Research suggests that bereaved children are a vulnerable population, at increased risk for social impairment and psychopathology (Baker, Sedney, & Gross, 1992). Multiple factors have been cited in the literature as possibly contributing to children’s adjustment to a loss. These factors include bereaved child’s age, gender, connection to the deceased, adjustment of the surviving parent, circumstances related to death, siblings, participation in intervention, and participation in rituals such as funerals and visiting the grave (Cerel, Fristad, Weller, & Weller, 2000). Mental health service providers must understand childhood and adolescent grief and loss on multiple levels, including developmental stages, to be more effective in working with these children. Working with children and adolescents from a comprehensive perspective gives one opportunities to better connect with these clients and understand their struggles, goals, and overall perspectives. In this paper, three developmental levels will be examined closely with relation to their effect on a child or adolescent’s perceptions of parental death and the type of counseling each should receive. Additional resources are discussed following counseling interventions.
Children and adolescents differ from adults developmentally, cognitively, emotionally, physically and psychologically (Fiorini & Mullen, 2006). A child’s thoughts, feelings, and worries are often dismissed or minimized, under the assumption that a little person equals a little problem (Fiorini & Mullen, 2006). Mental health professionals must guard against this misconception, and aim to validate and normalize a child’s issues post parental loss. These differences require mental health professionals who work with children and adolescents to have specialized knowledge in child and adolescent counseling. Adolescents differ from children in many ways and have different needs from counseling. Yes, there are a vast number of challenges mental health professionals must battle when working with parentally bereaved children and adolescents. In order to see what counseling practices are most appropriate for each age group, and developmental framework is a necessary beginning (Fiorini & Mullen, 2006). It is important to note that children and adolescents progress through the stages of development at varying rates and that some never reach the level of formal operations (Piaget, 1970). It is thus important to assess children’s cognitive abilities and not make assumptions about their capacity to understand and cope with loss (Fiorini & Mullen, 2006).
Developmental Differences in Responses to Loss of a Parent
Much of the literature regarding children, adolescents, and loss is connected to Jean Piaget’s model of child development (Piaget, 1970), though he never specifically addressed death in his studies. Although his model begins with the sensorimotor stage, this analysis first examines the preoperational stage of development, as that is when children first enter school. During the preoperational stage, children think in egocentric terms and cannot conceptualize concepts such as “forever” because of their inability to think abstractly (Vernon, 2004). A preschool child, thus, may speak of death but still may expect the parent to come back (Fiorini & Mullen, 2006). Their unidimensional thought interferes with their ability to understand cause and effect and makes it difficult for them to see why their parent is no longer present (Vernon, 2004). Children who are about preschool age seem to recognize four main feelings: sad, mad, glad, and scared. With these children, the counselor at least initially, should only use simple words and synonyms when reflecting feelings. In children ages three through five, imagination and magical thinking begin to develop. Magical thinking is a child’s tendency to believe that they possess powers that allow them to control the world through their own thoughts. It is important to understand the role of magical thinking, because it helps explain why some children believe they could have changed the course of events and prevented the person from dying (Fry, 1995). These children may exhibit feelings of fear, anger, sadness, regression, or anxiety because of their misconceptions. Worse, children this age have difficulty understanding that they can experience different emotions simultaneously (Berk, 1999) and may feel uncomrfortable, confused, or overwhelmed about all of their emotions. Adults, therefore, should listen to their concerns about loss, and allow the children as much choice and control as is feasible (Fiorini & Mullen, 2006). It is encouraged to let the child cry, regress, and attach to an object or person in order to help with the healing process (Fiorini, 2006). Adults are also encouraged to label the child’s feelings and connect feelings to what is upsetting the child, since toddlers cannot express themselves well independently, and may often express their emotion in a behaviorally inappropriate manner (Vernon, 2006).
Children ages five to nine are entering the concrete operational stage and losing their egocentricity. They are increasing in their ability to reason, problem solve, and communicate their feelings to others. Goldman (2004) reports that children around the age of five are beginning to express logical thoughts and fears about death, are starting to understand that all body functions stop, and are beginning to internalize the universality and permanence of death. By age 8, most children have become concrete operational thinkers and are able to understand concepts like reversibility and permanence (Vernon, 2006). More complex emotions can be identified by 7- and 8-year-olds, like guilt, shame, and self-doubt. They also become more adept at hiding their emotions, despite their increased understanding of and ability to express them (Berk, 1999). As a response to loss, children at this age may exhibit feelings of sadness, anxiety, withdrawal, confusion, fear and worries of being ignored or ostracized for having a nontraditional family structure. Alternatively, the child may respond with aggression or withdrawal, may have nightmares, may lack concentration, and may begin performing poorly in school (Fiorini & Mullen, 2006).
