Journal of Clinical Child and Adolescent Psychology 2004, Vol. 33, No.

4, 819-831

Copyright 2004 by Lawrence Erlbaum Associates, Inc.

OTHER ARTICLES Treatment of Childhood Traumatic Grief

Judith A. Cohen and Anthony P. Mannarino
Department of Psychiatry, Allegheny General Hospital, Drexel University College of Medicine Childhood traumatic grief (CTG) is a condition in which trauma symptoms impinge on children's ability to negotiate the normal grieving process. Clinical characteristics of CTG and their implicationsfor treatment are discussed, and data from a small number of open-treatment studies oftraumatically bereaved children are reviewed. An empirically derived treatment modelfor CTG is described; this model addresses both trauma and grief symptoms and includes a parental treatment component. Future research directions are also addressed. Childhood traumatic grief (CTG) refers to a condition in which a child or adolescent has lost a loved one in circumstances that are objectively or subjectively traumatic and in which trauma symptoms impinge on the child's ability to negotiate the normal grieving process. (Throughout this article, the term child is used to refer to children and adolescents.) This article describes our current understanding of CTG, as well as the treatment implications of these clinical features. Four treatment studies have included traumatically bereaved children or youth; data from these and other studies suggest important components for treating CTG. An empirically informed individual child and parent trauma- and grieffocused cognitive-behavioral treatment (CBT) model for CTG has been developed from this information and is described here. Recommendations for future clinical and research efforts are presented. Grief, Mourning, Uncomplicated Bereavement, and Complicated Bereavement Bereavement refers to the state of having lost a loved one, regardless of the emotional reaction to that loss; grief refers to the person's reaction to the loss; and mourning refers to the family, religious, and cultural rituals through which bereavement and grief are expressed (Stroebe, Hansson, Stroebe, & Schut, 2001). The Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR], American Psychiatric Association, 2000) utilizes the term uncomplicated bereavement to refer to the "typical" grieving process through which children and adults adjust to the death of a loved one (DSM-IV-TR). Uncomplicated bereavement is described in The Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994) as having much in common with depression (i.e., it is characterized by great sadness, sleep and appetite problems, lack of interest in normal activities, and difficulty concentrating). Adult complicated bereavement is a condition in which adult bereavement is complicated by separation distress and trauma symptoms related to the loss of the relationship (Prigerson, Shear, & Jacobs, 1997). In complicated bereavement, the traumatic nature of the loss is due to the security-enhancing nature of the relationship and the bereaved's dependency on that relationship. Distinctions between complicated grief and CTG are discussed in detail elsewhere (Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002). Children's understanding of death varies according to developmental level; this has been discussed in detail elsewhere (Black, 1998; Cohen et al., 2002; Emswiler & Emswiler, 2000; Grollman, 1995; Webb, 2002a; Wolfelt, 1996). Uncomplicated bereavement in children is also manifested in varying ways depending on the family's modeling and support of emotional expression, religious and cultural beliefs, and mourning rituals, as well as the child's own cognitive and expressive style.

Preparation of this article was funded in part by Grants SM54319 from the Substance Abuse and Mental Health Services Administration and K02 MHO 1938 from the National Institute of Mental Health. We thank Elissa Brown, Robin Goodman, Susan Padlo, Karen Stubenbort, Tamra Greenberg, Carrie Seslow, and the Traumatic Grief Task Force of the National Child Traumatic Stress Network for their conceptual contributions to this article, and Ann Marie Kotlik for assistance in its preparation. Requests for reprints should be sent to Judith A. Cohen, Allegheny General Hospital, Department of Psychiatry, Four Allegheny Center, Eighth Floor, Pittsburgh, PA 15212. E-mail: jcohenl@wpahs.org

819

COHEN AND MANNARINO

Reconciliation is a term used to describe the process of the child adjusting to and accepting the reality of life without the loved one and reinvolving oneself in the activities of living (Wolfelt, 1996). The following tasks have been conceptualized as critical to the reconciliation process (Wolfelt, 1996; Worden, 1996): accepting the reality of the loss; fully experiencing the pain of the loss; adjusting to an environment and self-identity without the loved one, including integrating positive aspects of the deceased into one's own self-image; converting the relationship from one of present interacting to one of memory; finding meaning in the loved one's death; and experiencing the comfort of a continuing or new supportive adult presence in the child's life. These tasks require the child to tolerate sustained thoughts about the deceased loved one and the child's past interactions with the deceased; to remember the totality of that person and tolerate regret or guilt about things left unsaid or undone in that relationship; and to face and bear the pain associated with the loss. It is important to note that children can experience intensely painful normal grief reactions, and these must be distinguished from CTG. As discussed later, children with traumatic grief are unable to complete these tasks of reconciliation because reminiscing about the loved one typically serves as a trauma reminder, with the subsequent development of trauma symptoms.

include recurrent upsetting recollections or dreams of the traumatic event that led to the loved one's death or a sense of the event happening over again. Children often have intense physiological reactivity or psychological distress in response to reminders of the traumatic cause of death ("trauma reminders"; Pynoos, 1992). Avoidance or numbing symptoms may include efforts to avoid thoughts, feelings, or conversations about the death or people, places, or situations that remind the child of the traumatic cause of death. Children with CTG may also experience a diminished interest in normal activities, feeling emotionally distant or detached from others, a restricted affective range, or a sense of a foreshortened future. Hyperarousal symptoms may include sleep disturbance, irritability or angry outbursts, decreased concentration, increased startle reaction, or hypervigilance {DSM-IV-TR).

CTG CTG (also called traumatic loss or traumatic bereavement) is conceptualized as the encroachment of trauma symptoms on the child's ability to successfully navigate the normal grieving process (Elder & Knowles, 2002; Layne, Pynoos, et al., 2001; Nader, 1997; Pynoos, 1992; Rando, 1993; Webb, 2002b). In essence, children with CTG cannot get their minds off of the traumatic and threatening circumstances of the death and thus the loss itself cannot be fully experienced and the pain of the grief cannot recede. In CTG, intrusive and disturbing trauma-related thoughts, images, and memories may be triggered by at least three types of reminders, described by Pynoos (1992). Trauma reminders are situations, people, places, sights, smells, or sounds that remind the child of the traumatic nature of the death. For example, tall buildings or hearing airplanes overhead may be trauma reminders for children whose parents died in the September 11th terrorist attacks. Loss reminders are people, places, objects, situations, thoughts, or memories that remind the child of the deceased loved one. A parent's birthday or seeing pictures of their deceased parents may be loss reminders for these children. Change reminders are situations, people, places, or things that remind the child of changes in living circumstances caused by the traumatic death. Having to move to a smaller house in a new neighborhood or having to bring an uncle instead of a father to a father-son baseball game may be change reminders for these children. Essential Features of CTG In CTG, trauma reminders, loss reminders, and change reminders may all segue into memories, thoughts, and images of the traumatic nature of the loved one's death, which leads to distressing, intrusive

