See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/23458000

Childhood Traumatic Grief: A Multi-Site Empirical

Examination of the Construct and its Correlates

Article  in  Death Studies · February 2008

DOI: 10.1080/07481180802440209 · Source: PubMed

CITATIONS READS

41 314

8 authors, including:

Lisa Amaya-Jackson Heike Thiel de Bocanegra

Duke University Medical Center University of California, Irvine
56 PUBLICATIONS   2,978 CITATIONS    95 PUBLICATIONS   952 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Medi-Cal Managed Care Medical Record Review on Family Planning Services View project

Medicaid managed care medical record review View project

All content following this page was uploaded by Heike Thiel de Bocanegra on 26 March 2015.

The user has requested enhancement of the downloaded file.

This article was downloaded by: [University of California, San Francisco]
On: 25 March 2015, At: 20:27
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,
UK

Death Studies
Publication details, including instructions for
authors and subscription information:
http://www.tandfonline.com/loi/udst20

Childhood Traumatic Grief:

A Multi-Site Empirical
Examination of the Construct
and its Correlates
a b
Elissa J. Brown , Lisa Amaya-Jackson , Judith
c d
Cohen , Stephanie Handel , Heike Thiel De
e f g
Bocanegra , Eileen Zatta , Robin F. Goodman &
c
Anthony Mannarino
a
St. John's University , Queens, New York, USA
b
Duke University , Durham, North Carolina, USA
c
Allegheny General Hospital , Pittsburgh,
Pennsylvania, USA
d
Wendt Center for Loss and Healing , Washington,
DC, USA
e
University of California San Francisco , San
Francisco, California, USA
f
Children Who Witness Violence Program, Mental
Health Services , Cuyahoga County, Cleveland, Ohio,
USA
g
A Caring Hand, The Billy Esposito Beareavement
Center , New York, New York, USA
h
Allegheny General Hospital , Pittsburgh,
Pennsylvania, USA
Published online: 15 Nov 2008.

To cite this article: Elissa J. Brown , Lisa Amaya-Jackson , Judith Cohen ,

Stephanie Handel , Heike Thiel De Bocanegra , Eileen Zatta , Robin F. Goodman
& Anthony Mannarino (2008) Childhood Traumatic Grief: A Multi-Site Empirical
Examination of the Construct and its Correlates, Death Studies, 32:10, 899-923, DOI:
10.1080/07481180802440209
 To link to this article: http://dx.doi.org/10.1080/07481180802440209

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the
information (the “Content”) contained in the publications on our platform.
However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness,
or suitability for any purpose of the Content. Any opinions and views
expressed in this publication are the opinions and views of the authors, and
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

are not the views of or endorsed by Taylor & Francis. The accuracy of the
Content should not be relied upon and should be independently verified with
primary sources of information. Taylor and Francis shall not be liable for any
losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or
indirectly in connection with, in relation to or arising out of the use of the
Content.

This article may be used for research, teaching, and private study purposes.
Any substantial or systematic reproduction, redistribution, reselling, loan,
sub-licensing, systematic supply, or distribution in any form to anyone is
expressly forbidden. Terms & Conditions of access and use can be found at
http://www.tandfonline.com/page/terms-and-conditions
 Death Studies, 32: 899–923, 2008
Copyright # Taylor & Francis Group, LLC
ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481180802440209

CHILDHOOD TRAUMATIC GRIEF: A MULTI-SITE

EMPIRICAL EXAMINATION OF THE CONSTRUCT
AND ITS CORRELATES
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

ELISSA J. BROWN
St. John’s University, Queens, New York, USA
LISA AMAYA-JACKSON
Duke University, Durham, North Carolina, USA
JUDITH COHEN
Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
STEPHANIE HANDEL
Wendt Center for Loss and Healing, Washington, DC, USA
HEIKE THIEL DE BOCANEGRA
University of California San Francisco, San Francisco,
California, USA
EILEEN ZATTA
Children Who Witness Violence Program, Mental Health Services,
Cuyahoga County, Cleveland, Ohio, USA
ROBIN F. GOODMAN
A Caring Hand, The Billy Esposito Beareavement Center, New York,
New York, USA
ANTHONY MANNARINO
Allegheny General Hospital, Pittsburgh, Pennsylvania, USA

Received 1 April 2006; accepted 12 July 2006.

The project was a result of the collaborative efforts of its authors under the support and
guidance of the National Child Traumatic Stress Network, funded by the Substance Abuse
and Mental Health Services Administration. We also want to acknowledge granting
agencies that have funded the work of the various authors, including the Silver Shield Foun-
dation. We thank Megan Doyle and Laura Maberry for their assistance with this manuscript.
We dedicate this project to the youth and caregivers who participated, and their deceased
significant others. At the time of the study, Dr. Thiel de Bocanegra was Vice-President of
Research and Evaluation at Safe Horizon.
Address correspondence to Dr. Elissa Brown, Associate Professor of Psychology,
Marillac Hall, St. John’s University, 8000 Utopia Parkway, Queens, NY 11439.

899
 900 E. J. Brown et al.

This study evaluated the construct of childhood traumatic grief (CTG) and its
correlates through a multi-site assessment of 132 bereaved children and
adolescents. Youth completed a new measure of the characteristics, attributions,
and reactions to exposure to death (CARED), as well as measures of CTG,
posttraumatic stress disorder (PTSD), depression, and anger. CTG was distinct
from but highly correlated with PTSD, depression, and, to a lesser degree, anger.
In contrast to a recent study of complicated grief, CTG severity was significantly
associated with the degree to which the death was viewed as traumatic. CTG was
also associated with caregivers’ emotional reaction at the time of the death and
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

caregivers’ current sadness. Clinical implications and recommendations for future

research are discussed.

Bereavement is a ubiquitous experience, even for children. Every

year, approximately 4% of children experience the death of a
parent (Social Security Administration, 2000). By 21 years of age,
over half of all participants in a representative inner-city sample
had experienced the sudden unexpected death of a close relative or
friend; traumatic death was the most frequent traumatic experience
reported by this cohort (Breslau, Wilcox, Storr, Lucia, & Anthony,
2004). The leading causes of death for men and women ages
35–54, most of whom are parents, are heart attacks, homicide, suicide,
traffic accidents, and other accidents (World Health Organization,
1991). Although most children cope well even after sudden death,
some research has indicated that children bereaved by parental death
experience increased rates of psychiatric problems in the first two
years after the death (e.g., Cerel, Fristad, Verducci, Weller, & Weller,
2006). However, empirical research is limited about the range of
‘‘normal’’ children’s grief reactions, and, at what point, if any, these
reactions enter into a range that could be considered ‘‘pathological’’
(i.e., severe enough to warrant clinical intervention).

