The Courage to Remember

Childhood Traumatic Grief Curriculum Guide 

From the

National Child Traumatic Stress Network

Childhood Traumatic Grief Working Group 

Educational Materials Subcommittee

Robin F. Goodman, PhD 

National Child Traumatic Stress Network

Judith Cohen, MD 

Center for Traumatic Stress in Children and Adolescents 

Allegheny General Hospital

Matthew D. Kliethermes, PhD 

The Greater St. Louis Child Traumatic Stress Program

Julie Kaplow, PhD 

New Jersey Medical School

Carrie Epstein, MSW

Safe Horizon

Christopher Layne, PhD 

Brigham Young University

Robert Franks, PhD 

National Center for Child Traumatic Stress, Duke University

Amy Blalock, BA 

National Center for Child Traumatic Stress, Duke University

Lt. Christine Guthrie, MPH 

Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

National Child Traumatic Stress Network

NCTSN.org

2005

The National Child Traumatic Stress Network is coordinated by 

the National Center for Child Traumatic Stress, Los Angeles, CA and Durham, NC

This project was funded by the

Substance Abuse and Mental Health Services Administration (SAMHSA),

US Department of Health and Human Services (HHS). The views, policies, and opinions expressed are

those of the authors and do not necessarily reflect those of SAMHSA or HHS.

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TABLE OF CONTENTS 

Introduction 1

About this Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

About the National Child Traumatic Stress Network . . . . . . . . . . . . . .2

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Who Should Be Trained? 3

How Should This Training Be Used? 4

What Should You Learn or Take Away from This Training? 6

Overview Of Childhood Traumatic Grief 7

What Is Childhood Traumatic Grief? . . . . . . . . . . . . . . . . . . . . . . . . .7

Cultural and Individual Variations . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Overlap of Childhood Traumatic Grief, Posttraumatic Stress Disorder, 

and Trauma Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

How Is Childhood Traumatic Grief Related to 

Other Trauma Reactions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

How Does Childhood Traumatic Grief Differ from 

Uncomplicated Grief? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Who Suffers from Childhood Traumatic Grief? . . . . . . . . . . . . . . . . .16

How Is Childhood Traumatic Grief Recognized? . . . . . . . . . . . . . . . .16

How Is Childhood Traumatic Grief Treated? 19

Principles and Overview of Treatment . . . . . . . . . . . . . . . . . . . . . . .19

What Are the Key Components of Childhood 

Traumatic Grief Treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Individualized Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

What Role Do Parents Have in the Treatment? . . . . . . . . . . . . . . . .22

Structure of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

What Are the Key Components of Childhood 

Traumatic Grief Treatment? 25

Treatment Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

1. Psychoeducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

2. Affect Expression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

3. Stress Management Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

4. Cognitive Affect Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

5. Trauma Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

6. Cognitive Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
How Are Grief-Related Issues Handled in the Treatment Process? 39

7. Communicating about Death . . . . . . . . . . . . . . . . . . . . . . . . . . .39

8. Mourning the Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

9. Addressing Ambivalent Feelings about the Deceased . . . . . . . . .42

10. Preserving Positive Memories . . . . . . . . . . . . . . . . . . . . . . . . .43

11. Redefining the Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . .44

12. Committing to New Relationships . . . . . . . . . . . . . . . . . . . . . .44

13. Making Meaning of the Death . . . . . . . . . . . . . . . . . . . . . . . . .45

14. The Natural Evolution of Grief and Termination . . . . . . . . . . . . .46

Treatment of Childhood Traumatic Grief with 

Young Children and Groups 48

How Is Childhood Traumatic Grief in Young Children Treated? . . . . .48

Why and How Is Childhood Traumatic Grief Treated in Groups? . . . .49

Conducting Group-Based Treatment for Childhood Traumatic Grief . .52

Concluding Thoughts: Recognize, Respond, Remember 54

Appendices: Handouts, Resources, References 56

Feeling Faces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

Progressive Muscle Relaxation Scripts . . . . . . . . . . . . . . . . . . . . . .58

Learning to Relax through Imagery . . . . . . . . . . . . . . . . . . . . . . . . .63

Cognitive Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

Thinking, Feeling, Behaving Illustrations . . . . . . . . . . . . . . . . . . . . .65

Sample Trauma Narrative by School-Age Child . . . . . . . . . . . . . . . .67

Sample Trauma Narrative by Teen . . . . . . . . . . . . . . . . . . . . . . . . .70

Information for Parents on Childhood Traumatic Grief . . . . . . . . . . .72

Reference and Resource List . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

Professional References — PTSD . . . . . . . . . . . . . . . . . . . . . . .76

Professional References — Bereavement . . . . . . . . . . . . . . . . . .77

Professional References — Childhood Traumatic Grief . . . . . . . .78

Books for Children and Teens on Trauma and Bereavement . . . . .80

Suggested Treatment Books and Supplies . . . . . . . . . . . . . . . . .81

Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

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INTRODUCTION

ABOUT THIS GUIDE

Children who have experienced the traumatic death of a person significant in their

lives may have reactions and symptoms that we are beginning to understand are 

distinct from the grief following nontraumatic death. We believe that children who 

have experienced traumatic grief and who are troubled by overwhelming traumatic

memories can be identified and helped to cope with traumatic reactions and 

ultimately remember the person who died in a healthy, meaningful way.

The material presented in The Courage to Remember video and this companion guide

represents the results of significant advances in the field of childhood traumatic grief

and the unique collaboration of researchers and clinicians in academic and community

settings throughout the country. We developed the video and guide using extensive

expert involvement and commentary. Although the focus of these training materials 

is on individual work with school-age children and teens, additional information and

resources are provided regarding work with young children and groups. The materials

provide specific guidelines and options for interventions to

• educate care providers about childhood traumatic grief,

• introduce others to principles of treatment that have been identified as helpful 

in treating the condition, and

• offer practitioners an opportunity to enhance their treatment skills.

We hope to improve awareness about childhood traumatic grief as well as increase

the ability of clinicians to respond in the most effective way possible. 
ABOUT THE NATIONAL CHILD TRAUMATIC STRESS NETWORK

This project is the result of a collaboration within the National Child Traumatic Stress

Network (NCTSN), which comprises 54 research and treatment centers from around

the United States. The Network is funded by the Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration, US Department of

Health and Human Services. The mission of the NCTSN is to raise the standard of

care and improve access to services for traumatized children, their families, and 

communities throughout the United States. The Courage to Remember videotape and

guide serve to further the mission of the Network by increasing the availability of care

for children and expanding public and professional awareness of the specific condition

of childhood traumatic grief.

ACKNOWLEDGMENTS

We wish to thank the professionals who appeared in It’s OK to Remember and 

The Courage to Remember: Dr. Judith Cohen, Dr. Robin F. Goodman, Dr. Tamra

Greenberg, Dr. Alicia Lieberman, Dr. Anthony Mannarino, Dr. Robert Pynoos, and

Karen Stubenbort, as well as many other professionals from the National Child

Traumatic Stress Network.

In addition we gratefully acknowledge the individuals and organizations that 

contributed to the review of these materials, including: SD Williams, Stephanie

Handel, Dana Naughton, Dr. Ann Kelley, Dr. Esther Deblinger, Bereavement Center 

of Westchester, Center for Trauma Recovery University of Missouri–St Louis, Healing

the Hurt, Highmark Caring Place, Safe Horizon, Wendt Center for Loss and Healing,

Center for Child and Family Health of North Carolina, National Center for Child

Traumatic Stress faculty and staff, and the SAMHSA/CMHS National Child Traumatic

Stress Initiative program staff.

We also would like to recognize the many hours of creative and editorial time spent 

by our production team, Dr. Robin Goodman, Dr. Bob Franks, and Mike Wertz from

Apple Box Studios, in the development, revision, and final production of these 

educational materials.

This work would not be possible without the support and vision of Dr. Robert Pynoos

and Dr. John Fairbank, co-directors of the National Center for Child Traumatic Stress

at UCLA David Geffen School of Medicine and the Duke University School of Medicine. 

And special thanks go to the families who courageously shared their stories.

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WHO SHOULD BE TRAINED?

This Childhood Traumatic Grief guide was developed as a companion to the training

video The Courage to Remember. The video is an advanced training tool and assumes

that you are familiar with the concepts of trauma and bereavement and with general

mental health principles. 

This training is intended for all professionals and trainees working with children, 

especially school-age children and adolescents. Readers and viewers with a 

background in medicine (e.g., psychiatrists, nurses), mental health (e.g., clinical and

school psychologists, social workers), and bereavement (e.g., pastoral and bereavement

counselors) may find the information especially relevant. Professionals specializing 

in bereavement can benefit from the focus on differentiating childhood traumatic 

grief reactions from other types of grief reactions. Professionals in other fields may 

be unaware of the extent to which trauma and grief are part of a child’s life. Equipped

with further knowledge, you will be better able to identify problems related to 

childhood traumatic grief and help children and families get appropriate care.
HOW SHOULD THIS TRAINING BE USED?

It may be helpful to first view the introductory video, It’s OK to Remember, which 

provides basic background information on childhood traumatic grief. The training

video, The Courage to Remember, is the companion to this curriculum guide. As a

training package, the two videos and the guide can be used in a variety of ways: 

• If you are a clinician using them on your own, we hope you will find the concepts

and techniques helpful in your everyday practice with children. 

• If you are a trainer, a minimum total of three hours for the training is suggested;

one hour for viewing the videos (each is approximately 30 minutes in length) 

and two hours for training and a discussion of the concepts presented in the

videos and described more fully in the guide. This could be completed in one 

day or over two to three course sessions. Ideally the videos should not be shown

back-to-back. Use the materials in whatever way best suits your program needs.

• If you are an administrator at your institution, we hope you will support the goals

of this training program and encourage participation by your staff and faculty.

• You are also directed to the Information for Parents on Childhood Traumatic Grief

found at the end of the guide, which provides suitable information that can be

used as a handout for parents. Additional background information and handouts

for medical and mental health professionals, educators and the media on

Childhood Traumatic Grief are available at the NCTSN website, NCTSN.org. 

• We invite you to explore other resources and information on topics related to

childhood traumatic stress available at NCTSN.org. 

The Courage to Remember video and guide are by no means exhaustive presentations

of childhood traumatic grief. Depending on your level of training, prior experience, 

and background, additional training is strongly recommended. For example, it may 

be helpful to pursue specific training in cognitive behavioral techniques or work with

bereaved children to become more familiar with the concepts presented here. You may

also want to read more about Posttraumatic Stress Disorder (PTSD), trauma, grief, and

the research being done in these areas by utilizing the resource and reference section

at the end of the guide. Additional supervision and consultation is urged as practitioners

develop their expertise. Both when beginning to treat children with childhood traumatic

grief and even once trained, it is extremely helpful to discuss issues, share experiences,

and get support for your work from colleagues and supervisors.

Specific references for professionals, parents, and children can be found at the end

of the guide. Specific organization and Internet resources for further training 

information can be found at the end of the guide.

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The video and guide cover issues related to the diagnosis and treatment of childhood

traumatic grief in the same sequence. This guide provides more in-depth 

explanations, step-by-step instructions, additional resources, and quoted excerpts

from professionals and family members seen in the videos to identify main concepts.

A variety of different icons have been used throughout the guide to help you more

easily find the information you need. Icons will be used to highlight the following: 

GLOSSARY OF ICONS

Important issues or terms

are defined.

Main concepts about

childhood traumatic grief

or treatment are identified

within the text.

Case examples and quotes

are used to illustrate 

certain concepts.

The treatment being

described is conducted 

in individual child, parent,

and joint parent and child

sessions. We are aware

that the treatment may be

conducted with a primary

caregiver who is not a

parent, but for ease of

presentation we are using

the term “parent” generically

to describe the child’s

significant adult caregiver(s).

The treatment components

described here can be

adapted to other situations

and for children of different

ages, such as a group of

adolescents. 

Different treatment 

components and suggested

tools to use with clients

will be described. 

Specific activities used in 

the treatment sessions 

are described.

Different handouts are

referred to and provided 

(1) as background 

information for parents

and professionals and 

(2) for use in sessions 

or for homework. 

At times you will be

referred to additional 

references that can be

found at the end of 

the guide.

At times you will be

referred to additional

resources that can be

found at the end of 

the guide.

DEFINITION TREATMENT

COMPONENT

ACTIVITY

HANDOUT

REFERENCE

RESOURCE

MAIN

CONCEPT

CASE

EXAMPLE

PARENT

CHILD

CHILD

PARENT

JOINT
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WHAT SHOULD YOU LEARN OR TAKE AWAY 

FROM THIS TRAINING?

Childhood traumatic grief is a condition that children may develop after the death of 

a significant person under circumstances that have been traumatic for the child. 

We are beginning to understand how to identify this condition. In childhood traumatic

grief, a child has reactions and symptoms similar to those found in children 

with PTSD. These reactions make it difficult for the child to follow the usual path 

of bereavement and reminiscence about the deceased person in a positive and 

meaningful way. 

There are promising treatments that have been shown to be most helpful for children

with childhood traumatic grief. Treatment can be done with individuals and with groups

of children of different ages, and it should address both trauma and grief symptoms.

Treatment initially involves treating the trauma aspects of the condition and then 

moving on to help the child deal with bereavement issues and master specific tasks. 

The intervention described in this program draws from a variety of existing approaches.

The treatment includes teaching the child skills for managing stress, helping the child

to create a story about the death, and finally supporting the child while engaging in

specific activities related to bereavement. The goal of the treatment is to enable the

child to remember and cope with previously troubling thoughts and feelings about the

death and go on to have more positive and comforting memories about the person.
OVERVIEW OF CHILDHOOD TRAUMATIC GRIEF

WHAT IS CHILDHOOD TRAUMATIC GRIEF?

After being broadsided, the car was spinning out of control. When it stopped, eightyear-old Devon, who was buckled up in the back seat and pinned in the car, yelled for

his mother to wake up. He heard the sirens, then watched the paramedics drag his

mother onto the street and saw blood running down her face. Later, whenever he rode

in a car, he refused to put on his seat belt because he wanted to get out as fast as

possible in case of an accident.

Twelve-year-old Anna’s brother drowned in the neighbor’s pool. She had a fight with him

right before he left, teasing the five-year-old about not being able to swim. Later she

frequently had nightmares in which she couldn’t breathe, so she stayed up most of

the night. In school, she was exhausted, sleepy, and couldn’t concentrate. Her grades

plummeted, but she said she didn’t care and deserved whatever punishment she got.

Childhood traumatic grief is a condition in which children who lose

loved ones under very unexpected, frightening, terrifying, traumatic 

circumstances develop symptoms of posttraumatic stress and 

other trauma symptoms that interfere with their ability to progress

through typical grief tasks, because they are stuck on the traumatic

aspects of the death. —Judith Cohen

Childhood traumatic grief can develop following the death of a significant person 

when the death has been perceived by the child as traumatic. The hallmarks of the

condition are reactions related to (1) trauma, a situation that is sudden and terrifying

and that results in death and may have also been life threatening for the child, and

(2) grief, feelings of intense sadness and distress from missing the person who died

and the changes that have resulted. The distinguishing feature of childhood traumatic

grief is that trauma symptoms interfere with the child’s ability to navigate the typical

bereavement process. In other words, a child’s preoccupation and inability to relinquish

a focus on death leaves little or no room for other more helpful thoughts about 

the person who died, leaves little emotional energy for adjusting to change, and 

compromises the child’s ability to function in school or with friends. According to our

current understanding, childhood traumatic grief is distinct from uncomplicated

bereavement and conditions such as PTSD, yet it shares features of both. The 

definition, characteristics, and assessment of childhood traumatic grief are still 

evolving and likely vary due to such things as the type of death, age and cognitive

ability of the child, culture and beliefs, and family situation. 

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DEFINITION

CASE

EXAMPLE

CASE

EXAMPLE
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The child’s perception, not just the cause of death, plays a key role in determining the

development of symptoms. Not every child develops traumatic grief after a death that

happened in a particularly dramatic or threatening manner, such as death from a homicide,

war, or motor vehicle accident. In some cases, childhood traumatic grief can result

from a death that most would consider expected or normal, such as death from illness

or natural causes. There may be isolated traumatic moments that can be lodged in

the child’s memory, such as seeing a parent in profuse pain, that provoke the child’s

reaction. Childhood traumatic grief can affect children’s development, relationships,

achievement, and later effectiveness in life if not treated or otherwise resolved.

Children loose their developmental momentum that they had been 

pursuing. They need support to regain that developmental momentum,

and without the support it often happens that children really stop 

gaining these skills that are appropriate for their age, and that has

long-term repercussions. —Alicia Lieberman

The traumatic aspects of the death and the child’s relationship to the person that

died are entwined in such a way that thoughts or reminders of the trauma and 

overwhelming painful grief about the person who died are linked together. The child’s

traumatic reaction can stem from the sudden and horrific nature of the death with 

or without the child’s life also being in danger. The grief reaction stems from the 

sadness of missing the person and all that has changed. The child contends with 

the complex mix of trauma and grief. Hence, in providing treatment the clinician must

address both.

A child survivor of a car crash in which her mother was killed may be confronted with

reminders of the smell of rubber and gasoline, the fear of being trapped in the car,

the sight of blood and a mother’s lifeless body, and a caretaker whose absence is felt

every waking moment. 

CULTURAL AND INDIVIDUAL VARIATIONS

Communication, expression and behavior following trauma and death can vary according

to one’s race, ethnicity, culture, and religion. It is important to be fully aware of these

variations in order to accurately identify those reactions outside the norm of what is

accepted and that prevent the child from participating fully in productive activities. 

For example, intense displays of emotion may be more common in some cultures than

in others, and spiritual beliefs about an afterlife may influence a child’s reactions and

expressions. In some cultures it may be common practice to refrain from using the

name of the deceased for a certain period of time, hence, what may be interpreted 

as avoidance in one setting is respectful and necessary in another. Either through 

naturally occurring common practices or due to unfortunate war or devastation, 

CASE

EXAMPLE

MAIN

CONCEPT
children in different countries may also have more or less exposure to death throughout

their life, which can influence their response. Regarding intervention, you must be

sensitive to instances when certain treatment principles may be contrary to what is

accepted practice in the child’s particular family. For those times when a practitioner is

unfamiliar with a family’s practices and beliefs it is essential to seek consultation or

consider additional referral.

