Multidimensional Grief Therapy: Pilot Open Trial of a Novel Intervention for Bereaved Children and Adolescents
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This study describes a pilot open trial of Multidimensional Grief Therapy, an assessment-driven, phasic individual therapy for bereaved youth. This study provides a preliminary outcome evaluation with respect to maladaptive grief reactions, post-traumatic stress symptoms, and depressive symptoms in bereaved youth.
The sample consisted of 65 bereaved youth (ages 6–17 years, M = 11.62, SD = 2.76; 53% female; 33.3% Hispanic, 31.8% African American/Black, 27.3% Caucasian, 6.1% mixed/biracial, 1.5% Native American). The study utilized a single-group open trial design. Youth referred to the study due to the death of a loved one completed measures of grief reactions, posttraumatic stress symptoms, and depressive symptoms. Measures were also completed following Phases I and II of the treatment.
Youth who completed Phase I (n = 42) reported significant reductions from baseline, with large to very large effect sizes (Cohen’s D range = 0.77−1.35) for all three domains of maladaptive grief, post-traumatic stress symptoms, and depressive symptoms. Youth who completed Phase II (n = 22) exhibited significant reductions from the end of Phase I, with medium to large effect sizes (range = 0.57–0.90) for two domains of maladaptive grief as well as for posttraumatic stress symptoms and depressive symptoms.
Although further evaluations using a wider array of outcomes are needed to evaluate MGT and the maintenance of treatment gains over time, the present study provides preliminary evidence supporting MGT as an individual treatment for bereaved youth experiencing maladaptive grief reactions, post-traumatic stress, and depressive symptoms.
KeywordsBereavement Grief Posttraumatic stress disorder Treatment effectiveness Depression
This research was supported by grants from the Substance Abuse and Mental Health Service Administration (SM-16008 and SM-062111), both given to J.K.
R.M.H.: Completed the data analysis and prepared the initial and revised manuscript draft. B.O.: Assisted with data analysis and data preparation. C.M.L.: Collaborated with writing the manuscript. E.R.: Assisted with the writing and preparation of the manuscript. S.Y.: Assisted with execution of the study. RSP: Collaborated in editing the manuscript. J.B.K.: Designed and executed the study; collaborated in the writing and editing of the manuscript.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
All procedures performed in this study were in accordance with the ethical standards of the institutional review board and with the 1964 Helsinki Declaration. The Baylor College of Medicine IRB approved this study.
Informed consent/assent was obtained from all individual participants included in this study.
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. 5th edn. Arlington, VA: Author.Google Scholar
- Angold, A., Costello, E. J., Messer, S. C., & Pickles, A. (1995). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research, 5(4), 237–249.Google Scholar
- Ayers, T. S., Wolchik, S. A., Sandler, I. N., Twohey, J. L., Weyer, J. L., Padgett-Jones, S., & Kriege, G. (2014). The family bereavement program: Description of a theory-based prevention program for parentally-bereaved children and adolescents. OMEGA—Journal of Death and Dying, 68(4), 293–314.Google Scholar
- Bados, A., Balaguer, G., & Saldaña, C. (2007). The efficacy of cognitive–behavioral therapy and the problem of drop‐out. Journal of Clinical Psychology, 63(6), 585–592.Google Scholar
- Berg, L., Rostila, M., & Hjern, A. (2016). Parental death during childhood and depression in young adults—a national cohort study. Journal of Child Psychology and Psychiatry, 57(9), 1092–1098.Google Scholar
- Boelen, P., Lenferink, L., Nickerson, A., & Smid, G., Clinical Psychology and Experimental Psychopathology (2018). Evaluation of the factor structure, prevalence, and validity of disturbed grief in DSM-5 and ICD-11. Journal of Affective Disorders, 240, 79–97.Google Scholar
- Boelen, P. A., van den Hout, Marcel, A., & van den Bout, J. (2006). A cognitive-behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109–128.Google Scholar
- Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162(2), 214–227.Google Scholar
- Breslau, N., Peterson, E. L., Poisson, L. M., Schultz, L. R., & Lucia, V. C. (2004). Estimating post-traumatic stress disorder in the community: lifetime perspective and the impact of typical traumatic events. Psychological Medicine, 34(5), 889–898.Google Scholar
- Cerel, J., Fristad, M. A., Verducci, J., Weller, R. A., & Weller, E. B. (2006). Childhood bereavement: psychopathology in the 2 years postparental death. Journal of the American Academy of Child & Adolescent Psychiatry, 45(6), 681–690.Google Scholar
- Clark, D. C., Pynoos, R. S., & Goebel, A. E. (1994). Mechanisms and processes of adolescent bereavement. New York, NY: Cambridge University Press.Google Scholar
- Claycomb, M. A., Charak, R., Kaplow, J., Layne, C. M., Pynoos, R., & Elhai, J. D. (2016). Persistent complex bereavement disorder symptom domains relate differentially to PTSD and depression: A study of war-exposed Bosnian adolescents. Journal of Abnormal Child Psychology, 44(7), 1361–1373.Google Scholar
