AN EXPLORATORY STUDY OF POST-TRAUMATIC STRESS DISORDER SYMPTOMS AMONG BEREAVED CHILDREN

Transcription

1 OMEGA, Vol. 51(4) , 2005 AN EXPLORATORY STUDY OF POST-TRAUMATIC STRESS DISORDER SYMPTOMS AMONG BEREAVED CHILDREN RENE S. MCCLATCHEY M. ELIZABETH VONK University of Georgia, Athens ABSTRACT Purpose: This study reports on the incidence of post-traumatic stress disorder (PTSD) symptoms among a sample (n = 46) of bereaved children. PTSD symptoms in children who have experienced loss due to an expected death through illness have not been previously studied. Method: An exploratory cross-sectional design was used to compare Impact of Event Scale (IES) scores between two groups of bereaved children. One group experienced the sudden, unexpected death of a family member; the second group experienced the expected death of a family member following protracted illness. Findings: Overall, almost two-thirds of the children were found to be experiencing moderate to severe levels of PTSD related symptoms of intrusion and avoidance as measured by the IES. Additionally, there was no significant difference in the IES scores of the two groups of children. Implications: Findings are discussed in relation to current practice with and research on bereaved children. In America 1.9 million children receive benefits from a deceased worker (Social Security Administration (SSA), 2003). As many children do not qualify for death benefits after the death of a parent for various reasons, the number of children who have lost a parent is most likely well above 2 million. The death of a parent during childhood, whether through trauma or protracted illness, is a unique and overwhelming event (Worden, Davies, & McCown, 1999) and often leads to 2005, Baywood Publishing Co., Inc. 285

2 286 / MCCLATCHEY AND VONK complex psychological reactions, the resolution of which may require the assistance of mental health professionals. In this article, the results of a study of post-traumatic stress disorder (PTSD) among grieving children are presented and discussed. Following a brief review of childhood grief and loss as it relates to both unexpected and expected death, the relationship between loss, grief, and trauma responses in children will be explored. Next, the extant literature related to PTSD in children will be reviewed. This literature will provide the context within which the results of the present study will be discussed. CHILDHOOD GRIEF AND LOSS Several researchers have looked at the effects of loss and grief on children and have found, among other things, that the manner in which a parent dies affects children s grief reactions. For example, children bereaved by sudden, unexpected loss related to parental suicide experience a complicated form of bereavement and need tremendous support to overcome the shock, guilt, unanswered why questions, and possibly the trauma of discovering or witnessing the suicide (Knieper, 1999). Suicidal ideation may also be higher among children who have lost a parent to suicide. In addition, suicide may carry a stigma in some circles and further isolate a child bereaved in such a manner. Children of suicide may also develop a mixed attachment or a complex hatred toward a parent who has died from self-inflicted causes. An estimated 31,000 suicides occur annually in the United States (Hoyert, Kung, & Smith, 2005). Calculating that each fourth suicide leaves behind one child (Small & Small, 1984) over 7,000 children experience the loss of a parent to suicide annually. However, the numbers may be much higher as many suicides may be misreported as accidental deaths. Other forms of sudden, violent deaths, including terrorist attacks, school shootings, and drunk driving also create accelerated pain (Selekman, Busch, & Kimble, 2001). A senseless act can cause terror in surviving children, who may question their own safety, as well as create doubt in their sense of justice and fairness. Indeed, some authors claim that a childhood trauma can lead to psychotic thinking, dissociation, passivity, self-mutilation, and anxiety disorders in adulthood (Terr, 1991). Even an expected death after a prolonged illness, however, can have grave consequences. The Harvard Child Bereavement Study (Worden & Silverman, 1996) reported that a significantly large group of children show serious problems at one year (19%) and at two years (21%) after the death of a parent. In fact, approximately 50% of children who lose a parent are noticeably impaired in their everyday functioning during the first year of bereavement (Black, 1978). Bereaved children ages 3-6, as well as those in elementary school, showed elevated levels of depression, anxiety, and behavior problems (Kranzler, Shaffer, Wasserman, & Davies, 1990; Felner, Ginter, Boike, & Cowen, 1981). Loss of a

