Individual and systemic variables associated with prolonged grief and other emotional distress in bereaved children.

Most children confronted with the death of a loved one do not experience persisting psychological problems. However, for some, acute grief reactions develop into prolonged grief disorder (PGD) and other mental health problems. Research findings suggest that bereavement outcomes in children are associated with negative cognitions and avoidant coping and with different parenting behaviours. However, knowledge about factors influencing grief in children is still limited and few studies have examined the relative impact of psychological (individual-level) variables and systemic (family-level) variables in affecting their responses to loss. The aim of the current study was to examine the association of different bereavement outcomes in 8-18 year old children (including levels of self-rated PGD, depression, and posttraumatic stress (PTS)) with sociodemographic variables, individual-level variables (including negative cognitions and anxious and depressive avoidance), and family-level variables (including the severity of caregiver's PGD, depression, and anxiety, and indices of parenting behaviours, rated both by children and by their caregivers). Questionnaire data were used from 159 children plus one of their caregivers, gathered as part of the pre-treatment assessment in a randomized controlled trial. Results showed that most of the children's bereavement outcomes, including PGD severity and PTS severity, were associated with indices of negative cognitions and avoidance behaviours. Caregiver's depression and anxiety showed a very small, yet significant, association with two children's outcomes. Caregiver-rated reasoning/induction (one index of parenting behaviours) showed a small association with children's PTS-related functional impairment. Exploratory analyses indicated that the linkage between parenting behaviour and children's outcomes may be moderated by whether the behaviour comes from father or mother. This is one of the first studies examining how individual cognitive behavioural variables plus the mental health of caregivers and indices of parenting may affect PGD and other outcomes in bereaved children. The findings provide tentative indications that individual and family-level variables influence these outcomes, albeit that more research is urgently needed.

Heterogeneity of posttraumatic stress symptoms in bereaved children and adolescents: Exploring subgroups and possible risk factors.

Bereaved youths are at risk of developing posttraumatic stress (PTS), but there are large individual differences in presentation and severity of PTS symptoms among bereaved youths. The study sought to identify subgroups based on the distribution of self-rated loss-related PTS symptoms in a sample of 264 bereaved youths (aged 7-18). Based on latent class analysis, we identified three subgroups: no disturbance (37.9%), intermediate disturbance (39.0%) and pervasive disturbance (23.1%). Subgroups differed in PTS severity and symptom configuration. Specifically, avoidance was relatively more pronounced in bereaved youth with no and intermediate PTS disturbance, whereas emotional numbing was relatively more pronounced in bereaved youth with intermediate and pervasive PTS disturbance. Associations between subgroup membership, emotional stability and demographic and loss-related variables were also examined. Multinomial logistic regression indicated that youths in the pervasive disturbance subgroup reported lower emotional stability than youths in the no disturbance subgroup. Other variables were unrelated to subgroup membership. The study highlights the importance of considering the heterogeneity in PTS symptomatology in the diagnoses and treatment of loss-related traumatic stress in bereaved youth. Moreover, it underscores the need for further research on possible risk and protective factors involved in the maintenance and development of this traumatic stress.

Child Posttraumatic Stress after Parental Cancer: Associations with Individual and Family Factors.

OBJECTIVE: This study aimed to examine the severity of posttraumatic stress disorder (PTSD) symptoms in children of parents with cancer and to identify individual and family factors associated with these symptoms. METHODS: The sample consisted of 175 children (52% girls, aged M = 11.98, SD = 3.20, range = 6-20 years) from 92 families, of which 90 parents with a current or past cancer diagnosis and 71 healthy co-parents also completed questionnaires. Children reported on PTSD symptoms, trauma-related cognitions, emotion regulation difficulties, general family functioning, and family communication. Both parents reported on their own PTSD symptoms. Associations were investigated using multilevel regression. RESULTS: Twenty-seven percentage of the children showed clinically relevant PTSD symptoms. Intraclass correlations indicated that children from the same family showed little overlap in these symptoms. Multilevel analyses showed that child trauma-related cognitions and emotion regulation difficulties were related to higher levels of PTSD symptoms at the individual level. General family functioning was only related to child PTSD symptoms at the family level. Child PTSD severity was unrelated to parental PTSD symptoms and family communication at the family level when taking into account the other factors. CONCLUSIONS: The current study highlights the psychological impact of parental cancer on children. Individual factors contributed more strongly to child PTSD symptoms than family factors. Trauma-related cognitions and emotion regulation difficulties might be targeted through specific psychoeducation for children and parents, family-oriented support and interventions, and evidence-based treatments for child PTSD.

