Nader, K. O., & Layne, C. M. (2009, September). Maladaptive Grieving in Children and Adolescents: Discovering Developmentally-linked Differences in the Manifestation of Grief. Traumatic Stress Points, 23(5), 12-16. more

September 2009 Volume 23, Issue 5 International Society for Traumatic Stress Studies I www.istss.org I istss@istss.org I +1-847-480-9028 President’s Column Patricia A. Resick, PhD President IN THIS ISSUE: As summer draws to a close during this Labor Day weekend, and we look forward to all of the fall activities, I want to update you on what you will have to look forward th to with the 25 Annual Meeting of ISTSS. But first, an announcement: Journal of Traumatic Stress (JTS) I am pleased to announce that Daniel Weiss, PhD has been chosen to become the new editor of the Journal of Traumatic Stress. Paula Schnurr, PhD, current JTS editor, will step down after she completes her term and finishes with the manuscripts that have been submitted during her tenure. Dr. Weiss is a professor of medical psychology in the Department of Psychiatry, School of Medicine, at UC San Francisco. He has been on the faculty of UC San Francisco since the late 1970s. Dr. Weiss served as a statistical consultant for JTS from 1999-2002 and as an associate editor since 2005. Dr. Weiss has a number of ideas that he brings to the role that include smooth transition, maintaining and hopefully increasing our impact ratings (the metric by which journals are judged and which affects the quality of articles that are submitted to the journal), and plans to expand the scope of topics that are published in JTS. We congratulate and thank Dr. Weiss for taking on this important role. 25 Annual Meeting If you have not decided whether to attend this year’s conference, I hope you will consider doing so. I believe we have an excellent conference planned, including a number of highlights in addition to our usual outstanding array of institutes, workshops, and symposia. As you may have noticed, in my opening sentence, I mentioned the silver anniversary of our conference and the upcoming anniversary of our organization at the end of next year. Looking back as well as looking forward will be dual themes of this year’s conference. On the theme of looking forward, last year we had a day-long series of symposia on the topic of DSM-V. That track was very successful and generated a great deal of discussion, as well as a special series of articles that are being published in JTS. Building on the momentum of the DSM track last th President’s Column LGBTI Special Interest Group Award Recipients Annual Meeting Updates New – Learning Collaboratives ISTSS Logo Design Concept Announced 2009-2010 Election Results Media Matters Student Section Book Corner StressPoints Call for Submissions Amazon Store Hopi Foundation: ISTSS Co-Sponsor Child and Youth Care Forum Trauma and World Literature Maladaptive Grieving in Children… StressPoints Leadership Upcoming Events 1 2 3 4 5 5 5 6 7 9 10 10 11 11 12 13 17 17 year, this year’s conference will continue the discussion as we move toward field trials to test some suggested changes in diagnosis as well as consider PTSD and the dissociative disorders within the larger context of diagnosis. Our featured speakers will bring a range of perspectives. Darrel Regier, MD, MPH, is the vice chair of the DSM-V Revision Task Force. His impressive biography is listed in the Preliminary Program for the conference. Dr. Regler is going to be speaking on the DSM process and the attention to dimensional aspects of disorders, and developmental considerations that cut across various diagnoses and how these cross-cutting aspects will be considered in an attempt to streamline assessment and provide more individualized treatment. David Barlow, PhD, professor of psychology and psychiatry at Boston University will also consider a transdiagnostic approach to the problem of high rates of comorbidity and will consider how key aspects of disorders may cut across various diagnoses. Understanding these shared components could lead to unified treatment approaches that will apply to a range of diagnoses. The third invited address will be by David Spiegel, MD, a professor of President’s Column continued on page 2 Page 2 President’s Column from page 2 StressPoints in the field, the evolution of science of trauma and PTSD, clinical innovations and treatment development trends, and the internationalization of the field. We will celebrate the 25 anniversary by moving the opening reception to the last night of the conference and will have a celebration of our 25h anniversary. At the conference, we will also unveil our new logo. We thought it was time for a fresher look for the next phase of our organization. Last but not least, we are going to implement the master clinician series in a way that should highlight the similarities and differences between different types of therapy for PTSD (older generation, do you remember the Gloria tapes that were shown in the 1970s to illustrate Gestalt Therapy: Perls; ClientCentered Humanistic Therapy: Rogers; and Rational Emotive Therapy: Ellis? I just found them on You Tube). Over the course of the conference we are going to have one “client” playing the part of a returning combat veteran receiving Prolonged Exposure (David Riggs); Acceptance and Commitment Therapy (Robyn Walser); Cognitive Processing Therapy (Kathleen Chard); Virtual Reality Exposure Therapy (Barbara Rothbaum) and the new United Transdiagnostic Treatment (David Barlow). We think it will be fun as well as informative. So, on behalf of the Program Committee and the Board of Directors, we invite you to attend what is shaping up to be an excellent conference at the lovely Westin Peachtree Plaza Hotel in Atlanta Georgia. th psychiatry and behavioral sciences at Stanford University School of Medicine. Dr. Spiegel will discuss possible changes in dissociative disorder diagnoses in the DSM-V, the role of dissociation in PTSD and ASD, and potential placement of the dissociative disorders along with PTSD and ASD into a traumatic stress disorders classification. Finally, not listed in the preliminary program, a panel has been added on Saturday afternoon, at the end of the conference, to discuss with the audience several questions that have been posed to a working group to consider as field trials are developed. This panel presentation will be more interactive with the audience than the invited addresses and will provide an opportunity for conference attendees to react to what they have heard during the conference. The panel will be chaired by Matthew Friedman and panelists include Richard Bryant, Terence Keane, Dean Kilpatrick and Paula Schnurr. Looking back, the conference will honor our history and contributions in several ways. There will be two presidential panels at the conference. One is called “International Society for Traumatic Stress Studies”, Past President Bonnie Green will chair this panel including Yael Danieli, Robert Pynoos, Matthew Friedman, John Briere, and Elana Newman. Each of these past presidents will represent 20% of the life of the organization and will talk about important issues and concerns that were prominent during their tenure. The second Presidential Panel will consist of Charles Figley, as Chair, and Sandra Bloom, Paula Schnurr, Terence Keane and Alexander McFarlane will discuss important developments in the field over the past 25 years. These topics include: trends in understanding changing issues A New Special Interest Group: The Lesbian, Gay, Bisexual, and Transgender Issues SIG Lesbians, gay men, bisexuals and transgendered individuals (LGBT) have been demonstrated to have higher rates of exposure to trauma and other stressors, depression, and post-traumatic stress disorder than their heterosexual siblings and than the general population. However, until relatively recently, research in this area was often limited to identifying rates of trauma and stress exposure with more limited examination of other post-traumatic outcomes, along with studies of the associations between trauma exposure and HIV or AIDsrelated outcomes, and HIV/AIDS-related treatment. The newly-formed LGBT Special Interest Group (SIG) seeks to promote and support further work with these populations, the presentation of such work at the ISTSS Annual Meeting, and other dissemination efforts. The SIG will also seek to provide support for those interested in these issues, regardless of sexual orientation or gender identity, along with potential other goals to be determined by those attending the SIG’s first meeting. The SIG will meet on Saturday, Nov. 7, 2009 from 12:30 – 1:45 pm in the Roswell Room of the ISTSS meeting hotel, the Westin Peachtree Plaza, Atlanta, Ga. Please also consider attending the Diversity SIG on Thursday, Nov. 5, 2009 in International Room E on th the 6 floor of the Westin Peachtree plaza, from 12:301:45 pm. For further information, please contact Elisa Triffleman, chair of the ISTSS Diversity Committee at elisatriffleman@earthlink.net. For a listing of all ISTSS SIGs, visit http://www.istss.org/sigs/index.cfm. StressPoints Featured 2008 Award Recipient Roger Allan Simpson, PhD Professor of Communication, University of Washington ISTSS recognizes Roger Simpson, PhD (Dart Professor of Journalism and Trauma at the University of Washington, Department of Communications) as the 2008 Frank Ochberg Award for Media and Trauma Study. Roger is well known to ISTSS members for his role as the founding director of the Dart Center for Journalism and Trauma, from 2000—2006. During his tenure, he facilitated many collaborative projects with ISTSS. For example, he has facilitated many symposia about journalism and trauma at our annual conferences, collaborated on media training for our members at conventions, provided StressPoints material, and served on ISTSS committees. Professor Simpson conducted the first study of the occupational health of journalists, specifically examining the rates of PTSD symptomatology among journalists. His scholarly book, Covering