Traumatic bereavement literature review

A brief summary of research related to traumatic bereavement.

Grief in childhood

The experience of grief following the loss of a loved one is a normal part of bereavement (Cohen et al., 2004; Revet et al., 2020). However, for a minority of children and young people, grieving becomes problematic. Difficulties in navigating the normal process of grieving are associated with negative mental health outcomes, including depression and post-traumatic stress disorder (PTSD), and require support (Cohen et al., 2004; Revet et al., 2020; Prigerson et al., 2021, Melham et al., 2007). Although considerable efforts have been made to sensitively determine when normal grieving becomes problematic, this has yet to be clearly defined in children and young people (Kaplow et al., 2014; Revet et al., 2020). The resulting lack of consensus has contributed to a diversity of terminology and measurement within the body of literature on traumatic bereavement. Drawing on this literature, we consider how we might formulate the broad concept of ‘traumatic bereavement’.

What might be considered a ‘traumatic bereavement’?

We propose that in a traumatic bereavement (TB), the child or young person’s perception of the death – the meaning they make of it – can result in it being experienced as a trauma. The trauma gets in the way of the typical process of grief and blocks the child or young person’s ability to process the loss. That is, the trauma of the death of a friend or family member disrupts the natural grieving process, leading to lasting negative impact on everyday functioning. The context the child is living in and also the circumstances of the death (see below) may influence their response.

Other terms related to traumatic bereavement

There are other terms which refer to presentations that overlap with or are closely related to traumatic bereavement. Childhood traumatic grief (CTG) occurs when a child or young person experiences the loss of a loved one in circumstances that are objectively or subjectively traumatic and the resultant trauma impedes the child or young person’s ability to go through the normal grieving process (Cohen & Mannarino, 2004). CTG is similar to TB and the terms are sometimes used interchangeably (Cohen & Mannario, 2004). However, while CTG focusses on PTSD reactions to the death, TB encompasses other reactions such as depression and anxiety.

Other terms that have been used in research to describe difficulties with the grieving process, include: complicated grief, complex grief, maladaptive or maladjusted grief, unresolved grief, traumatic loss, delayed grief, or pathological grief. Many of these terms are used interchangeably.

Diagnostic terms

Prolonged grief disorder (PGD) is a formal diagnostic label used to diagnose difficulties with grief following a bereavement. It is included in the Diagnostic and Statistical Manual of Mental Disorders 5^th Edition Text Review (Prigerson et al., 2021). Separation distress from the loved one who died is a key aspect PGD. To be diagnosed with PGD in childhood, symptoms of separation distress and other accompanying symptoms must be present to an impairing degree for at least 6 months after the loss.

A review of the evidence: Factors related to poorer psychological adjustment in bereaved children and young people

Studies which have examined the factors related to traumatic bereavement and related terms are surprisingly scarce. The studies have used a range of terms and measurements and examined grief in different contexts and circumstances. This has resulted in a mixed picture of the factors that influence the development of traumatic bereavement and the presentation of associated symptoms.  It is worth noting that the research presented in this section has all originated in the United States and so may not be always generalisable to other groups of children.

Study characteristics

Study author and date	Child gender	Child ethnicity*	Number of participants (age range)	Construct	Measure	Type of bereavement	Circumstances
Brown & Goodman, 2005	41% female	89% Caucasian, 11% Hispanic or Biracial	83 (8-18 yrs)	CTG	EGI	Parental bereavement	9/11
Brown et al., 2008	48% female/ 52% male	58% African American, 32% Caucasian, 10% Biracial	132 (7-18 yrs)	CTG	EGI	Death of a significant other	Medical, interpersonal violence, terrorism, accident
Hill et al., 2020	50.4% female	30.8% Hispanic, 30% non-Hispanic White, 22.8% African American/Black, 12.6% Other/Biracial/Multiracial, 3% Asian American/Pacific Islander, 0.8% Native American	594 (7-18 yrs)	PCBD	PCBD checklist	Death of a family member or close friend	Sudden natural death, anticipated death (illness), accident, suicide
Kaplow et al., 2014	44.4% female	73.2% Caucasian, 12.2% African American, 9.8% Asian, 2.4% Hispanic, 2.4% Other	63 (7-13 yrs)	MG	ICG-R	Death of a primary caregiver	Anticipated death (illness) or sudden natural death
McClatchy & Vonk, 2009	52.5% female	62% White, 31.6% African American, 5.7% Latino, 0.6% Asian	158 (7-16 yrs)	CTG	EGI	Parental bereavement	Sudden/violent or anticipated causes
Melham et al., 2007	52.7% male	Ethnicity of child not reported	129 (7-18 yrs)	CG	ICG-R	Parental bereavement	Suicide, accident, or sudden natural causes