Child adjustment to parental cancer: A latent profile analysis.

OBJECTIVE: This study aimed to identify latent classes of adjustment in children confronted with parental cancer, based on profiles of traumatic stress symptoms, health-related quality of life (HRQoL), and satisfaction with life. In addition, correlates of classes were examined. METHOD: Families were recruited through social media, health care providers, and cancer support centers. The sample consisted of 175 children (52% girls, aged M = 11.98, SD = 3.20, range = 6-20 years) from 92 families, including 90 parents with a current or past cancer diagnosis and 71 healthy parents. Children and parents completed self-report questionnaires at home. A latent profile analysis was conducted to identify classes based on child traumatic stress symptoms, HRQoL, and satisfaction with life. RESULTS: Four classes were identified, which were labeled (a) average functioning across domains (64%); (b) high stress, below-average HRQoL and life satisfaction (14%); (c) high stress, below-average HRQoL, and average satisfaction (11%); and (d) high functioning across domains (11%). Child age, parent traumatic stress symptoms, and perceived parental warmth were significantly associated with class membership. Child gender, which parent was diagnosed with cancer, and illness phase were unrelated to class membership. CONCLUSIONS: Meaningful subgroups of children can be distinguished based on positive and negative indicators of adjustment to parental cancer. Whereas the majority of children appear to adjust well, 25% of children display high levels of traumatic stress and impaired HRQoL, in some cases combined with low life satisfaction; these children may need specific attention to improve adjustment in the long term. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Pragmatic Quasi-Experimental Controlled Trial Evaluating the Outcomes of Blended CBT Compared to Face-to-Face CBT and Treatment as Usual for Adolescents with Depressive Disorders.

Depression is a major problem in youth mental health. Current treatment is on average effective, but adolescents are hesitant to seek help. Blended treatment could lower the barriers to seeking treatment. Evidence on effectiveness is, however, scarce. The present pragmatic quasi-experimental controlled trial aimed to compare the outcomes of blended cognitive behavioral therapy (CBT) to face-to-face CBT and treatment as usual. A total of 129 adolescents with clinical depression (82.2% female), aged 13-22 (M = 16.60, SD = 2.03) received blended CBT, face-to-face CBT or treatment as usual. Clinical diagnosis, depressive symptoms, and secondary outcomes were assessed at baseline, post-intervention, and six-months follow-up. Participants receiving blended CBT were, compared to participants receiving face-to-face CBT and treatment as usual, evenly likely to be in remission from their depressive disorder at post-intervention and at six-month follow-up. Depressive symptoms decreased significantly over time in all three conditions, and changes were not significantly different between conditions. Other secondary outcomes (suicide risk, internalizing and externalizing symptoms, severity of depression, and global functioning) did not differ between treatment conditions at post-intervention and six-month follow-up. Since there was no evidence for favorable outcomes for face-to-face therapies above blended CBT, blended CBT may also be an effective treatment format in clinical practice.

CBT for Prolonged Grief in Children and Adolescents: A Randomized Clinical Trial.

