Using multidimensional grief theory to explore the effects of deployment, reintegration, and death on military youth and families

Intergenerational coping: Examining how caregiver and child coping relate to resilience in bereaved children

The death of a loved one can have harmful effects on children's mental health, yet some bereaved children exhibit resilience. Various caregiver and child coping strategies, including active and avoidant coping, may affect the psychosocial functioning of bereaved children. The current study recruited 78 bereaved children aged 8-17 and one of their caregivers to explore: 1) how caregivers' coping strategies affect their child's coping strategies and resilience, and 2) associations between children's coping and their resilience. Results from the active coping mediation model revealed that children's active coping was significantly associated with their resilience, and caregivers' active coping was indirectly associated with children's resilience through children's active coping. The avoidant coping model was not significant. These preliminary findings highlight the importance of promoting active coping strategies among bereaved children and caregivers.

Death of a loved one: A potential risk factor for onset of functional seizures

Functional seizures (FS) are a symptom of Functional Neurological Disorder (FND), the second most common neurological diagnosis made worldwide. Childhood trauma is associated with the development of FS, but more research is needed to truly understand the effects of trauma on FS onset. A sample of 256 responses by adults with FS to the Childhood Traumatic Events Scale were analyzed using a Cox proportional hazard model. When investigating each unique childhood traumatic exposure and its associated self-reported severity together, experiencing death of a loved one and experiencing violence were significantly associated with FS onset, suggesting reduced time from trauma exposure to first FS. Death of a loved one in childhood is often overlooked as an influential risk factor for future development of serious mental illnesses such as FS. In this study we show death of a loved one in childhood should be considered as an influential traumatic experience and recommend FND researchers examine its prevalence in patient histories and the potential effects on attachment-related processes and clinical treatment formulations. We recommend future studies incorporate loss of a loved one during childhood (before age 18) in both quantitative and qualitative assessments of persons with FND.

When a parent dies: A scoping review of protective and risk processes for childhood bereavement

The death of a parent can have profound effects on child development. Yet, little is known about the individual and environmental processes that contribute to heterogeneity in child bereavement outcomes. A scoping review was conducted in samples of parentally bereaved children to identify key processes, synthesize results, and determine research gaps. This scoping review identified 23 studies (mainly from the United States), published between 1990 and 2023, that reported child (ages 3-22 years) individual and/or environmental protective and/or risk processes that contributed to bereavement outcomes. Individual processes (i.e., how children manage stressors and think about themselves/their environment) included child coping and perception of themselves and/or their environment. Environmental processes (i.e., contextual resources) included family, mentorship, and stress exposure. Findings can be used to apprise clinicians, families, and policymakers of the unique nature of childhood bereavement and to identify malleable processes to target in interventions designed to prevent problematic outcomes in bereaved children.

Protective Factors in the Context of Childhood Bereavement: Youth Gratitude, Future Orientation, and Purpose in Life

The objective of the study was to examine potential associations between positive youth development constructs (gratitude, future orientation, purpose in life) and psychological functioning (posttraumatic stress symptoms, depressive symptoms, maladaptive grief reactions) among bereaved youth and test whether these associations vary by age. A diverse sample of 197 clinic-referred bereaved youth (56.2% female; M = 12.36, SD = 3.18; 36.1% Hispanic, 23.7% White, 20.1% Black, 11.9% Multiracial, and 8.2% another race/ethnicity) completed self-report measures of psychological functioning and positive youth development constructs. Linear regression models indicated that gratitude and purpose were associated with lower posttraumatic stress and depressive symptoms among bereaved youth. Future orientation was associated with higher posttraumatic stress symptoms. Results were consistent across age. If replicated longitudinally, gratitude and purpose may be important protective factors against negative mental health outcomes in the aftermath of losing a loved one.

Caregiver behaviors associated with positive youth development among bereaved children

Grounded in Multidimensional Grief Theory, this study examined the cross-sectional associations between child-reported caregiver grief facilitation behaviors (ongoing connection, grief expression, existential continuity and support, grief inhibition/avoidance) and positive youth development outcomes (future orientation, gratitude, social responsibility) in treatment-seeking bereaved children ages 7 to 18 (N = 170; 54.1% girls; 35.9% Hispanic/Latinx, 24.9% White, 17.8% Black) from the United States. Results indicate that higher levels of perceived caregiver existential continuity and support (behaviors theorized to promote the continuity of child routines and reassurance of a positive future after experiencing a death) were associated with greater future orientation and social responsibility values among participants. Findings suggest that in the wake of a death, structured and supportive caregiver responses may be related to children's positive outlook on their future and commitment to others.

ICU Bereaved Surrogates' Transition Through States of Co-Occurring Prolonged Grief Disorder, Posttraumatic Stress Disorder, and Depression Symptoms

OBJECTIVES

Grief-related psychological distress often co-occurs to conjointly impair function during bereavement. Knowledge of comorbid grief-related psychological distress is limited: no longitudinal study has examined dynamic patterns of co-occurring prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression, and previous assessment time frames have been variable and potentially inadequate given the duration criterion for PGD. Therefore, the purpose of this study was to investigate the transition of distinct symptom states based on the co-occurrence of PGD, PTSD, and depression symptoms for ICU bereaved surrogates over their first two bereavement years.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Medical ICUs at two academically affiliated medical centers in Taiwan.