3 PTSD IN BEREAVED CHILDREN / 287 sibling is believed to be very difficult for a child as well, often attributed to the fact that parents who have lost a child may become emotionally unavailable. Communication patterns in such families often become closed after the death (Gibbons, 1992). It has also been suggested that unresolved grief in a child can have serious long-term consequences, such as marital breakdown, adult depression, and other psychiatric problems (Florian & Mikulincer, 1997). Though all children who lose a parent may be profoundly affected, teenagers especially may engage in risk-taking behavior such as drug and alcohol abuse, promiscuity, impulsivecompulsive behaviors, and reckless driving (Naierman, 1997). GRIEF AND TRAUMA IN CHILDREN A review of the literature shows, as would be expected, that most interventions for grieving children have consisted of support groups based on grief theory and the tasks of grieving (Worden, 1991). Evaluations of such interventions have been conducted with varying levels of methodological rigor, and have measured several outcomes including depression, improvement in concept of death, acting out behavior, self-esteem, grief adjustment, anxiety, conduct disorder, and coping (Adams, 1996; Huss & Ritchie, 1999; Sandler, Ayers, et al., 2003; Sandler, West, et al., 1992; Schilling, Koh, Abramovitz, & Gilbert, 1992; Tonkins & Lambert, 1996; Wilson, 1995 ). These studies, however, show mixed results of the efficacy of treatment, and it has been suggested that grief theory does not adequately explain what happens within a child after a violent death (Amick-McMullan, Kilpatrick, & Resnick, 1991; Sprang & McNeil, 1998). While many of children s symptoms following loss of a parent or sibling can be seen as grief responses, they also bear similarities to stress responses often seen among children who have been through very frightening experiences (Yule, 2001). For example, many children report sleep-disturbances and nightmares after a loss. Others report feelings of guilt, thinking they could have done something to prevent the death, or even that they caused the death (Schoen, Burgoyne, & Schoen, 2004). Further, many children experience difficulties in school after a loss, evidenced by lowered grades (Leon, 1986). Other children have been reported to show acting out problems after the loss of a parent (Christ, 2000). Another response reported by adults and children is the difficulty of the parentally bereaved child in separating from the surviving parent. Finally, bereaved children also have a tendency to avoid talking about their loss and grief. Violent or sudden loss of loved ones, and witnessing or learning of the loss of a loved one can be viewed as stressful events for children (Green et al., 1991). Viewing the experience of losing a parent or sibling as a stressful event places new light on children s reactions and has implications for the assessment and treatment of children following parental loss. Many grief experts would agree that some bereavement involves traumatic loss, such as loss due to suicide,

4 288 / MCCLATCHEY AND VONK homicide, or accidents; and that traumatic responses are to be expected (Raphael, 1997). Some authors have even argued for a specific diagnosis called traumatic/ complicated grief to be included in the next edition of the Diagnostic Statistical Manual (Prigerson & Jacobs, 2001). The suggested symptoms would include, among other things, intrusive thoughts about the deceased, subjective sense of numbness, detachment, or absence of emotional responsiveness, and shattered worldview (e.g., lost sense of security, trust, or control). As defined currently, posttraumatic stress disorder (PTSD) is known to affect approximately 10% of the nonmilitary population. PTSD was first identified as a specific diagnostic category in the third edition of the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (DSM III) (American Psychiatric Association (APA), 1980). To meet the current diagnostic criteria for PTSD, the person has to have: experienced, witnessed, or been confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person s response involved intense fear, helplessness, or horror (APA, 2000). In addition, to meet the diagnostic criteria for PTSD, a person has to have at least one re-experiencing symptom, three avoidance symptoms, and two symptoms of hyper-arousal, and symptoms must have persisted for at least one month (APA, 1994). Children may exhibit re-experiencing through nightmares about threats to self, disorganized or agitated behaviors, or activities that are symbolic of the trauma. Avoidance in children may be exhibited through belief that one will not live long enough to become an adult (APA, 1994). These symptoms often correspond with grief reactions in children who report sleep disturbances after a loss and show agitation through acting out behavior (Wilken & Powell, 1991). In addition, children are reported by parents/guardians to show avoidance of the death by not talking about their loss, or avoiding making plans for the future. Shah and Mudholkar (2000) divided the stressors that may trigger PTSD in children and adolescents into seven different categories: war, natural disaster, exposure to civilian violence, assaults/murders, accidents, rape, and incest. While few studies on post traumatic stress disorder (PTSD) in relation to children and loss of loved ones could be identified in the literature, there are several related to violent loss, such as war, accidents, assault, and murder. Exposure to war and war atrocities has been shown to cause post traumatic stress disorder in children. In studies of children who had experienced war violence in South Africa and Kuwait respectively (Nader, Pynoos, Fairbanks, al-ajeel, & al-asfour, 1993; Smith, 1993) approximately 60% of the children knew somebody who had died in the war activities. Close to three-fourths of the children showed moderate to severe PTSD symptoms. These studies clearly indicated that children who experienced the loss of a close one to a traumatic war event, experienced significant PTSD symptoms.