OBJECTIVE: Prolonged grief disorder was newly included in ICD-11 and resembles persistent complex bereavement disorder, newly included in DSM-5. Although prolonged grief disorder in adults can be successfully treated by cognitive-behavioral therapy (CBT), there is no evidence yet that CBT interventions can successfully alleviate the disorder in children and adolescents. The goal of this randomized clinical trial was to examine the effects of a CBT program, CBT Grief-Help, for prolonged grief disorder in children and adolescents in comparison with the effects of nondirective supportive counseling. METHODS: A total of 134 children and adolescents with prolonged grief disorder (mean age, 13.10 years [SD=2.84], bereaved a mean of 37.79 months [SD=36.23] earlier) were randomly assigned to receive either CBT Grief-Help (N=74) or supportive counseling (N=60). Both treatment conditions encompassed nine individual sessions with children and adolescents paralleled by five counseling sessions with parents or caretakers. Children and adolescents completed measures of prolonged grief disorder, depression, and posttraumatic stress disorder (PTSD), and their parents or caretakers completed measures of their children's problem behavior before treatment, immediately after treatment, and 3, 6, and 12 months after treatment. RESULTS: Both treatments yielded moderate to large effect sizes across prolonged grief disorder and most other outcome measures. Compared with supportive counseling, CBT Grief-Help resulted in significantly greater reductions in prolonged grief disorder symptoms at all posttreatment assessments, and it was more successful in alleviating depression, PTSD symptoms, and internalizing problems 6 and 12 months after treatment. CONCLUSIONS: Prolonged grief disorder and its symptoms in bereaved children and adolescents can be effectively treated by CBT interventions. The superior long-term effects of CBT Grief-Help relative to supportive counseling suggest that this treatment successfully strengthens children and adolescents in facing challenges brought about by bereavement.

Comparison of DSM-5 criteria for persistent complex bereavement disorder and ICD-11 criteria for prolonged grief disorder in help-seeking bereaved children.

BACKGROUND: Persistent complex bereavement disorder (PCBD) is a disorder of grief that newly entered DSM-5. Prolonged grief disorder (PGD) is a disorder of grief included in ICD-11. No prior studies examined and compared the dimensionality, prevalence, and concurrent validity of both conditions among bereaved children. METHODS: With data from 291 help-seeking bereaved 8-18 year old children, we used confirmatory factor analysis to evaluate the fit of different factor models for PCBD and PGD. In addition, we determined diagnostic rates for probable PCBD and PGD and calculated associations of PCBD and PGD caseness with concurrently assessed symptoms of overall disturbed grief, depression, posttraumatic stress, and parent-rated problem behavior. RESULTS: For PCBD and PGD, one-factor models-with all symptoms forming a unidimensional factor of disturbed grief-fit the data best. The prevalence of probable DSM-5 PCBD (3.4%) was significantly lower than ICD-11 PGD (12.4%). Both PCBD and PGD were significantly associated with concurrently assessed overall disturbed grief, depression, and posttraumatic stress; associations with parent-rated problems were moderate. LIMITATIONS: Findings were based on self-reported ratings of symptoms, obtained from three different scales not specifically designed to assess PCBD and PGD. The use of a help-seeking sample limits the generalization of findings to bereaved children generally. CONCLUSIONS: Findings support the validity of DSM-5 PCBD and ICD-11 PGD. Prevalence rates of both constructs differ. This needs further scrutiny.

Prolonged grief and posttraumatic stress in bereaved children: A latent class analysis.

Few studies have yet examined subgroups among children (aged 8-18) confronted with the death of a close loved one, characterized by different profiles of symptoms of prolonged grief disorder (PGD) and symptoms of bereavement-related posttraumatic stress disorder (PTSD). This study sought to identify such subgroups and socio-demographic and loss-related variables associated with subgroup membership. We used data from 332 children, most of whom (> 80%) were confronted with the death of a parent, mostly (> 50%) due to illness. Latent class analysis revealed three classes of participants: a resilient class (38.6%), a predominantly PGD class (35.2%), and a combined PGD/PTSD class (26.2%). Class membership was associated with self-rated levels of depression and functional impairment, and parent-rated behavioural problems. No significant between-class differences on demographics or loss-related variables were found. The current findings of distinct classes of PGD, and PGD plus PTSD attest to the construct validity of PGD as a distinct disorder, and can inform theory building and the development of diagnostic instruments relevant to children with pervasive distress following loss.

Psychometric Properties of the Grief Cognitions Questionnaire for Children (GCQ-C).