PATIENTS/PARTICIPANTS

Three hundred three family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Evaluation II scores > 20) from a disease.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Participants were assessed by 11 items of the Prolonged Grief Disorder (PG-13) scale, the Impact of Event Scale-Revised, and the depression subscale of the Hospital Anxiety and Depression Scale at 6, 13, 18, and 24 months postloss. PGD-PTSD-depression-symptom states and their evolution were examined by latent transition analysis. The following four distinct PGD-PTSD-depression-symptom states (prevalence) were initially identified: resilient (62.3%), subthreshold depression-dominant (19.9%), PGD-dominant (12.9%), and PGD-PTSD-depression comorbid (4.9%) states. These PGD-PTSD-depression-symptom states remained highly stable during the first two bereavement years, with transitions predominantly toward resilience. Prevalence for each state at 24 months postloss was 82.1%, 11.4%, 4.0%, and 2.5%, respectively.

CONCLUSIONS

Four highly stable PGD-PTSD-depression-symptom states were identified, highlighting the importance of screening for subgroups of ICU bereaved surrogates with increased PGD or comorbid PGD, PTSD, and depression symptoms during early bereavement.

Temporal reciprocal relationships among anxiety, depression, and posttraumatic stress disorder for family surrogates from intensive care units over their first two bereavement years

BACKGROUND/OBJECTIVE

Bereaved family surrogates from intensive care units (ICU) are at risk of comorbid anxiety, depression, and post-traumatic stress disorder (PTSD), but the temporal reciprocal relationships among them have only been examined once among veterans. This study aimed to longitudinally investigate these never-before-examined temporal reciprocal relationships for ICU family members over their first two bereavement years.

METHODS

In this prospective, longitudinal, observational study, symptoms of anxiety, depression, and PTSD were assessed among 321 family surrogates of ICU decedents from 2 academically affiliated hospitals in Taiwan by the anxiety and depression subscales of the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised, respectively at 1, 3, 6, 13, 18, and 24 months postloss. Cross-lagged panel modeling was conducted to longitudinally examine the temporal reciprocal relationships among anxiety, depression, and PTSD.

RESULTS

Examined psychological-distress levels were markedly stable over the first 2 bereavement years: autoregressive coefficients for symptoms of anxiety, depression, and PTSD were 0.585-0.770, 0.546-0.780, and 0.440-0.780, respectively. Cross-lag coefficients showed depressive symptoms predicted PTSD symptoms in the first bereavement year, whereas PTSD symptoms predicted depressive symptoms in the second bereavement year. Anxiety symptoms predicted symptoms of depression and PTSD at 13 and 24 months postloss, whereas depressive symptoms predicted anxiety symptoms at 3 and 6 months postloss while PTSD symptoms predicted anxiety symptoms during the second bereavement year.

CONCLUSIONS

Different patterns of temporal relationships among symptoms of anxiety, depression, and PTSD over the first 2 bereavement years present important opportunities to target symptoms of specific psychological distress at different points during bereavement to prevent the onset, exacerbation, or maintenance of subsequent psychological distress.

Post-traumatic stress disorder and traumatic events in China: a nationally representative cross-sectional epidemiological study

Post-traumatic stress disorder (PTSD) is one of the most severe sequelae of trauma. But a nationally representative epidemiological data for PTSD and trauma events (TEs) was unavailable in China. This article firstly demonstrated detailed epidemiological information on PTSD, TEs, and related comorbidities in the national-wide community-based mental health survey in China. A total of 9,378 participants completed the PTSD-related interview of the CIDI 3.0. Lifetime prevalence and 12-month prevalence of PTSD in total respondents were 0.3% and 0.2%. while the conditional lifetime and 12-month prevalence of PTSD after trauma exposure were 1.8% and 1.1%. The prevalence of exposure to any type of TE was 17.2%. Among individuals with the exposed to TEs, younger, without regular work (being a homemaker or retried), and intimate relationship breakdown (separated/Widowed/Divorced), living rurally were associated with either the lifetime PTSD or the 12-month PTSD, while the count of a specific TE, the unexpected death of loved one, was related to both. Alcohol dependence was the most common comorbidity among male participants with PTSD but major depressive disorder (MDD) for female counterparts. Our study can provide a reliable reference for future identification and intervention for people with PTSD.

Developmental Manifestations of Grief in Children and Adolescents: Caregivers as Key Grief Facilitators

The death of a loved one represents one of the most distressing and potentially traumatic life events in childhood and adolescence. Grief reactions in youth are influenced by ongoing developmental processes and manifest differently depending on the child's age and developmental stage. These grief-related processes unfold within youths' caregiving context, as children and adolescents rely heavily on the adults in their environment to navigate and cope with the death of a loved one. Despite the field's increasing recognition of the potential for maladaptive grief reactions to impede functioning over time, few longitudinal research studies on childhood grief currently exist. In this article, we will (a) provide a brief overview of the childhood bereavement literature; (b) review the new DSM-5 and ICD-11 Prolonged Grief Disorder diagnostic criteria through a developmentally-informed lens; (c) describe how grief reactions manifest in children and adolescents of different ages through the lenses of multidimensional grief theory and relational developmental systems theory; (d) highlight key moderating factors that may influence grief in youth, and (e) discuss a primary moderating factor, the caregiving environment, and the potential mechanisms through which caregivers influence children's grief.

Reintegration of crisis services employees: a systematic literature review

Purpose

Crisis services personnel are frequently deployed around the globe under highly demanding conditions. This raises the need to better understand the deployment process and more especially, sustainable reintegration after deployment. Despite recent research efforts, the study of the post-deployment stage, more specifically the reintegration process, remains fragmented and limited. To address these limitations, this review aims at (1) describing how reintegration is conceptualised and measured in the existing literature, (2) identifying what dimensions are associated with the reintegration process and (3) identifying what we know about the process of reintegration in terms of timing and phases.

Design/methodology/approach

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol, the authors identified 5,859 documents across several scientific databases published between 1995 and 2021. Based on predefined eligibility criteria, 104 documents were yielded.