5 PTSD IN BEREAVED CHILDREN / 289 Dyregrov, Gjestad, and Raundalen (2002) had similar results studying children after the Gulf War. Though only 20% of the children had experienced the death of a close family member, almost all of the children had lost a close friend in the war. Over three-quarters of the sample scored in the risk group for PTSD. Unlike the two war studies above, Dyregrov and his colleagues looked at grief responses as well. Girls reported significantly more reactions than boys, more frequently endorsing items related to dreaming, crying, and thinking about the lost one; though thinking about the lost one was the most frequent grief reaction for both boys and girls. The grief scores based on six items correlated significantly with PTSD intrusion scores, measured with the IES over two years after the war. There was no significant correlation with avoidance scores. This study, then, showed a close link between PTSD intrusion symptoms and grief. In another study, 75% of the children who survived a bus accident in Norway that killed 12 children, three parents, and the bus driver, disclosed symptoms of PTSD (Winje & Ulvik, 1998). However, children who had lost a parent or a sibling in the accident scored higher on the IES intrusion subscale than the children who had not lost a parent or sibling in the accident. Similarly, girls had a higher score on the intrusion subscale than males and showed more depressive symptoms. The children who had experienced a family loss in the accident did not show poorer long-term adjustment. The authors did not directly measure grief, but the elevated intrusion symptoms for those who experienced loss of a family member is striking. In any case, the results of the study underscore the relationship between traumatic loss and PTSD symptoms among children. Still other studies point to the relationship between traumatic loss, grief, and PTSD. For example, among children who had lost a family member to homicide, there did not appear to be a difference between witnessing and not witnessing the event in regards to PTSD symptoms (Clements & Burgess, 2002). The children showed both internalizing symptoms of PTSD such as depression, avoidance, withdrawal and reduction in activity levels, and externalizing symptoms such as agitation, aggressive behavior, hyperactivity, and emotional flare-ups. The authors also found grief reactions in the children, such as sadness, depression, loneliness, anger, and survivors guilt: the belief that they somehow could have prevented the death. Children who had lost a sibling to homicide showed symptoms of traumatic grief and the traumatic experience seemed to delay the course of the grief of these children (Brosius, 2004). The same was true for children who had witnessed the homicide of a parent (Eth & Pynoos, 1994). School age children showed mental constriction reminiscent of that seen in an adult and this constriction was most often observed in a deterioration of school work. The authors speculated that the children were less able to concentrate due to intrusive thoughts of the witnessed homicide act or due to depression and anxiety. Behaviorally, school age children affected by this kind of trauma became irritable, disrespectful, and offensive. In teenagers the authors found that the witnessing of the violent death of a parent

6 290 / MCCLATCHEY AND VONK precipitated an untimely transition into adulthood. The teenagers also had a propensity to act out and engage in truancy, sexual activity, and criminal behavior. These trauma-produced after-effects were shown to impede the children s grief work. It was more difficult for the child to think about the deceased because of the images of the violent death, and thus the child s ability to reminisce, an important part of grief work, was impaired. The numbness that accompanies PTSD symptoms also made it more difficult for the children to express their grief. When the traumatic anxiety decreased, the children were at risk for escalation of grief. Numbness is also a common grief reaction in children (Schoen, Burgoyne, & Schoen, 2004). The trauma experience may indeed get in the way of the grief process (Black, 1998). As a result of her extensive work with children who have been bereaved by uxoricide, or spouse killing, Black (p. 249) concluded,... interventions to prevent or ameliorate PTSD are usually necessary if the child has witnessed the killing or has witnessed previous domestic violence. Most children will then require therapeutic attention to promote mourning.... The author thus seemed to claim that the PTSD symptoms would have to be dealt with before the grief process could be addressed. The above studies indicate that a loss through a violent death results in PTSD symptoms in children in addition to grief reactions. It can be debated whether the loss of a parent to an expected death, such as cancer, can be considered a traumatogenic experience as it does not involve danger, violence, or threat or may not be a distinct or short-lived event (Smith, Redd, Peyser, & Vogl, 1999). It might be argued, however, that witnessing a parent withering away to cancer may involve a feeling of threat to a child who does not understand the disease or dying process, or is worried about his or her own well-being, a common response developmentally for young children (Christ, 2000). This witnessing could create a sense of intense fear and/or helplessness. It is also an event out of the ordinary, in the sense that it is unnatural for a young parent to die. In her dissertation on the effects of bereavement after sudden versus expected death in adults, Marcey (1996) states that the type of death did not influence the bereavement process. However, those who believed the death of their loved one to be preventable were more likely to suffer from PTSD. Considering that children often engage in what is called magical thinking, in which they assume the responsibility for the death of a loved one (Rando, 1984; Wolfelt, 1991), it would seem that children would see almost all death as preventable, and they may, therefore, be highly susceptible to PTSD symptoms whether the death is sudden or not. In addition, Terr (1991) defines childhood trauma as resulting from events that are single, sudden, and unexpected (type I trauma) and those that are long-standing and anticipated blows (type II trauma). Though Terr does not specifically mention protracted illness and the subsequent death of a parent, it seems logical to include such events in type II traumas. The authors of this article, therefore, pose two research questions: 1) Do most children who lose a loved one to death experience PTSD