Complicated Grief and Childhood Traumatic Grief

One such clinical syndrome, complicated grief (CG), has been

described in adults (Prigerson & Jacobs, 2001). CG includes intense
longing and searching for the deceased, intrusive thoughts of the
deceased, purposelessness and futility, numbness and detachment,
difficulty accepting the death, lost sense of security and control,
and anger and bitterness over the death. CG has been shown to
be distinct from depression and PTSD (Boelen, van den Bout, &
de Keijser, 2003).
 Understanding Childhood Traumatic Grief 901

Dialogue is ongoing in the child literature about the defining

features of complicated or traumatic grief and how to assess it. Two
somewhat overlapping constructs are being tested currently; differ-
ences in these constructs may reflect their conceptualization from
different ends of the developmental spectrum. The first construct
emerged from research on adult CG, described above, and pro-
poses that the same condition that exists in adults exists in children.
In this construct, separation distress and yearning (i.e., typical adult
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

CG symptoms) are the central features of the condition, whereas

potentially traumatic aspects of the death are not. This construct
has been tested using a child-modified version of the Inventory
of Complicated Grief (ICG–R; which was originally validated for
adult CG). Studies related to this construct have included a cohort
of adolescent survivors of suicide (Melham et al., 2004) and a
recently published study of 7–18 year olds whose parents died
from suicide, accidents, and sudden medical conditions (Melham,
Moritz, Walker, Shear, & Brent, 2007). Importantly, as the mean
age shifted downward from 18.3 years (Melham et al., 2004) to
13.3 years (Melham et al., 2007), the criteria for CG also shifted
to include a stronger emphasis on avoidance symptoms and to
exclude searching for the deceased.
A second construct is that of childhood traumatic grief (CTG),
which arose from early child development and child trauma
treatment research. CTG is conceptualized as occurring when
children whose loved ones die in circumstances that are subjec-
tively traumatic develop trauma symptoms, which impinge on
these children’s abilities to engage in the typical tasks of grieving
(Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002; Layne,
Goodman, Brown, & Farber, in press; Pynoos & Nader, 1990;
Salloum & Vincent, 1999). CTG has been assessed using the
Extended Grief Inventory (EGI; Layne, Savjak, Saltzman, &
Pynoos, 2001; see also Brown & Goodman, 2005). The EGI
includes items that overlap with the construct of CG as well as
additional items related to trauma symptoms that impinge on the
child’s ability to negotiate typical tasks of grieving. The CTG con-
struct has been explored by several independent research teams
using a variety of cohorts, including adolescents exposed to war
in Bosnia (Layne et al, 2001), children and adolescents experienc-
ing deaths due to a variety of causes (Cohen, Mannarino, &
Knudsen, 2004; Cohen, Mannarino, & Staron, 2006; Salloum &
 902 E. J. Brown et al.

Vincent, 1999), preschoolers experiencing the death of parents due to

family violence (Lieberman, Compton, Van Horn & Ippen, 2003),
and children whose parents died in the line of duty on September
11th, 2001 (Brown & Goodman, 2005).
Although the groups researching CG and CTG are continuing
to gather data using somewhat different instruments, their data
agree on three crucial points: First, there is a significant correlation
between CG=CTG and PTSD symptoms. Melham et al. (2007)
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

documented a correlation of .62 with between the ICG–R and

PTSD symptoms assessed via diagnostic interview. Brown and
Goodman (2005) found an inter-item correlation between the
EGI-CTG factor and PTSD symptoms of .73. Second, despite these
high correlations, CG=CTG is a distinct entity from PTSD. Con-
trolling for depression, anxiety and PTSD scores, Melham et al.
(2007, p. 497) found that CG scores remained significantly corre-
lated with functional impairment, suggesting that CG is a distinct
clinical dimension from the other entities. In two treatment studies,
Cohen et al. (2004, 2006) demonstrated that during a trauma-
focused treatment module, both PTSD and CTG scores signifi-
cantly improved, whereas during a grief-focused treatment mod-
ule, only CTG scores significantly improved. This finding
provided construct validity for CTG as a distinct clinical entity
from PTSD and preliminary support for phase-oriented treatment
for CTG. Third, type of death is not a correlate of CG=CTG sever-
ity (Cohen et al., 2004, 2006; Melham et al., 2007). These similari-
ties and the overlap in items on the EGI and ICG–R suggest that
childhood CG and CTG may be more similar than different.
Although empirical literature on CTG is emerging, our under-
standing of the epidemiology, etiology, and clinical characteristics
of CTG is limited.

Risk Factors Associated with Developing CTG

A number of factors may increase the likelihood of children devel-

oping CTG following a death. Risk factors for CTG may be con-
ceptualized temporally (i.e., before, during, or after the death).
They also can be conceptualized as occurring in certain critical
domains (e.g., cognitive, developmental, familial, or ecological
contexts). A full discussion of these potential risk factors is beyond
the scope of this paper; nevertheless, a complex interplay of these
 Understanding Childhood Traumatic Grief 903

factors, along with inherent resiliency, may determine how any

child responds to the death of a loved one. A better understanding
of certain important risk factors may enable us to better identify
children who are at risk of developing CTG and to develop
preventive interventions.

Pre-Death
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

Past trauma exposure places children at greater risk to develop PTSD

symptoms following a current trauma (Pine & Cohen, 2002). Simi-
larly, exposure to previous deaths of significant others may be a risk
factor for later mental health problems (Worden, 1996).