OVERLAP OF CHILDHOOD TRAUMATIC GRIEF,

POSTTRAUMATIC STRESS DISORDER, AND TRAUMA REACTIONS

The typical traumatic stress symptoms that children might experience

with childhood traumatic grief include things like intrusive thoughts 

or recurring images associated with the death of their loved one. It

could be the child becoming very constricted emotionally, becoming

numb as a way of not dealing with all the pain associated with the 

tragic circumstances of their loved ones death. The child who has 

childhood traumatic grief doesn’t have to have all those symptoms, 

just some of them. —Anthony Mannarino

There is overlap in the reactions and symptoms of uncomplicated bereavement, 

PTSD, and childhood traumatic grief. Children may show different signs of childhood

traumatic grief at different ages. However, difficulties specific to childhood traumatic

grief that can occur across developmental stages include those listed below. Although

the following reactions and symptoms are consistent with characteristics of PTSD,

they are notable as indicators of childhood traumatic grief because of the direct 

reference to the traumatic death. A helpful way of understanding the following reactions

is to view them as indicating a child’s distress, communicating to others that the child

is not letting go of thoughts, feelings, and behaviors related to the images, details, 

circumstances, and actions surrounding the death.

• Intrusive memories and preoccupations about things that happened before, 

during, and after the death: These can appear through nightmares, guilt, or 

self-blame about how the person died, or recurrent or intrusive thoughts about

the horrifying manner of death. Thoughts may also focus on wished-for protective

or rescue interventions, such as regret for not doing something that would have

changed the outcome.

A seven-year-old boy keeps thinking he should have done CPR to save the life of

his three-year-old sister who was caught in the crossfire of a drive-by shooting.

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CASE

EXAMPLE
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• Avoidance and a fear of strong feelings: This can be expressed by withdrawal 

or by the child avoiding reminders of the person, the way the person died, or the

event that led to the death. In attempting to keep strong unpleasant feelings

related to the death at bay, the child may also try to dampen all feelings, which

results in what adults would understand as “numbing.”

A 14-year-old girl could not go to any fast-food restaurant after her father was 

accidentally shot to death in one while they were getting milkshakes.

• Physical or emotional symptoms of increased arousal: These can include 

irritability, anger, trouble sleeping, decreased concentration, a drop in grades,

stomachaches, headaches, increased vigilance, and fears about safety for 

oneself or others. The reaction can generalize and occur in a context that 

resembles, but is different than, the original situation. 

A four-year-old girl started crying and screaming “stop shooting my mommy”

when she heard the fireworks at the park on the Fourth of July.

• Re-enactment: In re-enacting aspects of the events that are perceived to 

have led to the death, there is an attempt to intervene, manage feelings of 

helplessness, and undo what has been done and identify ways to prevent the

tragedy and death.

A six-year-old bereaved survivor of a motor vehicle crash repeatedly drew and cut

out replicas of the car and steering wheel. He built an oversized speedometer so

the driver of the other car would notice he was driving too fast. The boy went on

to make a car with extra protection that was strong enough to withstand any crash. 

HOW IS CHILDHOOD TRAUMATIC GRIEF RELATED TO 

OTHER TRAUMA REACTIONS?

Traumatic events can involve an actual death, other loss, serious injury, or threat to

the child’s own life or well-being. These events could include natural or man-made 

disasters, violence, war, or accidents. A child may be traumatized by direct exposure,

witnessing the event, or hearing about another person’s experience. For some children,

the response can have a profound effect on how they view themselves and the world.

They may develop changes in their behavior (externalizing problems) or emotional 

functioning (internalizing problems). Left untreated, the severe trauma-related reactions

can lead to more serious and chronic difficulties and, in some cases, coalesce into

PTSD. PTSD is diagnosed when the child has specific symptoms that continue for a

month or more following exposure to a traumatic event. The symptoms fall into the

three categories of re-experiencing, hyperarousal, and avoidance.

CASE

EXAMPLE

CASE

EXAMPLE

DEFINITION

CASE

EXAMPLE
When children with childhood traumatic grief show reactions and symptoms characteristic

of PTSD, the reactions and symptoms are directly related to the death and interfere with

the child’s day-to-day functioning and bereavement work. Children may present with other

symptoms not necessarily associated with PTSD but related to bereavement and traumatic

death. These may include guilt, yearning, anger, and rescue and revenge fantasies.

Eleven-year-old Lisa witnessed her mother’s murder. In an interview with a therapist

five days after her mom was fatally shot and stabbed by her estranged boyfriend, Lisa

revealed her feelings about revenge when describing a dream: “In my dream I had the

same knife he used to stab my mother and the same gun that he shot her with. Then

I went up to him and said ’Do you remember this, now you can feel it’ And I stabbed

him right where he stabbed my mother. Then I said, ’I guess you remember this too,’

and then I shot him.”

It was hard for Lisa to talk about her mother, who she dearly loved, without feeling as

if she was back in that room. In the days and weeks after the murder, when she had

that feeling, she would focus on her mother being killed. But as she stood at the door,

frozen in place, one suspects she worried about herself as well as about her mother

being killed.

In childhood traumatic grief, the interaction of traumatic and grief symptoms is such

that any thoughts or reminders, even happy ones, about the person who died can lead

to frightening thoughts, images, or memories of how the person died. 

Kevin, the 17-year-old brother of 15-year-old Briana, was killed in an avalanche. His body

was never found. She was haunted by feelings of guilt for not demanding he stay at the

lodge. She was so distraught that she isolated herself from friends. On further questioning,

it became clear that Briana and Kevin had many of the same friends. So when Briana

was with them, she was reminded of the good times they used to have together. But

this quickly led to her thinking about Kevin suffocating and it being her fault.

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CASE

EXAMPLE

DEFINITION

Lisa’s Drawings

CASE

EXAMPLE
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Three types of reminders may trigger unpleasant and distressing reactions:

1. Trauma reminders: places, situations, people, sights, smells, or sounds 

reminiscent of things associated with the actual death. These may include the

street corner where a fatal accident occurred, the bedroom where a parent died,

or the sound of an airplane reminding a child of a mother who died in a crash.

2. Loss reminders: people, places, objects, situations, thoughts, or memories 

that are reminders of particular aspects of the person who died — for example,

photo albums, an empty chair at the dinner table, or a new coach who has

replaced a parent who previously headed a child’s sports team.

3. Change reminders: situations, people, places, or things reminding the child 

of changes in his or her life resulting from the death — for example, moving to 

a new house or having to walk home with a babysitter rather than an older 

sibling who died.

Reminders can certainly provoke sadness or thoughts about the deceased. However,

in childhood traumatic grief, these reminders may lead to the child re-experiencing 

the traumatic events that led to the death. The terror associated with these memories

results in increased arousal symptoms. The child then attempts to handle the 

distressing re-experiencing and symptoms with avoidance or numbing, often 

characterized as a deadening of emotions in older children and a fear of feelings in

younger children. Because traumatic aspects of the death are so upsetting, the child

tries to avoid all reminders of the trauma, loss, or resulting changes so as not to 

stir up unpleasant thoughts or feelings. 

For example, a younger child may be afraid to sleep alone at night because of 

nightmares about a tragic shooting, whereas an older child may avoid flying in a 

plane because it brings up painful memories about a father who died in a plane crash.

One of the most common reminders of the trauma, loss, and change is the person’s

own family. Looking across at each other, knowing each has experienced the same

death even if having individual reactions, can be upsetting.

HOW DOES CHILDHOOD TRAUMATIC GRIEF DIFFER 

FROM UNCOMPLICATED GRIEF?

Any death can be difficult for a child, and certain reactions are more likely than others.

Uncomplicated bereavement is the intense sadness and longing for the deceased 

that children typically feel after the loss of a loved one. Complicated bereavement

has been described in adults as bereavement complicated by separation distress 

and traumatic symptoms related to the loss of the security-enhancing relationship 

with the deceased. This has not been clearly defined as a condition for children. 

DEFINITION
Uncomplicated or typical grief reactions in children vary according to age, developmental

level, previous life experiences, culture, beliefs, emotional health prior to the death,

and the family and social environment. Over time, a child is relieved of extreme 

sadness and is able to engage in accepted mourning rituals, and, when appropriate,

remember good times and have positive feelings about the person who died. However,

while grieving, a child typically may have: 

• Emotional reactions: feeling sad, angry, anxious, numb, lonely, guilty, powerless,

shamed, insecure, and remorseful.

• Changes in behavior: lack of interest and participation in usual activities, 

diminished self-care, unpredictable or odd behavior, angry or aggressive 

behaviors, increased risk taking, irritability and conflict with others, impulsivity,

regression to earlier behaviors, changes in sleep behaviors (increased or

decreased), difficulty sleeping or sleeping alone, changes in appetite (increase 

or decrease in weight), and changes in physical health.

• Difficulty with interpersonal interactions: withdrawal, social isolation, peer 

difficulties, clinging, irritability, difficulty sharing memories, difficulty participating

in group or athletic activities, and general lack of interest in others.

• Changes in thinking: constant thoughts and memories about the loved one, 

persistent thoughts about the death, disbelief about the death and the finality 

of the death, constant or intrusive thoughts about death, preoccupation with

one’s own or a loved one’s physical health and safety, difficulty making decisions,

confusion, impaired memory and concentration, lowered self-esteem and selfconfidence, disillusionment, thinking that the death was one’s fault, and 

survivor guilt.

• Altered perceptions: believing the deceased is still present, feeling the person’s

presence nearby, seeing the person’s face in a crowd, smelling the person’s 

perfume, hearing the person’s voice, and experiencing vivid dreams about 

the person.

• Physical reactions: susceptibility to illness, loss of energy, fatigue, difficulty or

changes in eating, physical complaints, and changes in physiological arousal 

(for example, increased heart rate, respiration, and startle response).

• Changes in academic functioning: poor school performance, difficulty studying 

or concentrating, and potential school failure.

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In nontraumatic bereavement, kids may be sad, or upset, or feel lonely,

but they are able to continue on with activities and eventually maybe

enjoy life again and be re-engaged with people and situations. The child

with traumatic grief is kind of stuck, so a child may not want to be

around a cousin who is the same age as a sister who died because 

it’s too upsetting, or a boy may not want to play baseball anymore

because he can’t bear the thought of looking in the stands and his

father not being there, and he falls apart. So these things segue into

the awful reminders, and the child then avoids every reminder, even a

positive one. —Robin Goodman

Throughout their lives, children continue to adjust to the loss and develop new ways

of coping. Over time, it is helpful for children to relate to their loss by engaging in, 

and mastering, certain bereavement tasks. The following chart presents the outcome 

of common bereavement tasks and how childhood traumatic grief interferes with 

completion of these tasks.

Completion of Bereavement Tasks for Children with Uncomplicated Grief 

and Indicators of Difficulty for Children with Childhood Traumatic Grief

MAIN

CONCEPT

In uncomplicated bereavement typically 

children will:

Accept the reality and permanence of

death

Experience and cope with difficult 

emotional reactions

Adjust to changes in their lives and

changes in their identity that result from

the death

Develop new relationships or deepen

existing ones

Childhood traumatic grief interferes

with bereavement due to:

Difficulty with accepting or unwillingness

to accept that the person has died due

to associations of the death with the

traumatic circumstance

Intense, distressing feelings that are

triggered by reminders leading to 

avoidance or lack of feelings

Changes that lead to unpleasant reminders

of the way the person died, possible

overidentification with the person who

died, feeling overly responsible

Feelings such as guilt, anger, and

revenge interfering with the formation 

of new relationships
In uncomplicated bereavement, children may feel sad when remembering the

deceased person but are generally able to have positive memories of the person and

continue with necessary life activities. It is important to keep in mind that bereaved

children are at risk for other types of mental health problems such as depression,

anxiety, and substance abuse either alone or in conjunction with childhood traumatic

grief. In childhood traumatic grief specifically, the terrifying and frightening aspects 

of the death are so prominent that they get in the way of adjusting to life in ways that

are deemed helpful for the bereaved. Because positive memories of the person 

who died lead directly to frightening reminders of the death, without help, the child

never reaches the point of finding comfort in memories, calling up better times, or

participating in what are culturally customary mourning practices. The child may also

have been unable to participate or benefit from various rituals used to ease grief, for

example, avoiding a funeral or being unable to cry for many months. In childhood 

traumatic grief, the traumatic reactions make it difficult for the child to

• reminisce or enjoy positive memories of the deceased person when that is

deemed comforting in the child’s culture,

• cope with the many life changes that occur as a result of the death, and

• continue with normal development in ways that are expected and necessary.

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CONCEPT

In uncomplicated bereavement typically 

children will:

Maintain a continuing, healthy 

attachment to the deceased person

through remembrance activities

Find some meaning in the death and

learn about life or oneself

Continue through the normal 

developmental stages

Childhood traumatic grief interferes

with bereavement due to:

Difficulty or avoidance of positive memories

because they are linked to horrible images

and upsetting thoughts and feelings

Inability or resistance to moving past 

the terrifying, unpleasant aspects of 

the death, negative feelings about self

related to the death or person

Emotional reactions and resulting 

behavior, e.g., withdrawal, anger, and

distrust, interfering with the ability 

to engage in positive, age-appropriate

activities and relationships 
WHO SUFFERS FROM CHILDHOOD TRAUMATIC GRIEF?

Children can develop childhood traumatic grief when they experience the death of a

significant person, such as a parent, a sibling, or a close friend. Children of all ages,

even a young preschooler, can have a traumatic reaction to a death, especially of a

primary caregiver. It is estimated that five percent of all children in the United States

experience the death of a parent before the age of 15, and children under the age of

three are often present when a sibling or parent dies in a traumatic circumstance,

making young children particularly vulnerable and in need of attention.

However, not all children who have experienced a death develop childhood traumatic

grief. In fact, many recover and do well over time. Although it is true that the majority

of children who experience a death do not develop childhood traumatic grief, the 

number of children who do struggle with childhood traumatic grief is quite significant.

For example, up to 70 percent of children in inner city communities have seen 

someone shot or stabbed. Even if only five percent of these children develop childhood

traumatic grief, this translates into thousands of children developing this condition

each year. Although all children witnessing a homicide are likely affected in some way,

some are better able to tolerate the experience, whereas others are deeply impacted

and cannot continue on as well as before the death.

HOW IS CHILDHOOD TRAUMATIC GRIEF RECOGNIZED?

Children’s symptoms and presentation may vary according to factors related to their

age, stage of development, culture, religious beliefs, social supports, and family 

functioning. However, the most common signs of childhood traumatic grief that 

can occur across the different developmental stages include intrusive memories

(e.g., nightmares) and increased arousal (e.g., irritability or difficulty sleeping), both 

of which can lead to avoidance and numbing to manage the distress. Not all children

will meet criteria for a diagnosis of PTSD. A child may have other difficulties more 

typically seen following an uncomplicated death, such as depression or anxiety.

Children may exhibit problems at home, in school, 

or with friends that are not readily understood 

as related to the death or usual trauma-related 

symptoms. For example, avoidance may be 

recognized by its consequences, such as poor 

concentration and failing grades, resistance to

engaging in previously enjoyed activities, or refusal

to participate in events or activities related to

remembering the person who died. The point in a

child’s life at which the death occurred is a factor 

in adjustment. Children’s reactions to trauma and

death can have a varied impact on their later 

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CONCEPT

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development. For example, when a toddler experiences the death of a parent, 

attachment behaviors may be affected, and a death that occurs in adolescence 

may impact a teen’s later interpersonal relationships. 

A child may present with symptoms not readily appreciated as indicating childhood

traumatic grief. For example, a pediatrician may see a child for recurrent stomachaches

or poor compliance with management of a chronic illness. The relationship between

the physical symptoms and the avoidance of childhood traumatic grief reminders may

become apparent upon further inquiry. As another example, a bereavement counselor

may find that the intensity of a child’s anger has not remitted over time and has 

interfered with the child’s ability to work through his or her grief-related feelings.

Symptoms of childhood traumatic grief may become apparent in the first months after

a death. However, childhood traumatic grief can also be unrecognized or not apparent

until many years later, when a traumatic or stressful time triggers childhood traumatic

grief symptoms. Because childhood traumatic grief reactions can interfere with 

ongoing development, problems may arise at significant stages of life. A mother’s

remarriage, a decade after a father’s death, may trigger memories of the car crash

that killed the father and result in intense, upset feelings, distress, and avoidance of 

activities related to the marriage. A missed opportunity to visit a grandparent who

dies of natural causes may stimulate an intense longing and guilt over a sibling who

committed suicide.

Childhood traumatic grief can pose developmental challenges. Children who idealize 

a parent who died may adhere to unrealistic expectations of others in future intimate

relationships. Similarly, when a significant person dies during a stormy phase of a

relationship, the conflicted feelings and guilt can infuse later relationships. A child’s

ability to fully understand death, coupled with a shocking death, can lead to inaccurate

beliefs and fear. 

When Jamal was seven, he was with his 39-year-old father, who died suddenly of a

heart attack. At 16, Jamal had an anxiety attack when he had chest pain from 

bronchitis. He thought he was going to die.

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EXAMPLE
Risk Factors for Childhood Traumatic Grief

Although it is not always possible to predict who will develop childhood traumatic

grief, there are a number of factors that put children at greater risk for developing

problems following a traumatic death. You should be alert to children who have

experienced the following:

• Previous traumas: Children who have experienced a previous trauma 

(e.g., abuse or a natural disaster) can be more vulnerable to experiencing a 

more intense reaction to a new trauma or traumatic loss. The circumstances 

of the current death may cause the person to remember and react to a 

previous trauma, and dealing with both can make the current reactions more

intense or severe.