Findings

Research has primarily focused on descriptive studies of negative individual and interpersonal outcomes after deployment. However, this review indicates that reintegration is dynamic, multi-sector, multidimensional and dual. Each of its phases and dimensions is associated with distinct challenges.

Originality/value

To the authors’ knowledge, this is the first research that investigates reintegration among different crisis services and provides an integrative social-ecological framework that identifies the different dimensions and challenges of this process.

How symptoms of prolonged grief disorder, posttraumatic stress disorder, and depression relate to each other for grieving ICU families during the first two years of bereavement

Background

Bereaved ICU family surrogates are at risk of comorbid prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Knowledge about temporal relationships between PGD, PTSD, and depression is limited by a lack of relevant studies and diverse or inappropriate assessment time frames given the duration criterion for PGD. We aimed to determine the temporal reciprocal relationships between PGD, PTSD, and depressive symptoms among ICU decedents’ family surrogates during their first 2 bereavement years with an assessment time frame reflecting the PGD duration criterion.

Methods

This prospective, longitudinal, observational study examined PGD, PTSD, and depressive symptoms among 303 family surrogates of ICU decedents from two academic hospitals using 11 items of the Prolonged Grief Disorder-13, the Impact of Event Scale—Revised, and the depression subscale of the Hospital Anxiety and Depression Scale, respectively, at 6, 13, 18, and 24 months post-loss. Cross-lagged panel modeling was conducted: autoregressive coefficients indicate variable stability, and cross-lagged coefficients indicate the strength of reciprocal relationships among variables between time points.

Results

Symptoms (autoregressive coefficients) of PGD (0.570–0.673), PTSD (0.375–0.687), and depression (0.591–0.655) were stable over time. Cross-lagged standardized coefficients showed that depressive symptoms measured at 6 months post-loss predicted subsequent symptoms of PGD (0.146) and PTSD (0.208) at 13 months post-loss. PGD symptoms did not predict depressive symptoms. PTSD symptoms predicted subsequent depressive symptoms in the second bereavement year (0.175–0.278). PGD symptoms consistently predicted subsequent PTSD symptoms in the first 2 bereavement years (0.180–0.263), whereas PTSD symptoms predicted subsequent PGD symptoms in the second bereavement year only (0.190–0.214). PGD and PTSD symptoms are bidirectionally related in the second bereavement year.

Conclusions

PGD, PTSD, and depressive symptoms can persist for 2 bereavement years. Higher PGD symptoms at 6 months post-loss contributed to the exacerbation of PTSD symptoms over time, whereas long-lasting PTSD symptoms were associated with prolonged depression and PGD symptoms beyond the first bereavement year. Identification and alleviation of depression and PGD symptoms as early as 6 months post-loss enables bereaved surrogates to grieve effectively and avoid the evolution of those symptoms into long-lasting PGD, PTSD, and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04216-5.

The bereavement experiences of children following sibling death: An integrative review

PROBLEM

Sibling bereavement is one of the most distressing adverse life events during childhood but has received less attention in research than other forms of childhood bereavement. This integrative review identifies potential risk and protective factors for maladaptive coping following sibling bereavement and the influence of these factors on adjustment to loss.

ELIGIBILITY CRITERIA

Articles were limited to peer-reviewed studies, published in English in 2000 and beyond. Target population was bereaved siblings 0-18 years, and outcomes examined grief experiences by child self-report or parent-proxy report.

SAMPLE

The Whittemore and Knafl integrative framework was applied. Multidimensional Grief Theory guided the review with twenty-five studies synthesized across its domains: Separation Distress, Existential/Identity Crisis, and Circumstance-Related Distress.

RESULTS

Adjustment following sibling death is a complex process associated with a host of risk and protective factors that contribute to the bereavement process for this population. Age, sex, circumstance-related factors, continuing bonds, parental distress, and limited social support were critical influencing factors.

CONCLUSION

Definitive predictor variables were not identified but a combination of variables that influence the adjustment of bereaved siblings are discussed.

IMPLICATIONS

Future research is needed to explore the risk and protective factors of maladaptive coping to inform intervention development to promote individual and family adjustment following sibling death.

An Analysis of Factors Predicting Post-Traumatic Stress Disorder and Grief Following Comrade Loss

This study explored how "inhibiting factors" associated with military-bereavement impact combatants' psychological sequelae following comrade loss. One hundred six eligible Israeli combat male-soldiers completed the Texas-Revised-Inventory of Grief, the post-traumatic-stress-disorder symptoms scale (PSS), the Male Role Norms Scale, the Social Acknowledgment Questionnaire, and a scale assessing Military Encouragement to Grieve (MEG-8). Time since loss had no impact on soldiers' levels of PSS or prolonged grief. Regression analysis indicated that higher masculinity-perception and disapproval from the family predicated higher PSS, above and beyond grief. Conversely, lower disapproval from the family, and higher disapproval from the general community, predicted higher grief, above and beyond PSS. Also, military encouragement significantly mediated the positive relationship between masculinity and sense of social-recognition. The results show how inhibiting factors contribute differently to the perpetuation of PSS and grief. This interplay sheds light on soldiers' "external" and "internal" loss processes of traumatic bereavement. The practical implications to treatment are also discussed.