Construct: CTG = childhood traumatic grief; PCBD = persistent complex bereavement disorder; MG = maladaptive grief; CG = complicated grief; MG = maladaptive grief; PGR = prolonged grief reaction
Measure: EGI = Extended Grief Inventory (Layne et al., 2001); PCBD Checklist (Layne et al., 2014); ICG-R= Inventory of Complicated Grief – Revised (Melham et al., 2007); Note: EGI is now retired (Kaplow et al., 2018)

*All studies were conducted in the USA. Child ethnic groups are presented as reported by the authors. For each study we list the size, age, ethnicity, and gender of the sample according to the terms given in the source literature. However, we recognise that there is not a clear consensus on how these terms are (or should be) presented in the literature, and that in some cases terminology and categorisation may cause unintended offense or harm. We are continuously discussing how to use language addressing race, ethnicity and gender when writing about research and are open to feedback to how this can be improved in our research communication and dissemination. Please send feedback on language or our approach to uktc (at) annafreud.org.

Child demographics

Gender

Child gender was not found to be associated with complicated grief (CG) (Melham et al., 2007) or childhood traumatic grief (CTG) (Brown & Goodman, 2005; McClatchy & Vonk, 2009; Brown et al., 2008). But, girls were found to have higher persistent complex bereavement disorder (PCBD) scores than boys (Hill et al., 2020).

Age

Child age was not found to be associated with CG (Melham et al., 2007). However, the findings with CTG are mixed, with two studies finding no difference in age (Brown & Goodman, 2005; Brown et al., 2008) and another finding younger children having higher levels of CTG than older children (McClatchy & Vonk, 2009).  Younger children were found to have higher PCBD scores than older children (Hill et al., 2020).

Ethnicity

Child ethnicity was not found to be associated with CG (Melham et al., 2007), but, the findings with CTG are mixed. Two studies of CTG found no difference associated with ethnicity (Brown & Goodman, 2005; Brown et al., 2008). However, one study reported African American children to have higher levels of CTG than White children (McClatchy & Vonk, 2009). Black and Hispanic children and were found to have higher PCBD scores than White children (Black and Hispanic children did not differ on PCBD scores) (Hill et al., 2020).

Type/cause of death

Children who experienced loss by parental suicide did not differ significantly in CG as compared to children who lost their parent to an accident or sudden natural death (Melham et al., 2007). Children who experienced a sudden or violent loss of a parent were found to have similar CTG scores as compared to children who experienced an expected parental loss, and the gender of the deceased parent (mother or father) was not associated with CTG (McClatchy & Vonk, 2009). In contrast to these findings, children who experienced an anticipated death of a significant caregiver (due to illness) had higher levels of maladaptive grief (MG) than children who lost their significant caregivers with a sudden natural death (Kaplow et al., 2014).

Exposure to death

Seeing the scene of the death, knowledge about the details of the death, whether the parent left a suicide note, and the last time the child spoke to their deceased parent were not associated with CG (Melham et al., 2007).

Perception of life threat

CTG was significantly positively associated with the child’s perception of threat to life at the time of the bereavement (Brown et al., 2008).

Emotional reactions

CTG was positively associated with caregivers’ emotional reaction to the death and the degree of sadness in the home (Brown et al., 2008). Feelings and expression of anger in the child were positively associated with CTG (Brown et al., 2008). Feelings that others blamed the child for the parental death, or the child’s feeling that others were to blame for the parental death were positively associated with higher CG scores (Melham et al., 2007).