• Prior mental health problems: Children with a history of mental health problems

may be vulnerable to having those difficulties exacerbated by the traumatic

death and the accompanying stress reactions. The prior mental health problems

can also make it more difficult for a child to manage the current situation.

Bereaved children are also at risk for depression and anxiety, hence it is 

important to thoroughly assess and differentiate a child’s response.

• Impaired functioning of parents and family: The ability of children’s primary 

caregivers to manage their own reactions to a traumatic death has a direct 

effect on how a child is able to cope with his or her own reactions. In a culture

where memorialization is encouraged, a caregiver’s avoidance of talking about

the person who died can make the child reluctant to communicate about the

death and hence interfere with the child’s adjustment.

• Poor/lack of social support: If a child is feeling unsafe, abandoned, sad, and

angry following a traumatic death, a good social support network can provide

comfort and reassurance. It is more difficult to seek and engage in new 

supportive relationships than to find support in relationships already in place. 

• Secondary adversities: The death of a significant person often results in many

life changes. The changes that result from the death, such as remarriage, 

loss of health or employment benefits, and changes in financial circumstances, 

housing, or school can cause tremendous stress for the child and family. Other

related activities, such as custody and criminal proceedings, also contribute to

the child’s stress reactions.

Jonathon lived with his single-parent mother. He did not get along well with his father

and rarely saw him. After his mother died in a homicide, his father obtained custody

and the boy moved to a new city. On top of witnessing his mother’s death, he now

had to deal with a new school, loss of his friends and church support, and the 

adjustment to living with a father he barely knew, a stepmother, and stepsiblings.

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EXAMPLE

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CONCEPT
HOW IS CHILDHOOD TRAUMATIC GRIEF TREATED?

PRINCIPLES AND OVERVIEW OF TREATMENT

In childhood traumatic grief, difficulties stem from exposure to a death that was 

experienced as terrifying, and in some instances the child felt his own life was in 

danger, as well. The threatening and traumatic reaction interferes with, and impairs,

the child’s ability to cope with the death and engage in meaningful and necessary

bereavement-related activities. When preoccupied and overwhelmed by trauma-related

distress, the child avoids or is unable to enjoy positive memories, develop relationships,

and fully participate in life. Due to this complex interaction of trauma reactions and

symptoms of usual bereavement, it is necessary to treat both the trauma and grief

responses in a sequential fashion.

Sometimes when we talk to parents, they are resistant to the idea of

children recounting the details of the trauma. In fact sometimes, quite

honestly, therapists are resistant to having children recount the details

of the trauma. The primary reason for that is that parents and therapists alike don’t want children to be exposed to more pain and more

difficulty. Parents often feel “my child has been through enough and if

we put them through more, it’s just going to be too much.” Kids might 

experience some pain associated with detailing what happened to their

loved one, but if they experience a little pain and anxiety associated

with doing that now, that is going to save the child from a deeper, more

disturbing problem later on because it wasn’t addressed when it could

have been. —Anthony Mannarino

WHAT ARE THE KEY COMPONENTS OF CHILDHOOD 

TRAUMATIC GRIEF TREATMENT?

The treatment described in detail here is for use with individual school-aged children.

Initially the focus of treatment is on the traumatic nature of the death. The child first

learns ways to cope with the frightening thoughts, images, feelings, and arousal 

associated with the traumatic experience. It is crucial to carry out the components of

childhood traumatic grief treatment in a progressive fashion in order to help the child

learn and build skills enhancing self-efficacy. Once the traumatic aspects recede, the

practitioner is better able to help the child integrate what was learned with a less 

trauma-focused world view and help the child actively engage in remembering the 

person who died. The child is then also better able look at the current and enduring

aspects of bereavement. 

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CONCEPT
Fifteen-year-old Thomas was home watching television when his father jumped to his

death outside their apartment window. The family was unaware that he had stopped

taking his medication for his schizophrenia. Thomas was afraid to go to sleep at night

due to the recurring images he saw of his father on the ground. During the day, he

was feeling the urge to jump out the window himself. He learned ways to manage the

impulses, talk about the suicide, and stop blaming himself for not making his father

take his medication and saving him. When baseball tryouts came and went, he drew

pictures about feeling lonely if he played without his father watching. Gradually he 

was able to think of how he could still feel encouraged by his father and enjoy going

to games with the rest of his family.

Researchers and practitioners in the fields of trauma and bereavement have 

collaborated, piloting their work and sharing their experiences to develop the current

childhood traumatic grief interventions. The childhood traumatic grief intervention

components being described are based on the common practice of supportive

bereavement counseling utilizing both directed activities and nondirected play 

interventions and cognitive behavioral therapy (CBT)–oriented treatment that has been

traditionally used to address problems related to

trauma as well as anxiety and depression. Cognitive

behavioral techniques have been adapted to teach

skills to manage specific thoughts and behavioral 

distress reactions the child is having in situations

that generate unhelpful and unpleasant feelings.

Gradual exposure through creation of a story is based

on the CBT technique that encourages the child to

speak directly about the traumatic circumstances

related to the death — what was heard, seen, and

most troubling — and to develop helpful strategies,

rather than avoidance, for dealing with traumatic

memories. Once the child’s trauma-related reactions

recede, the child can engage in activities enabling

access to comforting memories and adjust to a life

that is now different. Thus, following the sharing of

the child’s experience, treatment focuses on reconnecting the child to significant

memories about the person who died, their relationship, and plans for the future. 

INDIVIDUALIZED TREATMENT

Children and parents come to treatment with their own strengths, experiences, and

expectations. Bereaved individuals may be in pain but should be supported to find

and use the internal and external resources that have been most helpful at other

times in their life. All treatment should be based on a strong, caring relationship, 

guided by the principle of collaboration between client and practitioner in a way that

communicates a belief in the individual’s own abilities. 

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The treatment being described should not be followed in a cookbook fashion. You

should be flexible and creative in adapting the techniques to fit a particular client in a

particular treatment setting. Different strategies can be modified according to a child’s

and family’s culture, beliefs, customs, preferences, and styles. There are a number of

variations that can be used in teaching the various skills, and you should adapt them

to the child’s age and preference. For example, play rather than direct discussion may

be more appropriate when working with young children, and anticipation of future

mourning rituals should be integrated into the work. Clinical judgment and expertise

should determine the overall format, structure, and pace of treatment for specific

childhood traumatic grief issues and any other mental health problems.

Although the training video focuses on treating children and their parents in an individual

format, very similar treatment interventions have been utilized when working with

groups and with older adolescents. For example, trauma- and grief-focused groups

were used to help Bosnian youth recover from childhood traumatic grief following the

war in their country. This group treatment was also piloted for children who developed

childhood traumatic grief in response to urban violence in Los Angeles. Following the

description of the components and activities used with individual school-age children,

you will find guidelines for adapting the treatment for use with groups. Additionally,

treatment guidelines have been developed for preschoolers whose parents have died;

these focus on issues of attachment and safety. Introductory guidance when working

with young children and groups is provided later in the curriculum. 

For further information and treatment manuals for work with toddlers, adolescents,

and groups you are directed to the following resources: 

• Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing

a parent to death in the early years: Guidelines for the treatment of traumatic

bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.

• Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in

children: Treatment manual, available by contacting the National Resource Center

for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.

• Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in children:

Group treatment manual, available by contacting the National Resource Center

for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.

• Saltzman, W. R., Layne, C. M., Pynoos, R. S. (2003) Trauma/grief-focused 

intervention for adolescents, available by contacting wsaltzman@sbcglobal.net.

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CONCEPT

RESOURCE
WHAT ROLE DO PARENTS HAVE IN THE TREATMENT?

It is important to recognize the tremendous impact parents have on their child’s 

development, behavior, and coping with both trauma and grief. Parents should be

enlisted to help their children with traumatic grief. A parent’s own reactions and 

symptoms can interfere with the child’s progress,

hence the better the parent is doing the better

the child will do. 

Parents naturally wish to protect their children.

However, parents do best when helped to be 

honest and open with their children and express

their emotions appropriately. Children must be

taught about particular practices for ritualizing the

person or customs dictating how and when the

deceased are honored. In most Western cultures,

when a parent avoids or denies the death or 

the child’s difficulties, the children may conclude that being sad or remembering the

person who died is not acceptable. The child may feel that memories are forbidden or

feel the need to protect the parent, believing the parent will fall apart if the person

who died is talked about.

At bedtime, three months after his father died, seven-year-old Ben asked his mother

to read a book. It was one of his favorites that his father always used to read to him.

Ben joined in, laughed, and imitated the different characters as his father had done

many times. Although a pleasant reminder for Ben, Mom struggled to finish and 

quietly cried for hours once alone in her own bed.

It is crucial to include parents in the childhood traumatic grief treatment. When 

working with young children, treatment with the parent focuses on enhancing the 

parent-child attachment in addition to supporting and encouraging positive parenting

and the parent’s processing of her own traumatic grief reactions. With children 

school-age and older, the objective in working with parents is to

• understand the specific family and cultural beliefs,

• inform them about expected adult and child reactions and course of bereavement,

• help them process their own trauma and grief reactions,

• maintain good parenting practices while bereaved,

• learn ways to help the child with his or her trauma and grief reactions, and

• help the child continue with developmentally appropriate tasks.

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CASE

EXAMPLE
Twelve-year-old Anna survived an earthquake that killed several of her family members,

including her mother and grandmother. She appeared detached, with a fixed and

incongruous smile. Anna began to talk about her earthquake experiences. On the day

of the earthquake, her grandmother had come to their house to help her mother bake

a cake for Anna’s birthday. Suddenly “the earth shook” and the house collapsed on

top of them. Anna and her grandmother held on to each other under the collapsed

building for two days. She remembered her grandmother’s constant prayers to God to

save her grandchild. In recounting this, Anna said, “God, why didn’t you take me away

with them? Is it because I am not good enough? You made me live and suffer and

remember everything. God, I love my mother even though I was teasing her when the

earthquake happened, telling her that I loved grandmother more than her.” She had

difficulty falling asleep, nightmares about the earthquake, recurrent stomachaches,

and difficulty paying attention in class. She was ambivalent about her father’s plan to

remarry and saw herself as an obstacle to his finding a new wife. She confided in the

therapist that she felt obliged to keep smiling for the benefit of her father.

Information for Parents on Childhood Traumatic Grief can be found in the Appendices

on page 72. 

Parents and children may have had different levels of exposure to the circumstances

of the death and have experienced different levels of danger. Parents and children

might not both have been present at the scene of the death, they may have heard or

seen different details on the news, and may have learned of the death through different

means. They will also likely have had different relationships with the person who died

(e.g., spouse, sibling, or parent). Therefore their reactions and progress through 

treatment can be different. There are times when parents’ reactions and symptoms

warrant different or more intensive individual treatment. Parents should be referred for

additional treatment either as an adjunct to the childhood traumatic grief parent-child

treatment being described here or once the parent-child treatment is completed.

It’s very important to understand the specific religious beliefs, culture,

and customs that families use in dealing with bereavement, because

these may be very important when you hear about the stories of what

happened before or after the death, because you want to make sure

that your own specific beliefs or ideas are not imposed on the child

and the family. —Robin Goodman

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EXAMPLE

HANDOUT
For both the trauma- and bereavement-focused work, it is essential to be aware of,

and sensitive to, the family’s personal and cultural beliefs and practices. This is 

helpful for integrating personal beliefs into the treatment, knowing the origin and 

accuracy of a child’s beliefs, and planning for current and future bereavement-related

rituals and events. Certain topics or explanations for events may be common practice

in a particular culture, advocated by a family, and accepted by a particular child. Thus

there should be normalization for what is typical in a given cultural setting. 

STRUCTURE OF TREATMENT

The training video and the following sections in the printed guide outline the general

structure, format, and treatment components of childhood traumatic grief treatment

as it is conducted with individual children school-age and older. This treatment has

typically been provided in 12-to-16 sessions each for the child and parent, with joint

sessions held at appropriate times. However, the length of time for the childhood 

traumatic grief intervention can vary with the age of the child, severity of the problem,

and type of setting, thus requiring additional sessions. The individual treatment is

structured according to the following guidelines:

• The child and parent are seen individually in their own sessions to allow for 

freedom of expression. The work done in the child and parent sessions is 

complementary. Having the parent in companion treatment allows the parent to

facilitate training and reinforcement of the child’s newly learned skills, promote

understanding of issues, and increase communication between the child and the

parent. The child is engaged in specific skill-building, trauma, and memorializing

activities. The caregiver may be taught the same skills as the child, taught how

to help the child with new skills, and taught how to manage problem behavior.

• At specified times, joint caregiver and child sessions are conducted. Following

careful preliminary planning, the child and caregiver engage in a shared activity

related to the story of the death and remembering the person who died.

• In most situations it is suggested that the same therapist treat the child and 

parent. In certain situations it may be preferable to have different therapists for

the child(ren) and parent(s) — for example, when there are different levels of

exposure and intensity in the reactions, or when a parent is hesitant to bring 

up personally significant issues to a therapist who is also treating the child.

Regardless of the number of therapists involved in the treatment, the case

should be conceptualized as a family case rather than as separate child and

adult cases. The individual child and parent sessions can be held consecutively

on the same or different days. When there is more than one child in treatment,

the same therapist works with each child in his own session but conducts only

one parent session where issues for all children are discussed. Children can

start treatment at the same time or the most symptomatic child may begin first. 

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CONCEPT
WHAT ARE THE KEY COMPONENTS OF CHILDHOOD

TRAUMATIC GRIEF TREATMENT?

TREATMENT SEQUENCE

In doing the treatment, we often start with educating the child about

the kind of treatment and the reasons it’s important to focus on the

trauma. So the first job is to really help children feel more in control of

those upsetting reactions, and you do that by teaching them ways to

manage their stress. —Robin Goodman

The following trauma- and grief-focused treatment components represent techniques

that NCTSN professionals have found to be most effective in helping children 

overcome their trauma and grief reactions and symptoms. The intervention is based

on a particular sequence; it is important to address trauma-focused issues first

before moving on to grief-focused issues. When working on the trauma issues, keep 

in mind it may be necessary to address details of the death as well as a child’s

sense of his life being in danger prior to moving on to grief issues. The content and

activities are being presented as they would be used in individual treatment with the

child, with the parent, and in joint sessions. 

Summary of Treatment Component Sequence and Goals

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Trauma-Focused Phase Components

1. Psychoeducation

2. Affect expression

3. Stress management skills

4. Cognitive affect regulation

Goals

Will aquire knowledge about trauma 

and understand the cause of personal

trauma reactions 

Will be able to recognize and identify 

a variety of feelings

Will have a repertoire of portable 

relaxation and cognitive skills to use

when feeling distress related to the 

traumatic death

Will understand the relationship of

thoughts, feelings, and behaviors and

have ways to manage affect and 

automatic reactions
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Trauma-Focused Phase Components

5. Trauma narrative

6. Cognitive processing

Grief-Focused Phase Components

7. Communicating about death

8. Mourning the loss

9. Addressing ambivalent feelings about

the deceased

10. Preserving positive memories

11. Redefining the relationship

12. Committing to new relationships

13. Making meaning

14. Evolution of grief and termination

Goals

Will be able to tell the story of the 

traumatic death experience and 

gradually tolerate the more difficult,

most distressing elements

Will be able to recognize and correct

thoughts and beliefs that are not helpful

and inaccurate

Goals

Will understand, and be able to talk about,

death in an age-appropriate manner 

Will recognize and communicate the

things that are no longer the same and

what will be missed about the person.

Will acknowledge, communicate, and

accept any ambivalent feelings about

the deceased 

Will acknowledge and engage in an 

activity that focuses on positive memories,

and when necessary participate in a

memorial ritual

Will be able to differentiate between

activities done with the deceased and

aspects of the relationship that can be

committed to memory

Will be able to engage in new relationships,

understanding that they are different 

but necessary

Will find some meaning in the experience

through self-learning and/or activity

aimed at using the experience in a 

positive way

Will understand the ongoing and 

changing nature of grief; will be aware 

of and plan for future times that are

potentially difficult 
1. PSYCHOEDUCATION

The trauma-focused portion of treatment begins with psychoeducation about trauma

and the trauma response. Educating the child and parent about the common 

reactions to trauma and their causes provides a useful language and background 

for understanding what they are experiencing. It can also be a relief to have words 

to describe such confusing and distressing reactions.

Childhood traumatic grief reactions and symptoms can be very disturbing, feel unlike

anything else, and leave the child feeling quite different than before and different

from others. Therefore, when providing education to children it can be useful to 

reassure them that they are not “going crazy.” Many children will experience significant

relief just from having an “expert” explain that there is a rational reason for their 

difficulties, that their symptoms are a “normal response to an abnormal event” or

“understandable if you thought your life was in danger.” You can also explain that

when something very frightening happens, our brains remember things in different

ways than they do for ordinary events, and these memories keep getting played 

back to us like replaying a video over and over again. 

It may be helpful to provide children and parents with explanations for the various

symptoms associated with childhood traumatic grief. Re-experiencing symptoms 

can be described as the mind’s continued efforts to make sense of what happened 

or achieve a different outcome. Avoidance can be described as something we do

automatically in an effort to avoid the emotional pain associated with the trauma; 

the mental equivalent of jerking your hand away from a hot stove. When feeling 

threatened, an aroused state is understandable. Even though the original danger is 

no longer present, later hyperarousal symptoms can be explained as the person’s

body and mind going “overboard” in making efforts to avoid any further potential 

danger. Although adaptive in some situations, such reactions can become problematic

when they start to interfere with the child’s everyday functioning. It is also important

to identify specific people, places, or things that remind the child of the trauma, as

they are likely to elicit or exacerbate symptoms.

It is important that parents understand that children who experience a traumatic 

event often experience a significant increase in behavioral difficulties. One useful way

for explaining this issue is the idea of shaking up a beehive. Honeybees are typically

docile, but if someone shakes up their beehive they are likely to sting anything that

gets in their way. A traumatic event can “shake up” a child’s world in a similar manner

resulting in more active and aggressive behavior. 

Information for Parents on Childhood Traumatic Grief can be found in the Appendices

on page 72.