Around the age of ten or eleven, the change from concrete to formal operational thinking begins. Schave and Schave (1989) called this transition from concrete to formal operational thinking, “the most drastic and dramatic change in cognition that occurs in anyone’s life.” Children in the formal operational stage begin to develop the capacity for more abstract thinking and independence from parents. By age nine or ten, most children have developed an understanding of death as final, irreversible, and inescapable (Emswiler & Emswiler, 2000). However, because a marked degree of renewed egocentricity (Vernon, 2006), accompanied by emerging formal operational thinking, 9- and 10-year-olds theoretically may still be vulnerable to feelings of self-blame or guilt because of illogical conclusions that their interactions with the recently deceased parent somehow caused the loss (Schoen, Burgoyne, & Schoen, 2004). As children mature, and hormones develop, adolescence becomes marked by volatile emotions and moodiness. Because negative emotions can be overwhelming and cause adolescents to feel vulnerable, many often mask their feelings of fear or vulnerability with anger. This, in turn, results in people distancing themselves or increased conflictual interactions (Vernon, 2006), with potential support-givers. The dominant benefit of working with formal operational thinkers is their adult-like ability to engage in higher-level thinking. Adolescents can comprehend the concept of death, which serves as a vehicle for more in-depth spiritual and conceptual thought and counseling (Schoen, Burgoyne, & Schoen, 2004).
Evidenced Based Practices to Help Children Facing Parental Loss
The transitional events (Felner, Terre, Rowlison, 1988) model has provided mental health professionals with an excellent framework useful in studying children’s adjustment ability post stressful events. Though it has only recently begun penetrating the field of child bereavement, it has provided a wonderful basis for designing interventions to improve children’s outcomes by working on prospective “malleable risk and protective factors” that exist after the marker stress event (Haine et al., 2008). This model suggests that children’s adjustment following a major stressful event is influenced by the many stressful events that follow the marker stress event.
Further, this model takes on a dynamic approach that appreciates the interplay between the stressors encountered after a traumatic experience and a child’s protective resources. Following this model, the primary goal of intervention would be to decrease children’s exposure to stressful changes and to strengthen child’s resources for dealing with existing stressors.
Recently more effort has been focused on closing the gap between research and practice in the treatment of bereaved children (Sandler, 2005). Although the research on intervention efficacy for this population is sparse, it has yielded some information useful for mental health professionals (Ayers, Kennedy, Sandler, & Stokes, 2003; Ayers & Sandler, 2003). This next section summarizes empirically-supported findings that outline general practice for working with this population, though not divided into developmental levels. More detailed interventions for specific developmental phases will follow these general recommendations.
One of the tasks a child must go through after losing a loved one is the grief process (Holland, 2001). It is important to normalize the grief process, and to provide information that can reduce anxieties about the future to these children (Haines et al, 2008). Information about the grief process may decrease thoughts that may lead to serious adjustment problems (Haines et al, 2008). Examples of good topics to discuss include the wide range of emotions felt after the loss of a parent, including fault or guilt, talking about the parent postmortem, dreams or visions of the deceased parent, or fears that the parent will be forgotten. The death of a parent can have a significant negative impact on children’s self-esteem and locus of control (Haines et al., 2008), both of which have been associated with greater mental health problems. Parental death can lead to decreased economic resources, change in residence, less contact with friends and neighbors, increased responsibilities, and loss of time with the surviving parent (Wolchik et al., 2008), these changes can exacerbate negative feelings in an already fragile child. Reframing negative self-talk, encouraging adult members provide more positive feedback to these children, and encouraging engagement in activities outside of the counseling context that promote self-esteem are ways to raise self-esteem and re-center the child’s locus of control (Sandler et al., 2003). To inhibit the negative self evaluations that result from losing a locus of control, healthy control beliefs must be recultivated. Children benefit from sharing their concerns, and then having them addressed. For example, if a child is concerned with the emotional well-being of their living parent, and they feel they have influence on how fast that parent heals, children benefit from hearing that their parent will be able to manage distress better over time, and on their own. Further, direction toward focusing efforts children can control, like their academic performance, can help them regain that sense of control. Parents should be involved in this effort, and be discouraged from becoming overly reliant on their children for emotional support.
