درمان شناختی- رفتاری برای سوگ و داغداری طولانی مدت در کودکان: امکان سنجی و مطالعات متعدد در شروع مطالعه

Abstract There is growing recognition of a syndrome of disturbed grief referred to as prolonged grief disorder (PGD). Although mostly studied in adults, clinically significant PGD symptoms have also been observed in children and adolescents. To date, no effective treatment for childhood PGD yet exists. We developed a 9-session cognitive-behavioral treatment for childhood PGD, combined with 5 sessions of parental counseling. In the present article, the content of this treatment is described. We also describe findings of a multiple baseline study among 6 bereaved children and adolescents. This study showed that the intervention coincided with reductions in symptoms of PGD and other self-rated and parent-rated symptoms. All participating children and parents gave favorable scores to the satisfaction about each session, the contact with their therapist, and the information they received, attesting to the feasibility of this treatment approach.

Results Summary of Clinical Outcomes Pretreatment and posttreatment scores on the measures used are shown in Table 2 (CBCL scores are raw scores). Looking at pretreatment functioning, Participant 4 and 5 were at risk for clinical depression, considering the > 13 cutoff proposed by Kovacs (1992). Compared with a Dutch reference group (Verhulst et al., 1996), scores on the CBCL Internalizing scale of the CBCL of Participant 1, 3, 4 and 5 fell within the clinical range, whereas scores of Participant 6 fell in the subclinical (borderline) range. Scores of Participants 1 and 6 on the CBCL Externalizing scale fell in the subclinical range, whereas scores of other participants fell in the normal range. CBCL total scores of Participant 1, 4, and 5 fell within the clinical range. CBCL total scores of Participant 2, 3 and 6 fell in the subclinical range. Thus, although distress levels varied, participants all experienced moderate to severe levels of distress at pretreatment. Table 2. Scores on Symptom Measures at Pretreatment and Posttreatment Per Child P1: Debby P2: Eva P3: Ed P4: Mike P5: Anna P6: Yolanda Pre Post RCI Pre Post RCI Pre Post RCI Pre Post RCI Pre Post RCI Pre Post RCI Grief Checklist 13 2 - 18 2 - 10 3 - 15 0 - 6 2 - 16 4 - IPG-C 56 38 3.19 57 39 3.19 40 32 1.42 55 36 3.36 43 36 1.23 51 39 2.12 CPSS 6 2 0.88 8 1 1.53 6 5 0.22 13 4 1.96 10 3 1.53 12 6 1.31 CDI 5 1 0.94 1 2 − 0.23 9 5 0.88 27 11 3.51 16 5 2.57 11 5 1.40 CBCL internalizing 25 12 6.02 8 4 1.85 21 6 6.67 32 10 10.38 22 0 9.33 12 3 3.82 CBCL externalizing 12 3 4.59 8 2 3.06 8 5 1.51 5 4 0.51 8 0 3.85 12 2 4.81 CBCL total 61 26 11.36 45 14 10.06 41 19 8.94 58 22 15.33 49 2 19.54 42 8 14.14 Note. CBCL scores are raw scores. CDI = Children's Depression Inventory; CBCL = Child Behaviour Checklist; CPSS = Child Posttraumatic Stress Disorder Symptom Scale; IPG-C = Inventory of Prolonged Grief for Children; RCI = Reliable Change Index. Table options Pretreatment and posttreatment scores averaged across participants are shown in Table 3. As shown, across participants, there was a 77% decline in scores on the Grief Checklist, a 27% decline in IPG-C scores, and ≥ 58% declines in CDI, CPSS, and CBCL scores. Paired sample t-tests showed that reductions in symptom measures from pretreatment to posttreatment were all statistically significant. In terms of pretreatment to posttreatment effect sizes (Cohen's d), symptom reductions were large ( Table 3). Table 3. Scores on Symptom Measures at Pretreatment and Posttreatment for All Six Participants Mean scores (SD) at pretreatment Mean scores (SD) at posttreatment Paired Sample t-value Cohen's d % reduction from pretreatment to posttreatment Grief Checklist 13.0 (4.4) 2.2 (1.3) 5.7*** 3.3 77% IPG-C 50.3 (7.2) 36.7 (2.6) 6.2*** 2.5 27% CPSS 9.3 (3.0) 3.5 (1.9) 2.7*** 1.0 62% CDI 11.5 (9.2) 4.8 (3.5) 4.9* 2.3 58% CBCL internalizing 20.0 (8.7) 5.8 (4.5) 4.7*** 2.0 71% CBCL externalizing 8.3 (2.7) 2.7 (1.7) 4.3** 2.5 68% CBCL total score 49.3 (8.4) 15.2 (9.0) 10.4*** 3.9 69% Note. CDI = Children's Depression Inventory; CBCL = Child Behaviour Checklist; CPSS = Child Posttraumatic Stress Disorder Symptom Scale; IPG-C = Inventory of Prolonged Grief for Children. * p < .05. ** p < .01. *** p < .001. Table options Summary of Feasibility Outcomes On average, the nine treatment sessions were delivered over a period of 12.5 weeks (SD = 2.1 weeks). Scheduling of the sessions was conducted such that children could attend all nine therapy sessions and parents all five parent counseling sessions. For each participant, scores on the five feasibility items administered at the end of each