Complicated Grief in Palestinian Children and Adolescents

This study aims to identify the traumatic losses and resultant complicated grief of adolescents in occupied Palestine. A secondary analysis was conducted on a data set from 133, 11-14 year olds who had completed the Exposure to War Stressors Questionnaire, the Children’s Revised Impact of Events Scale and the Traumatic Grief Inventory for Children (TGIC). For the first time, a statistically significant cut-off was applied to the TGIC. As a consequence, the co-morbidity of complicated grief was explored with posttraumatic stress disorder and depression. Findings indicate adolescents in Nablus experienced multiple traumatic losses resulting in 20% experiencing complicated grief. Because of the strict statistical cut-off, indications are this may be an underestimate. Complicated grief presented as a distinct trauma response. Recommendations are made for future research and practice.


Introduction
This paper seeks to explore the nature of complicated grief for children and adolescents in the West Bank, occupied Palestine. It begins with comparing contested definitions and the range of terms used for complicated grief. The paper then clarifies the distinction between normal and complicated grief within which, adolescents' traumatic losses and resultant symptoms are understood. Individual and social context factors that mediate child and adolescent reaction to traumatic loss are identified and the limitations of assessment measures are discussed. Finally, this paper explores the nature and extent of complicated grief in a study of Palestinian adolescents who have experienced cumulative traumatic losses.

Conceptualising complicated grief
Recognition and understanding of complicated grief in children and adolescents is still in its infancy compared to empirical studies that have explored complicated grief in adults. In the same way the adult conception of post-traumatic stress disorder (PTSD) was applied to understanding child trauma, much of our conceptualization of childhood complicated grief comes from adult studies. However, a small number of studies, mostly with adolescents with a narrow range of losses, appear to indicate there may be a similarity between adult and adolescent complicated grief [1]. It is important to remember, however, that what might be treated as minor issues by adults, can be significant for children and adolescents, especially when there is cumulative loss [2]. According to Dyregrov et al. [3] children and adolescents' understanding of death and loss develops according to their cognitive development. If after a significant loss, adults are unable to respond to these developmental differences, it can leave children and adolescents vulnerable to trauma.
Not surprisingly, the nature of complicated grief in children and adolescents is contested [4] originally proposed the concept of childhood traumatic grief (CTG) which was validated in a study of 83 children, aged 8-18 years, who lost a parent through the September 11 terrorist attack. Melham et al. [1] however questioned whether CTG was sufficiently distinct from PTSD. More recently studies with adolescents suffering a wider range of losses have concluded that traumatic grief is not only distinct from PTSD but also a separate diagnostic category from anxiety and depression [5]. In contrast, [6] stress the commonality of symptom clusters and [7] highlighted their co-morbidity. From an adult oriented perspective, [8] argue that because childhood traumatic grief focuses on adult-based PTSD symptoms (intrusion, hyper-arousal and avoidance) blocking the grieving response, CTG may represent a specific aspect of adult complicated grief [9]. More recently however, caution against too readily applying adult conceptions of grief on children. For example, in a small study of experienced clinicians and researchers working with children in grief, found that professionals struggled to define complicated grief, Dyregrov and Dyregrov (in press) in children and adolescents. These participants did agree, however, that the major defining aspects of childhood complicated grief were intensity, duration and longevity of the grief reaction. Given the uncertainty in understanding childhood grief in traumatic circumstances, there continues to be a need to explore the conceptual validity and reliability of the nature of complicated grief in children and adolescents.
Definitions: Normal and complicated grief. A plethora and confusion of language exists in childhood grief literature with grief related terms often used interchangeably [10]. Provide helpful definitions. Bereavement is defined as the state of having sustained a loss through death and the overall adjustment to that loss. Mourning is the process of coming to terms with that loss, and grief is the experience of sustaining that loss. Children and adolescents, it appears, cope naturally with loss in a variety of ways often showing remarkable resilience. Our understanding of what is 'normal grieving' is influenced by factors such as gender, developmental level, ethnicity, socioeconomic status and the culture in which the child or adolescent lives; as well as our own beliefs about death and loss as adults. Despite cross-cultural variation in responses to grief, there is mounting consensus around the tasks of mourning, i.e. acknowledging the loss, experiencing the pain; adjusting to the new life; deepening relationships to cope; developing new relationships for the future; memorialization; meaning making for the loss and addressing normal developmental life tasks [11].
The most recent literature makes a distinction between normal and complicated grief. Children and adolescents experience either or both depending on various individual and situational factors. In seeking to understand complicated grief however, again a plethora of language emerges in the literature, e.g. traumatic grief; disabling grief, disenfranchised grief and prolonged grief are all used [4]. Despite this conceptual confusion, there is agreement that there exist certain subtypes of complicated grief in children and adolescents [3]. This includes: delayed or absent grief that is not expressed and is often accompanied by a preoccupation with the welfare of others; chronic grief where grief continues or is excessive, responses are intense and emotions are in a limited range; and inhibited or distorted griefwhere both inhibited and excessive grief is at some level a failure to acknowledge the loss. Traumatic aspects of the loss, such as witnessing the death, finding of the body or having fantasies about what happened may accompany sudden death and constitute a subtype of complicated grief [9].