Death Characteristics

Characteristics of the death itself may be vulnerability factors for

CTG. A few studies (Dyregrov, Nordranger, & Dyregrov, 2003;
Kaltman & Bonnano, 2003; Momartin, Silove, Manicavasagar, &
Steel, 2004) have demonstrated that more violent causes of death
(e.g., interpersonal violence) predict higher rates of PTSD and
depressive symptoms among bereaved adults than less violent causes
(e.g., medical problems). Among children, more violent causes of
death also made the grieving process qualitatively more difficult
and prolonged. Closer relationships with the deceased are associated
with higher rates of suicidality, PTSD, substance abuse, agoraphobia,
and other severe mental health symptoms among bereaved children
(Brent et al., 1995; Salloum & Vincent, 1999; Thompson, Norris, &
Ruback, 1998). Perceptions of life threat at the time of interpersonal
violence are associated with children’s internalizing and externalizing
symptoms (Brown & Kolko, 1999). Children who witness physical
distress in their dying parents have greater mental health difficulties
than children who do not observe such distress (Saldinger, Cain, &
Porterfield, 2003). In contrast, the extent of children’s knowledge
about the details of their parents’ death and seeing the scene of the
death may not affect CG scores (Melham et al., 2007).

Immediate Post-Death

Little information is available about risk or protective factors for

children immediately following the death of a loved one. Melham
 904 E. J. Brown et al.

et al. (2007) found that children’s involvement in removing the per-

sonal effects of the deceased and attendance at funerals did not
increase children’s CG scores.

Cognitive Domain

The meaning that children ascribe to the death is an important

domain to consider. Children, like adults, may question their faith
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

or conversely depend on it more strongly, wish to seek revenge, or

develop rescue fantasies (Layne et al., 2001). Melham et al. (2007)
documented that youth who felt that others were accountable for
their parents’ deaths or that others blamed them for the death
had significantly higher CG scores.

Developmental Domain

In considering the impact of deaths on children, it is crucial to be

attentive to developmental factors. For young children, the parent–
child relationship is by nature a strongly dependent one, in which
death ‘‘is traumatic in its own right because the child does not have
the emotional and coping mechanism to maintain . . . a sense of self
while undergoing the grieving process’’ (Lieberman, Compton,
Van Horn & Ippen, p. 3). Children are not small adults; they
experience distress but manifest it in developmentally distinct
ways. As Melham et al. (2007) have begun to document for CG,
when younger children are included in assessment studies, dimen-
sional or diagnostic criteria may begin to shift from those found in
adult cohorts.

Familial Domain

The role of parental and other emotional support both at the time
of the death and subsequently may be crucial to children’s
response. For many children, death represents the ultimate uncer-
tainty, loss of safety and threat, and as children mature they
become more, rather than less, able to understand the permanency
of death, and thus more able to recognize the threat (Lieberman
et al., 2003). Parents and other caretakers can provide a protective
shield for children at this vulnerable time, if they are able to con-
tain their own emotional reaction, but for many children, this is not
 Understanding Childhood Traumatic Grief 905

the case. Parental emotional support has been found to predict

children’s adjustment following diverse traumatic events (Pine &
Cohen, 2002). Nevertheless, following violent deaths, caretakers
and parents tend to be less able to provide emotional support to
children (Clements & Burgess, 2002). Lin, Sandler, Ayers,
Wolchik, and Luecken (2004) found that children’s resilience
following a caregiver’s death was positively predicted by the sur-
viving caregiver’s provision of warmth and discipline, and nega-
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

tively predicted by caregiver mental health problems.

None of the above studies included measures of CTG symp-
toms. The current study attempted to explore the aforementioned
relations within the constraints placed on conducting such a study
in five distinct community- and university-based child bereave-
ment and trauma centers. The inclusion of five metropolitan set-
tings provides a diversity of demographic characteristics, causes
of death, and recruitment strategies—all within a shared concep-
tual framework of trauma and bereavement issues in children
and adolescents.
In the present study, we examined several of the above factors
as clinical correlates of CTG. We hypothesized the following: (a)
CTG would be significantly correlated with PTSD, depression,
and anger; (b) children with previous trauma and bereavement his-
tories would be more likely to develop CTG than children without
previous trauma history; (c) the more ‘‘traumatic’’ the circum-
stances of the loved one’s death, the greater the CTG symptoms.
In particular, children whose loved one died from violent circum-
stances, were close in relationship to that loved one, perceived per-
sonal life threat at the time of the death, and witnessed the actual
moment of death would have greater symptoms of CTG; and (d)
caregivers’ emotional distress following the death would be posi-
tively associated with children’s level of CTG.

Method

Participants

The present study involved 155 children and adolescents who had
experienced the death of a significant other and were considering
mental health treatment for bereavement. For most of the children,
the deceased was a family member. Children were recruited from
 906 E. J. Brown et al.

five sites, all of which are located in metropolitan areas. The five
sites have been participants in the Substance Abuse and Mental
Health Services Administration’s (SAMHSA) National Child
Traumatic Stress Network, a collaboration of research and
community-based institutions designed to increase the access and
quality of mental health services for children exposed to trauma.
The sites are university-based (n ¼ 2) and community-based
(n ¼ 3) treatment programs for traumatized children. Referral
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

sources varied for the participating sites and included emergency

services (e.g., fire department), child protective services, schools,
crime victims’ compensation programs, medical examiner’s office,
clergy, hospitals, community bereavement programs, and self-
referrals. Following approval by each program’s institutional
review board of recruitment and assessment protocols, participants
were offered participation and informed consent. All of the parti-
cipants who were asked to participate in the present study agreed
to complete the measures. Participating sites and their referral
patterns are described below:

1. A university-affiliated, outpatient child and adolescent psy-

chiatry program in Pennsylvania that specializes in evaluation,
treatment, and research in the area of child trauma and
traumatic grief. Children and their caregivers presented to
their clinic for treatment following the traumatic death of a
family member. Referrals were primarily from the patients
themselves, pediatricians, victim advocacy programs, and a
local community child bereavement support program.
2. A university-based traumatic bereavement program in New
York that collaborated with a private foundation to provide
evaluation and treatment to bereaved children whose fathers
worked for emergency services (fire department, police depart-
ment, port authority, emergency medical services) and died on
September 11th, 2001. Families were contacted at least six
months after the terrorist attacks and offered evaluations. A sub-
set of the participants in the project was included in this sample.
3. A community-based urban program in New York that pro-
vides concrete services (financial support, legal services for
court proceedings), individual counseling and group support
for family members of homicide victims. Children receive
support group and other services that help them to cope with
 Understanding Childhood Traumatic Grief 907

the loss of their family members. Case managers obtained

preliminary consent from the clients to be contacted for further
information about the study.
4. A community-based urban program in Ohio that provides
specialized crisis intervention, assessment, and follow-up
services to children and their families in the immediate after-
math of a traumatic death. Most referrals are made by the
police department or child protective services. For the present
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

investigation, families were provided with their standard

immediate response (i.e., face-to-face intake visits, usually com-
pleted within one month of the referral) and then offered
participation.
5. A community-based mental health center in Washington, DC,
that provides professional counseling and crisis response to
families, and training services for the community on trauma,
grief, and loss. Guardians were offered participation in the
study when they were registering their children for grief coun-
seling or the center’s annual grief camp. Referral sources
included schools, hospitals, medical examiner’s office, clergy,
U.S. Attorney’s office, Crime Victims Compensation Program,
and child protective services.