Time since death

The time since the death was negatively correlated to CG (Melham et al., 2007) and inversely related to CTG (Brown et al., 2008), indicating that symptoms of problematic grief generally decrease over time. Although another study found that time since death was not associated with the development of CTG (McClatchy & Vonk, 2009). Research examining prolonged grief reaction (PGR) found that most children had a resolution of grief one year after a sudden parental loss. Yet, some children’s symptoms were slower to resolve and others experienced high levels of grief nearly 3 years after the loss (Melham et al., 2011).

Funeral / memorial

Attending the funeral and being involved in removing the personal effects of the deceased parent were not associated with CG (Melham et al., 2007). Higher CTG was associated with attendance of September 11th memorial services (Brown et al., 2008).

Other possible factors

Theoretical and clinical perspectives of grief have helped to identify other possible risk factors for TB. Factors which precede the loss may include the child’s previous experience of loss or trauma (Cohen et al., 2002; Revet et al., 2020), the nature of the child’s relationship to the deceased (Cohen et al., 2002; Revet et al., 2020), and general instability in the family (Revet et al., 2020). The child’s stage of cognitive and emotional development may influence their ability to understand the loss and navigate the tasks of mourning (Cohen et al., 2002; Revet et al., 2020; Brown et al., 2008). Grief reactions may resurface as the child grows older and their understanding of the death and the capacity to make meaning of it changes/increases (Revet et al., 2020; Revet et al., 2018). Feelings of guilt, regret, or responsibility for the loss may be associated with the difficulties with grieving (Cohen et al., 2002; Brown et al., 2008). The reactions of the surviving parent and other significant adults to the loss may impede their ability to provide optimal caregiving and support the child in their grief and finding meaning in the death (Cohen et al., 2002; Revet et al., 2020; Brown et al., 2008). Additional losses related to the death such as loss of the family home, school, supportive others, as well as changes to routine and roles may cause difficulties with grieving (Cohen et al., 2002; Revet et al., 2020). Further research is needed to help understand the role these factors play in the development and persistence of TB, as not all of these factors have been included in studies of traumatic bereavement in children.

Summary

In summary, findings of the association of gender, age, ethnicity, type/cause of death, time since death, and funeral/memorial involvement and difficulties with grief, are mixed. Children’s exposure to the death was not associated with CG. But, children’s perception of life threat at the time of death and the emotional reactions of the child and parent/caregiver were found to be positively associated with CTG and CG. It is important to note that extant research is limited. Further research, including replication of existing findings, is needed to understand the role various factors play in the onset and maintenance of difficult grief reactions. Additionally, there is considerable diversity in terminology and measurement of difficult grief reactions in children and young people which makes comparison of findings difficult. Future research will benefit from consensus of definition and measurement of problematic grief reactions.

What can professionals provide to help improve adjustment in children and young people?

Most research has focused on the role of intervention in helping children and young people who have experienced TB. Here we describe research on three different interventions for children and young people who have experienced TB.

Trauma-Focussed Cognitive Behavioural Therapy (TF-CBT) is an intervention used for treatment of symptomology related to a traumatic experience for children aged 6-17 and their parent/caregiver. The intervention includes trauma-focussed components and grief-focussed components, with trauma focussed components usually implemented first. The therapy often goes back and forth between components depending on the therapeutic needs (Cohen & Mannarino, 2004). TF-CBT has been found to be effective in the treatment of PTSD and CTG in traumatically bereaved children, as well as PTSD and depressive symptoms in their parents (Cohen et al., 2004; Cohen et al., 2006).

The Family Bereavement Program (FBP) is an intervention for parentally bereaved children aged 8-16 and their parent/caregiver. Families take part in 12 sessions where they develop skills which promote positive relationships and effective discipline practices. The sessions also help to reduce parent/caregiver distress and child exposure to negative events following the death (Sandler et al., 2013). FBP was found to reduce problematic grief (grief-related experiences that are disturbing, disruptive, and intrusive) at the end of the intervention and at a 6-year follow up (Sandler et al., 2010).