Problemy psychiczne po śmierci osoby bliskiej jako przedmiot ekspertyzy sądowej

Wśród różnych form przeżywania śmierci osoby bliskiej wymienia się żałobę, jej powikłaną postać a także współwystępujące z nią zaburzenia psychiczne (najczęściej zespoły lękowe, depresja, uzależnienie od substancji psychoaktywnych, zespół stresu pourazowego). Omówiono przypadek, w którym rodzice wystąpili do sądu o odszkodowanie i zadośćuczynienie za śmierć syna, który zginął na skutek obrażeń doznanych w wypadku drogowym. U powoda po śmierci syna wystąpiła reakcja żałoby, a u powódki stan żałoby powikłanej, z którym współwystępowały objawy depresyjne. Odmienne obrazy kliniczne u każdego z powodów były uwarunkowane innymi cechami osobowości, odmiennymi modelami radzenia sobie w sytuacjach trudnych, a także schorzeniami somatycznymi. Doprowadziło to do różnych implikacji orzeczniczych u każdego z badanych. W sprawach odszkodowawczych (śmierć osób bliskich) konieczna jest diagnostyka różnicowa pomiędzy żałobą, jej powikłaną formą a zaburzeniami o charakterze reaktywnym i endogennym. Przydatna jest w tym ocena psychologiczna predyspozycji osobowościowych a także mechanizmów radzenia sobie w sytuacjach obciążających. Niekorzystanie z leczenia psychiatrycznego lub terapii psychologicznej nie może przesądzać o braku zaburzeń psychicznych. W tego rodzaju sprawach opiniowanie wymaga szczególnej ostrożności i wyważonych ocen. Należy unikać nadmiernej medykalizacji przeżyć po stracie osoby bliskiej, ale nie można też traktować stanów psychopatologicznych jedynie w kategoriach fizjologicznej reakcji na śmierć bliskiego.

Racial, ethnic, and neighborhood income disparities in childhood posttraumatic stress and grief: Exploring indirect effects through trauma exposure and bereavement

Previous findings suggest that experiences with systems of oppression that disproportionately affect individuals based on race and neighborhood residency (e.g., systemic racism, neighborhood income disadvantage [NID]) can be associated with higher odds of developing psychological problems following traumatic events. Although race/ethnicity and NID residency are often associated, they are separate concepts that play unique roles in mental health outcomes among youth. Residents of Black, Latinx, and income-disadvantaged communities also have an increased risk of exposure to polyvictimization and the loss of multiple loved ones. Studies have not carefully delineated the potential relations between race/ethnicity and NID residency, polyvictimization, accumulated losses, and trauma and grief outcomes in youth. We examined mediation models to investigate whether polyvictimization, the loss of multiple loved ones, and exposure to violent death were potential mechanisms through which race/ethnicity and NID would predict trauma and grief outcomes in youth. Participants (N = 429) included Black (19.9%), Latinx (36.0%), and White (27.3%) children and adolescents who were assessed through a routine baseline assessment at a trauma and grief outpatient clinic. Black youth reported significantly elevated posttraumatic stress and maladaptive grief symptoms through higher polyvictimization and violent death exposure relative to White youth, βs = .06-.12, ps <.001. Latinx identity and NID were positively and directly associated with specific domains of maladaptive grief reactions, βs = .10-.17, ps < .001. If replicated longitudinally, these findings suggest that polyvictimization and violent death exposure may be mechanisms through which Black youth develop more severe traumatic stress and grief reactions.

‘Keeping silent to keep the peace’: changes in grandmother's access to their grandchildren following the loss of the son/father

Relations between grandmothers and their grandchildren following the loss of the son/father have not been studied to date. The present article focuses on this experience, as reflected in the stories of grandmothers (bereaved mothers) and spouses (widows) after the loss, and explores the perception of grandparenthood following the loss of the son/husband. Twenty semi-structured interviews were conducted with ten grandmothers (bereaved mothers) and spouses (widows) who were recruited as a convenience sample. Data were subjected to thematic analysis. The findings revealed three key patterns of the grandmother–grandchild relations, as perceived by the two groups of women. The patterns indicate complex relations between widows and bereaved mothers, which have implications for the access of the grandmothers to their grandchildren and for their perception of grandparenthood. The study sheds light on the patterns of relations in families that have lost the son/husband/father. The change in power balance between family members and the asymmetry in the family structure created by the absence of the son/husband affect grandparenthood relations. The study emphasises the role of the widows, as the middle generation, in shaping or mediating relationships following the loss. The findings stress the importance of clinical intervention with both the bereaved mothers and the widows.

Identifying Bereavement‐Related Markers of Mental and Behavioral Health Problems Among Clinic‐Referred Adolescents

Objective

This study examined bereavement‐related risk markers (number of deaths, cause of death, and relationship to deceased) of mental and behavioral health problems (suicidal thoughts or behaviors, self‐injury, depression, posttraumatic stress, and substance use) in a national sample of clinic‐referred bereaved adolescents.

Method

Participants included 1281 bereaved youth aged 12–21 years (M=15, SD=1.8; 62.1% female), from the National Child Traumatic Stress Network Core Data Set.

Results

Generalized linear mixed‐effects regression models controlling for demographics and other traumas revealed that youth bereaved by multiple deaths had higher posttraumatic stress scores than youth bereaved by a single death (Estimated difference ±SE=3.36 ± 1.11, p=0.003). Youth bereaved by suicide were more likely to report experiencing suicidal thoughts or behaviors (AOR=1.68, p=0.049) and alcohol use (AOR=2.33, p<0.001) than youth bereaved by natural causes. Youth bereaved by homicide were at greater risk for substance use than youth bereaved by natural death (AOR=1.76, p=0.02). Compared to parentally bereaved youth, youth who lost a peer were more likely to use alcohol (AOR=2.32, p=0.02) or other substances (AOR=2.41, p=0.01); in contrast, parentally bereaved youth were more likely to experience depression compared to those who experienced the death of an adult relative or unrelated adult (range of AOR: 0.40 to 0.64, p‐values<0.05).

Conclusion

These bereavement‐related contextual factors can serve as early markers of mental and behavioral health problems among bereaved youth.

Few studies have examined bereavement‐related risk markers of mental and behavioral health problems among treatment‐seeking adolescents.

