they love dies.

Bereavement is a state that people are in following a loved one’s death. One is considered to be “bereaved” following the death of a significant person in one’s life regardless of one’s emotional reaction.

Mourning refers to the rituals such as funerals, wakes, shiva, and other societal rites that we observe in honor of a loved one’s death.

HOW DOES CHILDHOOD TRAUMATIC GRIEF DIFFER FROM TYPICAL CHILDHOOD GRIEF?
As one can see from the above typical tasks of childhood grief, children (like adults) need to be able to think about their memories of their loved one in order to heal from the pain of the loss. Children with traumatic grief get “stuck” on the traumatic way their loved one died, such that whenever they try to remember happy times with their loved one, their memories veer off into thoughts about the terrible way the person died. Since these thoughts are not happy or comforting but instead frightening and upsetting, these children usually avoid thinking about the person who died. Alternatively, they cannot stop thinking about the person who died, but instead of these thoughts becoming comforting and healing, the thoughts continue to be hurtful, upsetting and even terrifying.
As a result of being “stuck” on the traumatic aspects of their loved one’s death, these children are not able to remember their loved ones in comforting, healing ways. Children with traumatic grief may develop sleep problems, difficulties with school, irritability, ongoing anger, sadness, or avoidance of friends, family and memories of the loved one. If these difficulties do not get better over time, they may interfere with important things that children need to do like school work, extracurricular activities, making and keeping friends, and spending time with family members. These children may also develop a psychiatric condition related to childhood traumatic grief called Posttraumatic Stress Disorder, which can be associated with more serious problems if left untreated.HELP IS AVAILABLE
We have developed a promising treatment for Childhood Traumatic Grief which is based on our proven treatment model for traumatized children. We have tested this model wtih many children in Pittsburgh as well as with children in New York following the terrorist attacks of September 11, 2001 and have found this approach helps children to recover from traumatic grief. Their parents, who also participated in treatment, experienced improvement in their own symptoms, even though the treatment was for the children’s, not the parents’, traumatic grief.
What makes our treatment different from typical bereavement programs that children receive in community settings?
**Children and parents are both included in treatment.
**Children and parents are seen individually at first, and then seen together, in family sessions so that children can share what they have done in treatment with their parents.
**Treatment includes several distinct components, with both trauma- and grief-focused phases of treatment.
**Treatment is both structured to provide all of the treatment components but also flexible to respond to individual family needs.
WHAT ARE THE COMPONENTS OF OUR TREATMENT APPROACH?
Our treatment is called Cognitive Behavioral Therapy for Childhood Traumatic Grief or CBT-CTG. The main components of CBT-CTG are the following:

-First, we provide children with coping skills so that they are prepared to work through the traumatic events that led to their loved one’s death.
-Once they have developed the needed coping skills, we help children develop a personal trauma narrative in which therapists gently guide them through the process of telling the story of how their loved one died.
-Children’s confused or distorted thoughts about how or why the person died, including self-blame for the loved one’s death, are examined and rethought through so that children have more accurate and helpful thoughts about their loved one’s death.
-Then we have joint child-parent sessions to share the trauma narrative and enhance the child’s ability to talk to the parent about the death.
-Once the child has resolved the trauma-related symptoms, we move to grief-focused sessions to help the child begin to grieve what has been lost, memorialize the loved one, and make meaning of the traumatic loss.
Throughout treatment we see the parent or other primary caretaker in individual parent sessions to share what the child is doing in therapy, discuss behavioral or other concerns the parent has regarding the child, and to reinforce the skills the child is learning in therapy.
-At the end of therapy, we have additional joint parent-child sessions to enhance family communication about the loss and to plan for coping with family trauma and loss reminders in the future.
EVIDENCE THAT CBT-CTG WORKS
We have completed two open studies which included more than 50 children. In the first study, we provided 16 treatment sessions of CBT-CTG. In the second study, we shortened this to only 12 sessions of CBT-CTG. In both studies, we found that children who received CBT-CTG experienced significant improvement in symptoms in the following areas:
Childhood Traumatic Grief
Posttraumatic Stress Disorder
Depression
Anxiety
Behavior Problems
Adaptive Functioning
(how the child did at school, home, with friends, etc.)
Additionally, parents who participated in the studies experienced improvement in their own Posttraumatic Stress Disorder symptoms, even though treatment only focused on the child’s symptoms.

FOR MORE INFORMATION ON CHILDHOOD TRAUMATIC GRIEF
We have worked with our colleagues in the Natinoal Child Traumatic Stress Network (NCTSN) to develop a variety of educational sheets for parents, teachers, therapists, pediatricians, and the media on Childhood Traumatic Grief. For more detailed information, please go to the NCTSN website at NCTSN.org.

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