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2. AFFECT EXPRESSION

Helping children with affect expression is an important next step in the treatment. 

The goal is to have children identify or label a variety of feelings, pleasant ones as

well as those that make them uncomfortable or that they perceive to be bad. It is

important to explain that children should pay attention to their feelings and that 

feelings are not good or bad. Certain feelings are more likely associated with the 

trauma (e.g., helplessness), others to bereavement 

(e.g., sadness), and others to everyday activities (e.g.,

annoyed). It is important for children to know the difference

between feelings and behaviors. All feelings are okay (e.g.,

feeling angry), but some behaviors (e.g., aggressive behaviors)

are not acceptable.

There are a number of therapeutic games and creative 

activities that can be used to help children with this component. Children can add

facial expression to an outline of a face, decorate two sides of a mask to show 

outside feelings visible to others and more private inside feelings, or pick songs that

portray different emotions. There are various games that also can be purchased that

focus on feelings identification. Once identified, it is important to also discuss what

situations accompany and cause different feelings and talk, draw, play, or act out

ways of coping with different feelings. A handout of different feeling faces can be 

useful in helping children learn to identify various feelings. 

See the resource list at the end of the guide for suggested games for purchase.

A Feeling Faces sheet can be found in the Appendices on page 57.

In addition to learning about their own emotions, it is essential that parents understand

the importance of the child being able to express his or her emotions. The goal is to

engage parents as partners in helping the child and support their role as coaches for

the child’s newly learned skills. When unaware of the benefit of or meaning of a

child’s expression of emotion, the parent may unknowingly discourage or even punish

the child. Parents should be accepting of the child’s full range of emotions but 

maintain discipline if the child engages in inappropriate behaviors.

Parents may also need to be taught appropriate ways to express their own emotions.

In particular, parents need to be coached to avoid exhibiting intense feelings of 

distress in front of the child. It may be appropriate to explore the parents’ own feelings

related to the traumatic death at this time and suggest ways to monitor and modulate

their emotions and model appropriate expression (e.g., “It’s sad that Dad isn’t here 

to help make a snowman”).

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3. STRESS MANAGEMENT SKILLS

Following feelings identification and regulation, it is important to teach stressmanagement skills. These skills are used as the child confronts previously avoided 

or uncomfortable thoughts and feelings experienced during and outside the sessions.

Stress-management skills are used to help children and parents manage unpleasant

physiological trauma reactions and symptoms, feel more in control, and cope 

effectively with traumatic reminders. It is important to help children identify ways they

can soothe themselves when experiencing unpleasant or difficult feelings. Children

are encouraged to think about things they use or do that already help them; for 

example, they can bring in CDs of songs that help them relax and feel happy, talk

about sports, or dance to relieve stress.

Some specific relaxation techniques that can be taught include: 

• Focused “belly breathing”: This Involves teaching the child to focus on breathing

rather than on anxiety symptoms. Children are taught to use diaphragmatic

breathing, slowly inhaling through the nose and exhaling through the mouth to 

a count of three-to-five seconds. They can be helped by placing a cup or stuffed

animal on their stomach and instructed to make it go up and down. Older 

children can imagine a balloon inside their stomach getting bigger and smaller

with each breath. 

• Progressive muscle relaxation: This involves alternating between tensing and

relaxing muscle groups and focusing on the different sensations associated with

tension and relaxation. Young children are often able to relax their bodies by 

pretending to be a “stiff piece of spaghetti” that becomes a “wet noodle” or 

a “tin soldier” who changes into a “Raggedy Ann doll.” 

Progressive Muscle Relaxation scripts can be found in the Appendices on page 58.

Imagery techniques: These can be thought of as “controlled daydreaming” in which

the child is taught to intentionally recreate the mental image of a safe or relaxing

place in their mind.

A Learning to Relax Through Imagery script can be found in the Appendices on

page 63.

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Other stress-management strategies include thought-stopping techniques such as

envisioning a stop sign. Alternatively, the child could first draw a picture of the two 

different scenes, one distressing and one that is pleasant. The child is then instructed

to visualize them on separate TV channels and instructed to replace a traumatic

thought with a more pleasant one by changing them on the imaginary TV. Older 

children may prefer other relaxation strategies such as listening to their favorite music. 

The child can also be taught to use positive self-talk to combat negative thoughts that

generate self-defeating or negative thoughts or unpleasant feelings. The following are

examples of positive self-statements. 

Negative: “I’m never going to be able to handle this.”

Positive: “I miss my mom, but I’m strong enough to deal with it.”

Negative: “Sometimes I was bad. Maybe that’s why Dad died.”

Positive: “I loved my dad. It’s not my fault that he died.”

Negative: “I’ll never be happy again.”

Positive: “A sad thing happened, but one day I’ll feel better.”

These skills are generally taught to both the parent and the child in the clinician’s

office, and the child is encouraged to practice them at home The parent is instructed

to assist the child in practicing the strategies. Parents may also personally benefit

from using these strategies. 

It may be necessary to explain the rationale for these techniques, as children and 

parents may think they are simplistic or initially feel self-conscious. It may be useful 

to use the analogy of a life preserver. Relaxation techniques are like a life preserver;

they help the child and parent to “stay afloat” until symptoms begin to diminish 

over the course of treatment. When someone who can’t swim falls into the water and

is drowning, it’s not the right time to teach him how to swim. Instead, it is better to

throw him a life preserver in order to keep him afloat until pulled out of the water. 

4. COGNITIVE AFFECT REGULATION 

Improving a child’s ability to manage distressing affect is the focus of the next 

strategy. This is also referred to as cognitive affect regulation, the goal being for 

the child to use productive, age-appropriate responses to distress. The child is 

taught ways to express and cope with distressing emotions, for example, counting 

to 10 when angry, giving himself a “time out,” or doing some physical exercise 

when upset. 

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In order to help parents and children manage affect more effectively, it can be helpful

to explain the relationship among thoughts, feelings, and behaviors using the visual

metaphor of a triangle, referred to as the Cognitive Triangle. The source of some 

distress may be the child’s appraisal of danger, reactions to feeling threatened, and

attempts to be safe. It is important to explain how situations trigger certain distressing

and automatic thoughts, feelings, and behavior. This concept can be described in the

following manner:

“Today we are going to talk about thoughts, feelings, and behaviors. In particular,

we’re going to talk about how our thoughts can affect the way we feel and then how

the way we think and feel can affect the way we behave. Thoughts are the things 

we say to ourselves in our own head where nobody else can hear them. When our

thoughts make us feel good, it can affect our behavior; we

may want to smile or laugh. When our thoughts make us 

feel bad, it can affect our behavior too; we may want to cry,

scream and shout, or hit somebody. It is helpful to understand

how thoughts, feelings, and behaviors are related and 

especially important to figure out what thoughts make us

feel bad and how to help ourselves. A lot of times, people

can learn how to change what they think. They can choose

to think about things more positively and do things that can

make them feel better.” (Paraphrased from Deblinger, D. &

Heflin, A. H. (1996). Treating sexually abused children and

their nonoffending parents: A cognitive behavioral approach. Thousand Oaks: SAGE

Publications, Inc.)

A Cognitive Triangle illustration can be found in the Appendices on page 64.

Metaphors and illustrations of children in different situations can be a helpful aid 

to the discussion. It is important to use examples to help children understand that

changing one’s thoughts can lead to feeling better and using more adaptive or 

productive behavior. The following examples can be helpful:

1. In the cafeteria, a table of girls ignores a girl, and she thinks, “They don’t like

me” (thought). This makes her feel hurt and lonely (feelings), and she cries in

the bathroom (behavior). Alternatively she could say, “There are other girls 

who treat me better” (new thought). She is then confident and hopeful 

(new feelings) and goes to sit with the other table of girls (new behavior).

Thinking, feeling, behaving Cafeteria illustration can be found in the Appendices

on page 65.

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2. A boy realizes he has a math test in three days and thinks, “I don’t know this

stuff very well, I’m going to flunk” (thought), which makes him feel fidgety and

hopeless (feelings), so he doesn’t study (behavior). If he replaces it with “I still

have plenty of time to learn this and do well” (new thought), he will be optimistic

and determined (new feeling) and study extra hard (new behavior).

Thinking, feeling, behaving Test illustration can be found in the Appendices on

page 66.

There are a variety of ways to introduce and teach these different skills and 

techniques, and they can be modified for children at different ages. Some or all 

of the techniques are also used according to the format of the treatment and the 

age of the child (individual/group, toddler/teen).

It is necessary to establish these skills in preparation for the next phase of treatment.

Collectively, these first steps help children feel more confident about managing upsetting

thoughts and feelings. Having learned coping strategies, the child will be less fearful of

being overwhelmed or flooded by unpleasant emotions when creating the trauma narrative.

5. TRAUMA NARRATIVE

Most therapists who treat children already use many of the techniques that have 

been presented. However, one part of this treatment may not be as familiar to some

therapists, because it involves encouraging children to directly recall and discuss their

most frightening memories. Learning which reminders are significant for the child allows

the therapist to prepare the child for managing unpleasant times, places, and reactions.

It is especially important to be mindful of any cultural taboos against such work.

A trauma narrative is the re-creation or retracing of the child’s experience of someone’s

traumatic death, told in their own words, pictures, and even songs. By creating the story,

the child is carefully exposed to the traumatic elements of the death and gradually

becomes able to tolerate the more painful and disturbing aspects of the experience. 

A child’s sharing of the trauma narrative with a parent increases their mutual support.

“The trauma narrative is typically developed gradually over several 

sessions. We will often start by having the child describe something

about him or herself; this helps children feel more comfortable in

telling their story or writing their book. Then we have the child focus on

what life was like before the traumatic event that took the loved one

away. As the child comes closer to talking about the traumatic loss

through talking about less threatening aspects, he or she is more able 

to engage in the process of gradually talking about more and more

upsetting aspects of the traumatic death itself.” —Judith Cohen

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HANDOUT

DEFINITION

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A child with childhood traumatic grief typically avoids reminders of details associated

with the death, because they cause overwhelming and upsetting thoughts and 

feelings. By confronting such feelings in a safe and controlled environment, while 

also using the stress-reducing strategies and coping skills previously learned, the

child is better able to tolerate trauma-related thoughts and feelings about the death.

Children (and adults) are often resistant to the idea of creating a trauma narrative. 

It is typically distressing for people to remember traumatic events in detail. Therefore,

it is often necessary to provide a rationale. Creating a trauma narrative can be 

compared to removing a splinter from your finger. The splinter likely hurts, but people

resist taking the splinter out with a needle or tweezers because they think it will hurt

too much. However, if the splinter is left in, the finger could become infected, the 

person could get sick, and it will be more difficult to treat. Therefore, it’s better to

remove the splinter as soon as possible, knowing that a small amount of pain early

prevents more problems and promotes healing. Then it is discussed that creating a

trauma narrative is like pulling out the splinter. Even though it is a little painful, it is

the best way for the person to heal from his or her traumatic experience. 

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The trauma narrative should focus as much as possible on various sensory details

(i.e., sights, sounds, smells, tastes, and tactile sensations) that the child associates

with the traumatic death. It is important to expose the child to the details as he has

remembered them, because they often serve as powerful reminders of the trauma

and triggers for symptoms.

Building the trauma narrative takes time and should be done over a number of sessions.

It should begin gradually with a conversation about less threatening details about the

traumatic death and the person who died. When discussing the actual death the first

time through, it may be helpful to focus on a factual account (e.g., who, what, when,

where, how) of the traumatic event, without asking about the child’s thoughts and

feelings about the detail. When developing the factual account, it is not important that

the narrative be perfectly accurate, but major discrepancies should be addressed. 

After the factual account has been created, the clinician should then go back through

the narrative with the client and ask questions about how the child felt, and what he

was thinking about during certain aspects of the traumatic event. It is important to be

careful to monitor the child’s distress while creating the trauma narrative and help the

child use the skills he learned prior to making the trauma narrative in order to handle

any distress that occurs while making the narrative. The goal is to have the child’s

distress decrease over time, with continued exposure to the trauma narrative. 

The child develops the trauma narrative jointly with the therapist through a series of

carefully guided questions. The initial trauma narrative may be brief, but it provides

anchor points that can be used in discussion to help the child elaborate on the details.

There are a variety of ways a child can create a trauma narrative. In addition to writing,

some children may prefer to document their story in other ways, such as by writing a

play, composing a song, play acting, or making a video. The child can be guided to

create the trauma narrative by engaging in a conversation or asking questions such as

the following:

Background for the Trauma Narative

• Tell me a bit about yourself and about school.

• What you like to do in your free time; do you have any favorite hobbies?

• What kinds of things did you and your dad do together? 

Beginning the Trauma Narative

• It would helpful for me to hear what it was like the day your mom died.

• Do you remember anything specific about the weather that day? 

• What is the first thing you remember about your mom’s death?

• I would like to know more about what it was like when you first found out 

your dad had cancer.

• All stories have a beginning; how does the story about your grandma’s death start?

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Creating the Factual Account

• I wanted to hear what you saw from the backseat of the car.

• Who was in the car when the accident happened?

• What happened after he pulled out the gun?

• Was it nighttime when that happened?

• What did he say next?

Incorporating Sensory Detail

• What did your brother’s hospital room look like?

• Could you smell the flowers at the funeral?

• What sort of sounds did you hear during the accident?

Incorporating the Child’s Thoughts and Feelings

• What did you think when he told you to shut up?

• I would like to know more about what if felt like to be trapped under the tree.

• How did you feel when you found out he had cancer?

• What did you think when the guy with the gun told your grandma to lay down?

• Wow, I think that would have made a lot of people feel really scared. How did 

you feel?

Sample excerpts from trauma narratives can be found in the Appendices on page 67.

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RESOURCE

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In addition to creating the trauma narrative with the child, the therapist talks to the

child about sharing the trauma narrative with the parent. The child is told the 

importance of being able to communicate openly and honestly and share thoughts

about the death and the deceased. The therapist will be reading the trauma narrative

to the parent without the child at first, prior to their joint meeting. In addition, the 

therapist prepares the child for a joint session by talking about parts to focus on 

and obtaining any particular questions the child would like the parent to ask.

The parent should be prepared for the joint session with the child in which the trauma

narrative is presented. This provides an opportunity for the parent to appreciate the

child’s unique experience. While the child is creating the trauma narrative, the therapist

shares what the child is creating as it is being developed. This allows the parent to

respond in private to the trauma narrative and plan for an appropriate response in the

presence of the child. 

Once completed by the child, ideally the trauma narrative is then shared with the 

parent, again according to carefully guided steps to prepare both child and parent for

the details that will be presented and any possible emotions. Reading the story

together and talking about it in a structured way helps the parent and child effectively

communicate about the upsetting circumstances of the death.

Some of preliminary work that should be done before the joint session includes the

following:

• Having the child practice reading the narrative aloud to the clinician.

• Discussing and addressing any concerns that the child may have about sharing

the trauma narrative with her parents (e.g., “What if they get angry?”).

• Discussing and addressing any concerns that the parent may have about 

listening to the child’s trauma narrative (e.g., “What if I get really upset?” 

“What do I say to her?”).

• Explaining, to the parents the rationale for having the child share the trauma 

narrative with them (e.g., “Your child looks to you for support, and you can be a

role model for how to cope and talk about the death.”)

• Preparing parents to be supportive, attentive listeners. 

• Gradually exposing the parents to aspects of the trauma narrative prior to having

the child share it with them to help desensitize the parent to the content of the

trauma narrative.

• Training the parent to talk about the death and the person who died, express

appropriate emotions, and model effective coping when listening to the TN.

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What was helpful to Hannah in treatment was the story that she got to

tell about her grandmother’s death. Because until then, I don’t think she

was able to express what she envisioned her grandmother’s death was

all about. She heard us discuss it, we discussed it with her in our terms,

but I don’t think she understood exactly, she wasn’t able to express

exactly what she thought, and the story gave her an opportunity to

understand what grandmommy might have been looking like while she was

dying in bed. Hannah had a vision in her head as to what this all looked

like that no one else shared, so for her to be able to draw this and talk

to somebody about this was very very helpful. I think it gave her more

permission to remember her without feeling so much pain because one of

her pictures was a great picture, at the end of the story where she’s

smiling on the ground, and she sees grandmommy up in the clouds with

a big smile, an angel smiling down on her. I think she felt safer. —Parent

6. COGNITIVE PROCESSING

As the trauma narrative is being created, the therapist is able to identify thoughts and

beliefs about the traumatic event that are inaccurate or not helpful. These are often

tied to feelings of responsibility for the death and related feelings of helplessness. It

is extremely difficult for the child or parent to feel he could have done something to

prevent the death and especially complex if there is any way the child or parent could

have changed the outcome.

Once the narrative is completed, cognitive processing is the final component of the

trauma-related portion of the treatment and is used to modify and correct these

thoughts and beliefs. 

The following are example questions for the child that may be helpful in eliciting 

distortions:

• Why did this happen?

• Was it anyone’s fault?

• Could something have been done to prevent it?

• Has this event changed you?

• Has this event changed what you think about other people? The world?

• Some kids think they should have done something different. Do you?

• Some kids think someone else should have done something different. Do you?

• Some kids think they made it happen. Do you ever feel that way?

• What do you think your life will be like in the future?

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• Why do things like that happen to people?

• Why did that person do what he or she did?

Unhelpful beliefs may be totally false, such as thinking “my brother died because I

was bad.” Unrealistic thoughts such as “I should have stopped the bad man from

hurting my mom” are also unproductive and harmful. Other thoughts may be accurate

but unhelpful, for example, when a child thinks “people who are burned in a fire are in

terrible agony.” When attempting to handle feelings of helplessness, children may feel

a need or begin to take on excessive responsibility. Ways to tolerate and address such

feelings can also be addressed. After a child’s specific trauma-related cognitions and

beliefs have been identified, the therapist and the child begin to evaluate and correct

them. This can be accomplished through the use of such techniques as the following:

• Progressive logical questioning: For example, “So you’re saying that you should

have stopped that guy from shooting your mom? How big was that guy? And how

big are you? So he probably weighed about 200 pounds and you weigh about 

60 pounds? Is there really any way that a 60-pound kid could stop a 200-pound

guy from doing something like that?”