Violence: A Guide to Ethical Reporting about Victims and Trauma with has revolutionized the way both professional and students approach victims in the news. This book distills the field of traumatic stress to working journalists and students, while advocating ethical interviewing practice and coverage of trauma survivors. Dr. Simpson is an educator of ethical journalistic practice. Using varied pedagogical approaches (workshops; actors to work Page 3 with journalists to role play scenarios; panel discussions; internet technologies), he has trained hundreds of journalists about traumatic stress studies, occupational health, and journalistic practice about victims. His ability to educate others on the relationship of journalistic practice and science of trauma has been instrumental in improving journalistic practice about trauma. The Ochberg award is given for significant contributions by clinicians and researchers on the relationship of media and trauma. Professor Simpson has certainly provided significant research and scholarship to the field (2 articles, 1 book). His scholarship is considered innovative and first-rate among communication scholars. In addition, his scholarship and his teaching have help raised awareness about the importance of telling stories about victims in new, more effective ways. Indirectly, his work has changed the experience of many survivors interacting with the press as well as public knowledge about trauma and recovery. For a list of past Frank Ochberg award recipients, visit http://istss.org/organization/awardwinners.cfm. Congratulations to the 2009 Award Recipients The following recipients will be presented with their individual award during the Business Meeting, 6:15 - 7:00 p.m. on th th Friday, November 6 at the 25 Annual Meeting in Atlanta, Georgia. To view past award recipients, visit the ISTSS Web site. Roger K. Pitman, MD Lifetime Achievement Award. This award is the highest honor given by ISTSS. It is awarded to the individual who has made great lifetime contributions to the field of PTSD. Matthew T. Tull, PhD Chaim and Bela Danieli YoungProfessional Award. This award recognizes excellence in traumatic stress service or research by an individual who has completed his or her training within the last five years. Paula P. Schnurr, PhD Robert S. Laufer Award for Outstanding Scientific Achievement. This award is given to an individual or group who has made an outstanding contribution to research in the PTSD field. Matthew J. Friedman MD, PhD Public Advocacy Award. This award is given for outstanding and fundamental contributions to advancing social understanding of trauma. Elana Newman, PhD Frank Ochberg Award for Media and Trauma Study. This award, established at the 2003 annual meeting, recognizes significant contributions by clinicians and researchers on the relationship of media and trauma. Linda A. Piwowarczyk, MD, MPH Sarah Haley Memorial Award for Clinical Excellence. This award is given to a clinician or group of clinicians in direct service to traumatized individuals. This written and/or verbal communication to the field must exemplify the work of Sarah Haley. Page 4 StressPoints Important Annual Meeting Deadlines! Early Registration Deadline: September 24, 2009 Hotel Cut-Off Deadline: October 2, 2009 Register and Save! Only ONE WEEK left to take advantage of the early registration rate. The Annual Meeting will cover today’s important topics in traumatic studies, including The Cutting Edge of Research in Diversity and Trauma; Neuroimaging and PTSD: New Findings and Evolving Technologies; Children and War in Socio-Cultural Context; Virtual Reality Exposure Therapy for PTSD and much more! Don't miss the number-one meeting in traumatic stress studies. The Westin Peachtree Plaza Hotel is the headquarters for the ISTSS Annual Meeting in Atlanta. The hotel will fill up quickly so make your reservations now. When making your travel and hotel arrangements, plan to stay overnight Saturday to take part in the 25th Silver Anniversary celebration as ISTSS honors past and current leadership. ISTSS Diversity Committee Meeting Open to All Annual Meeting Participants—Thursday, 11/05/09, 5:00-5:30 pm, Tower Meeting Room #1202, Westin Peachtree Plaza The ISTSS Diversity Committee is interested in your thoughts, opinions and questions about who we are as a Committee, diversity issues within ISTSS, and more broadly, about diversity and traumatic stress studies as a field of inquiry. We invite all interested Annual Meeting participants to come meet with us during the first part of this year’s Diversity Committee meeting. We’ll be discussing the past year’s activities, which will be followed by discussing and developing our priorities for the coming year. We welcome your input. If you have any questions, please contact Elisa Triffleman, chair of the Diversity Committee, at elisatriffleman@earthlink.net. Interested participants are also invited to come to the Diversity Special Interest Group (SIG) meeting on Thursday 11/05/09, 12:30-1:45 p.m. in International th Room E on the 6 floor of the Westin Peachtree Plaza, and the newly formed Lesbian, Gay, Bisexual and Transgender Issues SIG meeting on Saturday, 11/07/09, 12:30 pm -1:45 pm in the Roswell Room in the same hotel. Orientation Meeting for All Interested Participants at the 2009 Annual Meeting of ISTSS Welcome to the 2009 ISTSS Annual Meeting! As part th of ISTSS’s welcome to the 25 meeting, experienced members of ISTSS will be available and will facilitate discussion on Wed, Nov. 4, 2009 from 7:00 p.m. – 8:00 p.m. during an Orientation Meeting, in order to provide a framework for navigating the Annual Meeting and to introduce participants to ISTSS as an organization. While geared toward first-time attendees, all ISTSS participants are invited to join in, ask questions, and add comments and insights. Following the Orientation Meeting, which will be held in th International Room H on the 6 floor of the Westin Peachtree Plaza, a cash bar will be available from 8:00 – 10:00 p.m. down the hall in Vinings Room I. This information will also be available in the Final Program Book which is projected to be available on the ISTSS Web site sometime in October, 2009. For further information until November 2, 2009, please feel free to contact Elisa Triffleman, chair, ISTSS Diversity Committee at elisatriffleman@earthlink.net. For information about the Orientation Meeting thereafter, please check with ISTSS staff in the Registration area th in The Overlook Area on the 6 floor of the Westin Peachtree Plaza. Attention Students! Volunteer and Save Receive registration discounts for volunteering your th time at the upcoming ISTSS 25 Silver Anniversary Annual Meeting, November 5 – 7, 2009 in Atlanta, Georgia, USA. As a student member, you are eligible for a $40 discount on full student registration fee or the sliding scale rate, whichever is lower, in exchange for a commitment 4 hours of volunteer service during the conference. This is a great opportunity to save some money and meet fellow student volunteers. Fill out the appropriate forms and return them to ISTSS by October 14th in order to receive the registration discount. You are asked to provide information regarding times you would like to volunteer as well as a list of potential jobs from which you may choose. Students will be confirmed on a first-come, first-served basis. StressPoints NEW – ISTSS Learning Collaboratives At this year’s 2009 Annual Meeting in Atlanta, ISTSS will introduce a Learning Collaborative Program. A learning collaborative is comprised of a group of clinicians and researchers who get together to implement and evaluate an evidence-based treatment in community practice. For several years ISTSS has hosted workshops on both well-established and newly emerging, evidence-based treatments. Practicing clinicians who want to use these treatments rarely have the opportunity to get follow-up consultation on resolving difficulties in implementation or to hear from other clinicians about strategies they are using that make the treatment interventions go smoothly or in contextually- or culturally-sensitive ways that engage their clients. Conversely, developers of treatments rarely get to hear about what is going right and what is going poorly in a treatment when applied in varied “real world” practices. The learning collaborative is intended to address this gap in communication and foster mutual learning between clinicians and researchers. The general purpose of the learning collaborative is to provide a forum to facilitate a positive, effective and sustained working relationship among clinicians and treatment developers in the task of successfully implementing an evidence-based treatment in a private practice or community setting. At this year’s conference, a learning collaborative will follow each of two PMIs. Perhaps most importantly, learning collaboratives create social networks that provide professional support as well as opportunities to enhance clinical skills. Practically speaking, this year’s ISTSS learning collaboratives will be comprised of bimonthly phone conference consultations with the PMI faculty and all other participating clinicians. These phone conferences Page 5 will provide an opportunity to receive consultation in an ongoing “real-time” fashion about the use of the treatment with specific clients, to hear about successes and challenges that other practitioners are experiencing, and to suggest or receive problem-solving strategies from the group at large. Each Learning Collaborative involves a total of sixteen conference calls approximately twice per month from January through the end of September 2010. The phone conferences will be supplemented with a listserv, ISTSS website or message board where the PMI faculty will respond to community clinician difficulties in a rapid turn-around fashion. We hope that the learning collaborative will provide a forum that will enhance professional morale and confidence, particularly given the challenging treatment environments in which much