Number of prior traumas, number of prior losses, experiencing a death due to suicide or homicide, and experiencing the death of a parent (as opposed to another relative or friend) were each associated with higher levels of mental and behavioral health problems among bereaved adolescents.

Findings have implications for early identification of bereaved youth who may be in need of intervention.

Grief and Loss Among Veterans With Spinal Cord Injury: A Qualitative Study

PURPOSE

The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI).

DESIGN/METHODS

Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach.

RESULTS

The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience.

CONCLUSIONS/CLINICAL RELEVANCE

A better understanding of veterans living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

Caregiver behaviors and childhood maladaptive grief: Initial validation of the Grief Facilitation Inventory

The Grief Facilitation Inventory (GFI) is a newly-developed measure of caregiver behaviors theorized to facilitate or hinder children's adaptive grief reactions. We examine its factor structure, reliability, and validity. An exploratory factor analysis identified four factors: Ongoing Connection, Existential Continuity/Support, Caregiver Grief Expression, and Grief Inhibition/Avoidance. Both child- and caregiver-report versions had adequate-to-good internal consistency. The child-report GFI showed evidence of criterion-referenced validity via significant correlations with measures of child maladaptive grief and other psychological symptoms. Results provide preliminary evidence of the reliability, validity, and clinical utility of the GFI as a measure of caregiver grief-facilitation behaviors.

A framework of meaning attribution following loss

The loss of a loved one causes the world and the place of the bereaved survivor in it to change irreversibly. A key aspect of the grieving process is the integration of the loss in the bereaved survivor's life story, identity change, and a new future orientation through meaning attribution. Meaning attribution can have favourable or unfavourable effects on the grieving process and hence determines the extent to which a loss disrupts the bereaved survivor's functioning. A framework of meaning attribution after loss is presented, comprising 17 determinants that fall into five categories: event-related, cultural, social, individual and relational determinants. Each determinant may lead to both positive and negative meanings, thereby facilitating or complicating the grieving process. The framework of meaning attribution highlights the importance of an integrated network for mental health care, spiritual care, and end-of-life care in the prevention and treatment of traumatic grief. It also emphasizes the support from relatives, collective rituals, cultural views, legal settlements, and other societal factors that may foster or impede adaptation to loss. The framework of meaning attribution informs research across a range of research themes, including specialist care for traumatic grief, a culturally sensitive care network for traumatic grief, and improving care for ambiguous loss in a global context.

Interventions for child and adolescent survivors of intrafamilial homicide: A review of the literature

The nature of intrafamilial homicide is complex and traumatic. Child survivors are at significant risk for maladjustment, including negative psychological sequela, grief complications, and contextual challenges associated with the homicide. Thus, children may benefit from services addressing specific psychosocial challenges following intrafamilial homicide. In this paper, we review the literature to identify trauma- and grief-informed interventions implemented for youth following violent bereavement. Given limited research on this vulnerable population, we discuss interventions that show promise for child survivors, exploring specific needs, challenges, and potential implications of these interventions for treating children and families experiencing intrafamilial homicide bereavement.

Correlates of grief-related disorders and mental health outcomes among adult refugees exposed to trauma and bereavement: A systematic review and future research directions

BACKGROUND

With conflict driving millions of refugees away from their homes worldwide, there has been an increase in interest in the field of refugee trauma. However, while trauma and bereavement interlink, prior studies have focused on trauma and its related disorders (PTSD) and predictive factors. This paper reviewed up-to-date literature on the prevalence rates of prolonged grief disorder (PGD), its comorbidities, and associated risk factors among adult refugees.

METHOD

We systematically reviewed the literature using five databases (PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, Academic Search Elite, and PubMed). The process of study selection was designed according to PRISMA guidelines.

RESULTS

The initial search generated 126 articles, of which 12 met the inclusion criteria. The pooled prevalence of PGD was 33.2% (95% CI: 15.2-54.2%). Being an older refugee, traumatic and multiple losses implying the death of first-degree relatives appeared to be consistent risk factors for PGD, combined PTSD/PGD, depression, idioms of distress, and functional impairment. PGD, PTSD, and PTSD/PGD intersect on PTSD-intrusions and painful memories.

LIMITATIONS

All included studies adopted a cross-sectional design, thus limiting the understanding of causal pathways.

CONCLUSIONS

Our findings showed that the high prevalence of PGD and related comorbidities were influenced by the load of traumatic circumstances surrounding the death(s). The findings shed light on the current proposed grief-related diagnostic criteria . Psychopathological and transcultural aspects are discussed, and we provide concrete recommendations for improvements to future research in this field.

Differential Associations of Coping Strategies With Grief and Depression in Young Adults: The Role of Cause of Death and Relationship to the Deceased

Introduction: The impact of loss by death in young adults has been underinvestigated, although higher rates of traumatic deaths are reported at this developmental stage. This study examined the relative differential consequences of bereavement-related factors for Persistent Complex Bereavement Disorder (PCBD) and depression. In addition, coping strategies predicting the study outcomes were examined as a function of bereavement-related factors.

Methods: The study included 580 bereaved young adults with up to 5-year post loss. They were administered a battery of valided tools measuring PCBD symptoms, normal acute grief reactions as measured by the Core Bereavement Items scale, depressive symptoms, coping strategies, and bereavement-related characteristics. Covariance and regression analyses were used.

Results: We found that the dimensions of PCBD and depressive symptoms were differentially associated with the bereavement-related factors. More specifically, the death of an immediate family member was associated with higher levels of PCBD-separation distress, whereas the traumatic death of a friend and romantic partner was more associated with PCBD-social and identity disruption. Furthermore, the study revealed differential associations between PCBD severity, depressive symptoms, and coping strategies as functions of bereavement-related factors.