Symptoms of complicated grief
Children and adolescents who experience complicated grief tend to perceive the death or loss as overwhelming, where the trauma response blocks the normal process of grieving. Many of the symptoms experienced are similar to PTSD [12], e.g. intrusive images and thoughts, anxiety and fear, and avoidance of people, place thought and feeling. Other signs include somatic symptoms, depression, upset and loss of interest in activities. All tend to be reported at higher levels in the short and longer term [13]. Not all children and adolescents however show signs of trauma. Some recover without specific intervention [3], some flourish in the face of adversity [14] and for others; trauma symptoms may not develop till a later stage. Developmentally, younger children tend to become more repetitive in their play and can display destructive and irritable behaviour [15]. Parental reaction is known to either moderate or exacerbate such symptoms [16]. For example, a parent struggling with their own grief may be less emotionally accessible for their child and the lack of parental responsivity may increase child distress. Poor informational climate and parental emotional dysregulation can further exacerbate children's grief reactions [9]. Different cultures also influence how well or otherwise children and adolescents express grief. Differing rituals, expectations about emotional expression, religious beliefs, and family and community responses can all impact either positively or negatively on an adolescents grief response [17]. Gender can be another influencing factor as, girls tend to show higher symptoms levels than boys [18].

Exposure to traumatic loss
Because the above social context factors interact with an adolescent's perception of their experience of loss and adversity, traumatic loss is not easy to define [19]. Define traumatic loss events as sudden, unexpected and life threatening that result in feelings of helplessness. Within contexts of war, children experience chronic and acute loss which is both traumatic and cumulative [20]. Family members, pets, friends and teachers and other acquaintances are killed, homes and possessions are lost, as are body parts and body functions, e.g. blinded by a bomb blast. Schooling and other routines can all be lost. Many of the losses are sudden, violent and mutilating, e.g. witnessing a family member being shot or seeing mangled dead bodies [21]. For the current study, [22] definition is used because of its inclusion of a wide range of war-related factors. Walsh identifies the experience of traumatic loss as including sudden, random, unexpected, violent, disenfranchised (socially stigmatized) losses of people, places, body parts, health and animals. These losses are likely to be cumulative in nature. Experiences of torture, incarceration and abuse are also seen as traumatic losses.

Determinants of complicated grief
A wide variety of risk and protective factors have been identified for complicated grief in children and adolescents. These can be categorized into nine main themes (i) the closeness of the deceased person, e.g. sibling, parent, spouse; (ii) the nature of the attachment; (iii) the mode of death, such as natural, homicide or suicide; (iv) the adolescent's personality, e.g. resilient, coping as learned behavior; (v) the stage of maturity such as adolescence; (vi) the child's cognitive mastery and coping strategies [23]; (vii) the past history of loss and depression; (viii) the social context of religion, class and ethnicity and (ix) the presence of life changing events such as concurrent stressors. Risk and protective factors are not always the same for children and adolescents and adults, e.g. anticipation of parental death tends to lead to better mental health outcomes for adults than children. Where traumatic grief is not addressed long term mental health concerns can develop [18].