Specific coping strategies have also been associated with more positive adaptation following the death of a parent. Specific coping strategies include positive reframing coping, problem-solving, which includes using both cognitive and behavioral efforts in working toward counseling goals, and support-seeking coping, which involves searching for support when needed (Sandler et al., 1996). To encourage children’s investment into these coping strategies, counselors should get these children to come up with their own goals and select any coping tools they choose to work toward their goals. Counselors should encourage children to express their emotions regularly as one of their goals, as research shows that children who inhibit the expression of negative emotions, such as sadness or guilt, are more likely to experience greater mental health problems in the long-term. Eliciting discussions between children and their surviving parent about emotion-laden topics has also proven to help (Haines et al., 2008). Existing studies (e.g., Haine, Wolchik, Sandler, Millsap, & Ayers, 2006) clearly point to positive parenting as imperative for mental health intervention to succeed with grieving children. Mental health professionals should be educated regarding the importance of positive parenting well as parents’ general role in their child’s adaptation. Positive parenting exists when parents produce a structured and empathetic atmosphere that nurtures open communication about the deceased, in which children are given freedom to call on their surviving parent for emotional support. Family routines, disciplinary measures, traditions and anything more that can echo the environment prior to a major stressful change helps the child reestablish their emotions (Anderson, 2003).
Interventions By Developmental Age
Play therapy is one suggested approach to counseling children in the preoperational stage of development. Grief literature contains anecdotal and empirical support for the idea that play therapy can be helpful to children who are struggling with life circumstance of grief issues (Webb, 1999). In play therapy, the counselor uses toys and play as the primary vehicle for communication. Kottman (2001) and others have supported play therapy for counseling in early childhood because children of this age have a relatively restricted vocabulary and struggle to conceptualize and verbalize their feelings and thoughts. Communication, therefore, is prompted through various play strategies like pretend play or games. The goals of play therapy are well-matched to the needs of grieving children. Often, a goal of play therapy is to building up a child’s self-efficacy and competence by allowing them to do things themselves and make decisions for themselves in the playroom. Further, a counselor’s role in this type of therapy allows him or her to show sincere concern, empathic understanding, and consistent positive regard. This overlapping efforts work toward stopping a child’s negative self-concept, and increasing their self-esteem. Problem-solving skills are increased by allowing children to accept responsibility for their choices and behavior in the playroom. Other goals often include building the child’s emotional vocabulary, enhancing relationship-building skills with other potential support figures, and increasing the child’s ability to make self-enhancing decisions (Kottman, 2004). Play therapists use several skills including tracking, restating content, reflecting feelings, returning responsibility to the child, using the child’s metaphor, and limiting (Kottman, 2004). Tracking involves describing aloud the child’s behavior to the child to convey that what the child is doing is valued. By using vague descriptions like, “this,” “that,” them,” “it,” or “those,” instead of specific nouns, and using vague phrases like, “moving over there,” or “going up and down,” rather than specific verbs, the counselor allows the child to project his or her own meanings on the toys and on the actions in the playroom. This encourages self-expression and inhibits the counselor from tainting the child’s expressive acts with their own interpretations (Kottman, 2004). Restating is paraphrasing the child’s verbalizations to show the child that what he or she is saying is important. By using child-friendly vocabulary, the counselor tries to summarize the child’s thoughts without changing any of the meaning. Helping the child feel understood is a constructive way for a counselor to build rapport with the child, and build the child’s sense of importance (Kottman, 2004). Self-reliance and self-confidence can be increased by returning responsibility to the child in play therapy. Making the child execute certain behaviors he or she automatically requests assistance for, or giving the child the power to make certain decisions about the play session allows the child to build self-confidence and reliance. Children can be encouraged to communicate in a less-threatening, indirect manners by using a metaphor. Using a metaphor means the counselor tracks, restates content, and returns responsibility through the child’s story or play without imposing his or her interpretation on the meaning of the story. By doing this, the counselor allows the child a symbolic way of communicating feelings that he or she may not want to state directly, may not be able to fully explain, or may not completely understand (Kottman, 2004). Setting limits in the playroom is very important in keeping play therapy therapeutic and not becoming chaotic or losing its functional communication component. Setting limits enforces safety and structure onto sessions, and makes them a secure and consistent environment for grieving children to express themselves. Further, it provides the child with a sense of protection and stability, which acts as another support for their emotional improvement.