Discussion: The study has provided better understanding of clinical manifestations of PCBD as a function of etiologic risk factors. The results clarifying risk and protective factors are especially useful for improving effective bereavement-health counseling interventions among bereaved young adults.

Cause of Caregiver Death and Surviving Caregiver Coping Style Predict Thwarted Belongingness in Bereaved Youth

Both bereavement and thwarted belongingness serve as risk markers for youth suicide-related behaviors. This study examined candidate predictors of thwarted belongingness among bereaved youth, including caregiver cause of death and surviving caregiver coping style. A group of 43 caregiver-bereaved families (58 children aged 7-13-years-old) participated in a longitudinal study investigating associations between hypothesized bereavement-related contextual factors and youth thwarted belongingness. Cause of caregiver deaths included anticipated deaths preceded by illness (37%; n = 16), sudden natural deaths (25.6%; n = 11), accidental deaths (20.9%; n = 9), death by suicide (9.3%; n = 4), and death from drug overdose (7.0%; n = 3). Children's thwarted belongingness was significantly higher among youth bereaved by suicide compared to youth bereaved by sudden natural death, accident, and anticipated death by illness. Surviving caregivers' use of behavioral disengagement and positive reinterpretation and growth as coping strategies at Time 1 predicted lower thwarted belongingness in children at Time 2. Implications for risk screening and assessment of suicide risk among bereaved youth are discussed.

U.S. combat veterans' responses to suicide and combat deaths: A mixed-methods study

RATIONALE

Limited research has examined how combat veterans experience deaths of comrades to combat or suicide. We sought to investigate the process and identify factors that predict the level of grief among post-9/11 U.S. veterans.

METHODS

Using a mixed-methods study design during 2016-2017, U.S. combat veterans of the Iraq and Afghanistan conflicts who lost comrades to both combat and suicide (N = 28) participated in semi-structured interviews, and veterans who lost a comrade in combat or to suicide (N = 178) completed online surveys that assessed grief, combat exposure, unit cohesion, anger, posttraumatic stress symptoms (PTSS), and past diagnoses of PTSD and depression.

RESULTS

Text analyses of interview transcripts revealed seven themes: 1) Suicide death is unexpected and can make acceptance of loss harder; 2) Combat death is expected and can ease acceptance of loss; 3) Combat death is heroic and can make acceptance of loss easier; 4) Brotherhood forged in combat intensifies the emotional response; 5) Guilt over the inability to prevent a comrade's death makes acceptance harder; 6) Attribution of blame for a death creates anger; and 7) Detachment from the civilian world may make it more difficult to cope with comrades' deaths. Regression analyses of survey data indicated: 1) suicide loss predicted non-acceptance of the loss; 2) mode of death moderated the association between unit cohesion and grief; 3) combat exposure, anger, closeness to the deceased, and having a past diagnosis of depression predicted the level of grief; and 4) combat exposure is a similarly strong predictor of grief and PTSS. Results highlight how veterans' grief further delineates war's toll.

CONCLUSION

The mixed-methods design tells a rich story about a previously unexplored consequence of war. These findings have important public health implications because outcomes impact not only veterans but also their families and communities.

A Phenomenological Study: Experiencing the Unexpected Death of a Teammate

Phenomenological interviews were conducted with nine collegiate student-athletes (M = 24.11 years; SD = 3.76), from a range of sports, to explore how they experienced the unexpected death of a teammate. Qualitative analysis of interview data revealed a total of 626 meaning units which were used to produce a final thematic structure consisting of six higher order themes: Emotional Response, Behavioral Response, Faith, Social Support, Team Cohesion, and Change of Life Perspective. The results suggest that student-athletes who experience the unexpected death of a teammate go through a wide range of emotional (e.g., shock, denial) and behavioral responses (e.g., deliberate isolation from others, tributes), which ultimately changed their perspective on life. The specific nuances of these experiences offer several practical applications for sport psychology consultants, coaches, and administrators wishing to provide support to this population during such a difficult time.

Validation of the Persistent Complex Bereavement Disorder (PCBD) Checklist: A Developmentally Informed Assessment Tool for Bereaved Youth

The inclusion of Persistent Complex Bereavement Disorder (PCBD) in the DSM-5 appendix signifies a call for research regarding the distinguishing features and clinical utility of proposed PCBD criteria. Rigorously constructed tools for assessing PCBD are lacking, especially for youth. This study evaluated the validity and clinical utility of the PCBD Checklist, a 39-item measure designed to assess PCBD criteria in youth aged 8 to18 years. Test construction procedures involved: (a) reviewing the literature regarding developmental manifestations of proposed criteria, (b) creating a developmentally informed item pool, (c) surveying an expert panel to evaluate the clarity and developmental appropriateness of candidate items, (d) conducting focus groups to evaluate the comprehensibility and acceptability of items, and (e) evaluating psychometric properties in 367 bereaved youth (M_age = 13.49, 55.0% female). The panel, clinicians, and youth provided favorable content validity and comprehensibility ratings for candidate items. As hypothesized, youth who met full PCBD criteria, Criterion B (e.g., preoccupation with the deceased and/or circumstances of the death), or Criterion C (e.g., reactive distress and/or social/identity disruption) reported higher posttraumatic stress and depressive symptoms than youth who did not meet these criteria, η_p² = .07-.16. Youth who met Criterion C reported greater functional impairment than youth who did not, η_p² = .08-.12. Youth who qualified for the "traumatic bereavement specifier" reported more frequent posttraumatic stress symptoms than youth who did not, η_p² = .04. Findings support the convergent, discriminant, and discriminant-groups validity, developmental appropriateness, and clinical utility of the PCBD Checklist.