Posttraumatic Stress Disorder (PTSD) Symptoms in CTG The trauma symptoms that children with CTG experience are PTSD symptoms (i.e., reexperiencing of the traumatic event that led to the loved one's death; avoidance of reminders of the traumatic event, the death, and the loved one; and physiological hyperarousal). In CTG, these PTSD symptoms are an indication that the danger and trauma associated with the circumstances of death are taking priority over the loss itself in the child's mind. PTSD symptoms occur in relation to an event involving actual or threatened death or serious injury or threat to the physical integrity of the child or others, and include intense horror, fear, or helplessness (DSM-IV-TR). The current concept of CTG requires children to have significant PTSD symptoms that impinge on normal grieving, although children do not need to be diagnosed with PTSD to have CTG (and could conversely have full-blown PTSD without CTG). Many children react to traumatic events with resilience, developing no or few PTSD symptoms. Other children develop only transient PTSD symptoms, which spontaneously remit over several weeks. Still other children may develop generalized fears, specific phobias, depressive symptoms, or behavior problems in response to a frightening event (Pine & Cohen, 2002). PTSD symptoms in CTG may 820

CHILDHOOD TRAUMATIC GRIEF TREATMENT

reexperiencing of this trauma and physiological hyperarousal. For example, when a child whose brother has died in a school shooting walks to that same school (a trauma reminder), he may experience intrusive images of his brother's mutilated face, heart palpitations, irritability, and terror (i.e., PTSD reexperiencing and hyperarousal symptoms). The distress that such children experience on exposure to trauma, loss, or change reminders leads them to try to avoid such exposure to minimize their distress. For example, the aforementioned child may avoid walking to or attending that school. Such avoidance may generalize to apparently neutral or innocuous situations, people, places, or objects (this child may refuse to walk in the neighborhood where the school is located or refuse to attend any school at all). Such avoidance may allow these children to minimize the intensity or frequency of exposure to trauma, loss, and change reminders. However, when children have lost a loved one, these reminders are typically ubiquitous and usually impossible to totally avoid. Some children may develop emotional numbing to cope with those unavoidable or uncontrollable reminders. Numbing may take the form of extreme detachment or estrangement, in which the child feels different, set apart and alienated from others, even those in his or her own family or circle of friends who experienced the same traumatic loss (Nader, 1997). For children with traumatic grief, even positive reminiscing (i.e., thinking about happy times with the deceased) segues into thoughts, memories, and emotions related to the traumatic nature of the person's death. This, in turn, sets off the cascade of reactions described previously (i.e., reminiscing about the loved one leads to thoughts of the horrible way in which the person died), which leads to PTSD symptoms (reexperiencing, hyperarousal, physiological hyperreactivity, and intense psychological distress). These symptoms prompt numbing, avoidance, or both, which in turn interfere with the child's ability to reminisce about the loved one. Thus, in CTG, PTSD-like trauma symptoms impinge on the child's ability to reminisce about the loved one and to achieve reconciliation, which is necessary for the successful negotiation of normal (uncomplicated) bereavement. As Pynoos (1992) stated, "It is difficult for a child to reminisce ... when an image of... mutilation is what first comes to mind" (p. 7). This is the essence of the current concept of CTG. Associated Features of CTG In addition to this impingement of traumatic symptoms on children's ability to negotiate the grieving process, some children avoid acknowledging any similarities between themselves and the deceased, for fear that they will also share the fate of the deceased (dying in a horrifying and premature manner; Nader, 1997; Py-

noos, 1992). As noted previously, integrating some positive aspects of the deceased into one's own selfconcept is a key task of reconciliation; thus, children who are fearful of any identification with the deceased may be unable to successfully reconcile themselves to the loss of this person. Conversely, some children may overidentify with the deceased, to the point of taking the deceased's name or only wearing objects of clothing that used to belong to the deceased, as an attempt to avoid accepting the reality of the death and thereby avoid the pain accompanying uncomplicated bereavement (Nader, 1997). Children with traumatic grief may blame themselves for the death of the loved one or experience survival guilt, characterized by exaggerated guilt for being safe and alive when others are not (Nader, 1997; Pynoos & Nader, 1990). Some children may unrealistically blame themselves for not being able to rescue or save the deceased person and may develop rescue fantasies in which they manage to do so. Revenge fantasies may also occur, in which children imagine they are punishing the real or perceived killer of their loved one (Eth & Pynoos, 1985). Guilt and shame may also accompany the death of a loved one in circumstances to which society attaches a stigma, such as suicide, homicide under "suspicious" circumstances (for example, when the media report the death as occurring in the context of a drug deal), a drunk-driving episode, or an AIDS-related death (Eth & Pynoos, 1985; Nader, 1997). Unlike children whose loved ones died in circumstances viewed as heroic (e.g., firefighters or police officers who die in the line of duty), these children typically do not receive an outpouring of public sympathy or financial support. It is possible that the added stigma or negative community judgment about the manner of death may constitute a risk factor for developing CTG. Reactivity to ubiquitous and unavoidable trauma, loss, and change reminders may result in more extreme emotional numbing or avoidance in children with CTG, whereas such reminders may be beneficial or healing to children with uncomplicated bereavement. It is possible that the timing of these symptoms is important in differentiating children with traumatic grief from those with early uncomplicated bereavement. That is, developing trauma symptoms may be normative for children in the immediate aftermath of a traumatic death, but not after a month or longer. More empirical research is needed to determine whether this is the case. CTG and the Cause of Death In CTG, the cause of death is usually objectively traumatic. In some instances, deaths from so-called natural causes (cancer, heart attack, stroke, and so on) may result in traumatic grief, if the child's experience 821

COHEN AND MANNARINO

of the death was horrifying or shocking (e.g., if the child directly witnessed the death, the death was accompanied by what the child perceived as intense pain or suffering, or if the deceased's appearance at the time of death was mutilated, disfigured, or otherwise horrifying to the child). This should be differentiated from normal grief reactions (i.e., pain, sadness, loneliness, longing for the deceased), which are intensely experienced but are unrelated to explicitly traumatic aspects of the death. It is important to recognize that developing CTG is not normative for children who lose loved ones, even if the cause of death is objectively traumatic. For example, Pfefferbaum and her colleagues (1999) found that, although loss of a loved one and the closeness of the relationship to the deceased were correlated with higher levels of PTSD, the majority of children who lost loved ones in the Oklahoma City bombing in 1995 did not report elevated PTSD symptoms or functional impairment 7 weeks after the bombing. Brent, Perper, and Moritz (1993) and Brent et al. (1995) demonstrated similar findings with regard to close friends of adolescents who committed suicide; only 5% of these adolescents reported persistent PTSD symptoms. Additionally, siblings of adolescent suicide completers did not demonstrate an increased incidence of PTSD symptoms compared to a control group that was not exposed to suicide, despite having a prolonged elevation of grief symptoms (Brent, Moritz, Bridge, Perper, & Canobbio, 1996a, 1996b). Thus, it appears that the majority of children who lose loved ones under traumatic circumstances do not develop CTG, and development of persistent PTSD symptoms that intrude on children's ability to grieve should not be viewed as normative for such children. Secondary Adversities Following a familial death, children may experience secondary adversities such as the loss of home, health insurance, or family income. If the family has to relocate, children may also have to leave their school, peers, place of worship, and other social supports. In these situations, children and parents have to adjust not only to the loss of the loved one, but also to these additional losses. These adversities, as well as preexisting family stressors, likely impact on children's likelihood of developing CTG. Assessment of CTG The assessment of CTG entails evaluation of the child's and family's past and current functioning, the child's experience of the loved one's death, the child's PTSD symptoms (including identification of the child's personal trauma, loss, and change reminders), and the impingement of these symptoms on the child's 822

