Childhood Traumatic Grief

Childhood Traumatic Grief

Childhood traumatic grief is a condition that children may develop after the death of
a significant person under circumstances that have been traumatic for the child.
We are beginning to understand how to identify this condition. In childhood traumatic
grief, a child has reactions and symptoms similar to those found in children
with PTSD. These reactions make it difficult for the child to follow the usual path
of bereavement and reminiscence about the deceased person in a positive and
meaningful way.
There are promising treatments that have been shown to be most helpful for children
with childhood traumatic grief. Treatment can be done with individuals and with groups
of children of different ages, and it should address both trauma and grief symptoms.
Treatment initially involves treating the trauma aspects of the condition and then
moving on to help the child deal with bereavement issues and master specific tasks.
The intervention described in this program draws from a variety of existing approaches.
The treatment includes teaching the child skills for managing stress, helping the child
to create a story about the death, and finally supporting the child while engaging in
specific activities related to bereavement. The goal of the treatment is to enable the
child to remember and cope with previously troubling thoughts and feelings about the
death and go on to have more positive and comforting memories about the person.

OVERVIEW OF CHILDHOOD TRAUMATIC GRIEF
WHAT IS CHILDHOOD TRAUMATIC GRIEF?
After being broadsided, the car was spinning out of control. When it stopped, eightyear-
old Devon, who was buckled up in the back seat and pinned in the car, yelled for
his mother to wake up. He heard the sirens, then watched the paramedics drag his
mother onto the street and saw blood running down her face. Later, whenever he rode
in a car, he refused to put on his seat belt because he wanted to get out as fast as
possible in case of an accident.
Twelve-year-old Anna’s brother drowned in the neighbor’s pool. She had a fight with him
right before he left, teasing the five-year-old about not being able to swim. Later she
frequently had nightmares in which she couldn’t breathe, so she stayed up most of
the night. In school, she was exhausted, sleepy, and couldn’t concentrate. Her grades
plummeted, but she said she didn’t care and deserved whatever punishment she got.

Childhood traumatic grief is a condition in which children who lose
loved ones under very unexpected, frightening, terrifying, traumatic
circumstances develop symptoms of posttraumatic stress and
other trauma symptoms that interfere with their ability to progress
through typical grief tasks, because they are stuck on the traumatic
aspects of the death. —Judith Cohen

Childhood traumatic grief can develop following the death of a significant person
when the death has been perceived by the child as traumatic. The hallmarks of the
condition are reactions related to (1) trauma, a situation that is sudden and terrifying
and that results in death and may have also been life threatening for the child, and
(2) grief, feelings of intense sadness and distress from missing the person who died
and the changes that have resulted. The distinguishing feature of childhood traumatic
grief is that trauma symptoms interfere with the child’s ability to navigate the typical
bereavement process. In other words, a child’s preoccupation and inability to relinquish
a focus on death leaves little or no room for other more helpful thoughts about
the person who died, leaves little emotional energy for adjusting to change, and
compromises the child’s ability to function in school or with friends. According to our
current understanding, childhood traumatic grief is distinct from uncomplicated
bereavement and conditions such as PTSD, yet it shares features of both. The
definition, characteristics, and assessment of childhood traumatic grief are still
evolving and likely vary due to such things as the type of death, age and cognitive
ability of the child, culture and beliefs, and family situation.
The child’s perception, not just the cause of death, plays a key role in determining the
development of symptoms. Not every child develops traumatic grief after a death that
happened in a particularly dramatic or threatening manner, such as death from a homicide,
war, or motor vehicle accident. In some cases, childhood traumatic grief can result
from a death that most would consider expected or normal, such as death from illness
or natural causes. There may be isolated traumatic moments that can be lodged in
the child’s memory, such as seeing a parent in profuse pain, that provoke the child’s
reaction. Childhood traumatic grief can affect children’s development, relationships,
achievement, and later effectiveness in life if not treated or otherwise resolved.