Assessing complicated grief
In the same way childhood traumatic grief evolved from adult complicated grief as a concept, most measures to assess children and adolescents' complicated grief were originally adapted from adult measures. The Texas Revised Inventory of Grief [24], a measure of adult grief was applied to a group of adolescents who had experienced peer suicide suicide (Melham, Day, Shear, Day, Reynolds, and Brent, 2004) [25], adapted the adult Inventory of Complicated Grief-Revised [26] for use with children and adolescents who had lost a parent through suicide or sudden loss. From the same core measure, the Traumatic Grief Inventory for Children [27] was developed to provide a child centered adaptation. More recently, the Inventory of Complicated Grief-Youngsters [28] was also developed from the ICG-R (Dutch version). Both measures assess the extent of children and adolescents' maladaptive feelings, thoughts and behaviors to traumatic loss. While the above is not a comprehensive list, it highlights the limitations of the development of childhood complicated grief assessment measures to date.
As complicated grief in childhood is dependent on a myriad of factors including the age and nature of the child population under investigation, the definition used and measures used, it is difficult to assess the extent of complicated grief in children and adolescents. As a consequence, a wide range of the prevalence of childhood complicated grief has been suggested (8-64%) [29]. For a small proportion of the child and adolescent population, around 20%, complicated grief appears to be severe and enduring [30].

Occupied palestinian territories
Within the context of the occupied Palestinian territories, the concept of complicated grief in children and adolescence has almost been completely ignored by program developers and researchers. While there is a growing awareness of the types of war experiences and subsequent losses for adolescents in Palestine, these have yet to be set within a complicated grief understanding. Research wise, there have only been two studies to date, with only one being published that have sought to explore complicated grief in children and adolescents [31]. Evaluated the impact of the Teaching Recovery Techniques (TRT) program on PTSD in a group of [11][12][13][14] year olds in Nablus. The study included an assessment of complicated grief using the TGIC. However, due to the lack of a clinically significant cut-off, analysis was based on total scores. As a consequence, the extent of complicated grief in the child population could not be calculated The authors concluded, however, that complicated grief is a serious problem in adolescence that requires further investigation [32]. Thabet (2009) examined 374 children's trauma and grief responses in Gaza, utilizing a grief screening scale. The study found half the sample showed signs indicative of complicated grief. No gender difference was found however.

The current study
The current study then, aims to address the omission of research into complicated grief in occupied Palestine. Specifically, the study seeks to identify the nature and extent of traumatic loss and resultant complicated grief symptoms in adolescents in the West Bank. A secondary analysis is conducted on the Exposure to War Stressor Questionnaire, the TGIC and the DSRS. For the first time, a statistically significant cut-off is used for the TGIC enabling an assessment of the extent of complicated grief in the adolescent population. The extent of complicated grief is then compared with levels of reported PTSD and depression.

Sample
The current study provides a secondary analysis of a data set of 133 students aged 11-14 years in the town of Nablus, towards the north of the West Bank. Nablus was purposely selected because of high levels of ongoing violence and traumatic loss (MSF, 2010). From a sample of 450, students who fitted or were close to fitting the criteria for PTSD (33%; n=150) on the Children's Revised Impact of Events Scale [33] were selected for inclusion. Attrition (n=17) occurred due to incomplete data sets. The CRIES-13 measures the post-traumatic stress symptoms of intrusion, avoidance and arousal. A cut off of >17 on the subtests of intrusion and avoidance identified those students who would likely receive a diagnosis of PTSD. The CRIES-13 includes 13 symptom statements to be rated on a 4 point scale (not at all, rarely, sometimes, often). The Cronbach alpha coefficient of .80 indicates good internal consistency [33]. The average age of participants was 11.92 (SD=0.72) including 73 males and 60 females. Schools were public male; public female; United Nations Relief and Works Agency (UNRWA) female; and private mixed gender schools. Ethnically, all were Palestinian.