Children ages 7–18 years and their caregivers who were part-
icipants in the aforementioned programs were invited to partici-
pate in the study. Demographic data are presented in Table 1.
Children were excluded if they had severe developmental delays,
active psychosis, or behavior deemed dangerous to themselves
or others, and referred for immediate and intensive evaluation=
treatment. Of the 155 children interviewed, 132 completed all of
the items on the central measures on bereavement experiences
(Characteristics, Attributions, and Responses after Exposure to
Death, described below) and CTG symptoms (Extended Grief
Inventory, described below). Twenty-three children were lost to
missing data.

Measures

The following self-report instruments were used to measure

children’s experiences and symptoms.
 908 E. J. Brown et al.

TABLE 1 Demographic Information

Demographics Frequency Percent

Gender of child
Female 64 48
Male 68 52
Race of child
Caucasian 42 32
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

African American 77 58
Biracial 13 10
Lived with deceased at time of the death 73 56
People child lives with now (not
mutually exclusive)
Parent 96 73
Sibling 47 36
Aunt or uncle 18 14
Grandparent 23 17
Close friend 5 4
Other (cousin, foster parent, etc.) 29 29

Note. Mean age at time of evaluation ¼ 11.2 (SD ¼ 2.7; range 7–18 years). N ¼ 132. Lower
n’s due to missing data.

The Characteristics, Attributions, and Responses after

Exposure to Death, Youth and Parent versions (CARED-Youth
Report; CARED-Parent Report; Brown, Cohen, Amaya-Jackson,
Handel, & Layne, 2003) were developed for this study. Measure
content is listed in Appendix A. The CARED-Youth Report is a
39-item self-report measure with sections to assess: (a) child
exposure to previous deaths, (b) child report of the most difficult
death, (c) perceptions and peri-traumatic characteristics of most
difficult death (items 14–27 in Appendix A), (d) family relation-
ships and caregivers’ emotional functioning (items 34–35), and
(e) participation in death-related rituals (items 28–31, 37–39;
Handel et al., 2004). The CARED-Parent Report assesses the care-
givers’ perceptions of the most difficult death and children’s
trauma history. CARED-Parent Report provided the length of time
since death and number of traumas to which children were
exposed prior to the death for the current study.
The UCLA=BYU Extended Grief Inventory (EGI; Layne
et al., 2001) is a 28-item, self-report measure for children and
 Understanding Childhood Traumatic Grief 909

adolescents of the frequency with which traumatic grief reactions

have been experienced during the past 30 days. All items are self-
reported on a 5-point Likert scale from 0 (almost never, less than
once a month) to 4 (always, several times a day). The EGI contains
three factor-analytically derived subscales: Traumatic Grief
(TG), Ongoing Presence (OP), and Positive Memories (PM;
Brown & Goodman, 2005). For the present study, only the
TG subscale was used. The TG subscale includes 23 items that
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

measure the impact of traumatic stress on the ability to tolerate

memories of the deceased (e.g., ‘‘I don’t talk about the person
who died because it is too painful to think about him=her,’’)
but also includes several items that overlap with the CG con-
struct (e.g., ‘‘I can’t bring myself to accept that he=she is really
dead’’; ‘‘I feel that my life is empty without him=her’’; ‘‘I feel
more irritable since he=she died’’; ‘‘I keep wanting to look for
the person who died even when I know he=she is not there’’).
Brown and Goodman (2005) found strong internal consistency
(Cronbach’s a ¼ .94), and good criterion-referenced validity
(r ¼ .73 with a measure of PTSD, r ¼ .54 with a measure of
general anxiety, r ¼ .49 with a measure of depression) for the
EGI-TG subscale. The Cronbach’s alpha for the present sample
(N ¼ 132) was .91.
The Child PTSD Symptom Scale (CPSS; Foa, Johnson,
Feeny, & Treadwell, 2001) is a 24-item self-report measure of
PTSD symptoms and functional impairment developed for chil-
dren and adolescents. This instrument has high test–retest
reliability and convergent validity with a structured diagnostic
interview (Foa et al., 2001). The coefficient alpha in this sample
(N ¼ 132) was .87.
The Mood and Feelings Questionnaire (MFQ; Angold et al.,
1995) is 42-item, youth self-report measure of depressive symp-
toms. The MFQ has been shown to have a high concordance with
a diagnosis of major depressive disorder on structured diagnostic
interviews, and has strong validity and reliability. The coefficient
alpha for the present sample is .94.
The Children’s Inventory of Anger (ChIA; Nelson & Finch,
2000) is a 39-item standardized measure of children’s anger, using
a 4-point, visual-aided Likert scale. Scores are transposed based on
age and gender to a t-score distribution (M ¼ 50; SD ¼ 10). The
total score was used in the present study.
 910 E. J. Brown et al.

Procedures

Children referred for bereavement issues to the participating sites

or their affiliate programs were invited to participate in the study.
No recruitment advertisements were placed. Upon referral, the
children and their caregiver(s) were screened by phone or in per-
son for appropriateness for the study. Informed parental consent
and child assent were conducted prior to participation in the study.
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

Data were gathered in a manner consistent with the American

Psychological Association’s ethical standards (American Psychologi-
cal Association, 2002).
Participants completed the study instruments during the initial
phase of client services, prior to any treatment for their traumatic
grief and related symptoms. The ability to receive services was
not dependent on study participation. Therapists or research assis-
tants administered the packets after having been trained by the
representative author from each site. Assessment packets were
completed within a window of three sessions so as to minimize
the influence of clinical intervention on participant responses.