- Cohen, J. (1969). Statistical power analysis for the behavioral sciences. San Diego, CA: Academic Press.Google Scholar
- Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents. 2nd edn. New York, NY: Guilford Publications.Google Scholar
- Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: a pilot study. Journal of the American Academy of Child & Adolescent Psychiatry, 43(10), 1225–1233.Google Scholar
- Cohen, J. A., Mannarino, A. P., & Staron, V. R. (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(12), 1465–1473.Google Scholar
- Dillen, L., Fontaine, J. R. J., & Verhofstadt-Denève, L. (2009). Confirming the distinctiveness of complicated grief from depression and anxiety among adolescents. Death Studies, 33(5), 437–461.Google Scholar
- Elhai, J. D., Layne, C. M., Steinberg, A. M., Brymer, M. J., Briggs, E. C., Ostrowski, S. A., & Pynoos, R. S. (2013). Psychometric properties of the UCLA PTSD reaction index. Part II: Investigating factor structure findings in a national clinic‐referred youth sample. Journal of Traumatic Stress, 26(1), 10–18.Google Scholar
- Geronazzo-Alman, L., Fan, B., Duarte, C. S., Layne, C. M., Wicks, J., Guffanti, G., & Hoven, C. W. (2019). The distinctiveness of grief, depression, and posttraumatic stress: lessons from children after 9/11. Journal of the American Academy of Child & Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2018.12.012, in press.
- Goenjian, A. K., Karayan, I., Pynoos, R. S., Minassian, D., Najarian, L. M., Steinberg, A. M., & Fairbanks, L. A. (1997). Outcome of psychotherapy among early adolescents after trauma. American Journal of Psychiatry, 154(4), 536–542.Google Scholar
- Grassetti, S. N., Herres, J., Williamson, A. A., Yarger, H. A., Layne, C. M., & Kobak, R. (2015). Narrative focus predicts symptom change trajectories in group treatment for traumatized and bereaved adolescents. Journal of Clinical Child & Adolescent Psychology, 44(6), 933–941.Google Scholar
- Guldin, M., Li, J., Pedersen, H. S., Obel, C., Agerbo, E., Gissler, M., & Vestergaard, M. (2015). Incidence of suicide among persons who had a parent who died during their childhood: A population-based cohort study. JAMA Psychiatry, 72(12), 1227–1234.Google Scholar
- Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.Google Scholar
- Kaplow, J. B., Howell, K. H., & Layne, C. M. (2014). Do circumstances of the death matter? Identifying socioenvironmental risks for grief-related psychopathology in bereaved youth. Journal of Traumatic Stress, 27(1), 42–49.Google Scholar
- Kaplow, J. B., Layne, C. M., Oosterhoff, B., Goldenthal, H., Howell, K. H., Wamser‐Nanney, R., & Pynoos, R. (2018). Validation of the persistent complex bereavement disorder (PCBD) checklist: A developmentally informed assessment tool for bereaved youth. Journal of Traumatic Stress, 31(2), 244–254.Google Scholar
- Kaplow, J. B., Layne, C. M., & Pynoos, R. S. (2019a). Persistent complex bereavement disorder. In M. Prinstein, E. Youngstrom, E. Mash, & R. Barkley (eds). Treatment of disorders in children and adolescence. 4th edn. New York, NY: Guilford.Google Scholar
- Kaplow, J. B., Layne, C. M., Pynoos, R. S., & Saltzman, W. R., (2019b). Multidimensional grief therapy: A flexible approach to assessing and supporting bereaved youth. New York: Cambridge University Press, in press.Google Scholar
- Kaplow, J. B., Layne, C. M., Saltzman, W. R., Cozza, S. J., & Pynoos, R. S. (2013). Using multidimensional grief theory to explore the effects of deployment, reintegration, and death on military youth and families. Clinical Child and Family Psychology Review, 16(3), 322–340.Google Scholar
- Kaplow, J. B., Saunders, J., Angold, A., & Costello, E. J. (2010). Psychiatric symptoms in bereaved versus nonbereaved youth and young adults: a longitudinal epidemiological study. Journal of the American Academy of Child & Adolescent Psychiatry, 49(11), 1145–1154.Google Scholar
- Lambert, M. J., & Ogles, B. M. (2009). Using clinical significance in psychotherapy outcome research: the need for a common procedure and validity data. Psychotherapy Research, 19(4–5), 493–501.Google Scholar
- Layne, C. M., Kaplow, J. B., Oosterhoff, B., Hill, R., & Pynoos, R. S. (2017). The interplay between posttraumatic stress and grief reactions in traumatically bereaved adolescents: When trauma, bereavement, and adolescence converge. Adolescent Psychiatry, 7, 220–239.Google Scholar
- Layne, C. M., Kaplow, J. B., & Pynoos, R. S. (2014). Persistent complex bereavement disorder (PCBD) checklist—Youth version 1.0. Los Angeles, CA: University of California, Los AngelesGoogle Scholar
- Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagić, B., Savjak, N., Popović, T., & Houston, R. (2001). Trauma/grief-focused group psychotherapy: School-based postwar intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5(4), 277–290.Google Scholar
- Layne, C. M., Saltzman, W. R., Poppleton, L., Burlingame, G. M., Pašalić, A., Duraković, E., & Steinberg, A. M. (2008). Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 47(9), 1048–1062.Google Scholar
- Lenferink, L., Nickerson, A., de Keijser, J., Smid, G., & Boelen, P. (2018). Trajectories of grief, depression, and posttraumatic stress in disaster-bereaved people. Depression and Anxiety. https://doi.org/10.1002/da.22850.