session were averaged. These are shown in Table 4. Children were generally positive about their overall satisfaction with each session, the understanding of their therapist, the information they received, and the workbook. The averaged ratings across sessions all approached the maximum score of 5.0. Moreover, ratings of overall satisfaction were high, with the exception of the rating from Participants 3 (Ed) who gave a zero rating in Session 3. At this point in treatment, Ed reported feeling very angry about everything that was happening in his life at that moment. Nevertheless, feasibility scores averaged across sessions and children (shown in the last row in Table 4) indicated that, overall, children evaluated the program favorably. Table 4. Summary of Feasibility Data Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 All participants Mean Child Ratings Averaged Across Nine Sessions 1. I am satisfied about this session 5.0 5.0 2.3 4.0 4.0 5.0 4.2 2. I felt my therapist understood me 5.0 5.0 2.8 4.0 4.11 5.0 4.3 3. I understood the information that I received 5.0 5.0 3.0 4.0 4.11 4.44 4.3 4. The workbook was handy to work with 5.0 5.0 1.7 3.1 4.22 4.66 3.9 5. Overall satisfaction 10.0 10.0 4.0 7.6 7.39 8.0 7.8 Mean Parent Ratings Averaged Across Five Sessions 1. I am satisfied about this session 4.8 4.8 4.0 4.0 5.0 5.0 4.6 2. I felt my therapist understood me 4.5 4.5 4.3 4.3 5.0 5.0 4.6 3. I understood the information that I received 4.3 4.3 4.3 4.1 5.0 5.0 4.5 4. The workbook was handy to work with 4.0 4.0 3.9 3.3 4.5 4.5 4.0 5. Overall satisfaction 8.0 8.0 8.0 7.5 8.4 8.4 8.0 Note. Scores on items 1 through 4 range from 1 (totally disagree) to 5 (totally agree); scores on item 5 range from 0 (lowest) to 10 (highest). Table options Parents rated the same items as did their children. Mean scores across sessions are also shown in Table 4. For Participant 3 and 4, ratings from both parents were available. These were averaged for each session, before the overall averages across sessions, and across sessions and participants were calculated. The parents provided favorable evaluations of the program, with all scores approaching the maximum scores on the feasibility items. Individual Outcomes A key aim of multiple baseline studies is to determine if there is a clear treatment effect, after the introduction of the treatment, following the no-treatment baseline period. Accordingly, visual examination of graphed data provides a stringent test of the treatment efficacy as only unambiguous effects will become apparent (Parsonson & Baer, 1992). Weekly total ratings on the Grief Checklist across the (3-, 5-, or 7-week) baseline period and the treatment period are shown in Figure 1. With all six participants, treatment was started at the predetermined time, because stable trends in Grief Checklist scores were observed at the end of the baseline period. Weekly scores on the Grief Checklist for the six patients for baseline and ... Figure 1. Weekly scores on the Grief Checklist for the six patients for baseline and treatment phases. Figure options Importantly, all participants showed stability in PGD scores (Grief Checklist) across the baseline period and these scores declined rapidly and substantially with the introduction of the treatment. The combination of stable scores during the baseline periods and declines in grief severity during treatment suggests that the reduction in PGD symptoms from pretreatment to posttreatment was associated with the treatment interventions offered, rather due to spontaneous recovery. Participant 1, Debby Debby's Grief Checklist scores changed from 14 to 13 (− 7%) during the 3-week baseline period and reduced to 2 (− 85%) over the period of treatment. Cognitive restructuring focused on cognitions underlying Debby's anger towards doctors who had not prevented her father's death. Exploring the immediate effects of these cognitions helped Debby to see that ruminating about other's being to blame did not relieve her pain. The fear that mother would die too was targeted by calculating the chance that this would happen. Discussing that Debby could live with her favorite aunt if this disaster would in fact happen brought further relief to this fear. Problem solving skills were taught to help Debby provide support to her mother in other ways than constantly staying close to her (e.g., by phoning mother instead or staying physically close and by encouraging mother to make use of support that was offered by friends). According to RCIs (Table 2), Debby improved significantly (i.e. RCIs > 1.96; Jacobson & Truax, 1991) on the IPG and CBCL. Participant 2, Eva PGD scores of Eva declined from 19 at the start