Trauma and grief component therapy for adolescents (TGCT-A) is a psychotherapy intervention designed for adolescents who have had exposure to trauma and traumatic loss. TCGT-A is a flexible intervention which aims to reduce distress and enhance coping and processing of grief and trauma (Layne et al., 2008). It is comprised of components which are selected based on initial assessments. Adolescents who experienced trauma and loss due to community violence were found to have reduction in complicated grief after participation in an early version of TGCT-A (Saltzman et al., 2001). Adolescents who focussed on a loss narrative (exploring major losses) as part of TGCT-A, were found to have a reduction in maladaptive grief (Grassetti et al., 2015). Bosnian adolescents who were exposed to war showed reductions in maladaptive grief at post treatment assessment following TGCT-A (Layne et al., 2008).

Coronavirus (COVID-19) and bereavement in children and young people

Research into the impact of the coronavirus (COVID-19) pandemic on bereavement in children and young people is in the very early stages. Although the impact is not yet known, it has been predicted that TB will increase owing to the distressing and sudden nature of bereavement (Santos et al., 2021; Weinstock et al., 2021; Simon et al., 2020). A recent study examining the impact of COVID-19 on mental health found that loneliness, health worries related to COVID-19, and older age were predictors of grief reactions in adolescents (Murata et al., 2020). Important considerations for research include the need for timely assessment, the delivery of remote intervention where face-to-face support is not possible, and understanding the impact of social restrictions on bereavement, including funerals (Santos et al., 2021; Weinstock et al., 2021; Simon et al., 2020). Given that COVID-19 deaths were higher in the UK for those living in deprived areas and in Black, Asian and minority ethnic groups (Public Health England, 2020; Simon et al., 2020), children and young people from these groups may be at elevated risk for TB (Weinstock et al., 2021).

References

Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: an exploration of the construct in children bereaved on September 11. Journal of clinical child and adolescent psychology: the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 34(2), 248–259. https://doi.org/10.1207/s15374424jccp3402_4

Brown, E. J., Amaya-Jackson, L., Cohen, J., Handel, S., Thiel De Bocanegra, H., Zatta, E., Goodman, R. F., & Mannarino, A. (2008). Childhood traumatic grief: a multi-site empirical examination of the construct and its correlates. Death studies, 32(10), 899–923. https://doi.org/10.1080/07481180802440209

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.

Cohen, J. A., & Mannarino, A. P. (2004). Treatment of childhood traumatic grief. Journal of clinical child and adolescent psychology, 33(4), 819–831. https://doi.org/10.1207/s15374424jccp3304_17

Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 43(10), 1225–1233. https://doi.org/10.1097/01.chi.0000135620.15522.38

Cohen, J. A., Mannarino, A. P., & Staron, V. R. (2006). A pilot study of modified cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG). Journal of the American Academy of Child and Adolescent Psychiatry, 45(12), 1465–1473. https://doi.org/10.1097/01.chi.0000237705.43260.2c

Cohen, J. A., & Mannarino, A. P. (2019). Trauma-Focused Cognitive Behavioral Therapy for Childhood Traumatic Separation. Child abuse & neglect, 92, 179–195. https://doi.org/10.1016/j.chiabu.2019.03.006

Grassetti, S. N., Herres, J., Williamson, A. A., Yarger, H. A., Layne, C. M., & Kobak, R. (2015). Narrative Focus Predicts Symptom Change Trajectories in Group Treatment for Traumatized and Bereaved Adolescents. Journal of clinical child and adolescent psychology, 44(6), 933–941. https://doi.org/10.1080/15374416.2014.913249

Kaplow, J. B., Howell, K. H., & Layne, C. M. (2014). Do circumstances of the death matter? Identifying socioenvironmental risks for grief-related psychopathology in bereaved youth. Journal of traumatic stress, 27(1), 42–49. https://doi.org/10.1002/jts.21877

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Mannarino, A. P., & Cohen, J.A. (2011) Traumatic Loss in Children and Adolescents, Journal of Child & Adolescent Trauma, 4(1), 22-33, https://doi.org/10.1080/19361521.2011.545048

McClatchy, I. S., Vonk, M. E., & Palardy, G. (2009). The prevalence of childhood traumatic grief–a comparison of violent/sudden and expected loss. Omega, 59(4), 305–323. https://doi.org/10.2190/OM.59.4.