- Luecken, L. J., Hagan, M. J., Sandler, I. N., Tein, J., Ayers, T. S., & Wolchik, S. A. (2010). Cortisol levels six-years after participation in the family bereavement program. Psychoneuroendocrinology, 35(5), 785–789.Google Scholar
- Maciejewski, P., Maercker, A., Boelen, P., & Prigerson, H. (2016). “Prolonged grief disorder” and “persistent complex bereavement disorder”, but not “complicated grief”, are one and the same diagnostic entity: An analysis of data from the Yale Bereavement Study. World Psychiatry, 15(3), 266–275.Google Scholar
- Melhem, N. M., Moritz, G., Walker, M., Shear, M. K., & Brent, D. (2007). Phenomenology and correlates of complicated grief in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 46(4), 493–499.Google Scholar
- Melhem, N. M., Porta, G., Shamseddeen, W., Walker Payne, M., & Brent, D. A. (2011). Grief in children and adolescents bereaved by sudden parental death. Archives of General Psychiatry, 68(9), 911–919.Google Scholar
- Melhem, N. M., Walker, M., Moritz, G., & Brent, D. A. (2008). Antecedents and sequelae of sudden parental death in offspring and surviving caregivers. Archives of Pediatrics & Adolescent Medicine, 162(5), 403–410.Google Scholar
- O’Donnell, K., Dorsey, S., Gong, W., Ostermann, J., Whetten, R., Cohen, J. A., & Whetten, K. (2014). Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: Group‐based trauma‐focused cognitive–behavioral therapy. Journal of Traumatic Stress, 27(6), 664–671.Google Scholar
- Oosterhoff, B., Kaplow, J. B., & Layne, C. M. (2018). Links between bereavement due to sudden death and academic functioning: Results from a nationally representative sample of adolescents. School Psychology Quarterly, 33(3), 372–380. https://doi.org/10.1037/spq0000254.
- Pham, S., Porta, G., Biernesser, C., Walker Payne, M., Iyengar, S., Melhem, N., & Brent, D. (2018). The burden of bereavement: Early-onset depression and impairment in youths bereaved by sudden parental death in a 7-year prospective study. American Journal of Psychiatry, 175(9), 887–896.Google Scholar
- Pynoos, R. S., Steinberg, A. M., Layne, C. M., Liang, L., Vivrette, R. L., Briggs, E. C., & Fairbank, J. A. (2014). Modeling constellations of trauma exposure in the national child traumatic stress network core data setPsychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), S9–S17.Google Scholar
- Rolon-Arroyo, B., Rooney, E., Kaplow, J. B., Calhoun, K., Layne, C. M., Steinberg, A., & Pynoos, R. (2017). Psychometric properties of the UCLA PTSD Reaction Index for DSM-5 (RI-5): identifying clinically significant PTSD in culturally diverse youth. Poster presented at the Annual Meeting of the International Society for Trau matic Stress Studies, Chicago, IL.Google Scholar
- Salloum, A. (2008). Group therapy for children after homicide and violence: A pilot study. Research on Social Work Practice, 18(3), 198–211.Google Scholar
- Salloum, A., & Overstreet, S. (2008). Evaluation of individual and group grief and trauma interventions for children post disaster. Journal of Clinical Child & Adolescent Psychology, 37(3), 495–507.Google Scholar
- Salloum, A., & Overstreet, S. (2012). Grief and trauma intervention for children after disaster: Exploring coping skills versus trauma narration. Behaviour Research and Therapy, 50(3), 169–179.Google Scholar
- Saltzman, W., Layne, C., Pynoos, R., Olafson, E., Kaplow, J., & Boat, B. (2017). Trauma and grief component therapy for adolescents: a modular approach to treating traumatized and bereaved youth. New York, NY: Cambridge University Press.Google Scholar