Early childhood also lends itself a variety of other techniques in counseling, which take little time to execute, and help keep the child’s interest high. Since the average attention span of a 4- or 5-year-old is limited, counseling techniques need to be changing frequently, engaging, and concrete. Art therapy, for example, involves a lot of active engagement on the client’s part, has been found especially useful in treating children with grief, and can often help to initiate conversation about some of the child’s internal feelings. Even if discussion does not follow the art therapy session, the permanent product created by the client can be studied to see if any meaning can be derived from the art. Art media should not be limited to drawings. Children also respond well to clay sculpture, collages, and finger paints (Webb, 1999). Bibliotherapy is another useful tool for young children. Bibliotherapy helps enable younger clients verbalize their thoughts and feelings and gain insight or a sense of normalization when identifying with a character in a story (Bradley et al., 2006). Bibliotherapy, like art therapy, provides a safe distance from the real-life problem for children to process their grief (Bradley et al., 2006). Lastly, puppet play is especially well-suited for this younger population, as it allows them to displace their feelings about significant others onto concrete fictional characters (Bradley et al., 2006). There are many more options in working with preoperational thinkers. When scanning through the various options, counselors just need to be mindful that this population is literal, confused, and scared. In order to be effective, counselors must be engaging, and they must aim to expand children’s affective vocabulary and clarify any misconceptions they may have about death.
Early adolescence is a time of transition for students. Knight and Wadsworth (1994) maintain that teachers should provide "firsthand experiences of an exploratory nature" to at-risk middle school students for authentic learning to occur. Passaro and colleagues (2004) reported that at-risk middle school students who were supported with a Reality Therapy (Glasser, 1965) intervention in an in-school support room showed a 42 percent improvement in their average daily behavior ratings as well as a 12 percent decrease in the total number of out-of-school suspensions over the course of an academic year. When one combines these two pieces of information, one can deduce that counseling children in early adolescence has to maintain a similar level of activity in their counseling efforts, but can also begin introducing more conversation in the form of cognitive-behavior therapy to directly address some of the harsh realities they are facing.
Reality therapy is a form of cognitive-behavioral therapy which focuses on the demands of external reality, and is often used on children with behavioral problems. Its “common-sense advice” emphasis makes it ideal for this age group, because early adolescents merely sprouting their ability to discuss their actions and feelings, but lack the cognition to understand higher-level thinking and reasoning. William Glasser’s (1998) Choice Theory, a subset of reality therapy, has gained increasing attention from professional working with middle-schoolers. Choice Theory philosophy focuses on the attitudes and behaviors that are particularly problematic for the at-risk student. Choice Theory says we choose our thoughts, emotions, and behaviors, and these choices make up the quality of our lives (Day, 204). It helps these students rectify immature thinking so they make more logical choices for themselves. For young adolescents who have lost a parent, and their internal locus of control, Choice Theory focuses helps this matter by assisting the student to develop personal responsibility, thus helping the young adolescent to recenter his or her internal locus of control (Walter et al., 2008). Good adjunct strategies include role-playing, and adventure-based counseling. Role playing, or the use of acting and drama, allows early adolescents put on a disguise of sorts and communicate feelings under the safe pretense that it is all acting (Bradely et al., 2006) and if often used in the counseling setting to encourage the expression of emotion. Adventure-based counseling is an Adlerian technique that builds self-esteem, problem solving, and feelings of comradery (Day, 2004). Adolescents who are not strong in verbal expression or academics may find themselves leaders in adventure therapy groups. It often involves cooperative tasks like blindfolded trust walks or building something with limited materials, and errors have natural consequences that the group must deal with as a whole. Research has supported its use with this age group. Blanchard (1992) linked cognitive theory to adventure-based counseling in that the goal of certain adventures is to “change automatic thoughts of I can't to I can.” Moote pointed out the similarity between Rational-Emotive Behavioral Therapy (REBT) and adventure-based approaches, highlighting that both face issues of confronting fears and surpassing previous limits (Moote et al., 1997). What is important to remember for concrete operational thinkers is that they are still developing their higher-thinking and executive functioning abilities. They may give the false impression that they understand more than they actually do because of their developing bodies and growing expressive abilities, but their minds still work in very concrete ways and they are extremely fragile emotionally and cognitively.