ability to negotiate the normal grieving tasks of reconciliation. A detailed description of the assessment of CTG has been described elsewhere (Cohen et al., 2002). A factor analysis of the Expanded Grief Inventory (Layne, Savjak, Saltzman, & Pynoos, 2001), which has been used to assess CTG, is described elsewhere (Brown & Goodman, in press). Instruments to assess the child's experience of the death have been developed and are currently undergoing field testing by the National Child Traumatic Stress Network's Traumatic Grief Task Force (Brown, Handel, Cohen, & Amaya-Jackson, 2003). Implications for Treatment The previous discussion suggests that optimal treatment for CTG should include both trauma- and grieffocused treatment components. In the case of PTSD and other trauma-related symptoms, in which there are known efficacious treatments (Cohen, in press), these treatments should be adapted for use with CTG. In the absence of empirical studies, grief-focused treatments that are believed to assist children in the tasks of reconciliation (Wolfelt, 1996; Worden, 1996) also should be included in the treatment. Treatment Studies for CTG There have been a small number of open-treatment studies for adolescents and young adults with CTG, all using group-treatment approaches. One has been delivered in school setfings (Layne, Pynoos, et al., 2001). This treatment protocol includesfivefoci: traumatic experiences, reminders of trauma and loss, bereavement and the interplay of trauma and grief, posttrauma adversity, and developmental progression. Layne, Pynoos, et al. (2001) utilized this treatment model to treat 15- to 19-year-old Bosnian youth {N = 55) who survived the civil war in their country and documented that youth who received both the trauma-focused and the grief-focused treatment modules experienced significant improvement in PTSD and depressive and traumatic grief symptoms. Youth who only received the trauma-focused treatment modules (due to circumstances unforeseen at the start of the study) experienced significant improvement in PTSD and depressive symptoms comparable to the group receiving full treatment. Their improvement in traumatic grief symptoms, although sfiU statistically significant, was significantly less than that of the group receiving all five treatment modules. These findings support the contention that including both trauma- and grief-focused components may be essential for resolving CTG symptoms. Saltzman, Pynoos, Layne, Steinberg, and Aisenberg (2001) also used this school-based group approach to treat symptomatic 11- to 14-year-old students (A'^ 26) who had experienced community violence in Los An-

CHILDHOOD TRAUMATIC GRIEF TREATMENT

geles. Of these youths, all of whom had known of violent deaths in their communities, 7 had experienced the traumatic loss of a loved one. The study demonstrated significant pre- to posttreatment improvement in PTSD as well as improvement in participants' grade point averages at school, an important indicator of adaptive functioning. The 7 youths who had experienced loss of a loved one also demonstrated a significant decrease in traumatic grief symptoms. Salloum, Avery, and McCain (2001) used a different treatment model in an open group treatment study for 45 adolescent survivors of homicide victims. This 10-week treatment included psychoeducation about grief, facilitation of expressing grief-related thoughts and feelings, coping skills, safety enhancement, management of anger and thoughts of revenge, accessing support systems, spirituality, and identifying future goals. The study documented that participants experienced significant decreases in PTSD symptoms from pre- to posttreatment as measured by the University of California-Los Angeles PTSD Reaction Index (Steinberg, Brymer, Decker, & Pynoos, 2004). Pfeffer, Jiang, Kakuma, Hwang, and Metsch (2002) randomly assigned 102 children ages 6 to 15 years old bereaved by the suicide of a parent or sibling to a manualized group treatment or a no-treatment control group. The treatment consisted of 10 sessions and included psychoeducation about death, grief, suicide, and prevention of suicidal urges; problem-solving skills; feeling identification and expression; identification of positive aspects of the deceased while avoiding suicidal urges or hopelessness; managing traumatic thoughts; dealing with stigmatization; encouraging new supportive relationships; and enhancing optimism. This study documented that the treatment group experienced significantly greater improvement in anxiety and depression, but not in PTSD symptoms, compared to the no-treatment group. Unlike the Layne, Pynoos, et al. (2001) group-treatment model, neither of the last two treatment models included a specific measure of CTG, nor did either include interventions aimed directly at desensitizing participants to traumatic memories. Interestingly, PTSD symptoms improved in one study (Salloum et al., 2001) but not the other (Pfeffer et al., 2002). The reason for this difference is unclear but may be related to the fact that, unlike homicide, suicide is an intentional act committed by the victim. This may result in greater ambivalence toward the deceased, which may result in increased avoidance and difficulty in resolving PTSD symptoms. Inclusion of Parents in Treatment of CTG None of these studies included a parental treatment component, either because they were treating older

youth or because treatments were delivered in the school setting, where parents would not typically be available for participation. However, there are important reasons to consider including parents in treatments for children suffering from CTG. Epidemiologic studies have indicated that lack of parental and other social support is a risk factor for developing psychopathological symptoms following trauma exposure (reviewed in Pine & Cohen, 2002). Parents of children with CTG are typically bereaved themselves (i.e., the deceased loved one was their spouse, partner, or child) and may have their own trauma or traumatic grief symptoms. Therapeutic interventions may optimize the ability of these parents to be emotionally available and supportive to their children. This may be particularly true as parents can serve as models for their children in accomplishing the tasks of reconciliation or, in the presence of parental PTSD or traumatic grief, may conversely model avoidance of these tasks. Several treatment studies of children traumatized by sexual abuse have indicated that both parent emotional distress related to the child's trauma and lower levels of parental support for the child predicted poorer treatment outcome for these children (Cohen & Mannarino, 1996b, 2000). Debhnger, Lippman, and Steer (1996) also found that sexually abused children whose parents received treatment experienced significantly greater improvement in self-reported depressive symptoms than children whose parents did not receive treatment, even if the child did not receive treatment. It remains to be determined whether parental distress mediates child outcome in CTG. Even if this is not the case, it still may be beneficial to include a parental treatment component in treatment models for CTG. This may be particularly beneficial for those treatments that target children and younger adolescents, who are more dependent on parents as a primary source of support than older adolescents.