Caregivers' positive emotional expression and children's psychological functioning after parental loss

The death of a loved one, particularly a parent, has been identified as not only the most common, but also the most distressing form of adversity youth may experience in their lifetime. Surviving caregivers' communication with their children may play a critical role in shaping bereaved children's psychological functioning. However, few studies have examined the specific content (e.g., word usage) of caregivers' verbal communication as a predictor of psychological functioning in bereaved youth. In a sample of 39 parentally-bereaved children and their surviving caregivers, we investigated whether the frequency of caregivers' use of positive emotion words (e.g., "love", "happy", "hope") during a reminiscing task about the deceased was associated with children's psychological functioning and coping. In a cross-sectional analysis, we specifically examined whether these associations were moderated by the amount of time passed since children lost their parents. The Linguistic Inquiry and Word Count Program (LIWC) was used to code and evaluate the percentage of positive emotion words caregivers used during the discussion. When caregivers used more positive emotion words, children were less likely to experience depression, anxiety, and avoidant coping. Those associations were present for children who had experienced parental loss at least 105 days prior to the study. Our findings have implications for how caregivers can support their children and help to alleviate psychological distress in the aftermath of parental loss.

Predicting Grief Reactions One Year Following a Mass University Shooting: Evaluating Dose-Response and Contextual Predictors

This study identifies risk factors for grief following a mass school shooting. Participants (N = 1,013) completed online questionnaires 3-4 months (Time 1) and 1 year (Time 2) post-shootings. We tested models predicting Time 2 grief reactions, exploring direct and indirect predictive effects of exposure variables (physical and social proximity) through hypothesized peritraumatic mediators (peritraumatic perceived threat to self or others) while controlling for Time 1 grief and posttraumatic stress (PTS) reactions, pretrauma vulnerabilities. Findings demonstrate that closer social proximity predicted higher levels of Time 2 grief, directly and indirectly through increasing peritraumatic perceived threat to others' safety. Physical proximity and peritraumatic threat to self did not predict Time 2 grief reactions. Implications for grief screening instruments and theory building research through identifying risk factors and causal mechanisms are discussed.

Pilot Study of a Group-Based Psychosocial Trauma Recovery Program in Secure Accommodation in Scotland

The current study is the first to implement and evaluate a group-based trauma-specific program for adolescents in a secure accommodation facility in Scotland. A randomized control and qualitative pilot study compared an intervention group (n = 10), who received Teaching Recovery Techniques, to a waitlist control group (n = 7). Measures included subjective units of disturbance (SUDs), standardized trauma symptom questionnaires, and analysis of behavior monitoring logs. Adolescent interviews (n = 10) and a presenter focus group (n = 4) assessed program experience and views on future development. Sessions were videoed and analyzed for program adherence. Analysis involved MANOVA, and a quasi-qualitative thematic approach for participant views. Adolescents reported high SUDs and a range of trauma symptoms. A large effect size was found for reduced SUDs (d = 1.10) and positive trends were identified for symptoms and behavior change in the intervention group. Program adaptations included smaller groups, the use of visual materials and liaison with care staff to facilitate generalization. Recommendations are made for program development and large scale evaluation.

Military Service Member and Veteran Reintegration: A Conceptual Analysis, Unified Definition, and Key Domains

Returning military service members and veterans (MSMVs) may experience a variety of stress-related disorders and challenges when reintegrating from the military to the community. Facilitating the reintegration, transition, readjustment and coping, and community integration, of MSMVs is a societal priority. To date, research addressing MSMV reintegration has not identified a comprehensive definition of the term or defined the broader context within which the process of reintegration occurs although both are needed to promote valid and reliable measurement of reintegration and clarify related challenges, processes, and their impact on outcomes. Therefore, this principle-based concept analysis sought to review existing empirical reintegration measurement instruments and identify the problems and needs of MSMV reintegration to provide a unified definition of reintegration to guide future research, clinical practice, and related services. We identified 1,459 articles in the health and social sciences literature, published between 1990 and 2015, by searching multiple electronic databases. Screening of abstracts and full text review based on our inclusion/exclusion criteria, yielded 117 articles for review. Two investigators used constant conceptual comparison to evaluate relevant articles independently. We examined the term reintegration and related terms (i.e., transition, readjustment, community integration) identifying trends in their use over time, analyzed the eight reintegration survey instruments, and synthesized service member and veteran self-reported challenges and needs for reintegration. More reintegration research was published during the last 5 years (n = 373) than in the previous 10 years combined (n = 130). The research suggests coping with life stresses plays an integral role in military service member and veteran post-deployment reintegration. Key domains of reintegration include individual, interpersonal, community organizations, and societal factors that may facilitate or challenge successful reintegration, and results suggest that successful coping with life stressors plays an integral role in post-deployment reintegration. Overall, the literature does not provide a comprehensive representation of reintegration among MSMVs. Although, previous research describes military service member and veteran reintegration challenges, this concept analysis provides a unified definition of the phenomenon and identifies key domains of reintegration that may broaden our understanding and guide reintegration research and practice.

Unequal burdens of loss: examining the frequency and timing of homicide deaths experienced by young Black men across the life course

OBJECTIVES

I examined the frequency and developmental timing of traumatic loss resulting from the health disparity of homicide among young Black men in Baltimore, Maryland.

METHODS

Using a modified grounded theory approach, I conducted in-depth semistructured interviews with 40 Black men (aged 18-24 years) from January 2012 to June 2013. I also constructed adapted life history calendar tools using chronologies of loss, and (1) provided a comprehensive history of loss, (2) determined a specific frequency of homicide deaths, (3) indicated participants' relationship to the decedents, and (4) identified the developmental timing of deaths.

