BOSTON – The assumption that toddlers and preschoolers are not emotionally affected by traumatic grief in the same way as older children and adults are is not only wrong, it's dangerous, according to Chandra Ghosh Ippen, Ph.D.
Unaddressed traumatic grief in a very young child can manifest as vague but persistent fear and stress that threaten the child's core sense of safety and security, setting the stage for later behavioral problems and mental illness, Dr. Ippen said in a symposium at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
Defined as a condition in which a child has lost a loved one under sudden or frightening circumstances that negatively affect the child's ability to negotiate the normal grieving process, childhood traumatic grief overlaps with, but is distinct from, uncomplicated bereavement in children and adult traumatic grief, according to symposium moderator Dr. Judith Cohen of Allegheny General Hospital in Pittsburgh.
“Children with traumatic grief get 'stuck' on the traumatic way their loved one died,” she said, so that efforts to remember happy, positive times with their loved one evoke only thoughts of how the person died. As a result, these children are, in effect, retraumatized each time they think or talk about their loved one, which impedes the normal course of a healthy grieving process–specifically the ability to reminisce about and preserve positive memories of the person who died and to reinvest in new relationships, she said.
“In very young children, the impact of the traumatic loss of a parent or caregiver is most evident through what they do versus what they say–how they interact, their body language,” said Dr. Ippen, clinical research coordinator of the Child Trauma Research Project (CTRP) at the University of California, San Francisco.
“In these kids,” she said, “the physical reaction is immediately evident when the loved one's name is brought up or the topic of the circumstances of the loss is introduced.”
Although efforts to accurately define and measure childhood traumatic grief are just emerging, effective intervention is possible. Within the CTRP, for example, Dr. Ippen and her colleagues have found child-parent psychotherapy (CPP) to be an effective tool.
An attachment-based intervention, CPP incorporates psychodynamic, relationship, and cognitive-behavioral principles for infants, toddlers, and preschool children who have experienced trauma. The treatment, which is delivered by a psychotherapist and typically lasts from 6 months to 1 year, is based on the premise that trauma-related problems in young children should be addressed within the context of the child's primary attachment relationships.
“In young children, their attachment system is the main organizer of emotional and behavioral responses, so the goal is to promote safety and growth in that relationship,” Dr. Ippen said. Doing so, she added, “will affect their entire developmental trajectory.”
Through free play with the parent and child, and the therapeutic use of developmental guidance and information, CPP targets and strengthens the caregiver-child relationship. The ultimate goal is the restoration of the child's sense of safety and trust in adult caretakers.
In a study published in 2005, CTRP investigators demonstrated the efficacy of child-parent psychotherapy in a randomized controlled trial of young trauma-exposed children. Dr. Ippen, along with lead author Alicia Lieberman, Ph.D., director of CTRP, and Patricia Van Horn, Ph.D., associate director, compared the impact of CPP with that of usual care in 75 children aged 3–5 years who had witnessed domestic violence (J. Am. Acad. Child Adolesc. Psychiatry 2005;44:1241–8).
The study population was not made up of children who had lost a parent or a loved one to death, but the trauma symptoms were similar, Dr. Ippen noted.
After treatment, the CPP children showed significantly greater reductions in total behavior problems and traumatic stress symptoms, compared with the usual care group. Additionally, CPP caregivers showed significantly greater reductions in avoidant symptoms.
In a 6-month follow-up study, the investigators observed that the improvements in both children's behavior and maternal symptoms continued after treatment had ended (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:913–8).
“These findings suggest promise for childhood traumatic grief as well, where the goals are the same: to establish a safe and consistent environment and behavior, and to build empathetic relationships,” Dr. Ippen said.
“It's important to remember that where you have a child with trauma, you will generally have a caregiver with trauma.”
Therefore, using a relational approach simultaneously helps caregivers and children cope with their situations, she said. Also, promoting growth in the caregiver-child relationship “supports the healthy development of the child long after the intervention ends.”