Development of the CBT for CTG Model We direct a child psychiatric outpatient treatment clinic for traumatized children, the Allegheny General Hospital Center for Traumatic Stress in Children and Adolescents, located in an academically affiliated urban hospital. Much of the program's early efforts had been devoted to developing and empirically testing individual psychosocial treatments for sexually abused children and their nonoffending parents. These studies demonstrated that trauma-focused CBT treatment (TF-CBT) was efficacious in decreasing a variety of psychological difficulties in these children (Cohen & Mannarino, 1996a, 1998). These interventions were also used successfully in the Center for Traumatic Stress in Children and Adolescents with children who had been exposed to a variety of other types of trau823

COHEN AND MANNARINO

matic events. A recent multisite study, which indicated that the TF-CBT model was superior to child-centered supportive therapy in decreasing PTSD, anxiety, depression, and shame in 229 sexually abused children, documented that 70% of the children also had experienced either the sudden death or terminal illness of a loved one (Cohen, Deblinger, Mannarino, & Steer, in press). Although this study did not specifically assess CTG, experiencing a traumatic loss did not predict differential treatment response to TF-CBT. Following the crash of U.S. Air Flight 427 outside of Pittsburgh in 1994, the clinic had the opportunity to provide treatment to several children and parents who had lost loved ones in the disaster. This led to the development of a group-focused treatment for CTG (Cohen et al., 2001; Stubenbort, Donnelly, & Cohen, 2001). Based on the success of TF-CBT interventions in decreasing PTSD, depressive, anxiety, and behavioral symptoms in our randomized treatment trials, and the presumption that children with CTG would have to resolve some of their trauma symptoms prior to addressing their grief, we incorporated TF-CBT interventions into the early stages of an individual-treatment model for CTG. One advantage of individual treatment over the group approach is that the Center for Traumatic Stress in Children and Adolescents typically sees children bereaved by different events rather than a community-level tragedy. Individual treatment allows each child to develop his or her own trauma narrative and does not expose other children to the possibility of vicarious traumatization (through hearing other children's horrifying experiences). Also included in the model adapted from TF-CBT were child grief-focused interventions, which had garnered preliminary empirical support in children who had lost a parent to homicide (Salloum et al., 2001) or cancer (Schut, Stroebe, van der Bout, & Terheggen, 2001). This treatment model was being manualized when the September 11, 2001, terrorist attacks occurred. Almost simultaneously, the National Child Traumatic Stress Network was funded by Substance House and Mental Health Services Administration, and its Traumatic Grief Task Force was formed to develop a coordinated response to children impacted by the terrorist acts of September 11 th. This convergence of events allowed us to benefit from the suggestions of numerous therapists and researchers in New York City and nationally and to complete the treatment manual (Cohen et al., 2001), which was made available in November 2001. This individual treatment model is currently being empirically evaluated in an open trial at our clinic and in a randomized controlled trial in New York City (Brown & Goodman, 2002). The CBT for CTG treatment model includes 12-16 treatment sessions. It is used for children and adolescents (ages 6 to 17 years) who have significant CTG symptoms. The therapist provides individual treatment 824

to the child and parent in 8-12 of these sessions, whereas the remaining 4 are used for joint parent-child treatment sessions. If multiple siblings are treated, each child has individual sessions, whereas the parent receives one session per week to address issues for both or all children in the family. Although the treatment is manualized, therapist creativity and flexibility are critical for optimally individualizing how the treatment is implemented. Specific components of this treatment model are divided into trauma-focused and grief-focused segments, which are listed in Table 1; however, in practice, therapy often flows between trauma and grief elements according to the individual child's and parent's needs as well as external circumstances that may impact on the child's symptoms. Because the goals of this treatment are to decrease symptoms of CTG, PTSD, and other emotional and behavioral problems, initial and follow-up assessments in this model include the use of standardized instruments. The Expanded Grief Inventory and the University of California-Los Angeles PTSD Reaction Index are used, along with instruments that measure depression, anxiety, and behavior problems in children and PTSD and depression in the parents who participate in the treatment (see Table 1).

Trauma-Focused Components The trauma-focused components of this treatment model include the following interventions, which are listed in Table 1: affective expression skills; stress management skills; improving affective modulation, problem solving, and social skills through use of the cognitive triangle; creating the child's trauma narrative; cognitive processing; and joint parent-child sessions. Affective expression skills optimize children's and parents' ability and comfort with accurately identifying and appropriately expressing a wide range of emoTable 1. Trauma-Focused Versus Grief-Focused Interventions
Trauma-Focused Interventions Affective expression skills Stress management skills Cognitive triangle Creating the child's trauma narrative Cognitive processing Joint parent-child sessions Grief-Focused Interventions Talking about death; psychoeducation Mourning the loss Addressing ambivalent feelings about the deceased Preserving positive memories Redefining the relationship Committing to other relationships Making meaning of the traumatic loss Joint parent-child sessions

CHILDHOOD TRAUMATIC GRIEF TREATMENT

tions, including those they may perceive as "negative" (e.g., anger, fear) and therefore unacceptable. A variety of techniques or games may be used to facilitate feeling identification and expression; some of these are reviewed by Hall, Kaduson, and Schaefer (2002). Very young children may enjoy interventions that employ drawing or puppets to express feelings, such as Color Your Life (O'Connor, 1983); elementary school age children often enjoy games they can "win," such as Emotional Bingo (Western Psychological Services, 1998). Older children and adolescents may prefer more complex games such as The Stamp Game (Black, 1984), in which they identify and quantify how much of several emotions they would feel in various circumstances. Other feeling-identification activities may include making a feeling mask (representing "outside" feelings that others observe and "inside" feelings that are not shown to others), having adolescents use lyrics of popular music to exemplify different feelings, or allowing them to create their own rap songs to express a variety of emotions. The parallel parent session encourages parents to discuss a range of feelings they have about the traumatic death and also introduces several behavior management techniques, including the use of praise, active ignoring, effective time-out, and contingency management procedures. When clinically appropriate, parents can also be encouraged to discuss the child's reaction to the loved one's death with the child's teachers to assist in the child's recovery. Stress management skills assist the child and parent in handling physiological hyperarousal symptoms such as difficulty falling asleep, increased startle, and hypervigilance in innocuous situations. They also give children and parents an increased sense of control over these responses. Stress management techniques include deep breathing, progressive muscle relaxation, thought stopping, and positive self-talk. These skills are taught to both children and parents; parents may assist younger children in practicing them at bedtime or in other appropriate situations or remind older children or teens to utilize them when they are experiencing high levels of stress. For children or parents who do not respond positively to these relaxation techniques, the therapist may ask how they relax or unwind (e.g., listen to music, play sports, dance, knit). The therapist can then encourage the child or parent to use these activities when they are under stress or to experiment with other activities or techniques that bring about a similar sense of being relaxed. Improving affective modulation, problem solving, and social skills through use of the cognitive triangle introduces children and parents to the relations among thoughts, feelings, and behavior. Understanding these relations allows children to recognize that many of their negative feelings, problematic social interactions, and behavioral difficulties result from thoughts that are inaccurate or unhelpful. Modifying cognitions to be