7 PTSD IN BEREAVED CHILDREN / 291 symptoms? 2) If so, is there a difference in PTSD symptoms between children who experience a sudden and/or violent death or an expected death? Sample METHODOLOGY An announcement went out in February 2004 to school counselors in metro Atlanta about a bereavement camp for children who had lost a parent, sibling, or other loved one to death within the past three years. Eighty children had applied at the time of the registration deadline but only the first 60 were accepted due to lack of space and other resources. Families of 55 of the children accepted their spaces and the parents/guardians of these 55 children were asked to allow participation of their children in a study measuring PTSD symptoms in bereaved children. The parents of eight children declined to have their children participate or forgot to send a signed consent form with the child to camp. One subject s scores were discarded after it was discovered that a mistake had been made by the camp office, and this camper had attended the camp once before. The remaining sample consisted of 29 children ages 7 11 and 17 children ages (mean age 10.52). Twenty children were female, 15 were Caucasian, 1 Latino, and 30 African American. A majority of the sample had experienced the loss of a father (22) and 14 had lost a mother. Three of the campers had lost a sibling and seven a grandparent. Out of the total, a little over half had experienced an expected death (26) such as a loss to various cancers, organ failure, ALS, neurofibromatosis, and cerebral palsy. The remaining 20 children had experienced an unexpected death such as a loss to heart attack, murder, suicide, stroke, brain aneurysm, house fire, and car accident. Mean time since the loss was 10.3 months. Measure of Trauma Symptomatology The Impact of Event Scale was used to measure PTSD symptoms among the children participating in camp. The Impact of Event Scale is a self-report paper and pencil instrument consisting of 15 items used to measure subjective distress for many different life events (Horowitz, Wilner, & Alvarez, 1979). The IES is relevant to a specific stressor in the respondent s life and has two subscales. The intrusion scale has seven items, consisting of questions related to flashbacks, sleep disturbances, and intrusive thoughts and feelings. The avoidance scale has eight items related to denial of the significance of the occurrence. It includes avoidance of feelings, situations, and ideas; and numbing of responsiveness. The respondent indicates the frequency with which he or she has experienced certain feelings or thoughts over the past seven days on a 4-point Likert scale anchored at the low end by not at all, and at the high end by often. Higher scores indicate greater traumatic impact. Scores above the clinical cutting score of 26 show a

8 292 / MCCLATCHEY AND VONK moderate to severe impact of stress reactions (Horowitz et al., 1979). It has been suggested by Corneil, Beaton, Murphy, Johnson, and Pike (1999) in their work with firefighters that a mild range of stress reactions, that is, scores between 9 and 25, be added to the interpretation of the scoring system. The IES was originally developed to measure stress responses in individuals experiencing grief and personal injury, but was soon employed to measure psychological effects of traumas of varying kinds, such as war (Neal, Busuttil, Rollins, Herepath, Strike, & Turnbull, 1994), natural disasters (Jones, Ribbe, Cunningham, Weddle, & Langley, 2002), accidents (Bryant & Harvey, 1995), and rape (Roth, Dye, & Lebowitz, 1988). The Impact of Event Scale has proven to be a reliable and valid scale for assessing stress symptoms and for assessing change over time among adults and children (Dyregrov, Kuterovac, & Barath, 1996; Dyregrov & Yule, 1995). As the IES instrument does not take into account hypervigilance, it cannot be used to assess for a DSM-based diagnosis of PTSD, but is a valuable instrument to assess for PTSD symptoms. Procedure Approval to conduct the study was obtained from the appropriate Institutional Review Board. Children attending camp, whose parents/guardians consented to have them participate in the study, were read the assent form upon arrival to camp, which was held in May of 2004, by their assigned licensed clinical social worker. All 46 children agreed to participate and were accompanied by their social workers to a private spot at the camp. The younger children ages 7 11 were read the IES orally by the mental health professional. Children ages were allowed to complete the instrument themselves with the mental health professional as a resource for any questions. Data from the completed questionnaires were transcribed into SPSS for analysis. RESULTS The reliability for the total IES scale in this sample had a Cronbach s alpha coefficient of 0.755, for the intrusion scale, and for the avoidance scale. The mean total score in this sample on the IES was (SD = 13.38) with a range from 0 to 56. Using Horowitz s cut-off score of 26 (Horowitz et al., 1979), over 65% of the sample showed moderate to severe levels of PTSD symptoms. Using Corneil et al. s (1999) cut-off score for mild PTSD symptoms,, 89.1% of the sample showed symptoms from mild to moderate and severe. Dividing the sample into three loss groups, one whose loss was within the past 12 months, one whose loss was between months ago, and one whose loss was over 24 months ago, no statistically significant difference was obtained. However, there was a statistically significant increase in PTSD symptoms from a loss less than six months old (mean 29.00) to a loss over six months old (mean 31.75).