Children loose their developmental momentum that they had been
pursuing. They need support to regain that developmental momentum,
and without the support it often happens that children really stop
gaining these skills that are appropriate for their age, and that has
long-term repercussions. —Alicia Lieberman

The traumatic aspects of the death and the child’s relationship to the person that
died are entwined in such a way that thoughts or reminders of the trauma and
overwhelming painful grief about the person who died are linked together. The child’s
traumatic reaction can stem from the sudden and horrific nature of the death with
or without the child’s life also being in danger. The grief reaction stems from the
sadness of missing the person and all that has changed. The child contends with
the complex mix of trauma and grief. Hence, in providing treatment the clinician must
address both.
A child survivor of a car crash in which her mother was killed may be confronted with
reminders of the smell of rubber and gasoline, the fear of being trapped in the car,
the sight of blood and a mother’s lifeless body, and a caretaker whose absence is felt
every waking moment.
CULTURAL AND INDIVIDUAL VARIATIONS
Communication, expression and behavior following trauma and death can vary according
to one’s race, ethnicity, culture, and religion. It is important to be fully aware of these
variations in order to accurately identify those reactions outside the norm of what is
accepted and that prevent the child from participating fully in productive activities.
For example, intense displays of emotion may be more common in some cultures than
in others, and spiritual beliefs about an afterlife may influence a child’s reactions and
expressions. In some cultures it may be common practice to refrain from using the
name of the deceased for a certain period of time, hence, what may be interpreted
as avoidance in one setting is respectful and necessary in another. Either through
naturally occurring common practices or due to unfortunate war or devastation,
children in different countries may also have more or less exposure to death throughout
their life, which can influence their response. Regarding intervention, you must be
sensitive to instances when certain treatment principles may be contrary to what is
accepted practice in the child’s particular family. For those times when a practitioner is
unfamiliar with a family’s practices and beliefs it is essential to seek consultation or
consider additional referral.

OVERLAP OF CHILDHOOD TRAUMATIC GRIEF,
POSTTRAUMATIC STRESS DISORDER, AND TRAUMA REACTIONS

The typical traumatic stress symptoms that children might experience
with childhood traumatic grief include things like intrusive thoughts
or recurring images associated with the death of their loved one. It
could be the child becoming very constricted emotionally, becoming
numb as a way of not dealing with all the pain associated with the
tragic circumstances of their loved ones death. The child who has
childhood traumatic grief doesn’t have to have all those symptoms,
just some of them. —Anthony Mannarino

There is overlap in the reactions and symptoms of uncomplicated bereavement,
PTSD, and childhood traumatic grief. Children may show different signs of childhood
traumatic grief at different ages. However, difficulties specific to childhood traumatic
grief that can occur across developmental stages include those listed below. Although
the following reactions and symptoms are consistent with characteristics of PTSD,
they are notable as indicators of childhood traumatic grief because of the direct
reference to the traumatic death. A helpful way of understanding the following reactions
is to view them as indicating a child’s distress, communicating to others that the child
is not letting go of thoughts, feelings, and behaviors related to the images, details,
circumstances, and actions surrounding the death.
• Intrusive memories and preoccupations about things that happened before,
during, and after the death: These can appear through nightmares, guilt, or
self-blame about how the person died, or recurrent or intrusive thoughts about
the horrifying manner of death. Thoughts may also focus on wished-for protective
or rescue interventions, such as regret for not doing something that would have
changed the outcome.
A seven-year-old boy keeps thinking he should have done CPR to save the life of
his three-year-old sister who was caught in the crossfire of a drive-by shooting.
• Avoidance and a fear of strong feelings: This can be expressed by withdrawal
or by the child avoiding reminders of the person, the way the person died, or the
event that led to the death. In attempting to keep strong unpleasant feelings
related to the death at bay, the child may also try to dampen all feelings, which
results in what adults would understand as “numbing.”
A 14-year-old girl could not go to any fast-food restaurant after her father was
accidentally shot to death in one while they were getting milkshakes.
• Physical or emotional symptoms of increased arousal: These can include
irritability, anger, trouble sleeping, decreased concentration, a drop in grades,
stomachaches, headaches, increased vigilance, and fears about safety for
oneself or others. The reaction can generalize and occur in a context that
resembles, but is different than, the original situation.
A four-year-old girl started crying and screaming “stop shooting my mommy”
when she heard the fireworks at the park on the Fourth of July.
• Re-enactment: In re-enacting aspects of the events that are perceived to
have led to the death, there is an attempt to intervene, manage feelings of
helplessness, and undo what has been done and identify ways to prevent the
tragedy and death.
A six-year-old bereaved survivor of a motor vehicle crash repeatedly drew and cut
out replicas of the car and steering wheel. He built an oversized speedometer so
the driver of the other car would notice he was driving too fast. The boy went on
to make a car with extra protection that was strong enough to withstand any crash.