• Best-friend role-plays: For example, “What would you tell your best friend if he told

you that he believed that he should have stopped the guy from shooting his mom?”

• Therapist-child role reversal: For example, “I’m going to pretend to be you, and 

I want you to pretend to be a therapist. I’m going to tell you some things that

you’ve told me you think about. I want you to say what you think a therapist

would say about those things.”

• Corrective mantras: These may be more suitable for younger children who are less

able to engage in cognitive processing. The therapist may provide them with corrective

“mantras” such as “I did everything I could to help my mom.” The child practices

repeating the mantra when he finds himself thinking about the traumatic event.

Cognitive processing should also be done with the parent regarding his or her 

own thoughts. 

A mother thinks she should not have fought with her husband before he shot himself.

When asked what the fight was about, she explained that she told him that she did

not like the way he coped with losing his job. His getting drunk every night did not

solve anything and made things worse. She told him to see a therapist because he

seemed depressed. She says “I should have just left him alone and he wouldn’t have

killed himself.” The therapist reframed this, saying that the wife recognized his

depression and that alcohol was making the depression worse. She saw he needed

help and offered him support, doing everything she could have done to help him. The

therapist helps her to see that he was not in his right mind when he was depressed

and drunk. He killed himself for these reasons, not because she suggested he get help.

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HOW ARE GRIEF-RELATED ISSUES HANDLED 

IN THE TREATMENT PROCESS?

Following the trauma-specific treatment, the therapist helps the child with mastery 

of bereavement tasks. Many of the techniques used in bereavement therapy and 

supportive counseling are similar to what is done in this phase of the treatment.

Techniques often associated with CBT are also incorporated into the grief-related 

activities. The strategies or tools used in this phase of the treatment are tailored 

to the usual bereavement tasks. 

7. COMMUNICATING ABOUT DEATH

When the trauma symptoms recede as a result of the prior trauma-focused sessions, the

child is better able to address issues related to death. However, the child may still be

hesitant to talk about the death of a loved one due to societal taboos surrounding 

the topic of death and/or the parent’s own discomfort in talking about death. The

practitioner should know of any prohibitions against talking about those who die and

know any culturally specific terminology that is used when guiding the discussion. 

Many adults feel uncomfortable talking about death due to their own confusion and/

or grief and may therefore send subtle (or not so subtle) messages to children about

remaining silent. Consequently, it is helpful to begin this phase by having the child

openly communicate about death in session with the therapist. The goal is to educate

the child about death, have the child become comfortable talking about death, and

have the child ask questions to develop a clear understanding of death. The activities

below can encourage more open discussion. After talking about death in general, the

child will be more prepared to talk directly about his or her own bereavement.

Engaging in communication about death can be accomplished any number of ways,

such as playing a specific grief board game (e.g., The Good Bye Game) or creatively

restructuring a child’s favorite game with personally prepared bereavement-related

questions. Reading age-appropriate story books with the child and discussing the

information is also useful. The child is also encouraged to draw a picture of what he

or she believes “death” looks like. This can offer an opportunity for the therapist 

to correct any cognitive distortions or fears about death that the child may have. 

In addition, the child can list feelings that most people have after a loved one dies.

This also helps to normalize the child’s experience of loss.

See the resource and reference sections at the end of the guide for suggested 

grief-related games and books on page 81.

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A seven-year-old child and her therapist are reading a book about death and come

across a particular sentence: “Every living thing dies. Once it dies it can never come

back to life again.” About two minutes later, several pages after this section, the little

girl says, “I didn’t know that.” When the therapist asks what she means, the girl says, 

“I didn’t know that you couldn’t come back alive again.” This highlights the value of

communication about death and how direct discussion helps identify and correct 

cognitive distortions. 

Younger children may be preoccupied with more concrete questions or concerns

regarding the physical body of the deceased person. For example, a six-year-old child

asked how her deceased father would be able to go to the bathroom if he could not

get out of the coffin. These questions might be brought to light only if the child is

given the opportunity to voice his or her concerns, again emphasizing the need for

open communication regarding the death.

This is a good time to assess the parent’s ability to talk about death in general as

well as his or her own loss. It may be necessary to revisit and stress the importance of

talking about the loss, particularly if the parent seems hesitant to do so. In addition,

it is important for the therapist to have a good understanding of the parent’s religious

and cultural beliefs surrounding death and

grieving to ensure that the therapist does not

inadvertently give the child any conflicting

information. Finally, the therapist should

ascertain the parent’s own perception of

the child’s understanding of death. Parents

may be confused or upset about the fact

that a child is not showing strong emotions

about the death. However, parents may 

be more empathic toward the child if they

understand that the child’s nonemotional

response may be due to developmental 

limitations with regard to the child’s ability

to comprehend the permanence of death. 

The child may also be attempting to shield the parent from the child’s own sadness,

which may be an important area to explore with the child and parent together.

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EXAMPLE

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EXAMPLE

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8. MOURNING THE LOSS

Mourning the loss encourages and supports the child in acknowledging what has been

lost by the person’s death. 

It’s important for the child, in order to accept the magnitude of the

loss, to be able to name these things that they’ve lost. —Judith Cohen

The process may begin with an activity focusing on the characteristics of the person

who died. This can be done by writing a new “bereavement book” or even drawing 

pictures, guiding the child with prompts or questions similar to the process used for

creating the trauma narrative. As the child becomes more comfortable talking about

the person, she is encouraged to list or describe things she will miss sharing with the

person in the future. These can include things that the deceased person and the child

did for each other, including basic caregiving activities as well as unique aspects of

the relationship. This is a good time to talk about anticipating “loss reminders,” 

particularly if the activities that the child used to do with the deceased are now 

triggering posttraumatic reactions. Next, using the letters of the person’s first name,

the child creates an anagram, attaching a characteristic of the person to each letter.

The child is encouraged to identify which characteristics he or she will miss the most.

By helping children talk about the deceased, rather than avoid the topic, the child 

and therapist will be better able to anticipate painful situations that may arise and

prepare accordingly. 

The therapist should discuss with the parent what the child has been writing and/or

talking about with regard to the things the child has lost. This will likely precipitate

feelings of great sadness for the parent given that the parent will be grieving his or

her own losses in addition to the child’s losses. These feelings should be normalized

by the therapist. In addition, the therapist should help the parent to generate ways 

in which the child may optimally be able to deal with loss reminders in the future

(e.g., the parent may wish to attend all of the child’s football games that the child’s

deceased father used to attend). 

The therapist can also point out the ways in which the parent’s own grief responses

may be contributing to the child’s bereavement process. For example, if the parent

makes every effort to avoid the topic of the deceased person, it is likely that the child

will hold in his or her emotions. On the other hand, if the parent becomes overtly 

distraught at the mention of the deceased person’s name, the child may also choose

to avoid talking about the deceased in an effort to protect the parent. The therapist

should help the parent to support the child’s expression of emotion, while at the

same time find ways of helping the parent to receive the support that he or she needs.

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9. ADDRESSING AMBIVALENT FEELINGS ABOUT THE DECEASED

Another bereavement task involves acknowledging and accepting any ambivalent feelings

about the deceased. As with most relationships, the child has likely experienced 

some unpleasant aspects, even if the majority of interactions with the deceased were

positive. However, if the relationship was highly ambivalent prior to the death, or if the

death occurred in a way that is stigmatizing, such as suicide, the child’s feelings of

grief can be even more difficult to express. 

In particular, the child may feel guilty about having negative feelings such as shame 

or anger toward the deceased, and may think it means he or she didn’t really love 

the deceased person. Or, particularly in the case of a suicide, the child may blame

himself or herself for the death in some way (e.g., “If I had only behaved better, Mom

wouldn’t have wanted to kill herself”). This may lead to feelings of abandonment as

well as concerns regarding the deceased person’s true feelings toward the child.

Therefore, an important role of the therapist is to help the child to understand that 

it is normal to have both positive and negative feelings toward the deceased by

encouraging expression of all feelings about the person. 

There might have been some aspects of the relationship that 

weren’t always that positive. For example, you might have a child 

who loved her dad who died in tragic circumstances, but perhaps 

the dad never spent any time with her. —Anthony Mannarino

One useful technique in this process is having the child write a letter to the deceased,

in which he describes a range of feelings. The child also writes a letter that the

deceased would write back if he could. This can help the child to express feelings that

he or she may not have verbalized and also provide a sense of closure for the child.

The father of a 14-year-old girl died of a drug overdose. She was angry about how 

his lifestyle created such heartache for her mother, and she was ashamed of how he

died. She expressed these feelings in her imaginary letter to her father. In the letter

she composed as a response from him, he revealed that he was sorry for the pain 

he had caused and that he could never forgive himself for having his illness interfere

with his ability to show her how much he truly loved her.

In many cases, the parent may idealize the deceased person, which may preclude 

the child from fully expressing any negative feelings about the deceased. Therefore, 

it is important for the therapist to help the parent understand the child’s perspective

and address any dissonance between the parent’s and child’s respective beliefs

about the deceased person. However, given that the idealization of the deceased 

person is not necessarily harmful, caution should be used in correcting the child’s 

or the parent’s overly positive view of the deceased. Instead, the best approach is 

to encourage the parent to validate the child’s perspective and to focus on ways of

helping the child to resolve any “unfinished business” with the deceased.

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10. PRESERVING POSITIVE MEMORIES

This task is often a necessary prerequisite for helping children to give themselves 

permission to engage in new relationships. Different exercises are used to help 

children preserve positive feelings and memories of the deceased person. 

In order to successfully grieve the loss of a loved one, it’s 

important for the child to convert the relationship from one of 

interaction to a relationship that is based on memory, not current 

interaction. —Judith Cohen

Some positive memory activities include making a scrapbook or a memory box 

filled with reminders of the deceased person. Children are encouraged to ask other

family members to assist them with these activities in an effort to facilitate open

communication regarding the loss. Other techniques may include recreating a 

memorial service or another ritual, particularly if the child was unable to attend the

actual funeral. For situations in which no remains of the deceased were found, body

reconstructive techniques can be particularly helpful to foster a complete positive

memory of the physical person.

The parent should be encouraged to help the child recall and preserve positive 

memories of the deceased person. This may be difficult if the parent’s own relationship

with the deceased was conflicted. However, the therapist should help the parent

understand why positive memories are important for the child’s healing process. 

If a parent has died, and the remaining parent remarries, the child may fear how 

previous memories will be maintained. 

The parent may wish to add sections to the child’s bereavement book that focus 

on positive aspects of the child’s relationship with the deceased that the child may

have forgotten or omitted. This activity can help the child to understand that it is OK

to have both happy and sad memories about the deceased person. It also shows 

that the parent can tolerate thinking and talking about the deceased, and that this

does not have to lead to sad feelings.

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PARENT

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11. REDEFINING THE RELATIONSHIP

This bereavement task is designed to help children accept that the relationship with

the deceased has changed from one of interaction to one of memory. 

One technique that is often used to exemplify this change is a drawing of two balloons

— one that is anchored to the ground and the other that is floating toward the sky.

The child identifies things that she has lost in the relationship, such as going to 

baseball games together, and writes them in the floating balloon. The child also 

identifies things that remain in the relationship with the deceased, such as memories

of fun times spent with the deceased and writes them in the balloon on the ground.

This helps children to understand that although some aspects of the relationship have

changed, their positive memories can serve as the foundation for a new and different

relationship with the person who died. 

The child will likely need the parent’s “permission” to let go of the interactive relationship

with the deceased, given that many children feel guilty or disloyal in doing so. The 

parent may need assistance in understanding the importance of this task and working

through any resistance that he or she may have. The therapist can review specific

ways in which the parent can help the child to redefine his or her relationship with

the deceased. For example, parents may wish to be more cognizant of the language

they use to talk about the deceased (e.g., referring to the person in the past as

opposed to the present). 

12. COMMITTING TO NEW RELATIONSHIPS

The goal of this task is to have the child identify and discuss what has changed in 

his or her life since the death and the difference between a real previous relationship

and a new relationship with the person in one’s memory, and then engage in new 

relationships. Following the death of a loved one, children may be reluctant to engage

in new relationships. They may feel that they are being disloyal to the deceased loved

one if they form new relationships or that no other person will ever be able to make

up for the loss of the loved one. It is important to help the child realize that if he or

she forms new relationships it does not mean he or she loves the new person more

than the person who died. Also, the child may need assistance coming to the 

realization that, although new relationships will be different than the relationships with

the deceased, it is not a competition, and the new relationships can be satisfying. 

One way to help a child develop new relationships is to begin by identifying, in a list,

the things that he or she used to do with the deceased person. Next the child writes

in names of people who could fill those roles left empty by the deceased.

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This may be a particularly difficult task for parents if they are struggling with their 

own ability to move forward and develop new relationships. The therapist may need 

to spend some time discussing the parents’ own concerns/fears in this regard. The

therapist may also need to provide psychoeducation regarding the importance of

parental modeling of the development of new relationships and a strong future 

orientation. Parents should not only be encouraged to maintain and develop important

relationships for themselves, but they should also be encouraged to praise their 

children for developing new relationships. This can help to relieve any guilt that the

child may have for spending time with other people or leaving the parent by himself 

or herself.

13. MAKING MEANING OF THE DEATH

Making meaning of the death is a bereavement task that encourages children to view

their traumatic experience as one that, while difficult and painful, has helped them to

grow or become stronger in some way. If the child felt helpless due to fearing for his

life as well, e.g., having survived a hurricane in which a younger sister died, engaging

in an activity to make the world a better or safer place is constructive. 

You want to help children develop some meaning about the death. 

It’s not to turn it into a positive experience, but you want them to 

realize they may have learned things about themselves, about other

people, or may learn that there’s a way to help other kids that are 

in this same situation. —Robin Goodman

Some specific techniques involve asking children to talk about what they have 

learned about themselves or the world around them as a result of the death. Some

children may have learned they are stronger than they thought, while others may have

learned they have many people to count on for help. Some children find meaning in

their loss by helping other children who are going through similar situations, perhaps

by being a mentor or volunteer or helping to prevent the type of traumatic loss that

they experienced by joining a group like Students Against Drunk Driving. These 

activities can often help children to find meaning in the face of tragedy. Children 

are encouraged to look at what was learned from the death, at how the experience

can help the child help others. 

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The parent can help the child by pointing out ways in which the child has changed 

for the better or grown in some way since the loss. The parent can also offer 

suggestions for ways in which the child may be able to help others as a result of his

or her painful experience. 

14. THE NATURAL EVOLUTION OF GRIEF AND TERMINATION

One of the most important things we can do for children and 

parents in preparing them for the termination of treatment, and 

for coping with future trauma change and loss reminders, is to 

review with them the ‘three P’s.’ —Judith Cohen 

It is important to help the child and family with the three P’s of grief. Children and

families can be helped to predict difficult times in the future. For example, if the

child’s father usually accompanied her to her basketball games, it may be difficult for

the child to return to those games without him. Accordingly, the family should prepare

for future trauma and loss reminders. The therapist can help the family to strategize

about ways of making those reminders or difficult times easier to deal with. It is also

necessary to give permission to oneself — both the child and family — to have 

different feelings about the trauma and death as time goes by.

When talking with the parent about the evolution of grief, it is best to keep the 

perspective of the entire family in mind. Parents should be helped to develop an

understanding of the family members as individuals and the family as a whole. This

should be done by exploring and addressing various issues as they relate to the 

specific death as well as to current family life and future experiences. In particular,

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attention should be paid to the impact of the following issues on the individuals and

on the family:

• individuals’ different trauma and loss reminders

• individuals’ different experiences of the death and previous traumatic losses

• individual differences in the course of trauma and grief

• individuals’ different roles in the family

• developmental differences among all the individuals

• cultural differences

• generational differences

• the different stages in the family’s life

• the functioning of the family system

The parents should encourage mutual respect and support among the family 

members for their own grief issues and develop a family focused plan for managing

future grief and trauma related reminders and activities.

One helpful activity is to create a perpetual calendar (with months and dates but no

specific year). The child and/or parent identify times and dates of the year that will 

be more difficult, looking for patterns such as a time of year that is more stressful.

Dates that will recur such as the deceased’s birthday are indicated with one symbol

or color and occasions that are one-time events, such as a first day of school, can 

be indicated with another symbol or color. The individual is helped to make plans 

for coping with the stressful time and feelings, such as using good self-care, or 

creating new alternative rituals. This exercise also emphasizes to the family that 

difficult times will happen in the future, not just in the coming year, and helps them

learn ways to process and brainstorm ways to cope with those hard times. 

Termination requires its own specific attention. It is important to address the ways 

in which terminating treatment with the therapist (whom can be called upon again) is

different from a relationship that ends because of a death. For children and parents,

this can be a good opportunity to talk about different kinds of losses and generate

ways of coping with those difficult experiences. This is also a good time to review all

of the progress that both the child and the parent have made, and for the therapist to

offer praise for their tremendous effort. It is important for the therapist to remind the

parent and child that difficult times may arise again, particularly during life transitions,

and that therapy is always an option in the future, even if only used as a booster 

session. In addition, if the clinician believes the child or parent continues to have 

troubling symptoms or difficulty with usual activities, additional treatment may be 

warranted. It may be helpful to recommend additional trauma- or grief-focused 

treatment or a different type of treatment.

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ACTIVITY
TREATMENT OF CHILDHOOD TRAUMATIC GRIEF 

WITH YOUNG CHILDREN AND GROUPS 

HOW IS CHILDHOOD TRAUMATIC GRIEF IN YOUNG CHILDREN TREATED?