Data Analysis

Descriptive statistics were run on the CARED and psychiatric

symptom measures. To assess whether CTG was significantly cor-
related with PTSD, depression, and anger (Hypothesis 1), we con-
ducted zero-order correlation coefficients. To evaluate the relative
importance of children’s demographics, characteristics of chil-
dren’s trauma and bereavement history, cause of most difficult
death, characteristics of the most difficult death (including relation-
ship to deceased, perceived life threat, peri-traumatic aspects),
engagement in religious practices, length of time since the most
difficult death, and caregiver and family reactions as correlates
of CTG (Hypotheses 2–4), a multiple regression analysis was
planned with each of the aforementioned constructs entered as
blocks of predictor variables and EGI-TG as the dependent
variable. Before conducting the multiple regression analysis,
descriptive statistics were computed to compare demographic,
recruitment, and bereavement variables among the sites. Given
the variability in demographic characteristics among sites
 Understanding Childhood Traumatic Grief 911

heterogeneity of variance was a concern. To empirically examine

homogeneity of variance-covariance matrices across sites, a discri-
minant function analysis (DFA) was conducted with CARED items
and EGI-TG as the predictor variables and site as the criterion
variable. Box’s M tests were computed for each predictor; signifi-
cant findings revealed heterogeneity across sites (specifically, a
significant difference between the university-based traumatic
bereavement program in New York and all other sites) and thus,
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

lack of robust results. Thus, multiple regression analyses were con-

ducted separately, one with all homogenous sites run together and
one with the site that was distinct from the homogenous sites. Zero-
order and semi-partial correlations are compared between the two
regression analyses.

Results

Descriptive Statistics and Criterion Validity

Descriptive statistics were calculated for the continuous and categ-

orical items from CARED-Youth and Parent reports hypothesized
to be related to CTG (see Table 2). Table 2 also includes descrip-
tive statistics for the psychiatric symptom measures. The means
and standard deviations for the psychiatric symptom measures
are consistent with the descriptive statistics from other samples of
children exposed to trauma (Cohen et al., 2004; Foa et al., 2001;
Stein et al., 2003).
Zero-order correlations were conducted to evaluate the cri-
terion validity of the EGI-TG subscale. As expected, the EGI-TG
subscale was highly correlated with the CPSS (r ¼ .78; p < .01)
and MFQ (r ¼ .69; p < .01), and somewhat correlated with the
ChIA (r ¼ .24; p < .05).

Demographic, Recruitment, and Bereavement Differences among Sites

As presented in Table 3, descriptive analyses were conducted

between site and demographic variables, time since death, and
cause of most difficult death. Racial=ethnic differences appear to
exist among the sites, with the largest difference found between
the two New York sites—one whose child participants were
100% Caucasian, and the other whose participants were primarily
 912 E. J. Brown et al.

TABLE 2 Descriptive Statistics

Psychiatric symptom measures n M SD

EGI-TG 127 44.5 19.5

CPSS 114 18.3 10.8
MFQ 100 21.2 14.8
ChIA 91 51.4 10.0
CARED
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

Number of significant others who died 124 2.2 1.2

Number of previous traumas 98 0.8 1.1
Length of time since the death (months) 115 20.8 23.1
Peri-traumatic aspects of death1 125 1.7 1.7
Caregivers’ emotional reactions to death2 124 1.4 1.1
Degree to which people at home fight with each other3 126 1.3 1.3
Degree to which people at home are sad3 125 1.7 1.2
Frequency %

Cause of most difficult death

Medical 55 42
Interpersonal violence 40 31
Terrorism 16 10
Accident 6 5
Most difficult death
Parent 88 67
Sibling 15 11
Other relative (aunt, uncle, grandparent) 27 21
Other 2 2
Perceived life threat
In danger 30 75
Not in danger 90 25
Child attended memorial service
Yes 90 30
No 39 70
Child saw body in casket
Yes 93 71
No 38 29
Child attended church
Yes 97 74
No 34 26

Note. EGI-TG ¼ Extended Grief Inventory-Traumatic Grief subscale; CPSS ¼ Child

PTSD Symptom Scale; MFQ ¼ Mood and Feelings Questionnaire; ChIA ¼ Children’s
Inventory of Anger;. CARED ¼ Characteristics, Attributions, and Responses after Exposure
to Death. 1 ¼ sum of endorsed items 23–27 (saw person when about to die, there when per-
son died, rescue attempts, attempts to revive, saw body after death). 2 ¼ sum of endorsed
from item 34 (‘‘Cried, screamed, ‘‘fell out’’ or fainted, got physically ill, was in shock or
so surprised they didn’t know how to react, nothing, was calm, did something like hugging,
other’’). 3 ¼ scored from 0 (never) to 4 (almost always).
 Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

TABLE 3 Characteristics of Child Participants Across the Five Sites

Age Gender Race Loved one’s cause of death

Site n M (SD) Range n % n % n %

Pennsylvania 26 12.2 (3.3) (7–18) 11 42 Female 17 65 Caucasian; 14 58 Medical Cause

university-based
outpatient
program
15 58 Male 7 27 African 4 17 Interpersonal
American Violence
0 0 Terrorism
2 8 Other 6 25 Suicide
New York 19 11.1 (3.1) (7–17) 9 47 Female 19 100 Caucasian 0 0 Medical Cause
university-based
site
10 53 Male Caucasian 0 0 Interpersonal
Violence
19 100 Terrorism
0 0 Suicide
New York 12 10.3 (2.4) (7–15) 8 67 Female 0 0 Caucasian 0 0 Medical Cause
community- 8 67 African 12
based site 4 American 0
33 Other 0
4 33 Male 8 67 African 12 100 Interpersonal
American Violence
0 0 Terrorism
4 33 Other 0 0 Suicide

913
(Continued )
 Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

914
TABLE 3 Continued

Age Gender Race Loved one’s cause of death

Site n M (SD) Range n % n % n %

Ohio 7 12.3 (3.7) (7–17) 4 57 Female 1 14 Caucasian 0 0 Medical Cause

community- 3 4
based site 2
3 43 Male 4 57 African 5 71 Interpersonal
American Violence
0 0 Terrorism
2 29 Other 2 29 Suicide
Washington, DC 68 10.9 (2.2) (7–17) 32 47 Female 5 7 Caucasian 35 57 Medical Cause
community- 36 58
based site 5
36 53 Male 58 85 African 23 37 Interpersonal
American Violence
0 0 Terrorism
5 4 Other 4 7 Suicide