9 PTSD IN BEREAVED CHILDREN / 293 Children who had experienced an expected death had a mean total score of (SD = 12.96) and children who had experienced an unexpected, sudden death had a mean total score of (SD = ) (see Table 1). Using the SPSS program s independent sample t-test, the difference in mean scores was not significant at the 0.05 significance level (t = 0.605, p > 0.05). The mean score on the intrusion scale was (SD = 8.76) for the expected loss group and (SD = 8.987) for the sudden loss group. The mean score on the avoidance scale was (SD = 7.553) for the expected loss group and (SD = 8.53) for the sudden loss group. Neither subscales showed a statistically significant difference in the mean scores. There were no significant differences in scores by race, age, or gender (see Tables 2, 3, and 4), though girls did score slightly higher on both the intrusion and avoidance scales, younger children scored higher on the intrusion scale, and older children scored slightly higher on the avoidance scale. DISCUSSION Post-traumatic stress symptoms in children who have experienced an expected death through illness, such as cancer, have not been previously studied. It can be Table 1. PTSD Symptoms and Type of Death Sample size Type of death n % Mean Standard deviation Expected Sudden Total Table 2. PTSD Symptoms and Race Sample size Race n % Mean Standard deviation Caucasian African American Latino Total

10 294 / MCCLATCHEY AND VONK Table 3. PTSD Symptoms and Gender Sample size Gender n % Mean Standard deviation Female Male Total Table 4. PTSD Symptoms and Age Sample size Age group n % Mean Standard deviation Total argued that the death of a parent, sibling, or other close loved one can be stress inducing to a child who has little reference to death and is developmentally self-centered and who often engages in magical thinking (Christ, 2000). This study indicates that a large number of children who have experienced the loss of a loved one do experience PTSD symptoms. The difference between the mean scores of this sample and that of Dyregrov et al. s (1996) (33.72 for a displaced group and for a refugee group) indicates that a loss for children due to war violence escalates PTSD symptoms, but common causes of death in the United States (such as cancer, heart attacks, murder, and suicide) also create PTSD symptoms in children. However, it is important to note that the average score for females in this study (32.70) (SD = 14.72), approaches the raw mean score for the displaced group in Dyregrov et al. s study. The results of this study also indicate that children who have experienced an expected death have similar post-traumatic stress symptoms as those children who have experienced a sudden and/or violent death. These findings seem to fit with Terr s (1991) definition of childhood trauma that includes long-standing and anticipated blows (type II trauma) in addition to single, sudden, and unexpected events (type I trauma). Using this definition may then partly explain the similar levels of post-traumatic stress symptoms in the two groups. The fact that the children in this study who had the death further behind them actually

11 PTSD IN BEREAVED CHILDREN / 295 scored on the average higher than those who had a shorter time frame since the death, indicates that the psychological affects of the death are lasting and continue if no treatment is provided. This finding is congruent with that of other authors (Green, Lindy, Grace, & Leonard, 1992; Yule & Williams, 1990). These results point to the strong possibility that both unexpected and expected losses involve PTSD symptoms, and that any type of death may, therefore, involve a perceived threat to a child. The results of our study on bereaved children differ from previous studies on bereaved adults in which greater levels of numbing, avoidance, and other PTSD symptoms were found among adults who had experienced a sudden, unexpected death versus those who had experienced an expected death (Lundin, 1984; Schut, de Keijser, van den Bout, & Dijkhuis, 1991). Again, our study showed PTSD symptoms among bereaved children at similar levels for expected and unexpected deaths. A possible explanation for our findings may be that the magnitudes of existing PTSD symptoms are related to the quality of the relationship with the deceased rather than the manner of death. In addition, developmental issues such as dependency on the deceased or cognitive development may be involved. These possible explanations are not within the scope of this article, but would warrant further investigation. There are, of course, limitations to this study. The research method is preexperimental, using a small convenience sample, i.e., only children who went to this grief camp. The results, therefore, cannot be generalized to children other than those in the study. In addition, the sample size is small, and the statistical power is insufficient to detect small differences between groups. This may be responsible for the lack of difference in IES scores by race, gender, or age, which differs from previous studies (Briere & Elliott, 1998; Dyregrov et al., 1996, 2002; Horowitz et al., 1979). Though the IES has proven to be effective with a wide variety of populations, including children (Malmquist, 1986; Yule & Williams, 1990) and is perhaps the best scale for evaluating PTSD in children, it is not without its limitations and drawbacks. As mentioned earlier, the scale does not include symptoms for hypervigilance and cannot be used for the assessment of a DSM diagnosis of PTSD, but rather for PTSD symptoms only. In addition, Raphael (1997) questioned the validity of the IES as a measure of distress. She claimed that the makeup of the intrusive thoughts was not clearly defined, and that the intrusive thoughts could be equally a measure of thoughts of fond or nostalgic memories and not necessarily thoughts of aversive nature. Pynoos and his colleagues (1987) also pointed out that the Impact of Event Scale does not clearly distinguish between grief reactions and PTSD symptoms because both include avoidance and intrusion symptoms. The implications for further research seem clear. This is an exploratory study that indicates most children who experience a loss to death, either expected or unexpected, also experience mild to moderate levels of PTSD symptoms. More

