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Trevor, a nine-year-old boy, was grieving due to the murder of his brother. He was also experiencing traumatic symptoms, such as avoiding talking about his brother or what happened, having intrusive imagery of his brother being killed, having nightmares, and having difficulty concentrating in school. His mother reported that, since his brother’s death, Trevor was easily triggered and had been more withdrawn.

There are many grief support groups that may be helpful for Trevor, but these types of groups typically do not address traumatic symptoms. Similarly, there are several evidence-based practices for childhood trauma, but many of these interventions do not specially address childhood grief. Grief and Trauma Intervention (GTI) for Children was designed for children like Trevor who are experiencing both grief and traumatic stress due to the death of someone close, or as a result of traumatic events such as disasters, which can lead to multiple losses and trauma.

Goals of GTI for Children

GTI for Children, typically for children aged seven to 12, may be provided individually or in a group with other children. Practitioners have also provided the intervention as part of family therapy. There are four main goals of GTI for Children related to psychoeducation, expression and meaning-making, symptoms reduction, and building coping skills. The four goals can be detailed as follows:

1. To provide psychoeducation about both childhood grief and traumatic stress.

This goal is focused on providing education to the child and family about common reactions of children who are experiencing both grief and trauma. During this process, these reactions are normalised with respect to the traumatic event that has happened. Children are taught common grief and trauma reactions and then are taught how these thoughts, feelings, body reactions and behaviours are connected. Avoidance is specifically assessed and discussed, and, as the child learns more coping skills and feels a sense of safety, (s)he is encouraged to address those aspects of the trauma and loss that (s)he has been avoiding. Emphasising psychoeducation in the context of trauma and loss is in line with a trauma-informed care perspective that starts by recognising what has happened (ie the trauma) rather than starting by asking what is wrong with the person.

2. To provide a context for the child to express his or her thoughts and feelings about what happened, and to provide a safe environment to explore the meaning of the losses and impact on the child and family.

To reach this goal, the clinician must create a safe environment that respects sharing and exploration of thoughts and feelings. The use of narrative practices and the method of using drawing, discussing, writing, and witnessing from caring others, known as DDWW, during each session helps children meet this goal. The DDWW method is used throughout the intervention and allows the child multiple opportunities for expression, provides the avenue for exposure to the trauma narrative and losses, creates the platform for the child to engage in restorative retelling,^1,2 which can clarify and/or change the narrative of self, others and meaning of what happened and/or of trauma and loss reminders, and engages supportive others to validate the child and his or her experiences.

3. To decrease post-traumatic stress symptoms.

There has been much discussion about how best to diagnose or label grief when it has become problematic or maladaptive. For example, the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5)³ states that for the diagnosis of post-traumatic stress disorder (PTSD) in the context of ‘actual or threatened death of a family member or friend, the event(s) must have been violent or accidental’.

Bereaved children may experience post-traumatic symptoms from other types of death. In such cases, the description of ‘persistent complex bereavement disorder’, which has been added as a proposed disorder, might apply. Children do not have to meet criteria for PTSD or a bereavement-related disorder to participate in GTI for Children, but at least moderate symptoms have to be present that have occurred for more than a month; thus a goal is to minimise these symptoms.

A more thorough approach would be to add to this goal ‘and to improve functioning’, as it is not just PTSD symptoms that may be causing impairment. In the case of Trevor, this goal would mean that he would not avoid people and activities that reminded him of his brother, and he would have less or no intrusive death imagery and nightmares. Also, his grades would improve to where they were before his brother died, he would be more engaged in activities with other children, as he was before the death, and he would enjoy being with other children.

4. To build coping capacity.

Every child is unique and has strengths that can be very helpful throughout the child’s development and during a time of crisis. GTI for Children takes a strengths-based approach by assessing the child’s strengths and then working throughout the treatment to highlight and promote these strengths and resiliencies. There are also specific sessions that focus on positive coping strategies to help the child cope with trauma triggers and loss reminders, important anniversaries or dates, and feelings, including anger management for those children who are having behavioural problems. Stress management techniques, such as deep breathing exercises, are taught early on, and the child and family are encouraged to use the strategies.