more accurate and helpful assists children in modulating upsetting affective states, interacting more positively with peers, and selecting optimal behavioral strategies in challenging situations. For example, if a child walks into a classroom and another child turns away and does not speak to him, the first child might think "she doesn't like me" (thought). This may lead the child to feel sad, hurt, or angry (feelings). If he felt sad or hurt, that child might cry, turn away or isolate himself, whereas if he felt angry, he might confront or fight with the other child (behaviors). On the other hand, if this child thought "she must be shy" (alternative thought), he might feel sympathetic or generous toward the other child (new feelings). This might lead the child to initiate a conversation with the other child (new behavior). Learning about these relations hopefully assist children and parents in examining and modifying their thoughts to have less upsetting feelings and more productive behaviors. Practicing this with everyday (i.e., not related to the traumatic death) situations may be preferred at this early point in treatment. Parents and children may want to write down times between sessions when they felt upset or angry and try to identify whether a thought was contributing to that feeling. They can then consider whether that thought was accurate and helpful and, if not, try to identify more accurate or helpful thoughts to feel better. It is important for the therapist to note, however, that some negative feelings might be helpful to children or parents (e.g., anger at the murderer of their loved one might give them the determination to testify at trial and see that justice is served); in such a situation, the person is benefiting from the feeling and will not have a reason to change it. Creating the child's trauma narrative typically takes two to three sessions and encourages the child to gradually face increasingly painful and frightening aspects of the event that led to the death of their loved one. The goals of this component are to gradually desensitize the child to thoughts and reminders of the traumatic aspects of the death, to decrease avoidance of the more horrifying aspects of the experience, to help contextualize these events in the greater schema of his or her own life and the world, and to identify cognitive distortions about the death. The therapist may introduce this component by reading with the child one of several commercially available books about traumatic deaths that are written from a child's viewpoint. Then the therapist may ask whether the child would like to create a personal book about what happened when the child's loved one died. Children may opt to draw a series of pictures, a poem, a comic strip, or a song instead of creating a book. The narrative should include not only "what happened" but also the child's thoughts, feelings, and body sensations throughout the experience. This is typically accomplished by the child rereading aloud what he or she has already written and 825

COHEN AND MANNARINO

adding additional information on each subsequent reading. At some point the therapist should encourage the child to include the "worst moment" of the traumatic death in the narrative. Through such repetition and by gradually adding more painful or avoided aspects to the narrative, children become more comfortable with talking and thinking about the totality of the experience, with the result that they have less need to avoid such thoughts or discussions. The therapist also assists in this process by modeling competent coping, by hearing the child's story without becoming emotionally distraught, angry, or fearful and reassuring the child that hearing this story is not unbearable. As children create their trauma narratives, therapists ask permission to share these with parents and typically do so during the parallel parent sessions. When children resist this idea, it is rarely due to confidentiality concerns; more typically, children worry that hearing the narrative will upset their parents. Therapists reassure children that even though reading the narrative might naturally be upsetting to parents at first, their parents are eager to hear what their children are writing and will be able to handle it. (If, based on a parent's severe functional impairment, the therapist believes that the parent will not be able to tolerate exposure to the child's narrative, alternative interventions should be used.) This prepares the family for the joint sessions, when children and parents directly communicate about the traumatic events that led to the loved one's death. Cognitive processing of the traumatic aspects of the death allows children and parents to examine and modify cognitive distortions they may have about the death or its aftermath, which often contribute to difficult feelings and avoidant behaviors. Children and parents may have distorted ideas of their own responsibility in the death (i.e., that they could or should have done something to prevent it from happening). They also may develop distorted ideas about future safety or dangerousness of other people and the world around them. Some may lose faith in the social contract that provides for the punishment of those who hurt others (for example, if the murderer of the loved one is not caught or convicted). The therapist assists children and parents in identifying these thoughts and examining whether they are accurate (true) and helpful (contributing to healing rather than maintaining unrealistic self-blame, fear, or anger). For example, retaliatory or revenge fantasies may present underlying unrealistic feelings of guilt for not preventing the death; alternatively, they may represent the child's realistic regret about his or her own powerlessness to protect others from death. Some of the techniques used in this regard are overgeneralization, progressive logical questioning, and the best-friend role play. For example, if the child says, "I can't feel safe again," the therapist might overgeneralize (i.e., take the statement to a ridiculous 826

extreme that the child must realize is not true) by saying, "So there is nothing you can ever do to keep yourself safe at all?" The therapist may assist the child in recognizing that this extreme is not accurate through the use of progressive logical questioning, for example, by saying, "So when you cross the street you just have to close your eyes and pray, cause you can't look both ways?" When the child corrects this ("Of course I can look before I cross the street"), the therapist can say "Oh, so there are some ways that you can feel safe now," and from there continue to help the child recognize the many ways in which he or she can stay and feel safe and pinpoint the specific situations in which the child does not feel safe. Then the child and therapist (and parent, during joint sessions) can problem-solve about how to help the child feel safe in these specific situations. The best-friend role play is helpful for children and parents who are having difficulty finding alternative thoughts to their current inaccurate or unhelpful ones. The therapist plays the role of the child, and the child plays the role of his or her own real-life best friend. The therapist (playing the child) then expresses thoughts similar to what the child has expressed in therapy, for example, "I should have known a drunk driver would be on the road that night and warned my father not to go out. This was all my fault." The child, playing the best friend, will typically try to comfort the "child," by saying things such as "It wasn't your fault, you couldn't have known, you're not a mind reader" (which is often what the child has heard from others but has been unable to internally believe). The therapist persists in these distortions ("But it was my father, I just should have somehow known, if I only would have known he would still be alive"). This often prompts children to come up with more creative ways of convincing the child that he or she is not responsible ("Even if you had told him not to go out, he wouldn't have listened to you cause you're a kid and he was the grown up"). The therapist gradually comes around to the best friend's viewpoint and adds to this, if the child seems receptive ("Yeah, I guess you're right, even if I would have known and told him, he would have thought I was being silly. It is kinda silly to think you can predict the future, huh?"). This technique is often helpful for parents as well. Revenge fantasies express children's anger at the real or perceived perpetrator of the loved one's death, as well as their wishes to see justice served and thus maintain their belief in the social contract. Helping children identify and acknowledge these underlying themes can be achieved by the aforementioned processing techniques (i.e., exploring what would happen if the child actually tried to carry out these fantasies, that this could endanger him or her and might not succeed, that it is hard to see the perpetrator live when the loved one is dead, that this is unfair and makes the child

CHILDHOOD TRAUMATIC GRIEF TREATMENT

angry). Alternative strategies for resolving anger and reinstating the social contract can then be developed (e.g., testifying in court, taking social action to prevent future similar deaths, and so on). One of the goals of both creating the trauma narrative and cognitive processing is to place the traumatic death into the greater context of children's whole lives. Specifically, some children overidentify with the role of a helpless victim or a bereaved child and overlook the ways in which they have not been changed by the death. It is hoped that, in combination with the grief component focusing on making meaning of the traumatic death, these interventions will result in the traumatic death being a difficult and painful experience that children have gotten through and grown from, rather than the defining moment of these children's identity. Joint parent-child sessions are typically included at this point in treatment to allow children and parents the opportunity to openly discuss the traumatic nature of the loved one's death with each other. Due to the centrality of avoidance in CTG, these children will likely have been unable to communicate sucb thoughts and feelings previously and have not felt comfortable in asking parents questions about this experience. In these sessions children and parents are encouraged to ask and answer such questions, both to address specific concerns and to enhance open communication. When children read their trauma narratives to their parents in these sessions, they benefit from seeing their parents' ability to tolerate hearing details about the trauma and death, as well as from parental praise of the difficult task they have accomplished in creating the narrative. They are able to experience their parents' genuine pride and amazement that their children have come so far so quickly. This parental support is a crucial factor in children feeling that they have "permission" to grieve and move on from the loss of the loved one in the second part of treatment.