Note. Medical Cause includes medical conditions due to catastrophic illness and cardiac arrest. Interpersonal Violence includes murder by domestic
violence, community violence, and school violence. Accidents include both motor vehicle accidents and other unintended injury.
 Understanding Childhood Traumatic Grief 915

African American, with 0% Caucasians. Regarding the cause of

the most difficult death, 100% of the children from the univer-
sity-based New York site identified terrorism as the cause of death,
whereas interpersonal violence was the most common cause for
the community-based New York and Ohio sites. Medical ill-
ness was most frequently endorsed for the Pennsylvania and
Washington, DC sites.
A DFA was conducted with a priori predictors of CTG (age of
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

child, gender, race, number of significant others who died, number

of previous traumas, cause of most difficult death, relationship to
person who died, length of time since the death, peri-traumatic
aspects of the death, caregivers’ emotional reaction to the death,
degree to which people at home fight with each other and are
sad, child’s perceived life threat, child attended memorial services,
saw body in casket, attended church) and EGI-TG as the predictor
variables and site as the criterion variable. There were significant
differences in the variance=covariance matrices across sites,
Box’s M ¼ 624, F(171,3819) ¼ 2.12, p < .001, with the New York
university-based program ranking differently than the New York
community-based program, Pennsylvania university-based pro-
gram, and DC community-based program. The Ohio community-
based program was dropped from the analyses due to insufficient
sample size.

Relations between Death Characteristics and Children’s Traumatic Grief

Based on the DFA results, a multiple regression analysis was con-

ducted with EGI-TG as the criterion variable, including the three
sites with similar variance-covariance matrices. Predictor variables
were entered in seven steps: (a) demographics (age, gender, race),
(b) characteristics of children’s history (number of significant
others who died and number of previous traumas), (c) cause of
most difficult death (dummy coded as suicide vs. interpersonal
violence and medical problem vs. interpersonal violence), (d) char-
acteristics of the most difficult death (parent vs. other relative died,
perceived life threat at time of death, and peri-traumatic aspects of
the death), (e) religious practice (yes=no to children attended mem-
orial service, saw body in casket, and attends church), (f) time since
death, and (g) caregiver and family reactions (degree to which
people at home are sad and caregivers’ emotional reaction to the
 916 E. J. Brown et al.

death). As presented in Table 4, Step 4, characteristics of the most

difficult deaths, was significant and added 13% of the variance to
EGI-TG. Step 7, caregiver and family reactions, was significant and
added 10% of variance to EGI-TG. Steps 1 (5% of variance), 2
(4% of variance), 3 (0% of variance), 5 (1% of variance) and 6
(2% of variance) of the model did not reach significance. The total
variance account for by the model was 35%. For the total model
(see Table 5), child’s perception of life threat at the time of the
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

death, time since death, caregivers’ emotional reactions to the most

difficult death, and degree to which people at home are sad were
significantly associated with EGI-TG.
For the New York university-based site, sample size precluded
a multiple regression analysis. Instead, zero-order correlation
coefficients were computed. There was no variable for race
(because all children were Caucasian), no block for cause of most
difficult death (because all deaths were due to the events of

TABLE 4 Hierarchical Regression Analysis of Variables Predicting Traumatic

Grief for Sites with Similar Variance=Covariance Matrices

Variable R2 change F change df p value

Step 1: Demographics of the children Age .05 1.26 3, 75 .294

Gender Race
Step 2: Characteristics of children’s history .04 1.60 2, 73 .210
Number of significant others who died
Number of previous traumas
Step 3: Cause of most difficult death Suicide .00 .07 2, 71 .930
vs. interpersonal violence Medical
problem vs. interpersonal violence
Step 4: Characteristics of most difficult .13 3.75 3, 68 .015
death Parent vs. other relative died
Child’s perceived life threat Peri-
traumatic aspects of death
Step 5: Religious practice Child attended .01 .23 3, 65 .876
memorial services Child saw body in
casket Child attended chruch
Step 6: Time since death .02 2.07 1, 64 .155
Step 7: Caregiver and family reactions .10 2.98 3, 61 .038
Caregivers’ emotional reaction to death
Degree to which people at home fight
Degree to which people at home are sad
Total model .35 1.91 17, 61 .034
 Understanding Childhood Traumatic Grief 917

TABLE 5 Relations between Hypothesized Predictors and Combined Sites and

New York University-Based Site

EGI-Traumatic Grief

Sites with homogeneity

of variance NY university-
based site
Predictor Zero-order Semipartial Zero-order
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

Age
.09
.09
.26

Gender
.16
.12
.34
Race .09
.09 —
Number of significant .03
.02
.25
others who died
Number of previous traumas .18 .10 .34
Most difficult death due to .07 .07 —
medical problem
Most difficult death due to suicide .04 .04 —
Most difficult death was .24 .17 —
parent vs. other relative
Child’s perceived life threat .30 .23 .27
Peri-traumatic aspects of death .14 .12 .18
Child attended memorial services .01
.06 .61
Child saw body in casket
.04
.08 —
Child attended church
.10
.06
.18
Time since death
.18
.21
.62
Caregivers’ emotional .23 .23 .48t
reactions to death
Degree to which people
.01 .04 .06
at home fight
Degree to which people .22 .21 .56
at home are sad

Note. EGI ¼ Extended Grief Inventory. Sites with homogeneity of variance, n ¼ 79; NY
university-based site, n ¼ 13.

p < .05.

t < .10.

September 11th), no variable for relationship with person who

died (because only fathers were killed), and no variable for saw
body in casket (because none were able to do so). Zero-order
correlations are presented in Table 5. Like the larger model, time
since death, caregivers’ emotional reaction to the death and degree
to which people at home are sad were significantly correlated
with EGI-TG. In addition, attending a memorial service was
 918 E. J. Brown et al.

associated with higher EGI-TG scores than not attending a mem-

orial service.