trauma therapy is implemented, as well as create a network of providers and researchers with common interests. Learning Collaboratives available as Follow Up to the following PMIs: PMI-1 Maximizing PTSD Treatment by Incorporating Significant Others (Candice M. Monson, PhD, Susie Stevens) PMI-4 Effective Treatment for Complex PTSD Related to Childhood Abuse and Multiple Traumatization (Marylene Clotire, PhD) Register NOW! http://istss.org/meetings/reg.cfm. Congratulations to the ISTSS Logo Design Concept Winner ISTSS congratulates Gerrit van Wyk, MA, ClinPsych and his staff at TraumaClinic Emergency Counselling Network in South Africa for winning the first-ever ISTSS Logo Design Concept Contest. In July, ISTSS invited members to participate in the contest in hopes of receiving ideas about what ISTSS represents to its membership. These ideas would be used to help create the new logo for the Society which will be unveiled at the Annual Conference in Atlanta this November. (Note – the winning design concept is not the new logo of the association.) The winning concept creative team was selected by the ISTSS Executive Committee and the one person of its choice will be awarded with a complimentary year-long membership. Thank you to Gerrit and his staff at TraumaClinic and all who participated. Newly-Elected Leadership President-Elect Marylene Cloitre New Board members Jon Bisson Diane Elmore Harold Kudler Candice Monson Nnamdi Pole Congratulations to the new president-elect and board members. Thank to all those who were nominated and who participated in the election. Meet Your 2009-2010 Page 6 Media Matters: Can outreach projects Sue Lockett John, PhD University of Washington News media provide much of the public’s information and framework for understanding mental health. And where does mental illness appear most prominently in the news? In horrific stories of beatings, stabbings and shooting sprees by suspects “with a history of” mental illness, posttraumatic stress disorder (PTSD) or other diagnoses. Crime stories almost never include the important contextual fact that mental illness alone is not a trigger for violence, nor that people with mental illnesses are more likely to be victims than perpetrators. As an unintended consequence, news coverage feeds the stigma that discourages individuals with mental illness from seeking treatment and encourages society to withhold such necessities as insurance equity, employment and housing opportunities from people. Efforts to address this problem will be explored at the 2009 ISTSS Annual Meeting by an interdisciplinary panel titled “Fighting Stigmatization of Trauma Through Education and Media Relations.” Drawing on our own experiences in media relations, journalism and research, Eileen Watts Welch (Director of Advancement, Center for Child and Family Health at Duke University), Caleb Hellerman (Dart Fellow and senior producer, CNN Medical Unit) and I (media and research associate, Washington State Coalition to Improve Mental Health Reporting) will offer varied perspectives on media coverage of mental illness and how it could be changed. Victoria Reynolds, PhD, of Duke University will moderate. CNN’s Hellerman suggests that the growing number of well-developed, insightful stories about combat soldiers and veterans with PTSD—full of detail about daily lives, co-occurring disorders and steps toward recovery— might serve as models for reporting on others living with mental illnesses, including PTSD with non-military origins. PTSD currently is reported almost entirely through the prism of military exposure, he notes, leaving out many victims of crime, disaster and other traumas. Pointing out that a substantial number of positive stories are written on depression, which started being openly discussed after the development of anti-depressants, Hellerman predicts that available, effective treatments will lead to more open acknowledgement and reporting on other mental illnesses. “HIV was stigmatized until there was a treatment,” he says. “Fifty or 60 years ago, talking about cancer was taboo.” And remember erectile dysfunction. “It changed in a year.” StressPoints improve media coverage of trauma and mental illness? In the meantime, members of the mental health community are working toward more immediate changes in news coverage. One such effort is the Washington State Coalition to Improve Mental Health Reporting [1], an intensive statewide initiative launched last spring by stigma scholar Jennifer Stuber, Ph.D., assistant professor at the University of Washington School of Social Work. Its small research and action team monitors media coverage, sends corrective and complimentary feedback directly to journalists, initiates newsroom staff meetings and trains mental health professionals and people living with mental illness to generate fresh story ideas that provide a more accurate picture of mental illness. Its Website offers journalists easy access to mental health facts, reporting guidelines and tip sheets, exemplars and local sources. The content of six representative newspapers will be analyzed next year to see if the project produces quantifiable improvements in news coverage. If successful, it could serve as a template for other educational efforts to improve coverage of mental health [2]. Stuber is particularly troubled by crime stories that reflexively report any mention of a suspect’s “history of mental illness” (or even the absence of same). Research has shown many other factors to be far more predictive of violence (Elbogen and Johnson, 2009), but mental illness often is singled out by neighbors, family, public information officers, and reporters looking for answers in the midst of trauma. The coalition asks journalists covering breaking news to use restraint in identifying mental illness as a potential explanation for violence, to consider alternative or co-occurring conditions and to point out that the vast majority of violent acts have nothing to do with mental illness. Journalists generally consider a suspect’s mental state a “telling detail, and often it is,” says Hellerman, but it’s very hard to make that judgment at first, and it often becomes a shorthand way of dealing with a much more complicated story. Stuber says the coalition is really asking journalists to adhere to their own bedrock value of accuracy, and that anything less “perpetuates misconceptions and fears about mental Media Matters continued page 7 StressPoints Media Matters from page 6 Page 7 people want to know.” In today’s crowded, fast-moving media environment, he says, “you cannot bury stories you don’t want to talk about” or make people care about a message because it’s “good.” Nonetheless, Hellerman sees mental illness “on the cusp” of less stigmatized, more normalized reporting as treatments become available. “It’s an opportunity for medical reporters,” he says, as long as they remember that neither the treatment nor the disease define a person’s life. [1] Funded by Washington’s Mental Health Transformation Project through a federal grant from the Substance Abuse and Mental Health Service Administration (SAMSHA). [2] The World Psychiatric Association’s Global Anti-Stigma Program’s Calgary Pilot Program’s outreach to one local newspaper produced positive local coverage, which was negated by overall increases in negative news (Stuart, 2007). SANE Australia’s StigmaWatch has provided feedback to media on representations of mental illness and suicide for more than a decade. References Elbogen, E. B., & Johnson, S. C. (2009). The intricate link between violence and mental disorder: Results from the national epidemiologic survey on alcohol and related conditions. Archives of General Psychiatry, 66(2), 152-161. Stuart, H. (2007, October). Media ‘madness:’ From stigma to strategy. Canadian Psychiatry Aujourd’hui. Stuart, H. (2006). Media portrayal of mental illness and its treatments: What effect does it have on people with mental illness? CNS Drugs, 20(2), 99-106. illness by reinforcing the mistaken belief that people with mental illness are violent and ignoring the reality that most people recover from mental illness.” To balance the negativity and fear fostered by crime stories, the coalition also encourages positive stories of recovery, treatment and normalcy about people living with mental illnesses. Proactive efforts to place positive stories about prevention, treatment and interventions also figure into Eileen Watts Welch’s efforts to advance the goals of the Center for Child and Family Health in Durham, NC. She builds and nurtures relationships with local publishers and journalists so that she understands their needs and they know what she and the Center are trying to accomplish in the lives of children at risk of experiencing trauma. She networks at Rotary meetings and community fund-raisers, tracks reporters’ bylines and interests, and invites journalists to tour the Center and see its research, training and treatment programs in action. Successful media outreaches raise the Center’s profile, but also disseminate important messages about prevention and treatment of abuse and other childhood trauma. Welch sends press releases, of course, but attributes her best outcomes to learning what her local news organizations and reporters need and helping them find it. Even so, Hellerman says, creative tension persists between pro-social public health messages and the news mandate to “not hold back the tide of what Reflections on a dialogue between first- and last-year graduate students. Sabrina Skinner Walla Walla University Student Section: “Oh, the Thinks you can Think…” Vienna Nightingale, PhD Yale University Although we are each unique, we are in our respective programs as students because someone more advanced in our field saw in us the characteristics necessary to succeed in graduate school and beyond. Once in our programs, whether it is in medicine, psychology, social work, journalism or public health, we apply our skills and abilities to the tasks and obligations at hand. A number of students continue