Negative thinking is seen as an important mediating factor in the development of prolonged grief disorder (PGD), a syndrome encompassing debilitating symptoms of grief. No measure of specific grief related cognitions is available yet. Based on an adult measure of negative thinking in adults we developed a questionnaire for children, the Grief Cognitions Questionnaire for Children (GCQ-C). This study investigated several psychometric properties of the GCQ-C. Both reliability and validity were investigated in this study, in which hundred fifty-one children and adolescents (aged 8-18 years) participated. Findings showed that items of the GCQ-C represented one underlying dimension. Furthermore, the internal consistency and temporal stability were found to be adequate. Third, the findings supported the concurrent validity (e.g., significant positive correlations with self-report indices of PGD, depression and posttraumatic stress disorder), convergent and divergent validity of the GCQ-C. This study provides further evidence for the importance of negative thinking in PGD in children and adolescents.

An open trial of 'grief-help': a cognitive-behavioural treatment for prolonged grief in children and adolescents.

In the past years, there is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). Although mostly studied in adults, clinically significant PGD symptoms have also been observed in children and adolescents. To date, no effective treatment for childhood PGD yet exists. We recently developed a nine-session cognitive-behavioural treatment for childhood PGD combined with five sessions of parental counselling. In the current article, we present outcomes of treatment of 10 consecutive children and adolescents turning to our university clinic with elevated PGD symptoms as their primary problem and main reason to seek therapy. Patients were significantly improved at post-treatment, with large improvements in self-rated PGD and post-traumatic stress (effect sizes > 0.8) and small to moderate improvement in depression and parent-rated internalizing and externalizing problems (0.2 < effect sizes < 0.8). Additional predictor analysis of outcomes suggested that, among other things, this treatment approach is less efficacious for children and adolescents further removed from loss and those confronted with suicidal loss. That said, the treatment appears promising, and controlled evaluation is clearly indicated.

The effectiveness of Grief-Help, a cognitive behavioural treatment for prolonged grief in children: study protocol for a randomised controlled trial.

BACKGROUND: There is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). PGD is mostly studied in adults, but clinically significant PGD symptoms have also been observed in children and adolescents. Yet, to date no effective treatment for childhood PGD exists. The aims of this study are: (1) to investigate the effectiveness of Grief-Help, a nine-session cognitive-behavioural treatment for childhood PGD, combined with five sessions of parental counselling, immediately after the treatment and at three, six and twelve months follow-up; (2) to examine tentative mediators of the effects of Grief-Help, (i.e., maladaptive cognitions and behaviours and positive parenting), and (3) to determine whether demographic variables, child personality, as well as symptoms of PGD, anxiety, and depression in parents moderate the treatment effectiveness. METHODS/DESIGN: We will conduct a Randomised Controlled Trial (RCT) in which 160 children and adolescents aged 8-18 years are randomly allocated to cognitive behavioural Grief-Help or to a supportive counselling intervention; both treatments are combined with five sessions of parental counselling. We will recruit participants from clinics for mental health in the Netherlands. The primary outcome measure will be the severity of Prolonged Grief Disorder symptoms according to the Inventory of Prolonged Grief for Children (IPG-C). Secondary outcomes will include PTSD, depression and parent-rated internalizing and externalizing problems. Mediators like positive parenting and maladaptive cognitions and behaviours will be identified. We will also examine possible moderators including demographic variables (e.g. time since loss, cause of death), psychopathology symptoms in parents (PGD, anxiety and depression) and child personality. Assessments will take place in both groups at baseline, after the treatment-phase and three, six and twelve months after the post-treatment assessment. DISCUSSION: We aim to contribute to the improvement of mental health care for children and adolescents suffering from loss. By comparing Grief-Help with supportive counselling, and by investigating mediators and moderators of its effectiveness we hope to provide new insights in the effects of interventions for bereaved children, and their mechanisms of change. TRIAL REGISTRATION: Netherlands Trial Register NTR3854.

Symptoms of post-traumatic stress disorder in bereaved children and adolescents: factor structure and correlates.