Working with infants, toddlers, and preschoolers with

childhood traumatic grief following the death of a 

parent requires a specialized approach. Young children

depend completely on the parents for their sense of

security and well-being, and the parent’s death shatters

their age-appropriate expectations that the parent will be

reliably available for care and protection. Children in the

birth-through-five age range also have difficulty grasping

the finality of death. An attachment-oriented intervention

should be used for treating childhood traumatic grief 

in this age range. This approach focuses on 

• reestablishing and strengthening the quality of the relationship between the

young child and his new or existing primary caregiver,

• maintaining predictable daily routines, and

• providing opportunities that enable the child to learn that dead the parent will

not return.

This treatment also encourages children to resolve their traumatic memories of the

parent’s death through the use of therapeutic play interventions and to memorialize

the parent in age-appropriate ways with the help of the new or surviving caregiver. 

Detailed instruction on work with toddlers and young children can be obtained at:

Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing a

parent to death in the early years: Guidelines for the treatment of traumatic 

bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.

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RESOURCE
WHY AND HOW IS CHILDHOOD TRAUMATIC GRIEF TREATED IN GROUPS?

Both individual and group-based treatment address the trauma and grief-related aspects of

childhood traumatic grief. However, a group-based treatment may be especially appropriate

for adolescents. In addition to being cost effective, trauma- and grief-focused groups

are beneficial in a number of specific ways. For example, groups provide and encourage

• normalization and validation of emotions,

• direct member-to-member feedback and interaction,

• exposure to other members’ experiences,

• opportunities to offer positive and constructive feedback,

• peer support, and

• mutual understanding between members.

Group work can result in a member feeling less isolated or estranged, and it can impact

issues related to the adolescents’ emerging self-concepts, feelings of shame and

guilt, and the desire for revenge. For example, group therapy allows members to give

constructive and positive feedback, which can assist in increasing group cohesion and

treatment effectiveness. Member-to-member interactions can be a highly influential

tool for challenging and replacing maladaptive beliefs, such as pessimistic expectations

and cognitive distortions. Group treatment also makes use of the helper-therapy 

principle, wherein the chance to help others with a similar problem serves as a catalyst

for personal change. That is, helping others allows members to help themselves by

strengthening their self-concept, self-esteem, self-confidence, and interpersonal skills. 

Group work enriches members’ capacities to give and receive support and to speak

authentically and genuinely about their experiences. When others talk about their 

feelings in similar situations, feelings are validated. They develop and practice social

skills to help them select with whom, when, and how much of their experience to 

disclose. These skills help them to be self-protective, maintain closeness to selected

others, and recruit support from others when confronting distressing reminders and

difficulties. The supportive transactions that follow can greatly help members to 

challenge and change their pessimistic beliefs that no one cares, that no one can

understand what they have been through, that others will reject them if they shared

their feelings and experiences, or that no one can really help them deal with the 

serious problems they face. 

The skill set of a well-trained group therapist will overlap with, but are independent

from, the skill set of a competent individual therapist. Importantly, the interaction of

group members serves as the most direct mechanism of change; the group itself

serves as the primary vehicle of change, and the group leaders serve as the indirect

agents of change. Hence, skilled group leaders provide a therapeutic structure and

facilitate interactive processes.

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MAIN

CONCEPT

MAIN

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The goals of group-based and individual-based childhood traumatic grief treatment are

similar. These include 

• reducing the frequency, intensity, and degree of interference associated with

childhood traumatic grief reactions, including trauma-related symptoms, 

depressive reactions, and grief reactions;

• enhancing effective coping and positive adaptation in relation to distressing

reminders and grief-related adversities;

• enhancing the ability of youth to access high-quality social support from others;

and

• reducing trauma-related developmental derailment and encouraging engagement

in normal developmental tasks.

As with individual treatment, one focus of the group-based treatment is on the 

traumatic experiences.

Intervention tasks consist of psychoeducation to normalize and validate posttraumatic

distress reactions, and therapeutic exposure via construction of a trauma narrative,

the goal being to reduce reactivity and psychic numbing and to increase tolerance to

trauma related material.

A second therapeutic focus is on trauma and loss reminders, the goal being to 

normalize, validate, and promote effective coping with distressing reminders

Intervention strategies include identifying the nature and frequency of reminders of

trauma and loss, linking reminders with distress symptoms, and identifying maladaptive

coping responses. Additional strategies include using reminders to explore the personal

meaning of traumatic events, acquiring thought/emotional regulation and supportseeking skills to cope with reminders, and facilitating pro-active modification of the

physical environment to remove unhelpful and unnecessary distressing reminders. 

A third focus is on posttraumatic adversities and involves identifying and ameliorating

the effects of the reactions in the wake of traumatic events and losses. 

Intervention strategies focus on the seven major areas in which disruption is likely to

occur: school performance, peer relationships, family relationships, living conditions,

health problems, economic prospects, and neighborhood/community environment.

Additional areas are more grief-related and focus on acceptance, adaptation, and 

coping with life changes and losses and training in communication skills to enhance

support-seeking. As appropriate, direct intervention is also carried out at the family,

community, and/or national levels to reduce or remove unnecessary adversities.

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An additional therapeutic focus is bereavement and the interplay of trauma and grief.

In particular, intrusive distressing traumatic images, emotional numbing, and cognitive/

behavioral avoidance associated with traumatic death may interfere with normal grief

reactions, including reminiscing and establishing a memory-based psychological 

relationship with the deceased. 

Intervention tasks include identifying grief reactions, psychoeducation about the

nature and course of bereavement, and working on bereavement tasks related to

one’s past, present, and future relationship with the deceased. 

The last therapeutic focus is on resuming developmental progression and involves

efforts to ameliorate the adverse developmental impact of the on the child.

Intervention includes identifying missed developmental opportunities and difficulties

with functioning in major areas of adolescent development, including independence

from parents, the capacity for intimate relationships, moral development, ambition

and motivation for educational and occupational achievement, and citizenship. 

Additional tasks in group treatment include initiating developmental progression in

adversely affected life domains, identifying and replacing maladaptive basic beliefs

with more adaptive core beliefs, and promoting prosocial efforts with peers, at home,

at school, and in the community and neighborhood. Adolescents are especially prone

to interpret many of their distress reactions as regressive

or “childlike,” indications that they are “going crazy,” or

signs that they are weak, defective, or different from

their peers. Adolescents should be helped to understand

their reactions are expected, adaptive in the face of 

danger, often similar to those of adults, and capable of

being changed for the better. 

Because parents are integral to a teen’s life and to the

teen’s progress in treatment, parents are included in

very specific ways in group-based treatment. In conjunction

with the group treatment sessions described below, parents should be brought in for 

a minimum of two sessions. One session with parents should be devoted to providing

an overview of the treatment, psychoeducation about childhood traumatic grief, and

background about the interventions. In a second session, the focus in on helping 

parents understand their child’s needs with respect to support and helping parents

develop skills to provide such support, e.g., listening and giving appropriate feedback

to the teen. Parents may be brought in at other times as needed and during specific

modules in order to have teens share their experience and talk about specific

reminders that are difficult for them and about ways parents can be helpful to them.

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ACTIVITY

ACTIVITY
CONDUCTING GROUP-BASED TREATMENT FOR CHILDHOOD TRAUMATIC GRIEF

The group-based treatment is organized into four different modules that focus on 

the five different aspects of childhood traumatic grief. The different activities used

throughout a group-based intervention include those previously described for individual

treatment: psychoeducation, skills building, and process-oriented activities.

Potential group members should have an individual pregroup interview. Members 

need not have been exposed to the same traumatic death. However, it is strongly 

recommended that the magnitude of the trauma be similar for all members. In 

addition to a general assessment for appropriateness, the interviewer should work

with the teen to select the portion of the traumatic death experience that is suitable

for discussion in the group. It is often useful to focus on the individual’s subjective

experience rather than the potentially gruesome details of the death. The leader may

find that there are other portions of the experience that are better processed in an

additional individual treatment session.

The therapist should introduce the group by explaining the special nature of the group.

For example: “This group is designed to help you become more aware of your trauma

and grief reactions. As you share more as a group about the difficulties you experience,

you give the gift of telling your fellow group members that they are not alone. It takes

courage to share this kind of personal information. Working together will also help you

be more aware, not only of ways in which other people can support you so that you

can deal better with your problems and feel better, but also of ways in which you can

support other people. So, you’ll be practicing the skills of both giving support and

receiving support. In the group everyone is on a level playing field.”

The four basic treatment modules are described briefly below. The approximate 

number of session for each is identified. However, keep in mind that the length of

time varies due to such things as number of members in the group and the nature of

issues that arise during the group. As with all treatments, leaders should be flexible 

in adjusting the activities and number of sessions to meet the needs of the group.

Module 1: Up to six sessions. In the beginning of treatment, the goal is to develop

group cohesion and a positive group identity. Psychoeducation about childhood

traumatic grief is used. Interventions are also aimed at developing adaptive coping

skills (e.g., cognitive coping, affect management, and developing a plan to cope

with trauma reminders before, during, and following there occurrence). Social 

support and support-seeking skills are also important to develop in this beginning

stage, in order to lay a strong foundation for the later trauma- and grief-focused work.

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CASE

EXAMPLE

MAIN

CONCEPT
Module 2: Up to six sessions. The traumatic event is identified and a trauma 

narrative is developed and processed. In the pregroup interview, the therapist

begins working to identify aspects of the traumatic death that will be appropriate

for using in the group. In doing the trauma narrative, special attention is given to

identifying and processing the worst traumatic moments in order to increase 

tolerance and to enhance regulation of intense negative emotions. When group 

participants have a common experience, it may be possible to develop a groupwide

trauma narrative followed by individual trauma narratives.

Cognitive restructuring techniques help establish a frame of personal meaning that

places the trauma in perspective and increases perceptions of realistic control 

and life continuity. The number of sessions can vary with the number of group

members, hence length of time to sufficiently develop the trauma narratives and

any complexities related to the traumas will also vary. 

Module 3: Up to eight sessions. The group then undertakes grief-related work.

Once again, psychoeducation is used about loss reminders, grief tasks are

addressed, and the core emotions of grief, especially anger and guilt, are 

discussed. Additional tasks are reconstituting a nontraumatic mental image of 

the deceased to facilitate reminiscing, processing conflicted feelings relating to 

the deceased, acquiring social skills needed to communicate appropriately about

the loss, and renegotiating one’s relationship with the deceased. 

Module 4: Up to four sessions. The last portion of treatment should focus on

resuming and engaging in developmentally appropriate tasks and activities. Issues

relate to how the traumatic death affected the course of the child’s life are

addressed; these can be positive or negative. Treatment should identify missed

developmental opportunities, support the resumption of compromised developmental

activities, facilitate an active future orientation, and challenge and change 

maladaptive belief systems. Secondary adversities that impact the here and now

are looked at with an eye toward problem solving and a focus on the future. As

with all childhood traumatic grief interventions, termination issues are addressed

in the last session(s), with an emphasis on the difference between ending 

treatment and relationships that end in death.

For further information and treatment manuals for work with adolescents and groups

you are directed to the following resources:

• Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement 

in children: Group treatment manual, available by contacting the National

Resource Center for Child Traumatic Stress at (919) 682-1552 or 

nationalresourcecenter@duke.edu.

• Saltzman, W. R., Layne, C. M., Pynoos, R. S. (2003) Trauma/grief-focused 

intervention for adolescents, available by contacting wsaltzman@sbcglobal.net.

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RESOURCE
CONCLUDING THOUGHTS

RECOGNIZE, RESPOND, REMEMBER

For clinicians who are unfamiliar with childhood traumatic grief, 

it would be important to recognize that childhood traumatic grief

includes traumatic stress symptoms and that these symptoms 

interfere with the child’s ability to go through the normal steps of 

the bereavement process. —Anthony Mannarino

Things to look for include children who do not talk about their lost 

loved one, who avoid reminders such as going to the grave site, 

who do not want to remember or memorialize the person who died, 

and children who are very avoidant of talking about not only the 

death and the cause of death but also the loved one. —Judith Cohen

Professionals should be able to recognize the signs of childhood traumatic grief,

respond so as to help a child and family obtain the appropriate treatment, and help

the child and family understand that “it’s OK to remember.” 

The child and family can be relieved when they themselves and others come to 

recognize the difficulty they are having. Once in treatment, they can learn appropriate

ways to respond and handle their distress and can go on to remember the person

who died in a positive and meaningful way. 

As practitioners, I think it’s very important that we respond to 

childhood traumatic grief, because it’s something that children do 

not outgrow, and if we don’t respond, it’s quite likely that they’re 

going to continue to have the traumatic stress symptoms, and 

these children won’t be able to go through the normal grieving 

process. —Anthony Mannarino

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Using The Courage to Remember video and curriculum is the first step in developing

your skills at helping children with childhood traumatic grief. Although presented as a

specific structured intervention, treatment should always be adapted to the individual

child’s family and situation. Further training and supervision is recommended. This

work is challenging and rewarding. You should be mindful of your own experiences and

reactions to trauma and bereavement as it informs you work, and seek out your own

support if necessary.

We need to know that children always remember; the question is 

how they remember. For this reason, it’s very important to help a 

child translate visceral memories of fear and anger into cognitive 

memories so that the child can be helped to develop coping 

mechanisms for feelings that are overwhelming in order to help 

them become modulated and under control. —Alicia Lieberman

One of the best things you can do for these children is help them 

realize it’s OK to remember the way the person died as well as who 

the person was. —Robin Goodman

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APPENDICES

HANDOUTS, RESOURCES, REFERENCES

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Feeling Faces

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PROGRESSIVE MUSCLE RELAXATION SCRIPTS

The following scripts are taken from Ollendick, T. H., & Cerny, J. (1981). Clinical 

Behavior Therapy with Children. New York: Plenum Press. 

PMR Script 1

Suggested for children ages 9 and older. (Ollendick, 1978)

Head and Arms

Make a fist with your left hand. Squeeze it hard. Feel the tightness in your hand and

arm as you squeeze. Now let your hand go and relax. See how much better your hand

and arm feel when they are relaxed. Once again, make a fist with your left hand and

squeeze hard. Good. Now relax and let your hand go. (Repeat the process with the

right hand and arm.)

Arms and Shoulders

Stretch your arms out in front of you. Raise them high up over your head. Way back.

Feel the pull in your shoulders. Stretch higher. Now just let your arms drop back to

your side. OK, let’s stretch again. Stretch your arms out in front of you. Raise them

over your head. Pull them back, way back. Pull hard. Now let them drop quickly. Good.

Notice how your shoulders feel more relaxed. This time let’s have a great big stretch.

Try to touch the ceiling. Stretch your arms way out in front of you. Raise them way up

high over your head. Push them way back. Notice the tension and pull in your arms

and shoulders. Hold tight now. Great. Let them drop very quickly and feel how good it

is to be relaxed. It feels good and warm and lazy. 

Shoulders and Neck

Try to pull your shoulders up to your ears and push your head down into your shoulders.

Hold it tight. Okay, now relax and feel the warmth. Again, pull your shoulders up to

your ears and push your head down into your shoulders. Do it tightly. Okay, you can

relax now. Bring your head out and let your shoulders relax. Notice how much better 

if feels to be relaxed than to be all tight. One more time now. Push your head down

and your shoulders way up to your ears. Hold it. Feel the tenseness in your neck and

shoulders. Okay. You can relax now and feel comfortable. You feel good. 

Jaw

Put your teeth together real hard. Let your neck muscles help you. Now relax. Just 

let your jaw hang loose. Notice how good it feels just to let your jaw drop. Okay, bite

down again hard. That’s good. Now relax again. Just let your jaw drop. It feels so good

just to let go. Okay, one more time. Bite down. Hard as you can. Harder. Oh, you’re

really working hard. Good. Now relax. Try to relax your whole body. Let yourself go as

loose as you can. 

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Face and Nose

Wrinkle up your nose. Make as many wrinkles in your nose as you can. Scrunch your

nose up real hard. Good. Now you can relax your nose. Now wrinkle up your nose

again. Wrinkle it up hard. Hold it just as tight as you can. Okay. You can relax your

face. Notice that when you scrunch up your nose that your cheeks and your mouth

and your forehead all help you and they get tight, too. So when you relax your nose,

your whole face is relaxed too, and that feels good. Now make lots of wrinkles on your

forehead. Hold it tight, now. Okay, you can let go. Now you can just relax. Let your

face go smooth. No wrinkles anywhere. Your face feels nice and smooth and relaxed.

Stomach

Now tighten up your stomach muscles real tight. Make your stomach real hard. Don’t

move. You can relax now. Let your stomach go soft. Let it be as relaxed as you can.

That feels so much better. Okay, again, tighten your stomach real hard. Good. You 

can relax now. Kind of settle down, get comfortable and relax. Notice the difference

between a tight stomach and a relaxed one. That’s how we want to feel. Nice and

loose and relaxed. Okay. Once more. Tighten up. Tighten hard. Good. Now you can

relax completely. You can feel nice and relaxed. 

This time try to pull your stomach in. Try to squeeze it against your backbone. Try to

be as skinny as you can. Now relax. You don’t have to be skinny now. Just relax and

feel your stomach being warm and loose. Okay, squeeze in your stomach again. Make

it touch your backbone. Get it real small and tight. Get as skinny as you can. Hold

tight now. You can relax now. Settle back and let your stomach come back out where

it belongs. You can feel really good now. You’ve done fine. 

Legs and Feet

Push your toes down on the floor real hard. You’ll probably need your legs to help you

push. Push down, spread your toes apart. Now relax your feet. Let your toes go loose

and feel how nice that is. It feels good to be relaxed. Okay. Now push your toes down.

Let your leg muscles help you push your feet down. Push your feet. Hard. Okay. Relax

your feet, relax your legs, relax your toes. It feels so good to be relaxed. No tenseness

anywhere. You feel kind of warm and tingly.

Conclusion

Stay as relaxed as you can. Let your whole body go limp and feel all your muscles

relaxed. In a few minutes I will ask you to open your eyes and that will be the end of

the session. Today is a good day. You’ve worked hard in here and it feels good to work

hard. Shake your arms. Now shake your legs. Move your head around. Slowly open

your eyes. Very good. You’ve done a good job. You’re going to be a super relaxer.