Though trauma can distort both children and adolescents’ cognitions equally severely, adolescents are typically better equipped mentally to combat those distortions using cognitive behavioral therapy because of their increased ability to reason, problem-solve, and explain their feelings and their behaviors. This framework puts faith in the power of thinking to override emotional and behavioral impulses (Day, 2004). Like children, adolescents may develop irrational beliefs about causation for the parental death in order to gain some sense of control or predictability. Their maladaptive irrational beliefs can lead to damaged peer relations, damaged family relations, and/or a loss of faith in justice, God, or a favorable future. Adolescents are particularly vulnerable to developing struggles with affective regulation, self-esteem and self-efficacy, academic and vocational performance, and maintenance of personal safety (Cohen, Mannarino, Deblinger, 2006). This line of irrational thinking can lead some teenagers down a path of bad behavioral choices (Cohen, Mannarino, Deblinger, 2006) and perpetuate problems. These cognitions contribute significantly to the maintenance of post-traumatic stress disorder, other forms of anxiety, and depressive or behavioral difficulties. Cohen, Mannarino, Deblinger (2006) reported that their multi-site study on these types of youth had responded well to a specific treatment called the trauma-focused cognitive behavioral therapy. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a treatment that meets well-establish empirical support for formal operational thinking adolescents exposed to trauma like a parental death (Silverman et al., 2008). The TF-CBT approach incorporates several treatment components like psycho-education, coping skills, gradual exposure and/or processing of painful topics and/or situations, and parent training.
The TF-CBT model is a components-based treatment the emphasizes a set of central skills that progressively build on previously consolidated skills. Rather than describe a rigid session-by-session treatment, this model has inter-related components, each which are provided in a manner, intensity, and duration that best matches the needs of the adolescent. Respect for individual, family, religious, community, and cultural values is essential for any psychosocial intervention to work effectively. Counselors work together with the child and parent to decide the best way to implement the core components for their family, with an awareness that this treatment must occur in harmony with the family’s larger community and cultural context. Adaptability is crucial to the success of this treatment model. Counselors must be creative and flexible in implementing the core components and, the counselor’s judgment ultimately determines how the TF-CBT components are used to help each child and family. Family involvement is integrally included in the adolescent’s treatment, and a primary focus of treatment is improving parent-child interactions, communication, and closeness. Therapeutic relationships are also essential, in that they provide the adolescent one more support option, and one more person to confide in, cry to, and receive empathy and encouragement. Self-efficacy in adolescents is a long-term goal of this model, as it aims to provide life skills and enhance individual strengths so that these adolescents can grow into emotionally healthy adults (Cohen, Mannarino, Deblinger, 2006).
Although formal operational thinkers are better able to indulge in deep conversation and thought, this age group is often quite opposed to seeing a counselor. Music therapy is often a helpful adjunct in alleviating the hostility, discomfort, or lack of trust when initiating contact with parentally bereaved adolescents. Music therapy can alleviate feelings of depression, anxiety, loneliness, and grief (Bradley et al., 2006). Counselors may use music-listening strategies to reduce depression, increase self-concept, elicit memories, fantasies, or visual imagery. Songs may help them to understand their feelings and gain some self-understanding. Additionally, research has shown that background music can augment self-disclosure, decreases negative self-talk, and can enhance positive moods (Jensen, 2001).
Other Resources for Parentally Bereaved Children
Support networks are crucial for the maintenance of emotional well-being. Family therapy is another well-established, empirically supported tool used to help children cope with the loss of a parent (Haines et al., 2008). Specifically, the Family Bereavement Program, designed at Arizona State University, has designed a comprehensive and intensive family intervention effort for just this topic and touts the integrative approach of parent-child therapy in helping children heal from their loss (ASU; Sandler et al., 2003). Outside of therapy, many children turn to religious organizations to help cope with loss and grief (Anderson, 2003). Religion has long been connected with death, and research shows that clergy are among the first people to whom trauma victims turn for help, and that trauma victims report using religious behaviors to help them cope with stressful events (Thompson & Vardaman, 1997). Although limited, empirical literature does point to religion as typically promoting coping ability (Jenkins & Paragament, 1988; Maton 1989) spiritual support has been related negatively to depression and positively to self-esteem. Beyond these organized resources, there are hotlines, websites, and books parents and children can use to help them learn about and cope with their grief.
Parental death is one of the most traumatic events that can occur in childhood, and literature has found that the death of a parent places children at risk for a number of negative outcomes. This paper attempts to share some of the knowledge base regarding empirically-supported intervention efforts to help children and adolescents cope with the death of a parent and prevent prolonged mental health problems. By considering the many variables surrounding a specific child’s trauma, research has shown it is possible for children and adolescents to adjust and move on from this painful event. Addressing the child’s developmental age and other idiosyncratic features surrounding their parent’s death will guide a counselor down the right path in terms of support and intervention services, and increase the likelihood of the child’s readjustment.
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