Discussion

The major focus of this multi-site study was to determine whether

the characteristics, attributions, and reactions after exposure to
death would be associated with CTG. A model was proposed
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

and evaluated with 132 participants from varied backgrounds

and urban settings. Our findings provide some initial insight
regarding correlates of the development of CTG.
As hypothesized, symptoms of CTG correlated significantly
with symptoms of PTSD and depression. This finding both
supports the conceptualization of CTG and replicates previous
studies of CTG (Brown & Goodman, 2005; Layne et al., in press).
Interestingly, feelings and expressions of anger also appear to be
associated with CTG. This association may reflect the shared
negative affect with depression. Alternatively, Layne et al. (in
press) argued that vengefulness is an aspect of CTG warranting
further investigation.
The a priori model proposed that demographics, children’s
trauma and bereavement histories, cause of the most difficult
death, other characteristics of the most difficult death, religious
practice, time since the most difficult death, and caregivers’ func-
tioning would be predictive of CTG. The overall model accounted
for 35% of the variance in CTG. Characteristics of the most diffi-
cult death and caregivers’ functioning were significant blocks in
the regression analyses. In the overall model, children’s perceived
life threat, time since the most difficult death, caregivers’ emotional
reactions to the death, and degree of sadness in the home at the
time of the evaluation were associated with CTG.
The finding that children’s perceived life threat is related to CTG
is consistent with our current conceptualization of CTG. It may be the
traumatic aspects of the deaths, rather than the deaths themselves,
that are predictive of CTG. Thus, for children with CTG, traditional
bereavement interventions that focus on grief need to be expanded to
address trauma symptoms (Brown, Pearlman, & Goodman, 2004;
Cohen et al., 2004). Additional studies would be helpful to further
explore what aspects of traumatic deaths are most predictive of
CTG, as the CARED only included limited questions in this regard.
 Understanding Childhood Traumatic Grief 919

The amount of time since the most difficult death was inver-
sely related to CTG. This is consistent with findings from a recent
study that found significant negative correlations of CG scores with
duration since the death (Melham et al., 2007). Worden (1996)
found increases in anxiety and anger during the first year after
the death, but decreases by the two-year follow-up in grief and
self-esteem.
The finding that traumatic grief levels were strongly related to
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

the emotional reaction of the caregiver at the time of the death

and degree of sadness in the home supports the centrality of the
child–parent relationship, particularly after a death. Caregivers’
expression of strong, diverse emotions at the time of the death
may be a model of affect dysregulation for their children. Alterna-
tively, these extreme responses by caregivers may add to the
traumatic nature of the death (i.e., uncontrolled emotional out-
bursts may convey unpredictability and instability). Pervasive
sadness may model anhedonia and vegetative symptoms of
depression (e.g., psychomotor retardation). A home environment
defined by sadness may prevent children from moving through
the individual path of grieving, re-establishing an optimal develop-
mental trajectory. Additionally, caregiver distress and sadness may
interfere with effective parenting (Kwok et al., 2004) and, as a
result, increase CTG. More research is needed to understand the
influence of caregivers’ affect on children who have experienced
traumatic bereavement, especially considering cultural differences
in emotional expression.
In considering the caregiver impact on the development and
maintenance of CTG, professionals need to work with caregivers
to display emotions appropriately. In two pilot treatment studies
of CTG, Cohen et al. (2004, 2006) found that involving caregivers
in child-focused, cognitive behavioral therapy for CTG resulted in
decreases in their symptoms of PTSD and depression. Caregiver
improvement was associated with children’s reduction in CTG.
The New York university-based site was removed from the
analysis of the proposed model due to differences in the varian-
ce=covariance matrices. The New York university-based site
recruited middle-class families with (self-reported) strong support
systems and adaptive functioning prior to the World Trade Center
attacks on September 11th (Brown & Goodman, 2005). In
addition, pre-trauma mental health problems, found to be a
 920 E. J. Brown et al.

consistent predictor of response to current trauma (Fletcher, 2003),

were mostly absent in this sub-sample. Nevertheless, correlations
revealed a similar patterns of findings as the regression analysis.
Interestingly, only for this sub-sample, attending memorial services
was associated with higher CTG. Perhaps the variability in number
of memorial services attended and intensity of emotionality at the
memorial services was larger for the New York university-based
sample. Future studies on the influence of spirituality and religious
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

practice on CTG are warranted.

Study Limitations and Recommended Next Steps

Weaknesses of the present investigation limit generalizability of

findings. Sample sizes at some of the sites were small, resulting
in non-robust results. The age range of the sample was broad,
especially given the small sample size. Because some of the chil-
dren entered the study months or even years after the deaths,
CTG may be related to factors unrelated to the deaths. The
CARED-Youth and Parent Versions are in need of psychometric
testing. Although staff at each site was trained to administer the
assessment instruments, reliability was not confirmed.
In spite of the limitations of the present study, these findings
further clarify the construct of CTG. The traumatic aspects of the
deaths themselves and children’s perceptions of caregivers being
emotionally overwhelmed may characterize CTG. Studies with
larger sample sizes and diverse samples are needed to continue
to develop measures of traumatic death-related characteristics,
attributions, and responses, including CTG. Finally, future studies
that link assessment strategies and instruments for CG and CTG
would greatly contribute to the field’s understanding of whether
these are two different conditions, or a single clinical entity which
is currently being viewed from different vantage points.

References

American Psychological Association. (2002). Ethical principles of psychologists

and code of conduct. American Psychologist, 57, 1060–1073.
Angold, A., Costello, E. J., Messer, S. C., Pickles, A., Winder, F., & Silver, D.
(1995). The development of a short questionnaire for use in epidemiological
studies of depression in children and adolescents. International Journal of
Methods in Psychiatry Research, 5, 237–249.
 Understanding Childhood Traumatic Grief 921

Boelen, P. A., van den Bout, J., & de Keijser, J. (2003). Traumatic grief as a
disorder distinct from bereavement-related depression and anxiety: A repli-
cation study with bereaved mental health care patients. American Journal of
Psychiatry, 160, 1339–1342.
Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R.,
Schweers, J., & Roth, C. (1995). Posttraumatic stress disorder in peers of ado-
lescent suicide victims: Predisposing factors and phenomenology. Journal of
the American Academy of Child and Adolescent Psychiatry, 34, 209–215.
Breslau, N, Wilcox, H. C., Storr, C. L., Lucia, V. C., & Anthony, J. C. (2004).
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