therapists should not automatically assume that they are knowledgeable about a particular family's bereavement practices or beliefs based on that family's religion or ethnicity. The therapist should ask directly what children and parents believe happens after death, where or in what state they believe the deceased is currently, and whether they believe the manner of death negatively affected this. For example, some children believe a mutilated (i.e., not whole) body cannot be admitted to heaven; other families believe that death from suicide or drugs dooms the deceased to hell; some cultures place more credence than others in the meaning or predictive power of dreams about the deceased. Such beliefs may have a profound effect on children's and parents' grieving process; therapists must recognize that challenging culturally bound belief systems is rarely therapeutic. On the other hand, some beliefs may not be consistent with those held by the child's religion or culture and may be responsive to reinterpretation by religious leaders or community elders (e.g., a religious leader may reassure a child that souls with mutilated bodies can indeed be admitted to heaven). Talking about death in general may be helpful for many children who may have not to this point been able or willing to ask questions about death due to their traumatic grief symptoms. Initially, this discussion may consist of neutral questions about death, rather than about children's specific losses. For example, many children enjoy playing the Good-Bye Game (Childswork/Childsplay), in which cards with questions about death, funeral, cremation, heaven, and so on are drawn and children get points for answering (S. Padlo, personal communication, March 2003). This activity sets the stage for openly talking and asking questions about death. Mourning the loss requires children to acknowledge what they have lost (a task that children with CTG may not have been able to do prior to completing the trauma-focused interventions earlier in treatment). Children have lost both the interactive relationship they had (the special and everyday things they did with the deceased person) and the things they may have shared with that person in the future but now will never have the chance to (such as confirmation or Bar Mitzvah, high school graduation, wedding, and so on). Parents have additionally lost (if their partner or spouse died) having the other parent present to raise their children together or (if their child died) the chance to see that child grow into an adult. These losses are excruciatingly painful to many people, and children and parents may naturally experience ongoing pain in facing these losses. It is not the goal of this brief treatment model to totally resolve these; such losses may be associated with lifelong pain. The goal is to begin the process of acknowledging what has been lost and to help the person at least intermittently face the pain as it is experienced, rather than to attempt to consistently or perma827

Grief-Focused Components Grief-focused components of this treatment model include talking about death, mourning the loss, addressing ambivalent feelings about the deceased, preserving positive memories, redefining the relationship and committing to present and new relationships, making meaning of traumatic loss, and joint parent-child sessions (see Table 1). Because family, religious, and cultural traditions and rituals are central to bereavement and the manner in which children and parents mourn, it is important for the therapist to inquire and learn about these early in the grief-focused portion of treatment (often these have already been discussed earlier in treatment). Respect for these traditions and values is essential; however.

COHEN AND MANNARINO

nently avoid it. (Therapists should recognize that in certain circumstances avoidance is a positive coping response and may at times be an essential component of normal grieving.) To assist the child in talking about the deceased person, it may be helpful to write that person's name on a blank sheet of paper, with one letter for each horizontal line. Then the therapist can ask the child to fill in one word or phrase for each letter of the person's name that describes an important characteristic of the person who died (S. Padlo, personal communication, March 2003). For example, one child whose brother Daniel died completed this task as follows: Donut-lover Allowed me to use his Nintendo games Never impatient with me Intelligent, helped me with math Extremely funnytold the best jokes Liked to play baseball This allows children to gradually start talking about the deceased person in a manner and to an extent that is comfortable. Once children are able to talk about more details about the deceased, they may be willing to make lists of "Things I Miss" about the deceased, including everyday and special activities they shared, places they went together, shared rituals (e.g., bedtime, Christmas morning), and so on. Children may also want to list specific future plans they had made with the deceased that will now need to be modified (e.g., a planned family vacation, father coaching a child's sports team, siblings going to the same school together in the coming school year, and so on). At this point children and parents may want to start thinking about how these plans can be modified to cause them the least amount of distress (i.e., coping with future trauma and loss reminders while recognizing that there will be sadness when doing these activities in the absence of the deceased). In the parallel parent session, therapists may share the losses children named, as well as encourage parents to name and talk about their own losses. Issues such as how to raise children alone, how to interact with other couples as a single parent, dealing with in-laws, parental sexuality after loss of a partner, and changed religious beliefs or attitudes may be appropriate foci for parents who have lost a partner (Elissa Brown, personal communication, October 2003). If secondary adversities (loss of home, income, and so on) have resulted from the deceased's death, this may be an appropriate time to explore with parents how this has negatively impacted the child and family and how the therapist might be helpful in minimizing the adverse impact on the child (this may involve assisting the family in accessing community resources, with which the therapist should have adequate familiarity). 828

Addressing ambivalent feelings about the deceased allows children and parents to acknowledge that the deceased, like everyone else, had flaws and less likeable qualities without diminishing either the tragedy of his or her death or how much he or she was loved. It may be that there were unresolved confiicts between the child or parent and the deceased at the time of death, which now cannot be resolved face-to-face. There may have even been mistreatment, such as domestic violence or child abuse, perpetrated by the deceased toward other family members. These issues need to be honestly addressed rather than denied or hidden for the true totality of the deceased person to be acknowledged, reminisced about, and grieved. Addressing ambivalent feelings toward the deceased may be a particularly important intervention for those whose loved ones died in circumstances that are associated with stigma or negative judgments from the larger society, for example, deaths from suicide, drug overdose, or AIDS. Children and parents may be angry about or ashamed of how the loved one died and may feel isolated from those who do not know the manner of death or ostracized by those who do. Having the opportunity to openly acknowledge these feelings in therapy without being judged often allows children and parents to express their positive feelings about the deceased (which they may feel constrained from doing publicly for fear that this will be viewed as condoning the behaviors that led to the death), to thereby reminisce about the totality of the person whom they have lost and thus to start the process of grieving the loss. If ambivalent feelings for the deceased are present, some children may want to add to their earlier list of Things I Miss another list of "Things I Will NOT Miss" about the deceased (their bad temper, hitting me, calling me mean names, and so on). Some children choose to write a letter to the deceased person and then write the letter they think the deceased would write back to them in response. (Therapists must be sure that younger children understand that the deceased is not living in a distant location to which the letter is being sent.) Such techniques can assist children and parents in acknowledging and accepting their true feelings, both positive and negative, toward the deceased and thus allow them to begin grieving the total person they have lost. Preserving positive memories of the deceased is often a prerequisite to giving oneself permission to commit to existing and new relationships. At this point in treatment, children (who previously may have preferred to avoid mementos, pictures, and other reminders of the deceased) are encouraged to look through these and create a memory box, scrapbook, or other collection of memories, in which they display or save fond memories of the deceased person. Some children may prefer to do this through fill-in-the-blank sheets that the therapist and child can custom design for the