This study investigated the factor structure and correlates of posttraumatic stress-disorder (PTSD) symptoms among children and adolescents confronted with the death of a loved one. Three hundred thirty-two bereaved children and adolescents (aged 8-18; 56.9 % girls) who all received some form of psychosocial support after their loss, completed self-report measures of PTSD, together with measures tapping demographic and loss-related variables, depression, prolonged grief, and functional impairment. Parent-rated indices of impairment were also collected. We first evaluated the fit of six alternative models of the factor structure of PTSD symptoms, using confirmatory factor analyses. Outcomes showed that the 4-factor numbing model from King et al. (Psychological Assessment 10, 90-96, 1998), with distinct factors of reexperiencing, avoidance, emotional numbing, and hyperarousal fit the data best. Of all participants, 51.5 % met DSM-IV criteria for PTSD. PTSD-status and scores on the PTSD factors varied as a function of age and gender, but were unrelated to other demographic and loss-related variables. PTSD-status and scores on the PTSD factors were significantly associated symptom-levels of depression, prolonged grief, and functional impairment. Findings complement prior evidence that the DSM-IV model of the factor structure of PTSD symptoms may not represent the best conceptualization of these symptoms and highlight the importance of addressing PTSD symptoms in children and adolescents seeking help after bereavement.

Distinctiveness of symptoms of prolonged grief, depression, and post-traumatic stress in bereaved children and adolescents.

Studies among adults have shown that symptoms of prolonged grief disorder (PGD) are distinct from those of bereavement-related depression and post-traumatic stress-disorder (PTSD). This study was an attempt to replicate this finding in two distinct samples of bereaved children (N = 197; aged 8-12 years) and adolescents (N = 135; 13-18 years), confronted with the death of a parent, sibling or other close relative. Using confirmatory factor analyses, we compared the fit of a one-factor model with the fit of a three-factor model in which symptoms formed three distinct, correlated factors. In both samples, findings showed that the model in which symptoms of PGD, depression, and PTSD loaded on separate factors was superior to a one-factor model and displayed excellent model fit. Summed scores on the PGD, depression, and PTSD items were significantly associated with functional impairment, attesting to the concurrent validity of the PGD, depression, and PTSD factors. The current findings complement prior evidence from adult samples that PGD is a distinct syndrome and suggest that PGD symptoms should be addressed in the assessment and treatment of bereaved children and adolescent seeking help following their loss.

Psychometric properties of the Dutch Inventories of Prolonged Grief for Children and Adolescents.

UNLABELLED: A significant minority of bereaved adults develops prolonged grief disorder (PGD), a syndrome encompassing debilitating symptoms of grief distinct from depression and anxiety. Few studies have examined the phenomenology and correlates of PGD among children and adolescents. In part, this is due to the lack of a psychometrically sound questionnaire to assess PGD symptoms in these groups. Based on an adult measure of PGD, we developed two questionnaires of PGD symptoms for children and adolescents named the Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A), respectively. Psychometric properties of these measures were examined in three samples, including mostly parentally bereaved children (aged 8-12 years, total sample n = 169) and adolescents (aged 13-18 years, total sample n = 153). First, findings showed that items of the IPG-C and IPG-A represented one underlying dimension. Second, the internal consistency and temporal stability of both questionnaires were adequate. Third, findings supported the concurrent validity (e.g., significant correlations with measures of depression and post-traumatic stress-disorder [PTSD]), convergent and divergent validity (stronger correlations with similar questionnaires of 'traumatic grief' than with two dissimilar questionnaires of 'ongoing presence' and 'positive memories') and incremental validity (significant correlations with an index of functional impairment, even when controlling for concomitant depression and PTSD) of the IPG-C and IPG-A. This report provides further evidence of the clinical significance of PGD symptoms among children and adolescents and promising psychometric properties of questionnaires that can be used to assess these symptoms. KEY PRACTITIONER MESSAGE: The Inventory of Prolonged Grief for Children (IPG-C) and Inventory of Prolonged Grief for Adolescents (IPG-A) were developed to be able to assess symptoms of Prolonged Grief Disorder (PGD) among children and adolescents. In different samples, the internal consistency, temporal stability, and concurrent and construct validity of these questionnaires were found to be adequate. The IPG-C and the IPG-A can be used in research examining causes and consequences of PGD, and the effectiveness of bereavement interventions for children and adolescents. This study provides further evidence of the existence and clinical significance of PGD symptoms among children and adolescents and supports the inclusion of a new category for bereavement-related disorders in DSM-5.