Procedures
Research Ethics Committee approval was given by the University of Dundee (reference number: UREC 9025) requiring active informed consent by students, parents and teachers. The CRIES-13 questionnaire was used to screen for PTSD and was delivered to whole classes of children within their schools. Children who fulfilled the criteria for inclusion received the other measures in small class-based groups (n=10) two weeks after screening.

Measures
The Exposure to War Stressors Questionnaire [34] was used to assess the range and extent of types of traumatic war events and losses adolescents experienced. The EWSQ consists of 26 statements covering a range of traumatic events and losses requiring participants to give a yes or no response, with a total score of 26 indicating maximum exposure. Statement examples include 'Was any member of your family killed during the war? Did you see a dead body? Or Did you see someone being killed?' The Arabic translation of the EWSQ has a high Cronbach alpha coefficient (.94) indicating a high level of internal consistency.
Adolescent complicated grief was measured by the TGIC. It measures the extent of adolescent feelings, thoughts and behaviors indicative of complicated grief over 24 questions on a 5 point scale, i.e. almost never (less than a month); rarely (monthly); sometimes (weekly); often (daily) and always (several times a day). Symptoms assessed cover intrusive thoughts, feelings and memories, avoidance of feelings, thoughts, talking and situations; feelings such as sadness, longing, loneliness, guilt and anger and resultant impact on relationships. The total score on the TGIC equals 120. Not having a cut-off score, one standard deviation above the mean (62.8, SD=14.21) was taken as the clinically significant cut-off, i.e. 77.03. One standard deviation from the mean is seen as a strict measure of clinical significance and is used in other evaluative studies where standardized measures have had no clinical cut-off. The internal reliability of the Arabic TGIC is high (Cronbach alpha coefficient of .91).
To assess the extent of co-morbidity of complicated grief with posttraumatic stress and depression, scores on the TGIC were compared against scores on the CRIES-13 and the DSRS. The DSRS measures child and adolescent depressive symptoms over 18 items on a 3 point scale (most, sometimes, never). A cut-off of 15 and over was used indicating the probability of a depressive disorder [35]. High to moderate internal consistency has been found in adolescent studies [36]. The Cronbach alpha coefficient of the Arabic translation of the DSRS of .64 indicated a lower than expected level of internal consistency. All measures were blind-back translated from English to Arabic [37].

Analysis
Descriptive statistics and multivariate ANOVA was used to assess whether traumatic events led to significant levels of complicated grief symptoms, PTSD and depression. Post hoc analysis (Tukey HSD) was conducted on moderating variables. Pearson correlation coefficients assessed the degrees of association between the symptoms of PTSD, depression and complicated grief and odds ratios (ORs) were used to calculate co-morbidity of complicated grief with depression and PTSD at 95% confidence levels. All analysis were 2-tailed (p<.05) and conducted using SPSS version 20. All results were explored for the moderating variables of class groupings, year group (grades six, seven eight and nine), school type (public male, public female, UNRWA female and private school), gender and interaction of factors.

Complicated grief symptoms
Across the whole sample, there was a wide range of total scores on the TGIC of 88 points (28-116) with a wide range of dispersal (SD=14.21). Twenty percent of young people (n=15) out of 133 fitted the strict criteria for complicated grief. The one class exposed to significantly higher levels of types of trauma showed significantly higher levels of complicated grief symptoms with post hoc Tukey tests at p<.05. This result also showed up in post hoc Tukey tests of complicated grief by school type at p<.05, where UNWRA female schools showed a significant difference compared to male public schools. There was no significant gender difference in mixed private schools.
Complicated grief scores showed a low positive correlation with PTSD and depression scores, i.e. r(131) =.058, p=.510 and r(131)=.009, p =.918, respectively indicating no linear relationship between these symptoms. There was a similarly low correlation between PTSD and depression scores (r=.03, p=.727), again indicating no linear relationship.
In terms of co-morbidity, 20% (n=15) of participants fitted the criteria for complicated grief compared to 59% (n=79) for PTSD and 75% (n=100) for depression. Odds ratios were OR=0.25 and OR=0.86 respectively, with only the latter finding statistically significant for comorbidity at p<.05. This is perhaps not surprising given the high levels of depression reported. Indications are then, that complicated grief may be related to depression but appears to be a distinct concept from PTSD. This is despite the symptom overlap within the questionnaires.