CHILDHOOD TRAUMATIC GRIEF TREATMENT

deceased person (e.g., "What was the funniest thing your loved one ever did?" "What was his or her favorite piece of clothing?" "What was the best Halloween costume he or she ever wore?" "What was the best gift he or she ever gave you?"). Other children may choose to design their own tangible memorial of the deceased, such as a mural, collage, or photo album. Children should be encouraged to invite other family members to assist them in collecting and remembering things to include in this memorial; this may also help parents who are themselves reluctant to look through the deceased's belongings but willing to do this for their children's benefit. Particularly following a traumatic death, it is uncommon for children to be included in the planning of the funeral or burial rites. Children may at this point in treatment elect to plan their own memorial service, in which they can select the tributes to and memories of the deceased to be included. This may provide some closure that the initial funeral was unable to provide to children with CTG. This sense of closure may be particularly elusive if no corpse or remains of the deceased were found (as was the case for many victims of the September Uth attacks). Body reconstructive techniques may assist these children in this regard (Layne, Pynoos, et al., 2001; Pynoos, 1992). Redefining the relationship is an important step for children and parents to be able to move ahead in their normal development. It requires children and parents to accept that the relationship with the deceased has changed from one of interaction to one of memory. This is particularly crucial for children who are still in the process of moving through progressive developmental stages and who need relationships with others who are also growing and changing (unlike the deceased who can no longer grow or change). One technique that may help children to operationalize this change is by drawing one balloon anchored to the ground with another floating up in the sky. Children are asked to name all of the things they have lost in the relationship in the floating balloon (e.g., doing things together) and all the things they still have in the relationship in the anchored balloon (e.g., memories of times together). This can begin the painful process of letting go of the interactive relationship with the deceased. Committing to present and new relationships may be easier if the therapist acknowledges that none of these will be exactly like the relationship with the deceased, and therefore none of these relationships can or intend to "replace" the deceased person's place in the child's life or memory. However, the therapist can help the child to see that other people may be able to fill some of the roles that the deceased played in the child's life. For example, an uncle may take the father's place as the new coach of the child's baseball team, or a neighbor child can walk to school with the child in place of the child's sister. The therapist can help the child see that all of these people to-

gether will never be the same as having the deceased person back, but it will be better than having no one to fill any of these roles. Children may be assisted in committing to new relationships by naming different needs or roles that the deceased fulfilled for them and then identifying other people in their lives who potentially could fill one role or another. Children should be encouraged to "audition" such people in these roles and see who is the best fit for each. It is important to recognize and openly discuss potential barriers to committing to new relationships. These may include a fear of being disloyal to the deceased or a fear that the deceased will fade from memory. Children may fear their parents will be angry if they are able to be happy again, especially if children are further along in the grieving process than the parent. The therapist will need to address this concern with parents who are in this situation and identify ways in which the parent can encourage the child to enjoy present and new relationships even if the parent is not yet personally ready to do this. (In some cases, the parent may be ready to explore new relationships, i.e., start dating after the death of a spouse, but the child may object to this as disloyalty to the deceased parent.) This would also be an appropriate focus for this treatment component. Making meaning of the traumatic loss assists children in integrating this experience into a larger vision of themselves and the world around them. Ideally, children will recognize that adjusting to the traumatic death has not only been a frightening and painful process, but also one in which they have grown and become stronger in some way. Children may be encouraged to identify these aspects of the process through answering questions such as "How has this experience changed you?"; "What would you tell other children who have just had a traumatic loss?"; "What would you tell another child who is afraid of going to therapy for this?"; and so on. Most children respond that it has been very hard but it has been worth it because they learned how strong they are, they became more aware of how much their family members love them, they came to understand how many good and caring people there are in the world, and so on. Older children and parents may find meaning in trying to prevent other people from having to experience what they did or by helping other people who are going through similar circumstances. For example, children who lost a loved one in a drunk-driving accident may join Students Against Drunk Driving to spread the word about the dangers of this activity; parents who lost a child to community violence may become a victim advocate at a community program. Following the U.S. Air Flight 427 disaster, surviving family members formed the Flight 427 Air Disaster Support League, which advocated for more prompt and open communication from airline officials follow829

COHEN AND MANNARINO

ing such disasters and continues to provide peer support to families immediately following air disasters throughout the world (Stubenbort et al., 2001). Many parents and children have expressed the sentiment that these activities have helped them to find meaning in the death of their loved ones and in their own lives and to heal from their own loss. Joint parent-child grief sessions allow the family to openly express their feelings of loss, to reminisce fondly together about the deceased loved one, and to prepare for trauma and loss reminders that will occur in the future. It also allows parents and children to predict that sad feelings will be inevitable at certain times and to give themselves and each other permission to have and express to each other such feelings. It also gives children and parents the opportunity to see how far they have come from the beginning of treatment and to optimize their ability to communicate openly about difficult topics in the future. Ideally, by the end of this treatment, the parent will be the person the child is most comfortable turning to in the future for support and help in dealing with painful or difficult feelings, whether or not they are related to the traumatic death.

ceased person. Thus, trauma symptoms intrude and impinge on the child's ability to negotiate the normal grieving process. CTG is not the norm among children who have lost loved ones in traumatic circumstances. Preliminary studies have indicated that group traumaand grief-focused interventions provided in school settings are helpful in decreasing CTG and PTSD symptoms in youth exposed to war and community violence. An individual-treatment model for treating CTG in children that includes parents in treatment is currently being empirically tested in open and randomized controlled treatment trials; this article describes key trauma- and grief-focused components of this treatment model. Additional research is needed to determine whether the current concept of CTG is supported by epidemiologic data and whether current treatment models are effective for decreasing symptoms and optimizing adaptive functioning in children with CTG.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Black, C. (1984). The Stamp Game: A game of feelings. Denver: MAC Printing and Publications. Black, D. (1998). Coping with loss, bereavement in childhood. British MedicalJoumal, 316, 931-933. Brent, D. A., Moritz, G., Bridge, J., Perper, J., & Canobbio, R. (1996a). Long-term impact of exposure to suicide: A three-year controlled follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 646-653. Brent, D. A., Moritz, G., Bridge, J., Perper, J., & Canobbio, R. (1996b). The impact of adolescent suicide on siblings and parents: A longitudinal follow-up. Suicide and Life-Threatening Behavior, 26, 253-259. Brent, D. A., Perper, J. A., & Moritz, G. (1993). Psychiatric sequelae to the loss of an adolescent peer to suicide. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 509-517. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., et al. (1995). Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 209-215. Brown, E. B., & Goodman, R. (2002). Treatment of child traumatic grief {Grant proposal funded by Silver Shield Foundation, New York). Brown, E. B., Handel, S., Cohen, J. A., & Amaya-Jackson, L. (2003). Children's information on the death and parent's information on the death. Unpublished manuscript. National Child Traumatic Stress Network, Traumatic Grief Task Force. Cohen, J. A. (in press). Treating traumatized children: Current status and future directions. Journal of Trauma and Dissociation. Cohen, J. A., Deblinger, E., Mannarino, A. P, & Steer, R. (2004). A randomized controlled trial for children with sexual abuse-related PTSD symptoms. J American Academy of Child & Adolescent Psychiatry, 43, 393-402. Cohen, J. A., Greenberg, T, Padlo, S., Shipley, C , Mannarino, A. P, Deblinger, E., et al. (2001). Cognitive behavioral therapy for traumatic grief in children treatment manual. Unpublished manuscript, Drexel University College of Medicine, Pittsburgh. Cohen, J. A., & Mannarino, A. P. (1996a). A treatment outcome study for sexually abused preschool children: Initial fmdings.