The theme of spirituality is also addressed in the intervention, as many children may use their sources of spirituality to help them cope, while other children might find that their previously held beliefs are being challenged. Through the use of DDWW, songs, prayers and poems are encouraged to explore how the child’s spirituality might (or might not) be a source of comfort.

Reconnecting is a theme of GTI for Children in that they are encouraged to reconnect to things that they used to like to do or people they used to enjoy being with. If these people, places, and/or activities are no longer available due to the trauma or loss, then connecting to new ways of engaging with positive others is encouraged. Early in the intervention, the child is asked to identify the supportive people in his or her life. Having support and being able to seek help from these people is critical to helping the child cope. If the child cannot identify anyone, the clinician should work to help build a supportive environment for the child and to identify at least one supportive and positive adult the child can call their ‘go to person’. If GTI for Children is delivered at school or in a setting where the caregiver is not available, it is important that family meetings occur during the intervention. Also, at the end of the intervention, the child is asked to identify a caring adult with whom the child will share the book they made during the intervention.

The intervention is structured such that coping is addressed throughout the intervention in ways that encourage the child to use multiple coping strategies and to find helpful coping strategies that can be used in different contexts (ie school, home, neighbourhood), since one coping strategy may not be able to be used or effective in all contexts.

Addressing the unique needs of the child

The four goals are designed for all children in GTI for Children but we recognise that every child is different and may have unique needs. Therefore, the model is flexible in the way it is delivered and designed. First, GTI for Children is based on what we call the DEC: developmentally specific interventions, an ecological perspective, and culturally relevant methods. In other words, the intervention activities need to be delivered in a way that takes into account the development of the child.

An ecological perspective recognises that, while the child’s time in the intervention usually consists of 11 to 14 meetings (group, individual and family interventions combined), practitioners are encouraged to work on all levels that may be affecting the child, such as with school personnel, family members or on particular basic needs (food, medicine, recreation and so on) that the child and family may need. All of this work must be conducted in a culturally sensitive manner, and specific intervention activities may need to be modified so that they are culturally relevant for the child.

The imagined case of Trevor states that he is nine years old, but there are other important characteristics and circumstances such as his culture, family beliefs, environmental living conditions, school performance, peer support and so on that are all important to assess and take into account when providing the intervention.

GTI for Children also integrates grief and trauma interventions, rather than providing separate modules or interventions for both. It may be that some children need to address traumatic symptoms before engaging in reminiscing and memories of the deceased; whereas other children may be ready to talk about the deceased and focus on the person’s life, rather than death. Yet other children may vacillate between struggling with the trauma and manner of the death, and engaging in remembering the person’s life and what that person means to the child. The sessions and choice of activities allow for the clinician and child to develop a unique clinical process for the child. If the intervention is provided in a group, the child’s treatment can be tailored, and there is also an individual session to address the unique needs of the child. This can be accomplished while still adhering to the mode.

Conclusion

GTI for Children is considered an evidence-based practice and is listed on the United States Substance Abuse and Mental Health Services Administration National Registry for Evidence-based Programs and Practices (see ‘Useful resources’). It is a time-limited intervention that uses narrative practices and cognitive behavioural therapy to address both grief and trauma in children. Children like Trevor may continue to grieve for some time, and he may miss his brother throughout his life, but with GTI for Children, we can help him understand what he is going through, provide a safe place for him to express himself, decrease his symptoms and improve his functioning, and help him to cope in a way that allows him to stay on, or get back on, a positive developmental track and have a future with positive connections to others as he continues his journey of life.

Useful resources

GTI for Children
To order the treatment manual or to learn more, visit http://gtiforchildren.com/ (accessed 6 July 2015).

National Registry for Evidence-based Programs and Practice
For information about some prior studies on GTI for Children, visit http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=259 (accessed 6 July 2015).

Alison Salloum PhD is an associate professor at the University of South Florida School of Social Work. She has extensive clinical experience working with children, adolescents and families after violence and death, and her research focuses on effective ways to help children, adolescents and their families after trauma and loss. 

References

1 Rynearson R. Retelling violent death. Philadelphia: Brunner-Routledge; 2001.
2 Salloum A. Grief and trauma in children: an evidence-based treatment manual. New York: Routledge; 2015.
3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5th edition (DSM-5). Washington, DC: Author; 2013.

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