Moderating variables
A significant difference with the EWSQ F(3,129)=9.470, p<.0, was found between the oldest grade group compared to the other three grades with post hoc Tukey test at p<.05, with the oldest adolescents reporting less symptoms. The mean for the 14 year olds on the EWSQ was 32.80 (SD=4.87) with a narrow range of scores 28-32. The younger three age groups mean was 64.21 (SD=14.46) with a wide range of 30-116. This is a cautious finding given the small number of 14 year olds (n=5).
A significant difference with the TGIC F (,131)=5.07, p<.05, ɳ2=. 037 was found with females reporting slightly higher levels of complicated grief symptoms. The mean for males on the TGIC was 60.34 (SD=13.07) with a range of scores from 28-94 compared to females with a mean of 65.83 (SD=15.04) and a range of . When each individual question on the TGIC was analyzed using independent t-tests at p<.05, significant results were found for increased symptoms levels of females over nine of the 24 TGIC questions (Qs, 4,5,6,7,9,1,13,22). No significant difference was found looking at the interaction of class and gender with complicated grief F(,126)=15.638, partial ɳ2=.00. However, there was a significant difference found in interaction between school and gender F (4,128)=3.280, p<05, partial ɳ2 =.09. Indications are, there is potentially a school gender effect where a small number of female classes experienced a higher level of traumatic loss compared to males in public schools.

Traumatic loss exposure
Within the context of a fractured and dispersed society living under military occupation, it is surprising traumatic loss and complicated grief have not been a central focus of previous research. The current study highlights that for adolescents in Nablus, sudden, severe and cumulative violent trauma and loss is common place. Many of the losses reported involve family members. Both males and females appear to be equally at risk. Some areas in the West Bank experience more violence than others with adolescents in these areas experiencing higher levels of traumatic loss. Adolescents' traumatic loss in Palestine however, cannot be understood simply by traumatic loss events. Adolescents experienced a wide range of traumatic events some including explicit losses, e.g. when a parent is held in detention for some years compared to losses which are more implicit in nature, e.g. the loss of a predictable, safe world and the loss of a sense of self as competent. Further, due to the context, there may be a range of cumulative traumatic losses which can be more difficult to be resilient against [2].

Complicated grief symptoms
A fifth of adolescents in the sample showed clinically significant levels of complicated grief. This level of severe and enduring symptoms is comparable to previous studies [30]. The consequences of experiencing severe, multiple and cumulative loss would seem to be more akin to trauma than grieving [9]. Such symptoms appear to loop rather than resolve through the natural grieving process. Further, complicated grief appears to rupture the fabric of adolescents' everyday lives and development. Within school, for example, there is evidence of adolescents' reduced motivation, poor concentration and behavioral difficulties. Adolescents report family and relationship problems as a result of aggression and/or social withdrawal [38,39] emphasizes the long term consequences and vulnerability of unresolved complicated grief, where traumatic losses are revisited at different developmental periods throughout the life course. In occupied Palestine, more adolescents report embodied symptoms than typically reported in the West. In a context where traditional religious and cultural beliefs stigmatize the expression of behavioral problems as mental illness, it appears physical symptoms is a more socially accepted expression of distress.
A substantial number of adolescents, despite experiencing cumulative traumatic losses, did not report complicated grief, showing remarkable resilience. There may be a number of contextual factors underpinning this finding. For example, it is possible that the familial and communitarian nature of Palestinian society provides high levels of supports for adolescents. Further, a more communal understanding of traumatic loss in Palestine may normalize grief reactions and reduce adolescents' feelings of isolation. Religious and traditional cultural beliefs about loss and healing that emphasize enshrining, martyrdom and keeping the memory alive may also be part of fostering important situational protective factors [39].