Empirical Support for the CBT for CTG Model The above model has recently been tested in an open treatment study, which evaluated both overall improvement and the timing of symptomatic change (Cohen, Mannarino, & Knudsen, in press). This study indicated that children experienced significant improvement in PTSD symptoms, which occurred only during the first 8 (trauma-focused) treatment sessions; and in CTG symptoms, which occurred during both the first 8 and second 8 (grief-focused) interventions. This suggests both that CTG is distinct from PTSD, and that including both trauma- and grief-focused interventions is optimal for children with CTG. This study additionally indicated that children experienced significant improvement in depression, anxiety, and behavioral symptoms, and that participating parents experienced significant improvement in their own depression and PTSD symptoms (Cohen et al., in press). This sends preliminary support to the CBT for CTG treatment model described above.

Summary CTG is a condition in which children are "stuck" on the traumatic or dangerous circumstances of a loved one's death. Thoughts about the deceased segue into thoughts and memories of the terrifying circumstances of the death. This leads to avoidance of trauma and loss reminders and an inability to reminisce about the de830

CHILDHOOD TRAUMATIC GRIEF TREATMENT Journal of the American Academy of Child & Adolescent Psychiatry, 35, 42-50. Cohen, J. A., & Mannarino, A. P. (1996b). Factors that mediate treatment outcome of sexually abused preschool children. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 1402-1410. Cohen, J. A., & Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment fmdings. Child Maltreatment, 3, 17-26. Cohen, J. A., & Mannarino, A. P. (2000). Predictors of treatment outcome in sexually abused children. Child Abuse & Neglect, 24, 983-994. Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley, C. (2002). Childhood traumatic grief: Concepts and controversies. Trauma, Violence and Abuse, 3, 307-327. Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310-321. Elder, S. L., & Knowles, D. (2002). Suicide in the family. In N. B. Webb (Ed.), Helping bereaved children (pp. 128-148). New York: Guilford. Emswiler, M. A., & Emswiler, J. P. (2000). Guiding your child through grief. New York: Bantam. Eth, S., & Pynoos, R. S. (1985). Interaction of trauma and grief in childhood. In S. Eth & R. S. Pynoos (Eds.), Post-traumatic stress disorder in children (pp. 171-186). Washington, DC: American Psychiatric Press. Grollman, E. A. (1995). Bereaved children and teens: A support guide for parents and professionals. Boston: Beacon. Hall, T. M., Kaduson, H. G., & Schaefer, C. E. (2002). Fifteen effective play therapy techniques. Professional Psychology: Research and Practice, 33, 515-522. Layne, C. M., Pynoos, R. S., Saltzman, W. S., Arslanagic, B., Black, M., Savjak, N., et al. (2001). Trauma/grief-focused group psychotherapy: School-based post-war intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5, 277-290. Layne, C. M., Savjak, N., Saltzman, W. R., & Pynoos, R. S. (2001). UCLA/BYO Expanded Grief Inventory. Unpublished manuscript, Brigham Young University, Provo, UT. Nader, K. O. (1997). 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 grieving (pp. 17-41). Washington, DC: Taylor & Francis. O'Connor, K. (1983). The Color-Your-Life technique. In C. E. Schaefer & K. J. O'Connor (Eds.), Handbook of play therapy (pp. 251-258). New York: Wiley. Pfeffer, C. R., Jiang, H., Kakuma, T., Hwang, J., & Metsch, M. (2002). Group intervention for children bereaved by suicide of a relative. J American Academy of Child & Adolescent Psychiatry, 41, 505-5\3. Pfefferbaum, B., Nixon, S. J., Tucker, P M., Tivis, R. D., Moore, V. L., Gurwitch, R. H., et al. (1999). Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 1372-1379. Pine, D. S., & Cohen, J. A. (2002). Trauma in children and adolescents: Risk and treatment of psychiatric sequelae. Biological Psychiatry, 51, 5\9-52\. Prigerson, H. G., Shear, M. K., & Jacobs, S. C. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 154, 1003-1009. Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care, 11, 2-\0. Pynoos, R. S., & Nader, K. (1990). Children's exposure to violence and traumatic death. Psychiatric Annals, 20, 334-344. Rando, T. (1993). Treatment of complicated mourning. Champaign, IL: Research Press. Salloum, A., Avery, L., & McClain, R. P. (2001). Group psychotherapy for adolescent survivors of homicide victims: A pilot study. J American Academy of Child & Adolescent Psychiatry, 40, 1261-1267. Saltzman, W. R., Pynoos, R. S., Layne, C. M., Steinberg, A. M., & Aisenberg, E. (2001). Trauma/grief focused intervention for adolescents exposed to community violence: Results of a schoolbased screening and group treatment protocol. Group Dynamics: Theory, Research, and Practice, 5, 291-303. Schut, H., Stroebe, M. S., van der Bout, J., & Terheggen, M. (2001). The efficacy of bereavement interventions: Determining who benefits. In M. S. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 705-738). Washington, DC: American Psychological Association. Steinberg, A. M., Brymer, M. J., Decker, K. B., & Pynoos, R. S. (2004). The UCLA Posttraumatic Stress Disorder Reaction Index. Current Psychiatry Reports, 6, 96-100. Stroebe, M. S., Hansson, R. O., Stroebe W., & Schut, H. (Eds.). (2001). Handbook of bereavement research: Consequences, coping and care. Washington, DC: American Psychological Association: Stubenbort, K., Donnelly, G. R., & Cohen, J. A. (2001). Cognitive-behavioral group therapy for bereaved adults and children following an air disaster. Group Dynamics: Theory, Research, and Practice, 5, 261-276. Webb, N. B. (2002a). The child and death. In N. B. Webb (Ed.), Helping bereaved children (pp. 3-18). New York: Guilford. Webb N. B. (2002b). Traumatic death of a friend/peer. Case of Susan, age 9. In N. B. Webb (Ed.), Helping bereaved children (pp. 167-194). New York: Guilford. Wolfelt, A. D. (1996). Healing the bereaved child: Grief gardening, growth through grief and other touchstones for caregivers. Fort Collins, CO: Companion. Worden, J. W. (1996). Children and grief: When a parent dies. New York: Guilford.

Received November 5, 2003 Accepted March 25, 2004

831