case study

1Childhood Traumatic Grief: Information for Pediatric Providers

Why are pediatric providers important for grieving children?

Pediatric providers often support children and families through the death of a parent, sibling, or other important person. One in fourteen children will experience the death of someone close to them by age 181. Following a death, while most grieving children will successfully adjust to the death in time, some children may experience a condition called Childhood Traumatic Grief, in which traumatic stress reactions related to the death interfere with the child’s ability to grieve and adjust.

Especially after a death, many families are willing to seek help for physical complaints. However, they may be reluctant to ask for help for psychological or emotional issues or be unaware of a psychological component to physical health. Pediat- ric providers are in a unique position to identify children having ongoing difficulties. Often they are the first professionals to see a child needing help for Traumatic Grief and, therefore, in the best position to make referrals.

1 What Is Childhood Traumatic Grief?

Childhood Traumatic Grief is a condition in which children develop traumatic stress reactions to the death of family mem- ber, friend, or other important person in their lives. These symptoms then interfere with the bereavement process. In Childhood Traumatic Grief, even happy thoughts and memories of the significant person remind children of the traumatic way the person died. Children with Traumatic Grief get “stuck” on the traumatic aspects of the death and cannot proceed through the normal bereavement process.

Childhood Traumatic Grief: Information for Pediatric Providers

One in fourteen children will experience the death of someone close to them by age 18.

This project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS.

2Childhood Traumatic Grief: Information for Pediatric Providers

2 Who develops Childhood Traumatic Grief?

Children with Childhood Traumatic Grief experience the cause of death as horrifying or terrifying, whether the death was sudden and unexpected (e.g., due to homicide, suicide, a school shooting, motor vehicle accident, drug overdose, natural disaster, war, terrorism) or due to natural causes (e.g., cancer, heart attack, stroke). Even if the manner of death does not ap- pear to others to be sudden, shocking, or frightening, children who perceive the death in this way may develop posttraumatic stress reactions that lead to Childhood Traumatic Grief.

3 What are the signs a child might have Childhood Traumatic Grief?

In Childhood Traumatic Grief, the following traumatic stress reactions may interfere with the child’s grieving process:

Intrusive reactions such as upsetting thoughts, images, nightmares, memories, or play about the frightening way the person died

Physical or physiological distress such as headaches, stomachaches, symptoms mimicking the way the deceased died, jumpiness, trouble concentrating

Avoidance reactions such as withdrawal; acting as if not upset about the death; or avoiding reminders of the person, the way the person died, places or things related to the person, or events that led to the death

Negative mood or beliefs related to the traumatic death such as anger, guilt, shame, self-blame, loss of trust, believing the world is unsafe

Increased arousal such as irritability, anger, trouble sleeping, decreased concentration, dropping grades, increased vigilance, and fears about safety of oneself or others; self-destructive or risk-taking behaviors (e.g., substance abuse, suicidality)

Guidance for pediatric trauma screening is available at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initia- tives/resilience/Pages/PTSD-Fact-Sheet.aspx.

3 How does Childhood Traumatic Grief impact physical health?

Childhood Traumatic Grief can have a significant impact on children’s physical health and be indicated by the following:

Somatic symptoms severe enough to warrant sick-child pediatric visits

Presentation of new somatic symptoms with no clear underlying medical cause

Presentation of symptoms that mimic the deceased person’s cause of death

Significant worsening of existing chronic medical conditions (e.g., diabetes, asthma)

Noncompliance or decreased compliance with usual medication regimens

Depressed affect, changes in behavior, and other psychiatric symptoms

Self-injurious or suicidal behaviors, substance abuse, or other risky behaviors

Changes in eating or sleeping behaviors

4 How can you assess children with Childhood Traumatic Grief?

Children with Childhood Traumatic Grief often avoid talking about death or the person who died. Ask children directly about their experiences with trauma or the death of an important person. Not asking may inadvertently communicate to the child that it is unacceptable to discuss these things with adults. If your questions make the child’s symptoms worse, this may be a sign that professional help is warranted. Pediatric providers often are in the best position to talk to children about trauma and death because your patients already have a trusting relationship with you.

3Childhood Traumatic Grief: Information for Pediatric Providers

You may want to ask the parent to step out of the room during these conversations, because children with Traumatic Grief are often overly concerned with causing their parents additional emotional distress and may deny symptoms in a parent’s pres- ence to avoid upsetting them. To evaluate the presence of Childhood Traumatic Grief, pediatric providers can do the following:

Routinely ask parents and caregivers if their children have experienced any deaths or traumatic events since their last visit.

Ask children directly whether anything very scary or upsetting has happened since the last visit.

Follow up with children and families known to have recently experienced a death or with children who are approaching an anniversary or reminder of a death.

Pay particular attention to children who have experienced traumas in addition to the death of a significant person, as exposure to additional trauma may worsen Traumatic Grief symptoms.

Inquire about adjustment to deaths that are seemingly long past, as grief reactions sometimes surface at later points in life or developmental stages.

5 What can you do to help children with Traumatic Grief?

FOR CHILDREN

Assure the child that many children experience similar reactions following the traumatic death of an important person. Provide support and assurance that help is available.

Be sensitive when doing invasive medical procedures or examinations that may somehow remind the child of previous traumatic experiences or experiences related to the death.

Be aware of the effect of anniversary dates of the loss and potential reminders of the death (e.g., Mother’s Day, Father’s Day, holidays) and adjust medical appointments, procedures, and treatment recommendations in light of how Childhood Traumatic Grief impacts physical illness and treatment compliance.

Address treatment compliance issues directly with the child and parent. If barriers to compliance persist, a mental health consultation is warranted.

FOR CHILD AND PARENT

Discuss making a referral for specialized treatment with both the child and parent.

Refer the child to a mental health professional, ideally one who has experience in treating childhood traumatic stress and Traumatic Grief.

Encourage the family to call you if additional symptoms or other concerns arise, or if they have difficulty in arranging mental health follow-up.

Reassure children and parents that these problems can be successfully treated and that children can recover with appropriate help.

FOR PARENTS

Keep materials on hand to educate parents about Childhood Traumatic Grief (available at https://www.nctsn.org/what- is-child-trauma/trauma-types/traumatic-grief).

Educate parents about the value of getting professional help for the child’s Traumatic Grief.

4Childhood Traumatic Grief: Information for Pediatric Providers

Where do you find additional information and help?

Effective treatments are available for Childhood Traumatic Grief and children can return to their normal functioning. Additional information for children, parents, professionals, pediatricians, and educators is available at the National Child Traumatic Stress Network, www.NCTSN.org with materials specific to Traumatic Grief at www.nctsn.org/trau- ma-types/traumatic-grief.

Footnotes https://www.judishouse.org/cbem-methodology-and-sources 1.

Currently two treatment models have scientific evidence of helping children recover from Childhood Traumatic Grief:

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for children ages 3-18 years and their parents or primary caregivers provided in 12-15 individual or group sessions. More information is available here: https://www.nctsn.org/interventions/trauma-focused-cognitive-behavioral-therapy

Trauma Grief Components Therapy for Adolescents (TGCT-A) for teens ages 13-17 years, provided in groups. More information is available here: https://www.nctsn.org/interventions/trauma-and-grief-component-therapy-ad- olescents