RESULTS

On average, participants knew 3 homicide victims who were overwhelmingly peers. Participant experiences of homicide death started in early childhood, peaked in adolescence, and persisted into emerging adulthood. The traumatic loss of peer homicide was a significant developmental turning point and disrupted participants' social networks.

CONCLUSIONS

The traumatic loss of peer homicide was a prevalent life course experience for young Black men and identified the need for trauma- and grief-informed interventions. Future research is needed to examine the physical and psychosocial consequences, coping resources and strategies, and developmental implications of traumatic loss for young Black men in urban contexts.

Individual and psychosocial mechanisms of adaptive functioning in parentally bereaved children

The authors examined factors theorized to contribute to adaptive functioning in 56 parentally bereaved children (age 7-13) who had lost their caregiver within the previous 6 months. Adaptive functioning, defined as falling below clinical threshold levels on all measures of depression, posttraumatic stress, anxiety, and internalizing/externalizing symptoms, characterized 57% of the sample. Linear mixed modeling revealed that children in the adaptive functioning group had lower mean scores on avoidant coping and higher mean scores on coping efficacy, religiosity, parental positive reinforcement, and parental empathy. Findings suggest that adaptive functioning following parental loss is related to both child-intrinsic factors and child-extrinsic factors.

The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: a review

We reviewed research on the relationship between (a) exposure to psychological trauma and (b) nonsuicidal self-injury (NSSI) and suicidality (suicidal ideation [SI] and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the special issue of the Journal of Trauma & Dissociation on these topics. Exposure to childhood sexual abuse is the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also are associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with a discussion of implications for clinical practice and future directions for scientific research.

The burden of loss: unexpected death of a loved one and psychiatric disorders across the life course in a national study

OBJECTIVE

Unexpected death of a loved one is common and associated with subsequent elevations in symptoms of multiple forms of psychopathology. Determining whether this experience predicts novel onset of psychiatric disorders and whether these associations vary across the life course has important clinical implications. The authors examined associations of a loved one's unexpected death with first onset of common anxiety, mood, and substance use disorders in a population-based sample.

METHOD

The relation between unexpected death of a loved one and first onset of lifetime DSM-IV disorders was estimated by using a structured interview of adults in the U.S. general population (analytic sample size=27,534). Models controlled for prior occurrence of any disorder, other traumatic experiences, and demographic variables.

RESULTS

Unexpected death of a loved one was the most common traumatic experience and most likely to be rated as the respondent's worst, regardless of other traumatic experiences. Increased incidence after unexpected death was observed at nearly every point across the life course for major depressive episode, panic disorder, and posttraumatic stress disorder. Increased incidence was clustered in later adult age groups for manic episode, phobias, alcohol use disorders, and generalized anxiety disorder.

CONCLUSIONS

The bereavement period is associated with elevated risk for the onset of multiple psychiatric disorders, consistently across the life course and coincident with the experience of the loved one's death. Novel associations between unexpected death and onset of several disorders, including mania, confirm multiple case reports and results of small studies and suggest an important emerging area for clinical research and practice.

Do circumstances of the death matter? Identifying socioenvironmental risks for grief-related psychopathology in bereaved youth

We examined bereaved children's and surviving caregivers' psychological responses following the death of the other caregiver as a function of the stated cause of death. Participants included 63 parentally bereaved children and 38 surviving caregivers who were assessed using self-report instruments and in-person interviews. Surviving caregivers reported the causes of death as resulting from sudden natural death (34.9%), illness (33.3%), accident (17.5%), and suicide (14.3%). Results revealed differences between caregiver-reported versus child-reported cause of death, particularly in cases of suicide. Children who lost a caregiver due to a prolonged illness exhibited higher levels of both maladaptive grief (d = 3.13) and posttraumatic stress symptoms (PTSS; d = 3.33) when compared to children who lost a caregiver due to sudden natural death (e.g., heart attack). In contrast, surviving caregivers did not differ in their levels of maladaptive grief and PTSS as a function of the cause of death; however, caregivers bereaved by sudden natural death reported higher levels of depression than those bereaved by prolonged illness (d = 1.36). Limited sample size prevented analysis of outcomes among those bereaved by suicide or accident. These findings suggest that anticipated deaths may contain etiologic risk factors for maladaptive grief and PTSS in children.

Using the core curriculum on childhood trauma to strengthen clinical knowledge in evidence-based practitioners

The high prevalence of trauma exposure in mental health service-seeking populations, combined with advances in evidence-based practice, competency-based training, common-elements research, and adult learning make this an opportune time to train the mental health workforce in trauma competencies. The Core Curriculum on Childhood Trauma (CCCT) utilizes a five-tiered conceptual framework (comprising Empirical Evidence, Core Trauma Concepts, Intervention Objectives, Practice Elements, and Skills), coupled with problem-based learning, to build foundational trauma knowledge and clinical reasoning skills. We present findings from three studies: Study 1 found that social work graduate students' participation in a CCCT course (N = 1,031) was linked to significant pre-post increases in self-reported confidence in applying core trauma concepts to their clinical work. Study 2 found significant pre-post increases in self-reported conceptual readiness (N = 576) and field readiness (N = 303) among social work graduate students participating in a "Gold Standard Plus" educational model that integrated classroom instruction in core trauma concepts, training in evidence-based trauma treatment (EBTT), and implementation of that EBTT in a supervised field placement. Students ranked the core concepts course as an equivalent or greater contributor to field readiness compared to standard EBTT training. Study 3 used qualitative methods to "distill" common elements (35 intervention objectives, 59 practice elements) from 26 manualized trauma interventions. The CCCT is a promising tool for educating "next-generation" evidence-based practitioners who possess competencies needed to implement modularized, individually tailored trauma interventions by strengthening clinical knowledge, clinical reasoning, and familiarity with common elements.