HOW IS CHILDHOOD TRAUMATIC GRIEF RELATED TO
OTHER TRAUMA REACTIONS?
Traumatic events can involve an actual death, other loss, serious injury, or threat to
the child’s own life or well-being. These events could include natural or man-made
disasters, violence, war, or accidents. A child may be traumatized by direct exposure,
witnessing the event, or hearing about another person’s experience. For some children,
the response can have a profound effect on how they view themselves and the world.
They may develop changes in their behavior (externalizing problems) or emotional
functioning (internalizing problems). Left untreated, the severe trauma-related reactions
can lead to more serious and chronic difficulties and, in some cases, coalesce into
PTSD. PTSD is diagnosed when the child has specific symptoms that continue for a
month or more following exposure to a traumatic event. The symptoms fall into the
three categories of re-experiencing, hyperarousal, and avoidance.
When children with childhood traumatic grief show reactions and symptoms characteristic of PTSD, the reactions and symptoms are directly related to the death and interfere with the child’s day-to-day functioning and bereavement work. Children may present with other symptoms not necessarily associated with PTSD but related to bereavement and traumatic death. These may include guilt, yearning, anger, and rescue and revenge fantasies.

Eleven-year-old Lisa witnessed her mother’s murder. In an interview with a therapist
five days after her mom was fatally shot and stabbed by her estranged boyfriend, Lisa
revealed her feelings about revenge when describing a dream: “In my dream I had the
same knife he used to stab my mother and the same gun that he shot her with. Then
I went up to him and said ’Do you remember this, now you can feel it’ And I stabbed
him right where he stabbed my mother. Then I said, ’I guess you remember this too,’
and then I shot him.”
It was hard for Lisa to talk about her mother, who she dearly loved, without feeling as
if she was back in that room. In the days and weeks after the murder, when she had
that feeling, she would focus on her mother being killed. But as she stood at the door,
frozen in place, one suspects she worried about herself as well as about her mother
being killed.
In childhood traumatic grief, the interaction of traumatic and grief symptoms is such
that any thoughts or reminders, even happy ones, about the person who died can lead
to frightening thoughts, images, or memories of how the person died.
Kevin, the 17-year-old brother of 15-year-old Briana, was killed in an avalanche. His body
was never found. She was haunted by feelings of guilt for not demanding he stay at the
lodge. She was so distraught that she isolated herself from friends. On further questioning,
it became clear that Briana and Kevin had many of the same friends. So when Briana
was with them, she was reminded of the good times they used to have together. But
this quickly led to her thinking about Kevin suffocating and it being her fault.