Trauma exposure and posttraumatic stress disorder: A study of youths in

urban America. Journal of Urban Health, 81, 530–544.
Brown, E. J., Cohen, J. A., Amaya-Jackson, L., Handel, S., & Layne, C. (2003).
Characteristics and Responses upon Exposure to Death (CARED–Youth Report,
CARED–Parent Report). National Child Traumatic Stress Network.
Washington, DC: SAMHSA.
Brown, E. J. & Goodman, R. F. (2005). Childhood traumatic grief: An exploration
of the construct in children beveaved on September 11. Journal of Clinical
Child and Adolescent Psychology, 34, 248–259.
Brown, E. J. & Kolko, D. J. (1999). Child victims’ attributions about being physi-
cally abused: An examination of factors associated with symptom severity.
Journal of Abnormal Child Psychology, 27, 311–322.
Brown, E. J., Pearlman, M. Y., & Goodman, R. F. (2004). Facing fears and sad-
ness: Cognitive behavioral therapy for childhood traumatic grief. Harvard
Review of Psychiatry, 12, 187–198.
Cerel, J., Fristad, M. A., Verducci, J., Weller, R. A., & Weller, E. B. (2006). Child-
hood bereavement: Psychopathology in the 2 years postparental death.
Journal of the American Academy of Child & Adolescent Psychiatry, 45, 681–690.
Clements, P. T. & Burgess, A. W. (2002). Children’s response to family member
homicide. Family & Community Health, 25, 32–42.
Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood trau-
matic grief: A pilot study. Journal of the American Academy of Child & Adolescent
Psychiatry, 43, 1225–1233.
Cohen, J. A., Mannarino, A. P., & Staron, V. (2006). A pilot study of modified
cognitive-behavioral therapy for childhood traumatic grief (CBT-CTG).
Journal of the American Academy of Child & Adolescent Psychiatry, 45, 1465–1473.
Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., & Shipley, C. (2002).
Childhood traumatic grief: Concepts and controversies. Trauma Violence &
Abuse, 3, 307–327.
Dyregrov, K., Nordanger, D., & Dyregrov, A. (2003). Predictors of Psychosocial
distress after suicide, SIDS and accidents. Death Studies, 27, 143–166.
Fletcher, K. E. (2003). Childhood posttraumatic stress disorder. In E. J. Mash & R.
A. Barkley (Eds.), Child psychopathology (2nd ed.; pp. 330–371). New York:
Guilford Press.
Foa, E. B., Johnson, K. M., Feeny, N. C., & Treadwell, K. R. (2001). The Child
PTSD Symptom Scale: A preliminary examination of its psychometric
properties. Journal of Clinical Child Psychology, 30, 376–384.
 922 E. J. Brown et al.

Handel, S., Brown, E. J., Cohen, J., Amaya-Jackson, L., Thiel de Bocanegra, H., &
McGuire, S. (2004, April). Prevalence and correlates of children’s traumatic grief: A
collaborative study. Symposium conducted at the national meeting of The
National Center for Mental Health Promotion and Youth Violence Preven-
tion, Kansas City, MO.
Kaltman, S. & Bonnano, G. A. (2003). Trauma and bereavement : Examining the
impact of sudden and violent deaths. Anxiety Disorders, 17, 131–147.
Kwok, O., Haine, R.A., Sandler, I. N., Ayers, T. S., Wolchik, S. A., & Tein, J.
(2004). Positive parenting as a mediator of the relations between parental
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

psychological distress and mental health problems of parentally bereaved

children. Journal of Clinical Child and Adolescent Psychology, 34, 260–271.
Layne, C. M., Goodman, R. F., Brown, E. J., & Farber, M. L. (in press). A theor-
etical examination of childhood traumatic grief. Manuscript in process.
Layne, C. M., Savjak, N., Saltzman, W. R., & Pynoos, R. S. (2001). Extended Grief
Inventory. Unpublished psychological test, University of California, Los
Angeles.
Lin, K. K., Sandler, I. N., Ayers, T. S., Wolchik, S. A., & Luecken, L. J. (2004).
Resilience in parentally bereaved children and adolescents seeking preven-
tive services. Journal of Clinical Child and Adolescent Psychology, 33, 673–683.
Melham, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F. III, & Brent, D.
(2004). Traumatic grief among adolescents exposed to a peer’s suicide.
American Journal of Psychiatry, 161, 1411–1416.
Melham, N. M., Moritz, G., Walker, M., Shear, M. K., & Brent, D. (2007).
Phenomenology and correlates of complicated grief in children and ado-
lescents. Journal of the American Academy of Child & Adolescent Psychiatry, 46,
493–499.
Momartin, S., Silove, D., Manicavasagar, V., & Steel, Z. (2004). Complicated grief
in Bosnian refugees: Associations with posttraumatic stress disorder and
depression. Comprehensive Psychiatry, 45, 475–482.
Nelson, W. M. & Finch, A. J. (2000). Children’s Inventory of Anger. Los Angeles:
Western Psychological Services.
Pine, D. S. & Cohen, J. A. (2002). Trauma in children and adolescents: Risk and
treatment of psychiatric sequelae. Biological Psychiatry, 51, 519–531.
Prigerson, H. G. & Jacobs, S. C. (2001). Caring for bereaved patients. JAMA, 286,
1369–1376.
Pynoos, R. S. & Nader, K. (1990). Children’s exposure to violence and traumatic
death. Psychiatric Annals, 20, 334–344.
Saldinger, A., Cain, A., & Porterfield, K. (2003). Managing traumatic stress in chil-
dren anticipating parental death. Psychiatry: Interpersonal & Biological Processes,
66, 168–181.
Salloum, A. & Vincent, N. J. (1999). Community-based groups for inner city
adolescent survivors of homicide victims. Journal of Child and Adolescent Group
Therapy, 9, 27–45.
Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliott, M. N., &
Fink, A. (2003). A mental health intervention for schoolchildren exposed
to violence: A randomized controlled trial. Journal of the American Medical
Association, 290, 603–611.
 Understanding Childhood Traumatic Grief 923

Thompson, M. P., Norris, F. H., & Ruback, R. B. (1998). Comparative distress

levels of inner-city family members of homicide victims. Journal of Traumatic
Stress, 11, 223–242.
Worden, W. J. (1996). Children and grief: When a parent dies. New York: Guilford
Press.
Downloaded by [University of California, San Francisco] at 20:27 25 March 2015

View publication stats