12 296 / MCCLATCHEY AND VONK rigorous study of PTSD among bereaved children is warranted including studies that utilize larger and more diverse samples. In addition, different methods of measuring PTSD should be considered, including perhaps clinical interview or administration of standardized clinical diagnostic interviews. Further research in how death impacts children in regards to PTSD is definitely needed. While it may be premature to suggest implications for practice due to the exploratory nature of this study, the results pose interesting possibilities. In our study, the majority of the sample of bereaved children experienced high levels of PTSD symptoms. In addition, previous research suggests that the two phenomena of grief and PTSD appear to be two separate, but closely linked, entities. If further research substantiates these findings, assessment and treatment of bereaved children will need to expand from its current focus on grief and loss to include a focus on trauma and recovery. It will thus become paramount for the clinician to carefully assess for PTSD among those bereaved children with loss due to expected death, as well as to the more unexpected or traumatic death. Raphael (1997) stated that traumatic stress reactions and grief can exist intermittently or one can predominate. In addition, it may be, as proposed by both Lindy, Green, Grace, and Titchener (1983) and Black (1998) that trauma must be treated first in order to successfully navigate the grief process. It is, therefore, important for clinicians to understand the processes and interactions of these two occurrences to be able to help the bereaved and/or traumatized child and to prevent long-term psychological suffering. This study attempted to look at PTSD symptoms in children ages 7 17 who have lost a close loved one. Unlike previous studies, this study looked at children who had experienced both expected and unexpected losses. Our sample showed a significant presence of PTSD symptoms in both groups. In view of the fact that few successful treatment programs for bereaved children can be found in the literature, the results indicate strongly that more research in the area of childhood grief and its link to PTSD symptoms is needed. Further knowledge may allow social workers to provide children with appropriate assessment and treatment that helps to prevent long-term psychological consequences after the experience of a major loss. REFERENCES Adams, K. N. (1996). Bereavement counseling groups with elementary school students. Dissertation Abstracts International Section A: Humanities & Social Sciences, 56(11A), Amick-McMullan, A., Kilpatrick, D. G., & Resnick, H. S. (1991). Homicide as a risk factor for PTSD among surviving family members. Behavior Modification, 15, American Psychiatric Association (APA). (1980). Diagnostic and Statistical Manual for Mental Disorders (3rd ed.) (DSM-III). Washington, DC: Author. American Psychiatric Association (APA). (1994). Diagnostic and Statistical Manual for Mental Disorders (4th ed.) (DSM-IV). Washington, DC: Author.

