The plane crash in Ukraine brings up many questions related to loss and grief. How will those left behind cope with the devastating event? How can we support them? With regard to how young people cope with bereavement, Mariken Spuij’s recent PhD thesis provides new insights. She studied grief and its pathological extreme, Prolonged Grief Disorder, focusing on three topics:
- The phenomenology and correlates of Prolonged Grief Disorder
- The role of negative thinking in Prolonged Grief Disorder
- The development and piloting of the ‘Grief-Help’ intervention for children
Prolonged Grief Disorder
Pathological grief is characterized by persistent severe distress during more than 6 months after the loss, and including symptoms such as separation distress, disbelief regarding the death, numbness, and a sense that life is meaningless. Many of the symptoms are normal grief reactions; it is their intensity and duration that signal a need for additional support.
Similar to the relation between trauma and PTSD, Dr. Spuij and colleagues concluded that only a minority of children develops Prolonged Grief Disorder after loss. Children who have lost a parent appear to be more at risk than children who have lost someone else. The findings also suggest that posttraumatic stress, prolonged grief, and depression are separate, but related, constructs.
The team has developed a screening measure for grief reactions, the Inventory for Prolonged Grief for Children (8-12 years; IPG-C) and Adolescents (13-18 years; IPG-A) and recommend involving children’s own reports of their symptoms in the assessment: parents generally appear to underestimate their children’s symptoms.
The role of negative thinking
Negative thinking and avoidance behaviors may play an important role in the development and maintenance of prolonged grief. Spuij and colleagues adopted the model by Boelen et al, which includes 3 main elements:
- Poor integration of the separation with existing autobiographical knowledge;
- Negative global beliefs and misinterpretations of grief reactions; and
- Anxious and depressive avoidance strategies.
Spuij explains how the three elements are related to each other: “When a child like Bas has a negative thought, like ‘I am guilty of my mother’s death’ it is not surprising that he tries to avoid this thought. This avoidance of a thought is likely to prevent integration of the loss in Bas’ life and knowledge about himself, the world and his future.” (p.20)
To allow further child-focused research on this model, Spuij et al have developed the Grief Cognition Questionnaire for Children (CGQ-C). Example items of the questionnaire are
- “My life is worthless since he/she died.”
- “Ever since he/she died, I continue to think that I can also die.”
- “As long as I am sad, I don’t have to let him/her go.”
Preliminary data suggest that the measure is reliable and valid.
The intervention ‘Grief-Help’ for children
Grief-Help is a 9-session cognitive behavioral treatment for children with Prolonged Grief Disorder, combined with 5 sessions of parental counseling. It consists of 5 parts; see Table for a brief summary of the sessions for the child (Spuij, p.151).
|Session 1-2 ‘Who Died’||Expression of thoughts and feelings about the loss; information gathering about maladaptive thinking and behavior|
|Session 2-3 ‘What is Grief’||Psycho-education|
|Session 4-5 ‘Cognitive Restructuring’||Explanation of persistent negative thoughts, modification of thoughts using Socratic questioning and behavioral experiments|
|Session 6-8 ‘Maladaptive Behaviors’||Targeting ‘anxious avoidance’ through sharing of emotions and exposure, improving problem solving skills, targeting ‘depressive avoidance’ through behavioral activation|
|Session 9 ‘Moving Forward after Loss’||Summary, plans for continued practice and trouble shooting.|
Preliminary data on the effects of the intervention are promising. For example, in an open trial involving ten children, there were significant improvements of grief and posttraumatic stress reactions post-intervention. Spuij and colleagues are currently conducting a randomized controlled trial to further test the intervention’s effects.
To conclude, what are important messages from Spuij’s dissertation regarding children who lost a loved one in the plane crash? In my view, these are:
- Most children will do well, despite the terrible circumstances.
- To detect severe grief symptoms, monitor children and adolescents who have lost one or more loved ones closely (e.g. with the screening measures mentioned above).
- Take children’s self-report into account in this monitoring.
- Do not only look at grief symptoms but also at depression and posttraumatic stress.
- If a child has intense and persistent symptomatology, refer them to a specialized mental health clinician who can provide child-focused treatment.
- Tailored cognitive behavioral therapy, such as Grief-Help, appears a promising child-focused treatment option.
Spuij, M. (2014). Prolonged Grief in Children and Adolescents: Assessment, Correlates, and Treatment. PhD thesis defended 27-6-2014 at Utrecht University.
Spuij M, Prinzie P, Dekovic M, van den Bout J, & Boelen PA (2013). The effectiveness of Grief-Help, a cognitive behavioural treatment for prolonged grief in children: study protocol for a randomised controlled trial. Trials, 14 PMID: 24252587