- Saltzman, W. R., Pynoos, R. S., Layne, C. M., Steinberg, A. M., & Aisenberg, E. (2001). Trauma- and grief-focused intervention for adolescents exposed to community violence: Results of a school-based screening and group treatment protocol. Group Dynamics: Theory, Research, and Practice, 5(4), 291–303.Google Scholar
- Sandler, I., Ayers, T. S., Tein, J., Wolchik, S., Millsap, R., Khoo, S. T., & Coxe, S. (2010). Six-year follow-up of a preventive intervention for parentally bereaved youths: A randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 164(10), 907–914.Google Scholar
- Sandler, I. N., Ayers, T. S., Wolchik, S. A., Tein, J., Kwok, O., Haine, R. A., & Griffin, W. A. (2003). The family bereavement program: Efficacy evaluation of a theory-based prevention program for parentally bereaved children and adolescents. Journal of Consulting and Clinical Psychology, 71(3), 587–600.Google Scholar
- Sandler, I. N., Ma, Y., Tein, J., Ayers, T. S., Wolchik, S., Kennedy, C., & Millsap, R. (2010). Long-term effects of the family bereavement program on multiple indicators of grief in parentally bereaved children and adolescents. Journal of Consulting and Clinical Psychology, 78(2), 131–143.Google Scholar
- Sandler, I., Tein, J., Wolchik, S., & Ayers, T. S. (2016). The effects of the family bereavement program to reduce suicide ideation and/or attempts of parentally bereaved children six and fifteen years later. Suicide & Life-Threatening Behavior, 46(Suppl 1(2)), S32–S38.Google Scholar
- Sandler, I. N., Wolchik, S. A., Ayers, T. S., Tein, J., & Luecken, L. (2013). Family bereavement program (FBP) approach to promoting resilience following the death of a parent. Family Science, 4(1), 87–94.Google Scholar
- Shapiro, D. N., Howell, K. H., & Kaplow, J. B. (2014). Associations among mother-child communication quality, childhood maladaptive grief, and depressive symptoms. Death Studies, 38(1–5), 172–178.Google Scholar
- Spuij, M., van Londen-Huiberts, A., & Boelen, P. A. (2013). Cognitive-behavioral therapy for prolonged grief in children: Feasibility and multiple baseline study. Cognitive and Behavioral Practice, 20(3), 349–361.Google Scholar
- Spuij, M., Dekovic, M., & Boelen, P. A. (2015). An open trial of ‘grief‐help’: cognitive–behavioural treatment for prolonged grief in children and adolescents.Clinical Psychology & Psychotherapy, 22(2), 185–192.Google Scholar
- Spuij, M., Prinzie, P., Zijderlaan, J., Stikkelbroek, Y., Dillen, L., Roos, C., & Boelen, P. A. (2012). Psychometric properties of the Dutch inventories of prolonged grief for children and adolescents.Clinical Psychology & Psychotherapy, 19(6), 540–551.Google Scholar
- Tabachnick, B. G. & Fidell, L. S. (2013). Using multivariate statistics. 6th edn. Boston, MA: Pearson.Google Scholar
- Thapar, A., & McGuffin, P. (1998). Validity of the shortened mood and feelings questionnaire in a community sample of children and adolescents: A preliminary research note. Psychiatry Research, 81(2), 259–268.Google Scholar
- Tingey, R., Lambert, M., Burlingame, G., & Hansen, N. (1996). Assessing clinical significance: Proposed extensions to method. Psychotherapy Research, 6(2), 109–123.Google Scholar
- UN Children’s Fund (UNICEF) (2013). UNICEF Annual Report 2012. ISBN:978-92-806-4693-1, http://www.refworld.org/docid/51ee31214.html. Accessed 3 Aug 2018.
- Wamser-Nanney, R., & Steinzor, C. E. (2017). Factors related to attrition from trauma-focused cognitive-behavioral therapy. Child Abuse & Neglect, 66, 73–83.Google Scholar
- Wardecker, B. M., Kaplow, J. B., Layne, C. M., & Edelstein, R. S. (2017). Caregivers’ positive emotional expression and children’s psychological functioning after parental loss. Journal of Child and Family Studies, 26(12), 3490–3501.Google Scholar