13 PTSD IN BEREAVED CHILDREN / 297 American Psychiatric Association (APA). (2000). Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR). Washington, DC: Author. Black, D. (1978). The bereaved child. Child Psychology, 19, Black, D. (1998). Working with the effects of traumatic bereavement by uxoricide (spouse killing) on young children s attachment behaviour. International Journal of Psychiatry in Clinical Practice, 2(4), Briere, J., & Elliott, D. M. (1998). Clinical utility of the impact of event scale: Psychometrics in the general population. Assessment, 5(2), Brosius, K. K. (2004). Children who have lost their siblings due to homicide: A phenomenological study. Dissertation Abstracts International: Section B; The Sciences & Engineering, 64(8-B), Bryant, R. A., & Harvey, A. G. (1995). Avoidant coping style and post-traumatic stress following motor vehicle accidents. Behavior Research Therapy, 33, Christ, G. H. (2000). Impact of development on children s mourning. Cancer Practice, 8(2), Clements, P. T., & Burgess, A. W. (2002). Children s responses to family member homicide. Family & Community Health, 25(1), Corneil, W., Beaton, R., Murphy, S., Johnson, C., & Pike, K. (1999). Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries. Journal of Occupational Health Psychology, 4(2), Dyregrov, A., Kuterovac, G., & Barath, A. (1996). Factor analysis of the impact of event scale with children in war. Scandinavian Journal of Psychology, 37, Dyregrov, A., Gjestad, R., & Raundalen, M. (2002). Children exposed to warfare: A longitudinal study. Journal of Traumatic Stress, 15(1), Dyregrov, A., & Yule, W. (1995). Screening measures: The development of the UNICEF Screening Battery. Fourth European Conference on Traumatic Stress: Paris. Eth, S., & Pynoos, R. S. (1994). Children who witness the homicide of a parent. Psychiatry, 57, Felner, R. D., Ginter, M. A., Boike, M. F., & Cowen, E. L. (1981). Parental death or divorce and the school adjustment of young children. American Journal of Community Psychology, Florian, V., & Mikulincer, M. (1997). Fear of personal death in adulthood: The impact of early and recent losses. Death Studies, 21, Munice, IN: Accelerated Development, Inc. Gibbons, M. B. (1992). A child dies, a child survives: The impact of sibling loss. Journal of Pediatric Health Care, 6(2), Green, B. L., Korol, M. G., Grace, M. C., Vary, N G., Leonard, A. C., Gleser, G. C., & Smitson-Cohen, S. (1991). Children and disaster. Age, gender, and parental effects of PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 30(6), Green, B. L., Lindy, J. D., Grace, M. C., & Leonard, A. C. (1992). Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample. Journal of Nervous and Mental Disorders, 180, Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective stress. Psychosomatic Medicine, 42(3), Hoyert, D., Kung, H-C., & Smith, B. L. (2005). Deaths, preliminary data for National Vital Statistics Reports, 53(15), Hyattsville, MD: National Center for Health Statistics.

14 298 / MCCLATCHEY AND VONK Huss, S. N., & Ritchie, M. (1999). Effectiveness of a group for parentally bereaved children. The Journal for Specialists in Group Work, 24, Jones, R. T., Ribbe, D. P, Cunningham, P. B., Weddle, J. D., & Langley, A. K. (2002). Psychological impact of fire disaster on children and their parents. Behavior Modification, 26(2), Knieper, A. J. (1999). The suicide survivor s grief and recovery. Suicide & Life- Threatening Behavior, 29(4), Kranzler, E. M., Shaffer, D., Wasserman, G., & Davies, M. (1990). Early childhood bereavement. Journal of the American Academy of Child & Adolescent Psychiatry, 29, Leon, I. G. (1986). The invisible loss: The impact of perinatal death on siblings. Journal of Psychosomatic Obstetrics and Gynecology, 5, Lindy, J. D., Green, B. L., Grace, M., & Titchener, J. (1983). Psychotherapy with survivors of the Beverly Hills Supper Club fire. American Journal of Psychotherapy, 37, Lundin, T. (1984). Morbidity following sudden and unexpected bereavement. British Journal of Psychiatry, 144, Malmquist, C. P. (1986). Children who witness parental murder: Posttraumatic aspects. Journal of the American Academy of Child Psychiatry, 25, Marcey, M. M. (1996). A comparison of the long-term effects of bereavement after four types of death: Anticipated death, sudden death, drunk driver crash, and homicide. Dissertation Abstracts International: Section B: The Sciences & Engineering, 56(11-B), Nader, K. O., Pynoos, R. S., Fairbanks, L. A., al-ajeel, M., & al-asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32, Naierman, N. (1997). Reaching out to grieving students. Educational Leadership, 55, Neal, L. A., Busuttil, W., Rollins, J., Herepath, R., Strike, P., & Turnbull, G. (1994). Convergent validity of measures of post-traumatic stress disorder in a mixed military and civilian population. Journal of Traumatic Stress, 7, Prigerson, H. O., & Jacobs, S. C. (2001). Traumatic grief as a distinct disorder: A rationale, consensus criteria, and a preliminary empirical test. In M. S. Stroebe & R. O. Hansson (Eds.), Handbook of bereavement research: Consequences, coping, and care. Washington, DC: American Psychological Association. Pynoos, R. S., Nader, K., Fredrick, C., Gonda, L., & Stuber, M. (1987). Grief reactions in school age children following a sniper attack at school. Israel Journal of Psychiatry and Related Sciences, 24, Rando, T. A. (1984). Grief, dying and death: Clinical interventions for caregivers. Champaign, IL: Research Press Company. Raphael, B. (1997). The interaction of trauma and grief. In D. Black, M. Newman, J. Harris-Hendriks, & G. Mezey (Eds.), Psychological trauma: A developmental approach (pp ). London: Gaskell. Roth, S., Dye, E., & Lebowitz, L. (1988). Group therapy for sexual assault victims. Psychotherapy, 25, Sandler, I. N., West, S., Baca, L., Pillow, D., Gersten, J. C., Rogosch, F., Virdin, L., Beals, J., Reynolds, K. D., & Kallgren, C. (1992). Linking empirically based theory