Three types of reminders may trigger unpleasant and distressing reactions:
1. Trauma reminders: places, situations, people, sights, smells, or sounds
reminiscent of things associated with the actual death. These may include the
street corner where a fatal accident occurred, the bedroom where a parent died,
or the sound of an airplane reminding a child of a mother who died in a crash.
2. Loss reminders: people, places, objects, situations, thoughts, or memories
that are reminders of particular aspects of the person who died — for example,
photo albums, an empty chair at the dinner table, or a new coach who has
replaced a parent who previously headed a child’s sports team.
3. Change reminders: situations, people, places, or things reminding the child
of changes in his or her life resulting from the death — for example, moving to
a new house or having to walk home with a babysitter rather than an older
sibling who died.
Reminders can certainly provoke sadness or thoughts about the deceased. However,
in childhood traumatic grief, these reminders may lead to the child re-experiencing
the traumatic events that led to the death. The terror associated with these memories
results in increased arousal symptoms. The child then attempts to handle the
distressing re-experiencing and symptoms with avoidance or numbing, often
characterized as a deadening of emotions in older children and a fear of feelings in
younger children. Because traumatic aspects of the death are so upsetting, the child
tries to avoid all reminders of the trauma, loss, or resulting changes so as not to
stir up unpleasant thoughts or feelings.
For example, a younger child may be afraid to sleep alone at night because of
nightmares about a tragic shooting, whereas an older child may avoid flying in a
plane because it brings up painful memories about a father who died in a plane crash.
One of the most common reminders of the trauma, loss, and change is the person’s
own family. Looking across at each other, knowing each has experienced the same
death even if having individual reactions, can be upsetting.

HOW DOES CHILDHOOD TRAUMATIC GRIEF DIFFER
FROM UNCOMPLICATED GRIEF?
Any death can be difficult for a child, and certain reactions are more likely than others.
Uncomplicated bereavement is the intense sadness and longing for the deceased
that children typically feel after the loss of a loved one. Complicated bereavement
has been described in adults as bereavement complicated by separation distress
and traumatic symptoms related to the loss of the security-enhancing relationship
with the deceased. This has not been clearly defined as a condition for children.

Uncomplicated or typical grief reactions in children vary according to age, developmental
level, previous life experiences, culture, beliefs, emotional health prior to the death,
and the family and social environment. Over time, a child is relieved of extreme
sadness and is able to engage in accepted mourning rituals, and, when appropriate,
remember good times and have positive feelings about the person who died. However,
while grieving, a child typically may have:
• Emotional reactions: feeling sad, angry, anxious, numb, lonely, guilty, powerless,
shamed, insecure, and remorseful.
• Changes in behavior: lack of interest and participation in usual activities,
diminished self-care, unpredictable or odd behavior, angry or aggressive
behaviors, increased risk taking, irritability and conflict with others, impulsivity,
regression to earlier behaviors, changes in sleep behaviors (increased or
decreased), difficulty sleeping or sleeping alone, changes in appetite (increase
or decrease in weight), and changes in physical health.
• Difficulty with interpersonal interactions: withdrawal, social isolation, peer
difficulties, clinging, irritability, difficulty sharing memories, difficulty participating
in group or athletic activities, and general lack of interest in others.
• Changes in thinking: constant thoughts and memories about the loved one,
persistent thoughts about the death, disbelief about the death and the finality
of the death, constant or intrusive thoughts about death, preoccupation with
one’s own or a loved one’s physical health and safety, difficulty making decisions,
confusion, impaired memory and concentration, lowered self-esteem and selfconfidence,
disillusionment, thinking that the death was one’s fault, and
survivor guilt.
• Altered perceptions: believing the deceased is still present, feeling the person’s
presence nearby, seeing the person’s face in a crowd, smelling the person’s
perfume, hearing the person’s voice, and experiencing vivid dreams about
the person.
• Physical reactions: susceptibility to illness, loss of energy, fatigue, difficulty or
changes in eating, physical complaints, and changes in physiological arousal
(for example, increased heart rate, respiration, and startle response).
• Changes in academic functioning: poor school performance, difficulty studying
or concentrating, and potential school failure.

In nontraumatic bereavement, kids may be sad, or upset, or feel lonely,
but they are able to continue on with activities and eventually maybe
enjoy life again and be re-engaged with people and situations. The child
with traumatic grief is kind of stuck, so a child may not want to be
around a cousin who is the same age as a sister who died because
it’s too upsetting, or a boy may not want to play baseball anymore
because he can’t bear the thought of looking in the stands and his
father not being there, and he falls apart. So these things segue into
the awful reminders, and the child then avoids every reminder, even a
positive one. —Robin Goodman

Throughout their lives, children continue to adjust to the loss and develop new ways
of coping. Over time, it is helpful for children to relate to their loss by engaging in,
and mastering, certain bereavement tasks. The following chart presents the outcome
of common bereavement tasks and how childhood traumatic grief interferes with
completion of these tasks.