Co-morbidity
Perhaps surprisingly, given the degree to which post-traumatic stress items overlap within the three symptom questionnaires, complicated grief appeared to show little association to PTSD. A significant level of comorbidity however, was found for complicated grief and depression. It is possible this result may be a consequence of the exceptionally high levels of depression in the sample. Given the significantly lower levels of complicated grief found and the weak comorbid relationship to PTSD, it is argued that complicated grief may be a distinct trauma response. As other mental health concerns may be present in the adolescent population, there is a need for further examination of the relationship between complicated grief and other mental health conditions [31].

Moderating variables
The main determinant and cumulative effect in this study was the extent of traumatic loss. Such a finding is congruent with trauma literature which identifies traumatic events as the most significant factor in developing PTSD [40]. In this study, higher levels of cumulative violence, appears to result in higher symptom levels of complicated grief also. The small group of oldest adolescents however, reported the least symptoms. This appears to support the idea of age as a resilience factor, where older students can utilize increased cognitive, emotional and social capacities [31]. Although girls reported higher symptom levels for traumatic grief, in tune with previous studies [18], indications are that the geographical location of the female UNRWA schools, where the highest levels of traumatic loss exposure was reported, may be a more significant factor. There may however be a cultural influence in reporting, where the expression of emotion in girls is socially acceptable, whereas boys are supposed to be stoic and therefore less likely to report their internal experiences.

Limitations
The current study covered a narrow age range within adolescence. Older teens and children in the elementary and pre-school years' may experience complicated grief in very different ways. Conclusions about an age-effect are tentative given the small sample size of 14 year olds. Likewise, when looking at gender, the probability of a type 1 error was increased when individual questions were analyzed, as this increased the number of computations.
The TGIC was designed for assessing complicated grief following a single event or cluster of traumatic losses. In contrast, many adolescents in the current study experienced cumulative loss. There was however, no way to assess (i) the impact of complicated grief from previous losses; (ii) how adolescents coped with ongoing loss and grief and (iii) measure the extent to which adolescents were overwhelmed by cumulative events and/or from a specific salient event. In addition, the TGIC does not take account of the social context in which adolescents are grieving, for example, differences in support from traumatized and non-traumatized parents. These are all potential research questions for the future.
The use of one standard deviation above the mean as a clinically significant cutoff is not uncommon, however, it is possible that this metric could have under-estimated the extent of complicated grief in this group of adolescents. Such a cutoff is not a substitute for adequately assessing the validity and reliability of the TGIC. Finally, this study did not explore the meaning making aspect of loss and complicated grief for adolescents and how this could impact across their life course.

Conclusion
Adolescents in Nablus experienced multiple and cumulative types of traumatic loss that resulted in severe and pervasive levels of complicated grief for a fifth of the sample. Such a response appears to block the natural grieving process for adolescents [41] and the cumulative nature of losses appears to have undermined some adolescents' resilience [2]. The extent of complicated grief in the adolescent population was lower compared to PTSD and depression, although a significant level of comorbidity was found with depression. Results indicate that complicated grief may be a discrete trauma response for adolescents in occupied Palestine. Indications are then, that programmes are needed for children and adolescents that specifically target complicated grief.

Recommendations
There is a need for a large scale study to assess the extent of traumatic loss and complicated grief in the school population in occupied Palestine. It is recommended that longitudinal study designs are used to understand developmental and moderating factors (e.g. age and gender) as well as long term consequences of complicated grief, including the impact on children and adolescents' daily life. Valid and reliable measures developed with children and adolescents rather than adult are required. There is a need to assess the impact of pre-existing complicated grief from previous losses as well as how children and adolescents cope with complicated grief in a context of cumulative loss. An exploration of individual and situational factors that lead to children and adolescents' resilience in situations of ongoing traumatic loss would be important for future recovery programs. TGIC as a measure needs to be assessed for validity and reliability along with the identification of a clinically significant cut-off. Finally, there is a need for a rigorous analysis of the co-morbid relationship between complicated grief, PTSD, depression and other mental health conditions for adolescents in the occupied territories.