15 PTSD IN BEREAVED CHILDREN / 299 and evaluation: The Family Bereavement Program. American Journal of Community Psychology, 20(4), Sandler, I. N., Ayers, T. S., Wolchik, S. A., Tein, J. Y., Kwok, O. M., Haine, R. A., Twohey-Jacobs, J., Suter, J., Lin, K., Padgett-Jones, S., Weyer, J. L., Cole, E., Krieger, G., & Griffin, W. A. (2003). The family bereavement program: Efficacy evaluation of a theory-based prevention program for parentally bereaved children and adolescents. Journal of Consulting and Clinical Psychology, 71(3), Schilling, R. F., Koh, N., Abramovitz, R., & Gilbert, L. (1992). Bereavement groups for inner-city children. Research on Social Work Practice, 2(3), Schoen, A. A., Burgoyne, H., & Schoen, S. F. (2004). Are the developmental needs of children in America adequately addressed during the grief process? Journal of Instructional Psychology, 31(2), Schut, H. A. W., de Keijser, J. D., Van Den Bout, J., & Dijkhuis, J. H. (1991). Posttraumatic stress symptoms in the first years of conjugal bereavement. Anxiety Research, 4, Selekman, J., Busch, T., & Kimble, C. S. (2001). Grieving children: Are we meeting the challenge? Pediatric Nursing, 27(4), Shah, N., & Mudholkar, S. (2000). Clinical aspects of post-traumatic stress disorder in children and adolescents. In K. N. Dwivedi (Ed.), Post-traumatic stress disorder in children and adolescents. London, England: Whurr Publishers, Ltd. Small, A. M., & Small, A. D. (1984). Children s reactions to suicide in the family and the implications for treatment. In N. Linzer (Ed.), Suicide: The will to live vs the will to die. New York: Human Sciences Press. Smith, C. (1993). Post traumatic stress disorder in South Africa s children and adolescents. Southern African Journal of Child & Adolescent Psychiatry, 5(2), Smith, M. Y., Redd, W. H., Peyser, C., & Vogl, D. (1999). Post-traumatic stress disorder in cancer: A review. Psycho-Oncology, 8, Sprang, G., & McNeil, J. (1998). Post-homicide reactions: Grief, mourning and posttraumatic stress disorder following a drunk driving fatality. Omega: Journal of Death & Dying, 37(1), Social Security Administration (SSA). (2003). Beneficiary data. Retrieved May 26, 2005, from Terr, L. C. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148(1), Tonkins, S. A. M., & Lambert, M. J. (1996). A treatment outcome study of bereavement groups for children. Child & Adolescent Social Work Journal, 13(1), Wilken, C. S., & Powell, J. (1991). Learning to live through loss: Helping children understand death. National Center for Childcare. Manhattan, KS: Kansas State University Cooperative Extension Service. Wilson, D. L. (1995). An outcome study of a time-limited group intervention program for bereaved children. Dissertation Abstracts International Section A: Humanities & Social Sciences, 55(12-A), Winje, D., & Ulvik, A. (1998). Long-term outcome of trauma in children: The psychological consequences of a bus accident. Journal of Child Psychology and Psychiatry, 39(5), Wolfelt, A. D. (1991). A child s view of grief. Fort Collins, CO: Companion Press.

16 300 / MCCLATCHEY AND VONK Worden, J. W. (1991). Grief counseling & grief therapy: A handbook for the mental health professional. New York: Springer Publishing Company. Worden, J. W., Davies, B., & McCown, D. (1999). Comparing parent loss with sibling loss. Death Studies, 23, Worden, J. W., & Silverman, P. R. (1996). Parental death and the adjustment of school age children. Omega, 33, Yule, W., & Williams, R. M. (1990). Post-traumatic stress reactions in children. Journal of Traumatic Stress, 3, Yule, W. (2001). Post-traumatic stress disorder in children and adolescents. International Review of Psychiatry, 13, Direct reprint requests to: Ms. Rene S. McClatchey University of Georgia School of Social Work Athens, GA rsearles@uga.edu