Melhem, N. M., Porta, G., Shamseddeen, W., Walker Payne, M., & Brent, D. A. (2011). Grief in children and adolescents bereaved by sudden parental death. Archives of general psychiatry, 68(9), 911–919. https://doi.org/10.1001/archgenpsychiatry.2011.101

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Murata, S., Rezeppa, T., Thoma, B., Marengo, L., Krancevich, K., Chiyka, E., Hayes, B., Goodfriend, E., Deal, M., Zhong, Y., Brummit, B., Coury, T., Riston, S., Brent, D. A., & Melhem, N. M. (2021). The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depression and anxiety, 38(2), 233–246. https://doi.org/10.1002/da.2312

Prigerson, H. G., Boelen, P. A., Xu, J., Smith, K. V., & Maciejewski, P. K. (2021). Validation of the new DSM-5-TR criteria for prolonged grief disorder and the PG-13-Revised (PG-13-R) scale. World psychiatry : official journal of the World Psychiatric Association (WPA), 20(1), 96–106. https://doi.org/10.1002/wps.20823

Public Heath England. (2020). Disparities in the risk and outcomes of COVID-19. Retrieved from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf

Revet, A., Laifer, L., Raynaud, J.P. (2018). Grief reactions in children and adolescents. In: Bui E. (Ed.) Clinical handbook of bereavement and grief reactions. Current Clinical Psychiatry, (63-83). Humana Press. https://doi.org/10.1007/978-3-319-65241-2_4

Revet, A., Bui, E., Benvegnu, G., Suc, A., Mesquida, L., & Raynaud, J. P. (2020). Bereavement and reactions of grief among children and adolescents: Present data and perspectives. L’Encephale, 46(5), 356–363. https://doi.org/10.1016/j.encep.2020.05.007

Saltzman, W. R. , Pynoos, R. S. , Layne, C. M. , Steinberg, A. M. & Aisenberg, E. (2001). Trauma- and Grief-Focused Intervention for Adolescents Exposed to Community Violence. Group Dynamics: Theory, Research, and Practice, 5(4), 291–303.Sandler, I. N., Wolchik, S. A., Ayers, T. S., Tein, J. Y., & Luecken, L. (2013). Family Bereavement Program (FBP) Approach to Promoting Resilience Following the Death of a Parent. Family science, 4(1), 1-14. https://doi.org/10.1080/19424620.2013.821763

Sandler, I. N. , Ma, Y. , Tein, J. , Ayers, T. S. , Wolchik, S. , Kennedy, C. & Millsap, R. (2010). Long-Term Effects of the Family Bereavement Program on Multiple Indicators of Grief in Parentally Bereaved Children and Adolescents. Journal of Consulting and Clinical Psychology, 78(2), 131–143.

Santos, S., Sá, T., Aguiar, I., Cardoso, I., Correia, Z., & Correia, T. (2021). Case Report: Parental Loss and Childhood Grief During COVID-19 Pandemic. Frontiers in psychiatry, 12, 626940. https://doi.org/10.3389/fpsyt.2021.626940

Simon, N. M., Saxe, G. N., & Marmar, C. R. (2020). Mental Health Disorders Related to COVID-19-Related Deaths. JAMA, 324(15), 1493–1494. https://doi.org/10.1001/jama.2020.19632

Weinstock, L., Dunda, D., Harrington, H., & Nelson, H. (2021). It’s Complicated-Adolescent Grief in the Time of Covid-19. Frontiers in psychiatry, 12, 638940. https://doi.org/10.3389/fpsyt.2021.638940