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PMR Script 2

Suggested for children ages 5 through 8 years old. (Koeppen, 1974)

Hands and Arms

Pretend you have a whole lemon in your left hand. Now squeeze it hard. Try to

squeeze all the juice out. Feel the tightness in your and arm as you squeeze. Now

drop the lemon. Notice how your muscles feel when they are relaxed. Take another

lemon and squeeze it. Try to squeeze this one harder than you did the first one.

That’s right. Real hard. Now drop your lemon and relax. See how much better your

hand and arm feel when they are relaxed. Once again, take a lemon in your left hand

and squeeze all the juice out. Don’t leave a single drop. Squeeze hard. Good. Now

relax and let the lemon fall from your hand. (Repeat on right side.) 

Arms and Shoulders

Pretend you are a furry, lazy cat. You want to stretch. Stretch your arms out in front 

of you. Raise them up high over your head. Way back. Feel the pull in your shoulders.

Stretch higher. Now just let your arms drop back to your side. Okay, kitten, let’s

stretch again. Stretch your arms out in front of your. Raise them over your head. Pull

them back, way back. Pull hard. Now let them drop. Good. Notice how your shoulders

feel more relaxed. This time let’s have a great big stretch. Try to touch the ceiling.

Stretch your arms way out in front of you. Raise them way up high over your head.

Push them way, way back. Notice the tension and pull in your arms and shoulders.

Hold tight, now. Great. Let them drop very quickly and feel how good it is to be

relaxed. It feels good and warm and lazy. 

Shoulders and Neck

Now pretend you are a turtle. You’re sitting out on a rock by a nice, peaceful pond,

just relaxing in the warm sun. It feels nice and warm and safe here. Oh-oh! You sense

danger. Pull your head into your house. Try to pull your shoulders up to your ears and

push your head down into your shoulders. Hold in tight. It is not easy to be a turtle in

a shell. The danger is past now. You can come out into the warm sunshine, and once

again, you can relax and feel the warm sunshine. Watch out now! More danger. Hurry,

pull your head back into your house and hold it tight. You have to be closed in tight to

protect yourself. Okay, you can relax now. Bring your head out and let your shoulders

relax. Notice how much better it feels to be relaxed than to be all tight. One more

time, now. Danger! Pull your head in. Push your shoulders way up to your ears and

hold tight. Don’t let even a tiny piece of your head show outside your shell. Hold it.

Feel the tenseness in your neck and shoulders. OK. You can come out now. It’s safe

again. Relax and feel comfortable in your safety. There’s no more danger. Nothing to

worry about. Nothing to be afraid of. You feel good. 

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Jaw

You have a giant jawbreaker bubble gum in your mouth. It’s very hard to chew. Bite

down on it. Hard! Let your neck muscles help you. Now relax. Just let your jaw hang

loose. Notice how good it feels just to let your jaw drop. OK, let’s tackle that 

jawbreaker again. Bite down. Hard! Try to squeeze it out between your teeth. That’s

good. You’re really tearing that gum up. Now relax again. Just let your jaw drop off

your face. It feels so good just to let go and not have to fight that bubble gum. OK,

one more time. We’re really going to tear it up this time. Bite down. Hard as you can.

Harder. Oh, you’re really working hard. Good. Now relax. Try to relax your whole body.

You’ve beaten the bubble gum. Let yourself go as loose as you can.

Face and Nose

Here comes a pesky old fly. He has landed on your nose. Try to get him off without

using your hands. That’s right, wrinkle up your nose. Make as many wrinkles in your

nose as you can. Scrunch your nose up real hard. Good. You’ve chased him away.

Now you can relax your nose. Oops, here he comes again. Right back in the middle of

your nose. Wrinkle up your nose again. Shoo him off. Wrinkle it up hard. Hold it just

as tight as you can. OK, he flew away. You can relax your face. Notice that when you

scrunch up your nose that your cheeks and your mouth and your forehead and your

eyes all help you, and they get tight too. So when you relax your nose, your whole face

relaxes too, and that feels good. Oh-oh, this time that old fly has come back, but this

time he’s on your forehead. Make lots of wrinkles. Try to catch him between all those

wrinkles. Hold it tight, now. OK, you can let go. He’s gone for good. Now you can just

relax. Let your face go smooth, no wrinkles anywhere. Your face feels nice and

smooth and relaxed. 

Stomach

Hey! Here comes a cute baby elephant. But he’s not watching where he’s going. 

He doesn’t see you lying there in the grass, and he’s about to step on your stomach.

Don’t move. You don’t have time to get out of the way. Just get ready for him. Make

your stomach very hard. Tighten up your stomach muscles real tight. Hold it. It looks

like he is going the other way. You can relax now. Let your stomach go soft. Let it be

as relaxed as you can. That feels so much better. Oops, he’s coming this way again.

Get ready. Tighten up your stomach. Real hard. If he steps on you when your stomach

is hard it won’t hurt. Make your stomach into a rock. OK, he’s moving away again. You

can relax now. Kind of settle down, get comfortable, and relax. Notice the difference

between a tight stomach and a relaxed one. That’s how we want to feel — nice and

loose and relaxed. You won’t believe this, but this time he’s really coming your way

and no turning around. He’s headed straight for you. Tighten up. Tighten hard. Here

he comes. This is really it. You’ve got to hold on tight. He’s stepping on you. He’s

stepped over you. Now he’s gone for good. You can relax completely. You’re safe.

Everything is okay, and you can feel nice and relaxed. 

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This time imagine that you want to squeeze through a narrow fence and the boards

have splinters on them. You’ll have to make yourself very skinny if you’re going to

make it through. Suck your stomach in. Try to squeeze it up against your backbone.

Try to lie as skinny as you can. You’ve got to get through. Now relax. You don’t have

to be skinny now. Just relax and feel your stomach being warm and loose. OK, let’s

try to get through that fence now. Squeeze up your stomach. Make it touch your 

backbone. Get it real tight. Get as skinny as you can. Hold tight, now. You’ve got to

squeeze through. You got through that skinny little fence and no splinters. You can

relax now. Settle back and let your stomach come back out where it belongs. You can

feel really good now. You’ve done fine. 

Legs and Feet

Now pretend you are standing barefoot in a big fat mud puddle. Squish your toes

down deep into the mud. Try to get your feet down to the bottom of the mud puddle.

You’ll probably need your legs to help you push. Push down, spread your toes apart,

and feel the mud squish up between your toes. Now step out of the mud puddle.

Relax your feet. Let your toes go loose and feel how nice that is. It feels good to be

relaxed. Back into the mud puddle. Squish your toes down. Let your leg muscles help

push your feet down. Push your feet. Hard. Try to squeeze that mud puddle dry. OK.

Come back out now. Relax your feet, relax your legs, relax your toes. It feels so good 

to be relaxed. No tenseness anywhere; you feel kind of warm and tingly.

Conclusion

Stay as relaxed as you can. Let your whole body go limp and feel all your muscles

relaxed. In a few minutes I will ask you to open your eyes, and that will be the end 

of this session. As you go through the day, remember how good it feels to be relaxed.

Sometimes you have to make yourself tighter before you can be relaxed, just as we

did in these exercises. Practice these exercises every day to get more and more

relaxed. A good time to practice is at night after you have gone to bed and the lights

are out and you won’t be disturbed. It will help you get to sleep. Then when you are a

really good relaxer, you can help yourself relax at school. Just remember the elephant,

or the jaw breaker, or the mud puddle, and you can do your exercises and nobody will

know. Today is a good day. You’ve worked hard in here, and it feels good to work hard.

Very slowly now, open your eyes and wiggle your muscles around a little. Very good.

You’ve done a good job. You’re going to be a super relaxer. 

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LEARNING TO RELAX THROUGH IMAGERY

Here is an exercise that can help you to relax when you are feeling tense or nervous.

It’s kind of like day dreaming, but it’s something that you can do, on purpose, to help

make yourself feel more relaxed. Once you have learned this exercise, you can use it

almost any time that you want to. 

To get started: Get comfortable. Relax as much as you can. Take some deep breaths

and close your eyes. 

In your head, imagine that your are some place very beautiful and peaceful. It should

be a place that makes you feel happy and safe. It may be somewhere that you’ve

been before, or it may be a place that you’ve never been to except in your dreams. It

could be in a forest where you can smell the trees and hear the birds singing. It could

be on a warm beach where you can hear the ocean and feel the warm sand. You pick

the place.

When you have picked your special place, think about all of the things that you might

see there. What would you smell? Can you hear anything? Is there anything there that

you can touch? Taste? Are you alone, or is somebody with you? 

Keep taking deep breaths and relax your whole body. In your special place you can

feel relaxed, calm, and safe. It is your place...a place where nobody can bother you.

What are you doing in this place? Are you resting, sitting, or walking around? How do

you feel? This is you place...your safe place. 

Now that you have picked your special place, whenever you need a break you can go

there and help yourself to relax. It will be there in your imagination whenever you want

it. It is a place for you to relax and feel better. 

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The Courage to Remember: Childhood Traumatic Grief Curriculum Guide

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Cafeteria

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Test

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SAMPLE TRAUMA NARRATIVE BY SCHOOL-AGE CHILD*

I am Lauren. I am seven-and-a-half years old. My sister Kelsey died on September 27,

2000. She was five-and-a-half. My family and I had fun together. We played Uno. On

Tuesday September 26, 2000, the day before my sister died, we played games and

we had fun. We played lots of things together. We used to play Play-Doh. But the 

Play-Doh got hard. On Tuesday September 27 we were playing on the sunporch. On

September 27 I went to the bathroom. Meanwhile, my sister Kelsey was playing on

the sunporch. When I was going to the bathroom, I didn’t hear any noises. Meanwhile,

my sister was playing on the sunporch. I was playing my Gameboy while I was going to

the bathroom. When I went to the sunporch, Kelsey wasn’t there. I thought she ran

away, because when my mom yelled at her she moved into the bathroom! I looked

around the house for her. I looked around the house but she wasn’t there. 

Then I looked in the basement and she wasn’t there, so I looked out the window. I

saw her and I thought “oh oh!” I felt very sad. I saw the window hanging and she was

on the ground. She wasn’t bleeding. That’s what I don’t get. I went outside to see if

she was OK. I was staring at her. Her eyes were closed. I was feeling very sad and a

little scared because it looked like she might be dead. Then I went to go get my dad.

He was in the living room watching TV. I said, “Daddy, Kelsey’s down on the ground.”

He just got up and he was running fast. We went outside. I was underneath the 

sunporch. My dad was lying on the ground holding Kelsey’s head. She was trying to

move her arm. She was moaning. I felt sad. I think my dad felt sad too. My neighbors

called the ambulance. Josie asked me how she old she was and I said “five.”

They wouldn’t let me ride in the ambulance. I was mad. My dad rode in the ambulance

with Kelsey. I rode with Josie’s mom to Children’s Hospital. I thought my sister was

dead. We got to Children’s Hospital. They took her to the operating room. I’m not

sure. I went to the cafeteria and got an ice cream sandwich. Then I went up to the

playroom with Darcie and Debbie and played with the pool table. I forgot all about it.

We went down to the waiting room. We took up a whole room. My mom was there. I

saw her before too. She cried a lot. I felt sad. I went to be with Mom and Dad. They

hugged me. They squeezed me pretty hard. We were waiting for the news on Kelsey.

The doctor came in and said “she has another chance.” I thought she might stay alive. 

Two doctors came and shook their head and we knew. We asked to see her — now!

Everyone was crying. Daddy was so upset he threw a chair, well almost. Then they

took Mom and Dad back to Kelsey. They cried. Daddy left the room to talk to me.

Mommy stayed with Kelsey. It was hard for Mommy because Kelsey had a breathing

tube. Kelsey was wrapped in a blanket so Mommy could hold her. Daddy told me

Kelsey died. We walked down the hall and sat on the floor. 

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The doctor came in. I forget what he said. My mom and dad were squeezing me. 

The doctor said she died. I felt very sad. My mom and dad were crying. I never saw

Kelsey, but my mom got to hold her. That really stinks. I feel mad that I didn’t see her

or hold her or hug her or kiss her or even get to say good bye to her. My mom and

dad stayed and my Aunt Kathy and Gramma took me to Erica’s house. I was very sad.

Daddy went to hold Kelsey and Mommy went to be with me. We sat together. Mommy

went back to hold Kelsey. I went home with Aunt Kathy. I went to my friend Erica’s

house. When I woke up there were people around. Daddy carried me home. The 

people at the hospital were very nice. They gave me a Koala bear.

I stayed home from school. People came over to visit. Daddy called the coroner’s

office to find out when Kelsey would be sent to the funeral home. Kelsey broke her

head, some ribs, and maybe her neck. It broke our hearts. I remember that!

When Kelsey was being born, I helped with everything. It was the same with this. We

all went to Lazarus to pick out a dress for Kelsey to be buried in. It had sparklies and

a bow. She would’ve loved it. I got one too. Shelby and I put most of Kelsey’s shoes

in a bag. We went to see Mr. Zalewski (Walt) at the funeral home. We went to pick 

the casket. They had all different kinds, but just one for children. We picked out the

funeral cards. We made all the arrangements for the funeral. Friday night was a 

private family viewing. We went in by ourselves first. We went in and said hi and cried.

We wanted to see her. She looked like herself but like she was asleep. I touched her

arm. She was very cold. Ice cold. Then the family came in. We stood up by the casket

and people came up to see Kelsey and to support us. There were lots of hugs and

kisses. We put flowers and notes and pictures and a Barbie in her casket. I put a 

picture or note in. Saturday we had a viewing for everyone. There were so many 

people. We were there from two to four. Then the family went to eat. We stayed and

ate downstairs. I went with Grandma for awhile. Seven to nine was another viewing.

Sunday were viewings again. JJ brought Lauren a maroon bear. Kelsey got a white

one. Mommy and I went to Kelsey and sang “You are My Sunshine” and “I Love You 

a Bushel and a Peck.” Me and my friends sold penny candy for $1. We got about 

$20, and I bought mass cards for Kelsey.

Monday was the funeral. It was at 10 a.m. We went to the funeral home and said 

our final goodbyes to Kelsey. We rode in a limo to the church. The priest blessed us.

Father Joe was crying. We can’t remember what he said. We rode in the limo to the

cemetery. The cemetery was really big. There were a lot of people waiting in line to

come to her grave. I remember seeing her being buried. After the funeral we had a

wake. It was a party for our family and friends to show their support. I remember 

getting presents and getting chips, pretzels, and Pepsi. People were talking and crying.

I wore my daddy’s jacket. After the wake, we went to Grandma’s house. I didn’t go

back to school until the end of the week. The kids were hugging me. They made cards

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for us. I didn’t want to go back. My teachers knew. I didn’t like that. It was my personal

business. One day we were watching a movie about whales. It made me think about

Kelsey. I was crying and my parents had to come pick me up. It’s hard to get over.

About one week later, we went to pick out the headstone. They had all different

shapes and sizes. I picked out the marble piece and it was multicolored. The plaque

was Aztec blue. “Gone so young form our loving hearts...” It was at the cemetery

about a month later.

I went to school and soon. Mom and Dad went back to work. People sent cards and

money every day. The church took up a collection for us. Looking back on everything,

my life has changed a lot without Kelsey here. It’s changed me. I appreciate life more

and try to do well in school. I miss her in my life. I miss her sleeping with me. I miss

hugging her. I’m sad because my mom and dad cry. If I had a friend who had a brother

or sister die, I would tell them to go see a therapist and they will help you a lot and

make you feel at home. It’s hard to talk about, but it made me feel better to talk

about it. We learned a lot here. It makes you a lot better about your loss. I knew I’ll

always miss Kelsey, but I’ll always remember her in my heart. 

The End

*NOTE: The original trauma narrative included illustrations as shown in It’s OK to

Remember.

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SAMPLE TRAUMA NARRATIVE BY TEEN

Chapter 1: Who I Am

Hi. My name is Crystal. I am 13 years old and go to school in Pittsburgh. I like to play

sports such as basketball. I have one brother who is 15 years old. I like to listen to

music but most of all I like to hang out with my friends. I live with my mom during the

year and my dad during the summer. My brother lives with his mom.

Chapter 2: Our Relationship

Harold was my mother’s boyfriend. I knew him about three years. At first I got to know

him because he was friends with my mother. Then he became her boyfriend, and a 

little bit after that we decided to move into his house because it was a much bigger

place. When we moved I also had to switch schools. It was a tough experience at 

first but then I grew to like my new school. Harold always made me laugh. We would

always tease each other and wrestle. Sometimes he would take me out to dinner and

we would just hang out. He was like another father to me since I didn’t see my real

dad so much.

Chapter 3: Leading Up to the Day

A couple months before he died, Harold started working for another guy. Since he

worked as a plumber he got a good paycheck most of the time. The new boss hadn’t

paid him for awhile and Harold was getting pretty upset. After work on Fridays my

mom and Harold would go out for a drink. Sometimes they would fight a lot over 

stupid stuff and sometimes they got in bad fights. After he realized he hadn’t gotten

paid in a while he started getting angrier and would drink more. The fights would get

worse and caused me and Harold not to hang out as much since he was angry and

drunk a lot. About two weeks before he died he lost his job.

Chapter 4: The Big Day

The day Harold died was a pretty normal day. I got up and in the shower and headed

off to school as I normally did. After school I found a note on the table telling me that

my mom and Harold had gone out. I went upstairs to study and talk to my friends. I

was having a great conversation with one of my best friends when I heard them pull

up. It seemed to me that they were laughing and joking. But later I realized they were

arguing about something. Harold called up to me to get off the phone so he could call

the cops. I didn’t think anything of it because he would do that sometimes when he

was drunk. Throughout the evening they kept fighting about little things, nothing to

lose your relationship over. Later on I went to downstairs to get something to drink

before bed and my mom and I heard a loud bang. We didn’t know what it was so we

didn’t think anything of it. As I was laying in bed I heard a loud and terrible scream. I

got curious so I opened my bedroom door. I saw red flashing lights and I didn’t know

what to think so I laid back down. My mom came in with a police officer behind her

and took me outside. The police had just told my mom that Harold had killed himself

and she was screaming and crying. I didn’t know what to think. I wasn’t feeling 

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anything because I was in shock. I didn’t know what to think or feel. A detective had

come and asked my mom questions about what had happened. My grandma came

and so did Harold’s mom and one of his grown-up daughters. I felt really bad for my

mom because when Harold’s mom and his daughter pulled up his daughter got out of

the car and was screaming “what did you do to my father?!” His mom was praying

and I got out of the police car and gave her a hug. After a lot of commotion had gone

on, my mom, Grandma, and I went back to my grandma’s house and tried to sleep.