Completion of Bereavement Tasks for Children with Uncomplicated Grief
and Indicators of Difficulty for Children with Childhood Traumatic Grief
In uncomplicated bereavement typically
children will:
Accept the reality and permanence of
death
Experience and cope with difficult
emotional reactions
Adjust to changes in their lives and
changes in their identity that result from
the death
Develop new relationships or deepen
existing ones
Childhood traumatic grief interferes
with bereavement due to:
Difficulty with accepting or unwillingness
to accept that the person has died due
to associations of the death with the
traumatic circumstance
Intense, distressing feelings that are
triggered by reminders leading to
avoidance or lack of feelings
Changes that lead to unpleasant reminders
of the way the person died, possible
overidentification with the person who
died, feeling overly responsible
Feelings such as guilt, anger, and
revenge interfering with the formation
of new relationships

In uncomplicated bereavement, children may feel sad when remembering the
deceased person but are generally able to have positive memories of the person and
continue with necessary life activities. It is important to keep in mind that bereaved
children are at risk for other types of mental health problems such as depression,
anxiety, and substance abuse either alone or in conjunction with childhood traumatic
grief. In childhood traumatic grief specifically, the terrifying and frightening aspects
of the death are so prominent that they get in the way of adjusting to life in ways that
are deemed helpful for the bereaved. Because positive memories of the person
who died lead directly to frightening reminders of the death, without help, the child
never reaches the point of finding comfort in memories, calling up better times, or
participating in what are culturally customary mourning practices. The child may also
have been unable to participate or benefit from various rituals used to ease grief, for
example, avoiding a funeral or being unable to cry for many months. In childhood
traumatic grief, the traumatic reactions make it difficult for the child to
• reminisce or enjoy positive memories of the deceased person when that is
deemed comforting in the child’s culture,
• cope with the many life changes that occur as a result of the death, and
• continue with normal development in ways that are expected and necessary.

In uncomplicated bereavement typically
children will:
Maintain a continuing, healthy
attachment to the deceased person
through remembrance activities
Find some meaning in the death and
learn about life or oneself
Continue through the normal
developmental stages
Childhood traumatic grief interferes
with bereavement due to:
Difficulty or avoidance of positive memories
because they are linked to horrible images
and upsetting thoughts and feelings
Inability or resistance to moving past
the terrifying, unpleasant aspects of
the death, negative feelings about self
related to the death or person
Emotional reactions and resulting
behavior, e.g., withdrawal, anger, and
distrust, interfering with the ability
to engage in positive, age-appropriate
activities and relationships
WHO SUFFERS FROM CHILDHOOD TRAUMATIC GRIEF?
Children can develop childhood traumatic grief when they experience the death of a
significant person, such as a parent, a sibling, or a close friend. Children of all ages,
even a young preschooler, can have a traumatic reaction to a death, especially of a
primary caregiver. It is estimated that five percent of all children in the United States
experience the death of a parent before the age of 15, and children under the age of
three are often present when a sibling or parent dies in a traumatic circumstance,
making young children particularly vulnerable and in need of attention.
However, not all children who have experienced a death develop childhood traumatic
grief. In fact, many recover and do well over time. Although it is true that the majority
of children who experience a death do not develop childhood traumatic grief, the
number of children who do struggle with childhood traumatic grief is quite significant.
For example, up to 70 percent of children in inner city communities have seen
someone shot or stabbed. Even if only five percent of these children develop childhood
traumatic grief, this translates into thousands of children developing this condition
each year. Although all children witnessing a homicide are likely affected in some way,
some are better able to tolerate the experience, whereas others are deeply impacted
and cannot continue on as well as before the death.