to take the traditional route in academic achievement; however, for a number of reasons that are too lengthy to plunge into here, there are many students who have not taken the traditional path to academic achievement. These individuals face some of the same challenges other more traditional students have and may also have very different challenges. One such challenge is balancing the responsibilities of being a parent while still meeting the expectations of graduate school What follows is the result of a dialogue between a first year and last year graduate student in which these challenges are discussed, raising points of interest that can be applied to any number of challenges that can arise in graduate school. There are a number of graduate students actively involved in planning and organizing student activities for the International Society for Traumatic Stress Studies annual meeting. One such organizer is Vienna Nightingale, who at the time of the meeting, was a graduate student at Illinois Institute of Technology and an intern at the Vanderbilt University/Veteran’s Affairs Consortium. Vienna, with the help of Dr. Seuss (Seuss, 1975) shared her experiences and the lessons she Student Section continued page 7 Page 8 Student Section from page 7 StressPoints interview site. In route, she miscalculated the driving time due to a time zone change and arrived at the daycare center to deliver the necessary paperwork and have a site visit after they were already closed. She called the daycare center director and explained the circumstances. As a result, the director allowed her to drop off the paperwork that evening and worked it out so that Vienna could have an early morning site visit before dropping off her son and attending her interview. Vienna went to her interview feeling on top of the world after successfully strategizing again. On the drive home, she encountered a thunder storm. In the blinding rain, tractor trailers rocketed past her car. With no visibility and her son crying, she pulled over on the highway to wait. When the rain slowed, they drove to the next town and stayed for the night. Be Creative learned as a mother during the last couple years of her graduate school experience. This discussion had three major themes: 1.) planning ahead; 2.) expecting the unexpected; and 3.) being creative. Below we discuss these themes in the context of her experiences as a PhD candidate in clinical psychology and preparing for internship. Plan Ahead “There are so many THINKS that a Thinker can think! Oh, the THINKS you can think up if only you try!” * Although forethought is imperative in the process of obtaining a PhD and parenting a child, there is no ‘single’ or ‘right’ path in either process. Vienna was decisive in her internship application process. She sought programs with a general perspective, a strong trauma focus, and emphasis on cultural competency. She initially eliminated programs with 70-80 hour work week expectations. In this process, she was drawn to the VA system for its reputation of excellent training and a structured work-week. She applied to twenty programs, and received 12 interviews. Much planning and organizing went into this application process that is often referred to as ‘a full-time job.’ Vienna had a group of friends she referred to as her “mom group.” They collaborated to take turns watching each other’s children, to allow each other an affordable and feasible way to work on tasks relevant to their stage in graduate school. These co-op mom groups are easy to establish or join now that we have access to the internet. Further, she worked on her internship applications and research while her son was napping in the day and sleeping in the night. Expect the Unexpected “THINK? You can think any think that you wish… Think a race on a horse on a ball with a fish! Think of black water. Think up a white sky. Think up a boat. Think of BLOOGS blowing by.” * As a mother and a graduate student, where is the free time? Really, there is no free time, so time must be bent and reused at the same time. What does that mean? Well, having a successful interview requires preparation and preparation requires time. Slightly embarrassed, she discussed how she prepared. She admitted to singing possible interview questions and answers to her son to soothe him while at the same time preparing for interviews. Vienna had a number of insights and advice for other students in the process of applying for internship, and these same lessons can be extrapolated onto much bigger contexts. She said that these experiences further reinforced in her that she is able to handle challenges in front of her. Her creative use of resources has allowed her to remain the strong figure in her son’s life, while accomplishing her career goals. Since our first meeting she has received her PhD and has moved to Connecticut for a postdoctoral fellowship at Yale University’s Center for Interdisciplinary Research on AIDS. As she continues to pursue her research and academic goals as a postdoctoral fellow and enjoys her role as a mother to her 2 year old son, she is likely to continue to turn to hers and Dr. Seuss’ advice frequently: “Think left and think right and think low and think high. Oh, the THINKS you can think up if only you try!” * “You can think about Night, a night in Na-Nupp. The birds are asleep and the three moons are up.” * Although you want to plan ahead, it is just as important to be mindful of the likelihood that things are bound to change unexpectedly. As a case in point, Vienna shared her adventure of getting to one of her internship interviews. Due to unforeseen circumstances, the family member who was to watch her son while she attended this interview was not available. Again, creative measures were necessary. Through a discussion with a friend she learned of “drop-in-daycare centers” and quickly investigated. After a number of Google searches and phone calls, she found an appropriate daycare center that provided drop-in-service located near her Seuss, Dr. (1975). Oh, the thinks you can think! New York: RandomHouse. Featured title: ISTSS Amazon Store. StressPoints Soldiers of Conscience Review by Kent D. Drescher, Ph.D. National Center for PTSD Review of: PBS documentary, SOLDIERS OF CONSCIENCE (http://www.soldiers-themovie.com). Soldiers of Conscience is a documentary produced by two award-winning filmmakers Gary Weinberg and Catherine Ryan, and narrated by Peter Coyote. It provides a powerful look into the ethical complexities of war, and the moral decisions faced by those who fight them. The film is primarily comprised of interviews with eight United States soldiers and Marines from Operations Iraqi and Enduring Freedom (OIF/OEF), in which they discuss their own personal moral perspectives on war and killing. Four of the participants at the time of filming served in military training roles, one teaching philosophy at West Point, three others serving as drill instructors for basic training. The other four participants served in a variety of job roles while in Iraq and at some point arrived at a moral and ethical decision that led to filing for conscientious objector (CO) status. Two of those filings were approved by the military and the individuals honorably discharged, while the CO filings of the other two were rejected and ultimately resulted in court-martial, prison time, and less than honorable discharge. Each of those who filed for CO status was required in the filing to describe a “crystallizing event,” that is an event or series of events that led to a clear shift in their perspective and led to them objecting to “all” wars as opposed to simply objecting to this specific war. The viewer is allowed to hear these individuals describe in their own words the events that shaped their thinking and changed their beliefs. The film makes clear that filing for CO status is not currently, nor has it ever been, an "easy way out" of the military. Rather each member who filed to be a CO shared how much more difficult their military life became following the filing, and showed clearly that in most cases the filing did not shorten their time spent in the military. One of the strengths of the film is that its producers resist what might be an inclination to take sides and promote a political agenda. Rather, those interviewed are allowed to speak for themselves about their highly personal beliefs, honed and shaped by their experiences before, during, and after their OIF/OEF war zone deployments. The film also provides a helpful amount of historic context about conscientious objection in US history. Additional materials available on the website, further clarify the varying ways in which conscientious objectors to war have been treated from the period of the Page 9 Book Corner Revolutionary war to present day. It becomes clear that though the ability to declare oneself (on the basis of religious/moral beliefs) to be a conscientious objector has existed since before this nation was founded, the treatment of those who have made such a declaration has varied depending on the mood and outlook of the country toward each particular war. If there is a weakness in the film, it is that by allowing each interviewee to simply describe the experiences that led to their varying beliefs, the overall message of the film becomes diffuse and difficult to articulate. It is clear however that this is by design, not by accident. The filmmakers want viewers to exert energy to understand, interpret, and assign personal meaning to the film and in so doing enter into the difficult choices made by the service members who allowed themselves to be interviewed. Soldiers of Conscience is about the resolution of moral conflict in the context of war either through coming to terms with war’s necessity and the actions required to conduct it, or by removing oneself from involvement in war through declaring conscientious objection. The film chooses to portray these two ends of what could be seen as a more nuanced continuum of moral conflict in war. Theorists of moral distress in the medical arena have suggested additional points on the continuum such as Moral Uncertainty – i.e. being unsure what moral principles apply, Moral Dilemma – i.e. when two conflicting moral principals apply, and Moral Distress – i.e. negative feelings at the inability to do what is perceived to be right (LaRocca-Pitts, 2004). A number of trauma theorists and researchers have recently coined the term Moral Injury and define it as behavioral changes and changes in long-term view of self/others from involvement in perceived immoral situations. Book Corner continued page 10 Page 10 Book Corner, continued from page 9 StressPoints literature call on the mental health field to focus increased attention to the deleterious effects of moral conflict and moral injury in the lives of war veterans and military service men and women. Filmmakers Gary Weinberg and Catherine Ryan make a similar call using their own unique medium in their film, Soldiers of Conscience. References Drescher, K. D., & Foy, D. W. (2008). When they come home: Post traumatic stress, moral injury, and spiritual consequences for veterans. Reflective Practice: Formation and Supervision in Ministry, 28. Grosman, D. (1995). On killing: The psychological cost of learning to kill in war and society. New York: Little, Brown and Co. Larocca-Pitts, M. (2004). The chaplain's response to moral distress. Chaplaincy Today, 20(2), 23-29. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C. et al. (In Press). Moral Injury and Moral Repair in War Veterans: A Preliminary Model and Intervention Strategy. Clinical Psychology Review. MacNair, R. (2005). Perpetration-Induced Traumatic Stress: The Psychological Consequences of Killing. Authors Choice Press. Featured title: ISTSS Amazon Store. For this reviewer, the material presented in the film resonates with a growing awareness of the uniqueness of military combat amidst the array of traumatic experiences that can lead to a diagnosis of PTSD. During the past 40 years that saw the development of the PTSD diagnostic criteria that we have today in DSM-IV, the field has focused a great deal on the “least common denominator, ” i.e. those elements of trauma and corresponding symptoms experienced by most trauma survivors. In so doing however, the field may have, at times, neglected, or glossed over unique elements of specific traumas that powerfully influence the recovery trajectory, and long-term outcomes for these individuals. Combat is uniquely an activity where behaviors that are proscribed in other contexts (e.g., killing) are sanctioned and even celebrated when performed in accord with established rules of engagement. The stressor criterion for PTSD that defines traumatic events does not easily encompass inflicting of trauma and the act of killing within the definition. Nor do the PTSD symptom criteria adequately address issues of guilt, shame, alienation, loss of faith, and selfdestructiveness sometimes seen in combat veterans. Some writers have suggested that killing in combat may have inherent long-term emotional / psychological consequences that extend beyond the diagnostic criteria for PTSD and that might better fit the term “Moral Injury” (Grosman, 1995; MacNair, 2005; Drescher & Foy, 2008). Brett Litz and colleagues (Litz et al., In Press), in a forthcoming review and analysis of the combat research Interested in having your book reviewed? Or reviewing a book? Contact Editor Anne DePrince. Call for Submissions Consider submitting an article to Traumatic StressPoints! Stresspoints accepts articles (750-1000 words) on topics related to the study and treatment of traumatic stress-related disorders. StressPoints provides a vehicle for the rapid dissemination of news, as well as recent advances, issues, controversies, concerns, or innovations in research or applied contexts. Articles should be written in a style accessible to a multidisciplinary audience. Considering limited space, terse shorter articles will be given priority over longer articles. Articles should be well-documented (references do not count towards word count). With the electronic newsletter format, authors are encouraged to provide links to relevant web resources to facilitate readers’ access of additional or supporting information on the topic. For more information about submitting an article, please visit: http://www.istss.org/publications/TSTsample.cfm. Visit the ISTSS Amazon Store! The ISTSS Amazon Store (also accessible from the ISTSS homepage) features trauma-related books for professionals and the public, as well as fiction, memoirs, and movies with themes related to trauma and healing. The store allows ISTSS members and others to locate useful resources, while helping to support ISTSS. ISTSS earns a referral fee of 4% to 10% for items purchased through the site. Any Amazon purchase that originates through our store helps to support ISTSS. To find other Amazon items, just click the “Powered by Amazon” button in the upper left corner of the page and continue shopping. Titles featured in this issue are available at the ISTSS Amazon Store, including:  Soldiers of Conscience (DVD)  The Lazarus Project  Oh, the Thinks You Can Think Please send suggestions to Nancy Kassam-Adams at nlkaphd@mail.med.upenn.edu. StressPoints ISTSS Co-Sponsors Conference on October 2-3, 2009 - Flagstaff, Arizona USA The non profit Hopi Foundation in conjunction with the 2009 Barbara Chester Award presents "The Treatment of Extreme Trauma: A Unique Training Conference Opportunity." The conference, which is co-sponsored by ISTSS, has been organized to provide clinical and empirically based techniques and approaches to practitioners working with two sets of specialized population groups affected by trauma: Native American war veterans, and survivors of political torture. The Conference offers research updates and concurrent clinical practices focused on trauma. The workshop sessions are intensive and present the subject matter in considerable depth offering dynamic, didactic, and interactive learning experiences. Keynote speakers and workshop presenters – such as Judith Herman, Spero Manson, Terence Keane, James Shore, and Maria Yellow Horse Brave Heart -- are world class and reflect exceptional achievement in their respective fields. Alternative, effective therapies for the treatment of trauma are presented including the sweat lodge by Larry Roman Nose, Bernard Albaugh, and Frank Sheridan (Southern Cheyenne). The presenters provide a fine balance of updated clinical and research knowledge with wellgrounded, innovative, and best case practice applicability for treatment of trauma by service providers. Page 11 Treatment of Extreme Trauma Registration Fee: $250 [$300 after September 8] Who Should Attend: Practitioners who treat severe trauma Event Website: The Treatment of Extreme Trauma Location: High Country Conference Center 201 West Butler Avenue Flagstaff AZ 86001 Location Phone: (928) 523-9521 Location Website: http://www.highcountryconferencecenter.com/ CALL FOR PAPERS Child & Youth Care Forum Special Issue: Trauma Exposure and PTSD in Justice-Involved Youth Child & Youth Care Forum announces a forthcoming special issue on Trauma Exposure and PTSD in JusticeInvolved Youth. This special issue is being edited by Keith Cruise, PhD, MLS and Julian Ford, PhD. Manuscripts that address a wide variety of issues involving the effects of trauma exposure and PTSD symptomatology in juvenile justice populations will be considered for this special issue. Of particular interest are manuscripts that address empirical testing of screening and assessment tools, intervention outcomes, and longitudinal studies investigating a variety of outcomes (e.g., behavioral, legal, psychosocial). Manuscripts that address implementation of assessment and intervention practices across different juvenile justice settings (e.g., community, residential, detention/corrections) are especially relevant for this special issue. The deadline for manuscripts submission is November 15, 2009. Manuscripts should be between 20-30 doublespaced typewritten pages. Manuscript submission and review will be handled through the Child & Youth Care Forum electronic submission portal (http://www.editorialmanager.com/ccar/). When electronically submitting a manuscript, indicate that the manuscript is designated for the special issue using the Editorial Manager system. The editors request that authors also provide names and contact information of three qualified reviewers with each submission. Additional inquires regarding manuscripts for this special issue can be addressed to either Keith Cruise (cruise@fordham.edu) or Julian Ford (ford@psychiatry.uchc.edu). Page 12 Alexsandar Hemon’s The Lazarus Project Howard J. Lipke, Ph.D. Wheeling, IL Wise words may serve ignoble purposes, and advice that has, at first, been strongly rejected may eventually be accepted. In his novel, The Lazarus Project, Alexsandar Hemon demonstrates both situations. Hemon, a native of Bosnia now living in Chicago, tells intersecting stories. One is based on an historical event, the 1908 murder of a Jewish eastern European immigrant, Lazarus Averbuch, by the Chicago Police Chief. The other story is that of a modern immigrant to Chicago who goes back to his visit his home in post siege Sarajevo. In the first story, Lazarus’ sister, enraged and grieving, living in life threatening poverty, is the target of both brutal and subtle pressure to publicly accept the official version of her brother’s death. In the following passage Hermann Taube, an influential member of the Jewish Community, who is conspiring with the police, tries to convince Olga Averbuch to comply: ‘God knows our despair. God wants His chosen people to live in peace. God loves life, cares less about death. We need to live. I want to live, I want my children to live. Everyone I know wants to live. You have to ask yourself StressPoints Trauma and World Literature: what is more important to you, life or death. What is this world about – life or death?’ Olga stairs at him as he peers down the glass under the chair, then back up at her. She lowers her voice and speaks slowly, to insure he will understand every word: ‘ May your dismembered body rot in a ditch Herr Taube. May worms nest in your eye sockets. May you never have peace, not in life not in death…’ (p. 224) Eventually Olga decides to accede to the authorities and comply with the public funeral honoring her brother, a sham designed to defuse the outrage over his death. From her letter to her mother, below, it appears she has allowed the advice to mute her rage sufficiently to make the decision necessary to save her life and those of others. She writes her mother about her decision: ‘You must forgive me for what I have done, but I chose life over death. God will take care of the dead. We have to take care of the living.’ (p 272) Hemon, A. (2008) The Lazarus Project. New York: Riverhead Books Featured title: ISTSS Amazon Store. Passages from literature can capture truths about trauma and its survivors. ISTSS members are invited to share a favorite passage or quote from literature that might not be well known, but which offers insight about the psychological effects of trauma or path of healing. Send submissions to Harold Kudler or Howard Lipke at HLipke@aol.com. Developmentally-linked Differences in the Manifestation of Grief Kathleen O. Nader, Ph.D. Two Suns Chair, Trauma, Loss and Grief SIG Maladaptive Grieving in Children and Adolescents: Discovering Christopher M. Layne, Ph.D. National Center for Child Traumatic Stress The study of trauma-related dysfunction in adults has historically preceded that of children and adolescents. As was true in the early 1980’s for Posttraumatic Stress Disorder (PTSD), the majority of published studies dedicated to trauma-related maladaptive grief have focused on bereaved adults. Although developmental issues are often not emphasized in these studies, evidence suggests that grief and developmental processes are closely interrelated. Specifically, developmental capacities and processes may pervasively influence the ways in which children, adolescents, and adults grieve; in turn, bereavement and grief may profoundly influence development (Oltjenbruns, 2007). Unresolved maladaptive grief can persist for years (Melhem, Moritz, Walker, & Shear 2007), and may interfere not only with children’s and adolescents’ psychosocial functioning, but also with their developmental progression (Melhem et al.; Nader, 2008). However, our capacity as a field to identify and describe the full range and nature of these developmentally linked differences is limited by a lack of comprehensive, ageGrieving continued page 13 StressPoints Grieving continued from page 12 Page 13 appropriate, and psychometrically sound assessment instruments. Elucidating the nature of complicated or maladaptive grief reactions in childhood and adolescence will require a more comprehensive examination of a broader range of developmentally-linked grief reactions, specific types of bereavement, and the factors that mediate or moderate the effects of bereavement on youth adjustment. Accordingly, there is an urgent need to develop theoretical frameworks and assessment instruments that are capable of detecting and differentiating between adaptive and maladaptive forms of grieving in youths across different bereaved groups. This article discusses important developmentally-linked questions relating to maladaptive grief and summarizes related current study findings. contexts even more conceptually and methodologically challenging. Delineating Types of Complicated Grief The general grief literature describes more than one type of maladaptive grief. Unfortunately, investigations of proposed types of grief have historically been compartmentalized by (and potentially confounded with) the age group or bereavement type studied. At the 2008 ISTSS conference Traumatic Loss and Grief Special Interest Group [TLG SIG] meeting, members conferred about two forms of complicated or maladaptive grief reactions. Their discussions made clear that the DSM-V proposed Prolonged Grief Disorder (PG) focuses primarily on a lost relationship and the loss of aspects of life defined by that relationship, after the death of a primary attachment figure. Traumatic Grief (TG), on the other hand, focuses on the traumatic circumstances surrounding a death and the interference of the resulting traumatic stress reactions (or grief-related reminders of traumatic circumstances) on adaptive grieving processes. Until recently, the literature on PG focused primarily on adults, whereas the literature on TG focused primarily on children. Notwithstanding the attention given to TG and PG, integrative studies have yet to systematically compare and contrast a broad range of theorized grief reactions that span “normal” or adaptive grief reactions and “maladaptive” grief reactions (e.g., TG and PG). Further, no studies have systematically searched for differential relationships between different bereavement types (e.g., traumatic vs. peaceful deaths) and theorized patterns of maladaptive grief. Thus, more extensive empirical and theoretical study of the full spectrum of potentially adaptive and maladaptive grief reactions and their clinical course is needed. To delineate such reactions, studies are needed that compare and contrast trajectories of post-loss adjustment in age groups bereaved under varying circumstances. These include bereavement via (1) a loss not perceived as traumatic (e.g., an expected, peaceful death); (2) a loss perceived as “subjectively” traumatic only (e.g., feeling personally devastated and embittered by the loss of a significant person, due to non-violent causes such as old age); (3) a loss that took place under “objectively” traumatic circumstances (e.g., during natural disaster, homicide, violent accident, suicide), and (4) losses strongly characterized by both subjectively and objectively traumatic elements. The Distinction between TG and PG. To evaluate the distinctness versus similarity of TG and PG, studies are needed that test current theories and evolving, Grieving continued page 14 …integrative studies have yet to compare and contrast a broad range of theorized grief reactions… Normal Bereavement and Development Grief varies in its nature, expression, and phenomenology across life stages, cultures, and contexts (Baker & Sedney, 1996; Corr & Corr, 1996; Oltjenbruns, 2007). Developmental factors affect youths’ capacities to understand the universality, inevitability, unpredictability, irreversibility, and physical causes of death (Corr, 2008; Speece & Brent, 1996). Development also influences youths’ death-related preoccupations and the specific developmental tasks that grieving may disrupt. For example, regressive behaviors, such as fears that others will die and magical thinking (e.g., thoughts can kill), are more common in early childhood (Oltjenbruns, 2007). Adolescents may become more preoccupied with personal thought processes and how others think of them. Corr (2008) concludes that the extant grief literature yields confusing findings because of imprecision and disagreement about definitions of death-related terms. Moreover, early studies failed to adequately model and investigate the contributions of the nature, context, and aftermath of the loss. Normal grief is associated with a range of short-term difficulties including increased risk for illness, internalizing and externalizing symptoms, and academic underachievement, among others (Abdelnoor, & Hollins, 2004; Luecken, 2008). These links between normal grief and (typically short-term) functional impairment make the task of discriminating between adaptive versus maladaptive grieving within specific age groups and Page 14 Grieving continued from page 13 StressPoints to assess CG (items primarily assess symptoms proposed for PG), researchers reported a correlation between scores on these scales and PTSD (Brown & Goodman, 2005; Brown et al., 2008; Melhem, Day, Shear, Day, Reynolds, & Brent, 2004), anxiety (Brown & Goodman), and depression (Brown & Goodman; Brown et al., 2008). Melhem et al. (2004) found that, although CG, Depression, and PTSD intercorrelated strongly, they did not show evidence of statistical redundancy (see “Is CG distinct from PTSD?” below). CG predicted the course of depression and PTS, after controlling for baseline depression and PTS. Are complicated forms of grief distinct from normal bereavement? Studies conducted with bereaved adults have reported that complicated grief reactions differ in their factor structure and primary correlates compared to normal grief reactions (Boelen & van den Bout, 2008). Recent studies have replicated this distinction between assessed PG symptoms and normal grief reactions in youths (Dillen, Fontaine, & Verhofstadt-Deneve, 2008, 2009). Is CG distinct from PTSD? Recent studies have also reported evidence that PG symptoms differ from PTSD as well as from depression in bereaved youths. Melhem et al. (2004) followed youths into young adulthood who were exposed in adolescence to the suicide death of a friend or acquaintance. Depressed and nondepressed individuals were equally likely to develop CG. Evidence (reviewed earlier) that CG, Depression, and PTSD correlated but are not statistically redundant suggests that assessed PG symptoms are distinct from depression and PTS among traumatically bereaved adolescents, with a previous mental health disorder. Using two different scales and factor analytic methods, Dillen et al. (2009) also found evidence of the factorial distinctness of assessed PG symptoms in relation to anxiety and depression across different bereavement groups (e.g., violent vs. nonviolent traumas; death of a first degree relative vs. someone else; differences in time since the death). Notably, in the group bereaved by violent death, youths reported higher levels of anxiety, depression, and CG in comparison to youths bereaved by non-violent deaths. The three-factor structure (CG, anxiety, and depression) was, nevertheless, invariant across groups. Are age differences