of the 3-week baseline period to 18 upon implementation of the intervention (− 5%) and further decreased to 2 (− 89%) at posttreatment. Imaginal exposure to memories of moments surrounding her father's death was central to Eva's treatment. Experiencing that she could bear confronting the memories altered her catastrophic misinterpretations and reduced anxious avoidance. It was also discussed how Eva could gradually reengage in pleasant activities, while respecting the Hindustan rule of mourning. Eva believed that during the first year following the loss, her father was still present as a ghost and she felt that she would “betray” him if she would go out of the house and have fun again. Discussing that father would probably prefer Eva to experience joy rather than to stay at home feeling sad helped her to reengage in some of the activities that she used to enjoy before father died, including dancing. According to RCIs (Table 2), Eva improved significantly on the IPG and CBCL. Participant 3, Ed PGD scores of Ed remained a stable 10 during the 7-week baseline period and declined to 3 (− 70%) at the end of treatment. Therapy did not go smoothly. He continued to be hesitant to confront the reality of his sister's death. The therapist gradually gained Ed's trust using play and creative methods. Discussing the many good things Ed had done for his sister made him aware of how important she had been for him and, consequently, also seemed to help him to confront the reality and pain of the loss. Realizing that the many good things he had done for his sister were not made undone by her death made him feel proud. However, although all this promoted achievement of Tasks 1 and 2, the nine sessions turned out to be too short to work on Tasks 3 and 4. For instance, little time was left to help Ed to share his feelings with his family and friends and to practice other positive coping skills. According to RCIs (Table 2), Ed only improved significantly the CBCL; changes on the IPG (RCI = 1.42) represented a trend toward significant improvement. Participant 4, Mike Mike's PGD scores declined from 20 at the start of 5-week baseline period to 15 upon implementation of the intervention (− 25%) and further reduced to 0 (− 100%) after the ninth session. Cognitive restructuring was used to help Mike to alter his negative views of life and future. For instance, discussing the impact of his negative view of the future on his emotions and his motivation to prepare for his exams helped him to alter these negative beliefs. A behavioral experiment was used to test the prediction that friends would not respond supportively if he would share the story of his loss with them. Writing about his thoughts and feeling in a letter to an imaginary friend helped him to gain a more positive outlook on his future and to experience further benefits of emotional expression. Looking at the RCIs (Table 2), Mike improved significantly on all measures that were administered, including measures of PTSD and depression. Participant 5, Anna With Anna, PGD scores changed from 8 to 6 (− 25%) during the 6-week baseline period and to 2 (− 67%) at posttreatment. Treatment included a detailed review of the implications of father's death using the verbal and creative assignments from the first part of the workbook. This helped her to achieve Task 1. Avoidance of violin music was targeted using exposure to classical music (during therapy session) and gradually going to public places where such music was played (e.g., shopping centers). Problem-solving skills and cognitive restructuring were used to help Anna to better deal with her feelings of responsibility for the financial problems within the family. According to RCIs (Table 2) Anna improved significantly on the CDI and CBCL and to a lesser extent on the IPG and CPSS. Participant 6, Yolanda PGD scores of Yolanda increased from 14 to 16 (+ 14%) during the 7-week baseline period and declined to 2 (− 88%) after the ninth session. Cognitive restructuring was used to alter cognitions underlying guilt and self-blame. Specifically, the pie-chart technique helped her to see that there were many different unfortunate events that eventually led to her father's death and that there was no reason for blaming herself. The prediction that she was unable to enjoy activities that she used to enjoy before the loss was tested using behavioral assignments in which she tested the effects of picking up ice skating, her favorite hobby. Getting more active also helped her to achieve Task 4. Achievement of this task was further promoted with gradual activation. According to RCIs (Table 1), Yolanda improved significantly on the IPG and CBCL.