Chapter 5: The After Days

Harold committing suicide wasn’t all bad. My mom has gotten involved in her church a

lot more and has stopped drinking. She has also been spending more time with me. I

have changed in ways too. I don’t take things for granted anymore. I appreciate things

in new ways, because you never really know how much something means to you until

it’s gone. I have thought a lot about the way Harold died. Sometimes it makes me

upset because how could someone do such a foolish thing? It’s selfish, I think when

you commit suicide because you’re not thinking about the people that love you. If

Harold wasn’t drunk I don’t believe he would have done that. He was drunk at the

time and when you’re drunk you’re not in your right mind. I don’t think he killed 

himself purposely to hurt my mom. I knew he loved her and would never want her to

go through that kind of pain. If he had done it on purpose then he really wasn’t the

person I thought he was. I think he is 100 percent responsible for what he did

because he chose to get drunk and he chose to let himself get upset and everything.

My mom tried to help him not drink. I don’t really think anyone could have stopped

him from doing what he did. My mom once tried to get him to go to therapy or 

something. He said he would but I guess he didn’t. If this happened to another child 

I would tell them that everything happens for a reason. Don’t always think about the

negative about the situation. It may help you get stronger like it has with me.

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INFORMATION FOR PARENTS ON CHILDHOOD TRAUMATIC GRIEF

Introduction

This guide to childhood traumatic grief for parents builds on the “In-Depth General

Information Guide to Childhood Traumatic Grief” and “Brief Information on Childhood

Traumatic Grief,” which can be found at NCTSN.org. Those publications should be

read in conjunction with the information here as they provide essential background for

understanding the difference between uncomplicated bereavement following a death,

childhood traumatic grief, and other reactions to trauma.

Not every child who experiences a death will develop childhood traumatic grief. Many

children will experience an appropriate grieving response and in time, with adequate

support, adjust to the loss of the loved one. In some cases, however, children may

have enduring difficulties that interfere with their ability to function and remember 

the person who died in positive ways.

The information presented here provides an overview of childhood traumatic grief, its

general signs and symptoms, and some suggestions on what parents can do to help

their child. Using this guide can be a first step for parents to help them understand

their child’s experience of intense grief following a death of a loved one that the child

experienced as being especially difficult or traumatic. If you are a concerned parent or

guardian and after reading this guide you think that your child is demonstrating the

symptoms of childhood traumatic grief, we recommend that you seek further help.

What Is Childhood Traumatic Grief?

When someone special dies, it can be a very sad and painful experience for the child.

When the death occurs as a result of a traumatic event, or when the child experiences

the death as traumatic, the child may show signs of both trauma and grief. Childhood

traumatic grief is explained more fully in the “In-Depth General Information Guide to

Childhood Traumatic Grief,” but the following basic facts hold true:

• Childhood traumatic grief is an intense grief response that can occur following

the death of a loved one.

• Childhood traumatic grief is different from and can interfere with the normal

bereavement process following the death of a loved one.

• Not all children who have been exposed to deaths they perceive to be shocking

will develop childhood traumatic grief.

• Childhood traumatic grief may appear differently in different children.

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• Parents, caregivers, and important adults can help children cope with childhood

traumatic grief.

• Help is available to parents and children who are experiencing childhood 

traumatic grief.

Childhood traumatic grief is a condition that some children develop after the death 

of a close friend or family member. Children with childhood traumatic grief experience

the cause of that death as horrifying or terrifying, whether the death was sudden 

and unexpected (due to homicide, suicide, motor vehicle accident, natural disaster,

war, terrorism, or other causes) or due to natural causes (such as cancer or a heart

attack). Even if to you, as the adult, the manner of death does not seem to be 

sudden, shocking, or frightening, the child may perceive the death in this way and 

can be at risk of developing childhood traumatic grief. 

When a child is struggling with childhood traumatic grief, the child’s trauma reactions

interfere with his or her ability to go through a normal bereavement process. Because

of the interaction of traumatic and grief reactions, any thoughts, even happy ones, of

the deceased person can lead to frightening memories of how the person died. Because

these thoughts can be so upsetting, the child often may try to avoid all reminders of

the loss so as not to stir up upsetting thoughts or feelings. A younger child may be

afraid to sleep alone at night because of nightmares about a shooting that she 

witnessed, while an older child may avoid playing on the school baseball team his

father used to coach because it brings up painful thoughts about how his father died

in a terrible car accident. In this way, the child can get “stuck” on the traumatic

aspects of the death and cannot proceed through the normal bereavement process.

How Is Childhood Traumatic Grief Different from Normal Grief?

In both normal grief (also called uncomplicated bereavement) and childhood traumatic

grief, children often feel very sad and may have sleep problems, a loss of appetite,

and a decreased interest in family and friends. They may also develop increased 

complaints of physical discomfort (such as headaches or stomachaches), or they may

regress and return to behaviors they had previously outgrown (such as bed wetting,

thumb sucking, or clinging to parents). They may also be irritable, do risky things, be

withdrawn, have trouble concentrating, and think often about death.

Children experiencing normal grief usually want to talk about the person who died, do

things to remember the person, and perhaps find comfort in thinking about the person.

Over time they also are able to complete the following “tasks” of normal bereavement:

• Accept the reality and permanence of the death

• Experience and cope with the range of feelings about the person who died, such

as sadness, anger, guilt, and appreciation 

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• Adjust to changes in their lives and identity that result from the death

• Develop new relationships or deepen existing relationships with friends and family 

• Invest in new relationships and life-affirming activities

• Maintain a continuing, appropriate attachment to the person who died through

such activities as reminiscing, remembering, and memorialization

• Make some meaning of the death that can include coming to an understanding

of why the person died

• Continue through the normal developmental stages of childhood and adolescence

For children experiencing childhood traumatic grief, thinking or talking about the 

person who died often leads to thoughts of the traumatic manner of death. For this

reason, these children often try to avoid thinking or talking about the person who 

died and avoid facing the frightening feelings associated with these reminders. This

prevents them from completing the tasks of normal bereavement mentioned above.

What Are Some Common Signs that a Child Is Struggling with Traumatic Grief?

Not all children who experience a traumatic death will develop childhood traumatic grief.

Some children will be able to grieve the loss without complications. A small number of

grieving children may develop some reactions or symptoms that can become difficult

and perhaps interfere with their daily functioning. Signs that a child is having difficulty

coping with the death may be noticeable in the first month or two or may not be

apparent until one or more years later. Some of these signs include the following:

• Intrusive memories about the death: These can be expressed by nightmares,

guilt or self blame about how the person died, or recurrent or disturbing thoughts

about the terrible way someone died.

• Avoidance and numbing: These can be expressed by withdrawal, acting as if not

upset, or avoiding reminders of the person, the way he or she died, or the things

that led to the death.

• Physical or emotional symptoms of increased arousal: Children may show this

by their irritability, anger, trouble sleeping, decreased concentration, drop in

grades, stomachaches, headaches, increased vigilance, and/or fears about 

safety for oneself or others.

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What Additional Challenges Can Increase the Risk of Childhood Traumatic Grief?

(Secondary Adversities)

Children who must face additional difficult experiences as a result of the death or are already

facing stressful life circumstances are at risk for developing traumatic grief. For example,

after a father’s death, a child who has to move must contend with both the death of her

parent as well as changes in her social network, and a child who is witness to the murder

of a family member must deal with legal procedures and unpleasant questions from peers.

What Can Parents Do to Help Children and Teenagers?

Parents can play a very important role in helping children and adolescents affected by

childhood traumatic grief. Children may be struggling with finding ways to understand

and cope with their reactions to a traumatic loss. Here are some suggestions about

ways that parents can help support children:

• Be aware of the common reactions of children to death described above.

• Remember that not all children will develop childhood traumatic grief, and those

that do may demonstrate a range of symptoms depending on their developmental

level, personality, and prior history of traumatic experiences.

• Provide children of all ages with opportunities to talk about their worries and 

concerns. Children at different ages may need different types of support.

Younger children may need more attention, patience, understanding, and a few

extra hugs. Older children may need reassurance that it is normal to experience

a range of reactions and that there are adults in their lives to help them through

difficult times. Some children, especially older children, may not want to talk

about their experiences and feelings or may shut adults out.

• Understand that anger or regressive behavior may be a part of a child or 

adolescent’s reaction to a traumatic loss.

• Recognize that children of all ages carefully observe how the adults in their lives

are reacting and will often take their cues from the adults around them. Children

will find comfort by observing how adults manage difficult reactions and model

effective ways of coping.

• Be prepared to revisit the loss with children as they become older and acquire

new information, develop new questions, and have new experiences.

• Seek support from friends and family to help manage your own grief.

• Reach out for professional help if you’re concerned that a child’s reactions are

affecting his or her daily life.

Additional help is available through the National Child Traumatic Stress Network at

(310) 235-2633 and (919) 682-1552 or at NCTSN.org.

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REFERENCE AND RESOURCE LIST

Mental health professionals are encouraged to consult the following professional 

articles and resources to gain an understanding of childhood traumatic grief.

Background information sheets about the condition, based on these materials, as 

well as assistance locating an appropriate mental health professional with expertise

in Childhood Traumatic Grief is available from the National Child Traumatic Stress

Network at (310)235-2633 or (919) 682-1552 or at NCTSN.org.

Professional References — PTSD

Alexander, D. W. (1999) Children Changed by Trauma: A Healing Guide. Oakland, CA:

New Harbinger Publications.

Allen, J. G. (1995) Coping with Trauma: A Guide to Self-Understanding. Washington, DC:

American Psychiatric Press.

Amaya-Jackson, L. (2000) Post-traumatic stress disorder in children and adolescents.

In Sadock, B. J. and Sadock, V. A. Comprehensive Textbook of Psychiatry/VII.

Philadelphia: Lippincott Williams & Wilkins.

Black, D., Emanuel, R., & Mendelsohn, A. (1997) Children and adolescents. In Black,

D., Newman, M. (Eds.), Psychological Trauma: A Developmental Approach.

Washington, DC: American Psychiatric Press, 281–293.

Cohen, J. A., Berliner, L,. March, J. S. (2000) Treatment of children and adolescents.

In Foa, E. B., Keane, T.M. Friedman, M.J. (Eds.), Effective Treatments for PTSD:

Practice Guidelines from the International Society for Traumatic Stress Studies.

New York: Guilford, 106–138.

Davies, D. R., Burlingame, G. M., & Layne, C..M. (in press). Integrating small group

process principles into trauma-focused group psychotherapy: What should a group trauma

therapist know? In Schein, L. A., Spitz, H. I., Burlingame, G. M., Muskin, P. R. (Eds.),

Group Approaches for the Psychological Effects of Terrorist Disasters. New York: Haworth.

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and Adolescent Psychopharmacology, 9 (3), 203–220.

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Professional References — Bereavement

Christ, G. H. (2000) Healing Children’s Grief: Surviving a Parent's Death from Cancer.

New York: Oxford University Press.

Baker, J. E., Sedney, M. A., Gross, E. (1996) Psychological tasks for bereaved children.

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New York: Basic Books.

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Publishers Ltd.

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2120 L Street NW, suite 200, Washington, DC 20037, www.americanhospice.org]

Geis, H. K., Whittlesey, S. W., McDonald, N. B., Smith, K. L. & Pfefferbaum, B. (1998)

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America, 7 (1), 73–85.

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Professionals. Boston: Beacon Press.

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Pennels, M. & Smith, S. (1995) Forgotten Mourners: Guidelines for Working with

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Worden, J. W. (1991) Grief Counseling and Grief Therapy: A Handbook for the Mental

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Professional References — Childhood Traumatic Grief

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Melhem, N. M., Day, N. Shear, M. K., Day, R., Reynolds, C. F., Brent, D. A. (2004)

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M. S., Hansson, R. O., Stroebe, W. and Schut, H. (Eds.), Handbook of Bereavement

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(Eds.), Psychological Trauma: A Developmental Approach. Arlington, VA: American

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Raphael, B., Martinek, N. (1997) Assessing traumatic bereavement and posttraumatic

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Saltzman, W. R., Layne, C. M., Steinberg, A. M., Pynoos, R. S. (in press). Trauma/

grief-focused group psychotherapy with adolescents. In Schein, L. A., Spitz, H. I.,

Burlingame, G. M., Muskin, P. R., (Eds.), Group Approaches for the Psychological

Effects of Terrorist Disasters. New York: Haworth.

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disorder and prolonged grief in motherless daughters. Journal of Psychological

Practice, 4(1), 34–50.

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Conference of the National Association of Loss and Grief, Australasian Critical Incident

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Books for Children and Teens on Trauma and Bereavement

Agee, J. (1957) A Death in the Family. New York: Bantam. (ages 13 and up)

Aliki (1979) The Two of Them. New York: Greenwillow Books. (ages 3–8)

Buscaglia, L. (1982) The Fall of Freddie the Leaf: A Story of Life for All Ages.

Thorofare, NJ: Slack, Inc. (all ages)

Canfield, J. Hansen, M. V., Kirberger, K, (Eds.) (1997) Chicken Soup for the Teenage

Soul: 101 Stories of Life, Love and Learning. Deerfield Beach, FL: Health

Communications, Inc. (ages 12 and up)

de Paola, T. A. (1973) Nana Upstairs and Nana Downstairs. New York: Putnam. (ages 4–8)

Gray, A. (1999) (Ed.) Stories for a Teen’s Heart Sisters, OR: Multnomah Publishers.

(ages 13 and up)

Grollman , E. (1993) Straight Talk About Death for Teenagers: How to Cope With

Losing Someone You Love Boston: Beacon Press. (ages 13 and up)

Gunther, J. (1949) Death Be Not Proud: A Memoir. New York: Harper. (ages 13 and up)

Harris, R. H. (2001) Goodbye Mousie. New York: Margaret K. McElderry Books. (ages 4–8)

Holmes, M. M., Mudlaff, S. J. (2000) A Terrible Thing Happened: A Story for Children

Who Have Witnessed Violence or Trauma. Washington, DC: Magination. (ages 4–8)

Kremnetz, J. (1988) How it Feels When a Parent Dies. New York: Knopf. (all ages)

Mellonie, B. and Ingen, R. (1983) Lifetimes: A Beautiful Way to Explain Death to

Children. New York: Bantam. (ages 3–8)

O’Toole, D. (1998) Aarvy Aardvark Finds Hope : A Read Aloud Story for People of All

Ages About Loving and Losing, Friendship and Loss. Burnsville, NC: Celo Press. (all ages)

Paterson, K. (1977). Bridge to Terabithia. New York: Crowell. (ages 12 and up)

Porterfield, K. M. (1996) Straight Talk about Post-Traumatic Stress Disorder: Coping

with the Aftermath of Trauma. New York: Facts on File. (ages 13 and up)

Romain, T. (1999) What on Earth Do You Do When Someone Dies? Minneapolis: 

Free Spirit. (ages 9 and up)

Smith, D. B. (1973) A Taste of Blackberries New York: Crowell. (ages 9–12)

Thomas, P. (2001) Miss You: A First Look at Death. Hauppauge, NY: Barrons. (ages 4–8)

Varley, S. (1984). Badger’s Parting Gifts. New York: Lothrop. (ages 5–8)

Viorst, J. (1971) The Tenth Good Thing about Barney. New York: Atheneum. (ages 4–7)

White, E. B. (1952) Charlotte’s Web. New York: Harper. (ages 4–8)

The Courage to Remember: Childhood Traumatic Grief Curriculum Guide

National Child Traumatic Stress Network

NCTSN.org

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Suggested Treatment Books and Supplies

Creative Therapy Associates: http://www.ctherapy.com/ (How Are You Feeling Today

posters and supplies) 

The Goodbye Game, M & B Distributors PH: 1(204) 728-3758 

The Grief Game, Jessica Kingsley Publishers, 116 Pentonville RD, London N1 9JB,

www.jkp.com

Black, C (1984) The Stamp Game: A game of feelings. Denver: MAC Printing and

Publications.

O’Conner, K (1983) The Color-Your-Life technique. In C. E. Schaefer & K. J. O’Conner

(Eds.) handbook of play therapy (pp. 251-258). New York: Wiley.

WPS-11 Emotional Bingo for Children (6–12). Available @ www.slosson.com/item98761.ctlg

Manuals

Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in 

children: Treatment manual, available by contacting the National Resource Center for

Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.

Cohen et al. (2001) Cognitive behavioral therapy for traumatic bereavement in 

children: Group treatment manual, available by contacting the National Resource Center

for Child Traumatic Stress at (919) 682-1552 or nationalresourcecenter@duke.edu.

Lieberman, A. F., Compton, N. C., Van Horn, P. & Ghosh Ippen, C. (2003) Losing 

a parent to death in the early years: Guidelines for the treatment of traumatic 

bereavement in infancy and early childhood. Washington, DC: Zero to Three Press.

Saltzman, W. R., Layne, C. M., Pynoos, R. S. (2003) Trauma/grief-focused intervention

for adolescents, available by contacting wsaltzman@sbcglobal.net.

Training

Contact the National Child Traumatic Stress Network at (310) 235-2633 or 

(919) 682-1552 or www.NCTSN.org

Websites

National Center for PTSD, Managing Grief after Disaster. 

www.ncptsd.org/facts/disasters/fs_grief_disaster.html

National Child Traumatic Stress Network: NCTSN.org

The Courage to Remember: Childhood Traumatic Grief Curriculum Guide

National Child Traumatic Stress Network

NCTSN.org

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