among youth in the manifestation of posttrauma maladaptive grief similar to those found for childhood PTSD? Researchers have demonstrated developmental differences in normal bereavement (Oltjenbruns, 2007; Speece & Brent, 1996). Observed differences in disorders such as PTSD that vary as a function of age or circumstances (Cohen & Mannarino, 2008; Levendosky & Bogat, 2008; Meiser-Stedman, Dalgleish, Smith, Yule, & Glucksman, 2007; Scheeringa, Grieving continued page 15 developmentally based theories. TLG SIG members’ discussions of PG and TG suggest, for example, that the two proposed disorders are differentially linked to specific causal risk factors. Specifically, PG is described as a condition in which individuals are “stuck in a state of chronic mourning” (Prigerson, 2004). TG is described as the encroachment of traumatic distress reactions on grief processes in ways that interfere with the survivor’s capacity to grieve and mourn in comforting and adaptive ways (Eth & Pynoos, 1985; Figley, 1997, 1998; Nader, 1992, 1997; Pynoos, 1992). TG is theorized to emanate from exposure to a death that occurred during a traumatic event or in a traumatic way. Bereaved youth, irrespective of whether they were present at the death or whether they perceive the deceased as important to their survival or ability to function, perceive the death as a traumatic event and experience both traumatic stress and grief reactions (Cohen et al., 2002; Nader, 1997). In contrast, PG is theorized to develop after losses that occur under either traumatic or nontraumatic circumstances (Jacobs, 1999; Prigerson et al., 2008). The survivor perceives the deceased as important to his or her ability to function in life. Some evidence suggests that the intensity of grief reactions increases as a function of the degree of attachment to the deceased (Shear & Shair, 2005). The loss is experienced by the bereaved individual as personally devastating (and perhaps even experienced as “traumatic”) regardless of whether objectively “traumatogenic” elements were present in the circumstances of death (e.g., grotesque death, intense suffering). Relevant Research Findings Below, we summarize selected findings from the published literature that address some of the research questions discussed above. Because empirical data drawn from the full range of TG symptoms are lacking, we emphasize some of the findings relevant for theorybuilding and study design. The studies of PG in youths used child scales that primarily assess the construct of PG formulated from studies of bereaved adults. Does the combination of trauma and grief affect levels of traumatic reactions? Researchers long ago documented higher levels of trauma symptoms associated with grief following traumatic events. In the last two decades of the th 20 century, before the advent of scales specifically designed to measure complicated grief (CG), youths exposed to war (Nader et al., 1993), violence (Nader et al., 1990; Pynoos et al., 1987a, b), or terrorism (Pfefferbaum et al., 1999, 2001), who endorsed grief reactions or otherwise reported a close relationship to a person(s) who died under traumatic circumstances, were more likely to report higher levels of PTS symptoms. In the st 21 century, following the development of scales intended StressPoints Grieving continued from page 14 Page 15 • Is the distinction between adaptive versus maladaptive grief primarily quantitative—that is, are maladaptive grief responses similar to adaptive reactions, but more intense, frequent, persistent, or more strongly associated with psychiatric comorbidity, functional impairment, or developmental disturbance? • Is the distinction between adaptive versus maladaptive grief primarily qualitative, such that the latter is characterized by patterns of reactions that markedly differ in their etiology, manifestations, dimensionality, phenomenology, or clinical course? • Or are the differences between adaptive versus maladaptive grief even more complex, consisting of major quantitative and qualitative differences? • What is the relationship between posttraumatic stress and adaptive and maladaptive grief? For example, given that individuals who report experiencing the least post-loss distress may experience the most benign course of grief (Bonanno, Papa, Lalande, Zhang, & Noll, 2005; Shear & Shair, 2005), how does distress evoked by the traumatic circumstances of the death, or by the strain of attempting to process a traumatic death, contribute to the course and sequelae of grief? • Which dimensions or domains are informative in evaluating whether adaptive versus maladaptive grief responses are meaningfully distinct in their nature and implications? For example, are TG and PG distinguishable? Do they carry different implications for prevention, intervention, and/or policy? Wright, Hunt, & Zeanah 2006) have underscored the need to examine youth disturbances, such as maladaptive forms of grief, within a well-articulated developmental framework. Future Research Directions Scale Construction. Designing scales that capture the full range of grief reactions proposed in the literature is not an easy task. Nevertheless, such efforts are essential to assessment of fundamental questions relating to whether the various proposed subtypes of grief are manifest in various age, cultural, and bereavement groups and are meaningfully distinct from one another. Questions relevant to scale development include, for example: • How should functional impairment and developmental derailment in reference to age- and culturally-linked developmental tasks (e.g., selfregulatory skills, interpersonal competence, selfconcept) be used to detect maladaptive grief? • How can we best evaluate whether processing PTS is a necessary prerequisite to successfully grieving the loss of a loved one who died traumatically? • How do trauma- and grief-related bad dreams differ? • How does the hyperaroused sleep of PTSD differ from grief-related sleep disturbances? • If changes in a child’s grief narrative demonstrate recovery (Rynearson, 1995), how are these changes best measured? In pursuing these and other questions, it may be tempting to employ measures developed for adult populations by simplifying their language. Instead, efforts to capture developmentally-linked differences in grief should be solidly based in developmental theory and findings with a clear appreciation that age-related differences may be both quantitative and qualitative. Specifically, patterns of childhood versus adult grief may differ with respect to their etiology, clinical manifestations, dimensionality, phenomenology, clinical course, correlates, moderators (see Layne et al., 2009), mediators (see Layne et al., 2006), or sequelae (e.g., physical illness, impaired academic performance, disturbances in relationships). Some grief inventories are currently undergoing revision to facilitate the empirical examination of different proposed grief constructs (e.g., the interplay between trauma and grief, separation distress). Research Questions. Many research questions relating to adaptive and maladaptive grieving in bereaved youth remain unanswered. For example, how and in which domains of study and application (e.g., theory, empirical study, implications for prevention or intervention, public policy, etc.), should we, as a field, discriminate between adaptive versus maladaptive grief responses in children and adolescents? Relevant questions include: Do the links between grief and one’s relationship to the deceased…vary across age groups, genders, and/or cultures? Additional questions center around how symptoms and mediators/moderators may vary across age and circumstance. For example: • Do the links between grief and one’s relationship to the deceased, or the specific circumstances of the death, vary across age groups, genders, and/or cultures? • Is grieving influenced when bereavement involves both the loss of a significant attachment relationship and (direct or indirect) exposure to the traumatic circumstances of the death? • Do DSM IV-indicated pathological grief reactions (e.g., self-harm; perceiving the deceased is actually there) reliably discriminate between “normal” and maladaptive grief groups, or between subtypes of maladaptive grief (TG vs. PG)? • How do we effectively identify and ensure Grieving continued page 16 Page 16 Grieving continued from page 15 StressPoints Figley, C. R. (1998). The Traumatology of Grieving. Philadelphia: Brunner/Mazel. Jacobs, S. (1999). Traumatic grief: Diagnosis, treatment, and prevention. Philadelphia: Brunner/Mazel. Layne, C. M., Beck, C. J., Rimmasch, H., Southwick, J. S., Moreno, M. A., & Hobfoll, S. E. (2009). Promoting “resilient” posttraumatic adjustment in childhood and beyond: “Unpacking” life events, adjustment trajectories, resources, and interventions. In D. Brom, R. Pat-Horenczyk, & J. Ford (Eds.), Treating traumatized children: Risk, resilience, and recovery. New York: Routledge. Layne, C. M., Warren, J. S., Saltzman, W. R., Fulton, J., Steinberg, A. M., & Pynoos, R. S. (2006). Contextual influences on post-traumatic adjustment: Retraumatization and the roles of distressing reminders, secondary adversities, and revictimization. In Schein, L. A., Spitz, H. I., Burlingame, G. M., & Muskin, P. R., (Eds.), Group Approaches for the Psychological Effects of Terrorist Disasters (pp. 235-286). New York: Haworth. Levendosky, A. & Bogat, A. (2008). Current findings on PTSD for children under 8: Domestic violence as a case example. Presented at the 24th annual ISTSS conference, Terror and its Aftermath, November 14, Chicago, IL. Luecken, L. (2008). Long-term consequences of parental death in childhood: Psychological and physiological manifestations. In Stroebe, M., Hansson, R., Schut, H., & Stroebe, W. (Eds). Handbook of bereavement research and practice: Advances in theory and intervention, (pp. 397-416). Washington, DC: American Psychological Association. Meiser-Stedman, R., Dalgleish, T., Smith, P., Yule, W., & Glucksman, E. (2007). The Posttraumatic Stress Disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. American Journal of Psychiatry, 165, 1326-1337. Melhem, N., Day, N., Shear, K., Day, R., Reynolds, C. & Brent, D. (2004). Traumatic Grief among adolescents exposed to a peer’s suicide. American Journal of Psychiatry, 161, 1411-1416. Melhem, N., Moritz, G., Walker, M., & Shear, K. (2007). Phenomenology and correlates of Complicated Grief in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 46(4), 493-499. Nader, K. (1992). Interplay of trauma and grief. In Pynoos, R. S., Grief and trauma in children and adolescents. Bereavement Care, 11, 2-10. Nader, K. (1997). Childhood traumatic loss: The interaction of trauma and grief. In Figley, C.R., Bride, B.E. & Mazza, N. (eds.), Death and Trauma: The Traumatology of Grieving, (pp. 17-41). London: Taylor and Francis. Nader, K. (2008). Understanding and Assessing trauma in children and adolescents: Measures, Methods, and Youth in Context. New York: Routledge. Nader, K., Pynoos, R., Fairbanks, L., Al-Ajeel, M., & Al-Asfour, A. (1993). Acute post traumatic stress reactions among Kuwait children following the Gulf Crisis. British Journal of Clinical Psychology, 32, 407-416. Nader, K., Pynoos, R., Fairbanks, L., & Frederick, C. (1990). Children’s PTSD reactions one year after a sniper attack at their school. American Journal of Psychiatry, 147, 1526-1530. Oltjenbruns, K. (2007). Lifespan issues and loss, grief, and mourning: Part 1: The importance of a developmental context: Childhood and adolescence as an example. In Balk, D., Wogrin, C., Thornton, G., Meagher, D. (Eds). Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement, (pp. 143-163). New York: Routledge/Taylor & Francis Group. Pfefferbaum, B., Nixon, S. J., Tucker, P. M., Tivis, R . D., Moore, V. L., Gurwitch, R. H., Pynoos, R. S., & Geis, H. K. (1999). Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38(11), 1372-1379. Pfefferbaum, B., Call, J.A., Lensgraf, S. J., Miller, P.D., Flynn, B.W., Doughty, D. E.,Tucker, P., & Dickson, W. L. (2001).Traumatic grief in a convenience sample of victims seeking support services after a terrorist incident. Annals of Clinical Psychiatry, 13, 19-24. Prigerson, H. (2004). Complicated grief: When the path of adjustment leads to a dead-end. Bereavement Care, 23, 38-40. Prigerson, H., Vanderwerker, L., & Maciejewski, (2008). A case for inclusion of Prolonged Grief Disorder in DSM-V. In Stroebe, M., Hansson, R., Schut, H., & Strobe, W. (Eds.). Handbook of Bereavement Research and Practice: Advances in Theory and Intervention (pp. 165-186), Washington, D.C.: APA Books. Pynoos, R. S. (1992). Grief and trauma in children and adolescents. Bereavement Care, 11, 2-10. Pynoos, R. Frederick, C., Nader, K., Arroyo, W., Eth, S., Nunez, W., Steinberg, A., & Fairbanks, L. (1987a). Life threat and posttraumatic stress in school age children, Archives of General Psychiatry, 44, 1057-1063. Pynoos, R. S., Nader, K., Frederick, C., Gonda, L., & Stuber, M. (1987b). Grief reactions in school age children following a sniper attack at school, Israeli Journal of Psychiatry and Related Sciences, 24(1-2), 53-63. Rynearson, E. (1995). Bereavement after homicide. A comparison of treatment seekers and refusers. British Journal of Psychiatry, 166, 507-510. Scheeringa, M., Wright, M., Hunt, J., & Zeanah, C. (2006). Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. American Journal of Psychiatry, 163, 644-651. Shear, K & Shair, H. (2005). Attachment, loss, & Complicated Grief. Developmental Psychobiology 47, 253–267. Speece, M. & Brent, S. (1996). The development of children’s understanding of death. In Corr, C. & Corr, D. (Eds.). Handbook of Childhood Death and Bereavement, (29-50). New York: Springer Publishing. appropriate services for youths whose unusual configurations of risk, vulnerability, or lack of protective factors do not place them cleanly within well-defined grief subgroups? For example, youths, who reported no close relationship to a person who died under traumatic circumstances, but who experienced other vulnerability enhancing factors (e.g., intense guilt or anger toward the deceased), have reported severe dysfunction and suicidal feelings (Nader et al., 1990). Conclusion In summary, these observations underscore the need for further theory-building and theory-testing concerning the nature and distinctions between adaptive and maladaptive forms of grief reactions in bereaved youths. Accurately capturing the manifestations, correlates, and course of maladaptive grief in children and adolescents will entail assessing their grief reactions from a developmental perspective and examining age-related variations in a broad range of reactions and external criterion variables. Given that “normal” grief reactions can have problematic (and developmentally significant) consequences for youth, such efforts will require work at the theoretical as well as empirical levels to better understand the nature and implications of grief-related constructs for intervention, prevention, and public policy. References Abdelnoor, A. & Hollins, S. (2004). The effect of childhood bereavement on secondary school performance. Educational Psychology in Practice, 20(1), 43-54. Baker, J., & Sedney, M. (1996). How bereaved children cope with loss: An overview. In Corr, C. & Corr, D. (Eds.). Handbook of Childhood Death and Bereavement, (pp. 109-129). New York: Springer Publishing. Boelen, P. & van den Bout, J. (2008). Complicated grief and uncomplicated grief are distinguishable constructs. Psychiatry Research, 157, 311-314. Bonanno, G. A., Papa, A., Lalande, K., Zhang, N., & Noll, J. G. (2005). Grief processing and deliberate grief avoidance: A prospective comparison of bereaved spouses and parents in the United States and the People’s Republic of China. Journal of Consulting and Clinical Psychology, 73, 86–98. Brown, E. J., Amaya-Jackson, L., Cohen, J., Handel, S., De Bocanegra, H., Zatta, E., Goodman, R. & Mannarino, A. (2008). Childhood Traumatic Grief: A multi-site empirical examination of the construct and its correlates, Death Studies, 32, 899–923. Brown, E. J., & Goodman, R. F. (2005). Childhood traumatic grief: An exploration of the construct in children bereaved on September 11. Journal of Clinical Child & Adolescent Psychology, 34(2), 248-259. Cohen, J. & Mannarino, A. (2008). Assessment of trauma in school-aged children. Presented at the 24th annual ISTSS conference, Terror and its Aftermath, November 14, Chicago, IL. Cohen, J. A., Mannarino, A. P., Greenberg, T., Padlo, S., Shipley, C. (2002). Childhood traumatic grief: Concepts and controversies. Trauma, Violence & Abuse, 3(4), 307-327. Corr, C. (2008). Children’s emerging awareness of death. In K. J. Doka & A. S. Tucci (Eds.), Living with grief: Children and adolescents (pp. 5-17). Washington, DC: Hospice Foundation of America. Corr, C. & Corr, D. (Eds.). (1996). Handbook of Childhood Death and Bereavement. New York: Springer Publishing. Dillen, L., Fontaine, J. R. J., & Verhofstadt-Denève, L. (2008). Are normal and Complicated Grief different constructs? A confirmatory factor analytic test. Clinical Psychology and Psychotherapy, 15, 386-395. Dillen, L., Fontaine, J. R. J., & Verhofstadt-Denève, L. (2009). Confirming the distinctiveness of complicated grief from depression and anxiety among adolescents. Death Studies, 33, 437–461. Eth, S., & Pynoos, R. (1985). Interaction of trauma and grief in childhood. In S. Eth & R. Pynoos (Eds.), Post-traumatic stress disorder in children (pp. 171186). Washington, DC: American Psychiatric Press. Figley, C., Bride, B.E. & Mazza, N. (Eds.), (1997). Death and Trauma: The Traumatology of Grieving. London: Taylor and Francis. . StressPoints Traumatic StressPoints Leadership Editor Page 17 Upcoming Events September 21-22, 2009 and September 23-26, 2009 TRAINING INSTITUTES 2009 In conjunction with the 14th International Conference on Violence, Abuse and Trauma Town and Country Resort & Convention Center, San Diego, CA IVATConf@alliant.edu www.IVATCenters.org October 2-3, 2009 ISTSS is a proud co-sponsor of: The Treatment of Extreme Trauma: A Unique Training Conference Opportunity Sponsored by The Hopi Foundation, a non-profit organization High Country Conference Center, Flagstaff, Arizona Friday, October 9, 2009 Cleveland Clinic's Neurological Institute Upcoming PTSD and Anger & Rage Events Anger & Rage Symposium Embassy Suites, Independence, Ohio www.clevelandclinicmeded.com<UrlBlockedError.aspx October 21-24, 2009 6th European Congress on Violence in Clinical Psychiatry City Conference Centre Fokets Hus, Stockholm, Sweden November 5-7, 2009 ISTSS 25th Annual Meeting with Pre-Meeting Institutes Nov. 4 The Westin Peachtree Plaza, Atlanta, Georgia, USA www.istss.org April 7-10, 2010 Association for Death Education and Counseling (ADEC) 32nd Annual Conference Hyatt Regency Crown Center, Kansas City, Missouri, USA www.adec.org/conf/index.cfm April 19, 2010 ISTSS Psychotraumatology Meeting Zürich World Trade Center, Zürich, Switzerland June 2-5, 2010 6th World Congress of Behavioral and Cognitive Therapies (WCBCT) Boston, Massachusetts, USA Boston University and the Association for Behavioral and Cognitive Therapies (ABCT) November 4-6, 2010 ISTSS 25th Annual Meeting with Pre-Meeting Institutes Nov. 3 Le Centre Sheraton Montreal Hotel, Montreal, Quebec, Canada www.istss.org November 3-5, 2011 ISTSS 26th Annual Meeting with Pre-Meeting Institutes Nov. 2 Baltimore Marriott Waterfront, Baltimore, Maryland, USA www.istss.org Anne P. DePrince, PhD (adeprinc@du.edu) Diane Elmore, PhD, MPH Harold Kudler, MD Heidi LaBash Kathryn Becker-Blease, PhD Contributing Editors Dean Lauterbach, PhD Howard Lipke, PhD Meg Spratt, PhD Patrick A. Palmieri, PhD Andrew Stone, MD Onno van der Hart, PhD ISTSS President Patricia Resick, PhD ISTSS Headquarters Executive Director Rick Koepke, MSW Administrative Director, Leadership and Education Diane Rutherford Janice Greenberg Administrative Director, Committees Member Services Specialist Marti Buckely Traumatic StressPoints Deanna Marchetti, MA Managing Editor