Author: Howarth, Robyn A
Date published: January 1, 2011
Journal code: JMHC
About 2.5 million (3.5%) of children in the United States will lose a parent before the age of 1 8 (Social Security Administration, 2000). Parental death has been found to have an impact on both short- and long-term psychological adjustment, and ensuing psychological difficulties can be largely attributed to the quality of care children receive after the loss (Tremblay & Israel, 1998). Although most children who experience the death of a parent are thought to adequately adjust within one year (Worden & Silverman, 1996), a number of them experience significant depressive symptoms, social withdrawal, and academic difficulties long after the death (Cerei, Fristad, Veducci, Weiler, & Weller, 2006). Improving the psychological adjustment of children who have lost parents is an important goal for counselors because parental death affects so many aspects of children's lives and functioning (Wolchik, Tein, Sandler, & Ayers, 2006).
Mental health difficulties following the loss of a parent are a function of both individual and family variables and environmental processes (Lin et al., 2004). Parental death is a traumatic event for children not only because of the actual loss of the parent but also due to the changes it causes in multiple domains of children's lives. Most researchers conceptualize parental death as a series of stressors related to a decrease in economic resources, change in residence, less contact with friends and neighbors, increased responsibilities, and loss of time with the surviving caregiver (Wolchik, Ma, Tein, Sandler, & Ayers, 2008). Parental death may also introduce stressors that limit the surviving caregiver's ability to provide a stable environment, consistent discipline, adequate warmth and support, and open communication with the child (Wolchik et al., 2006).
As a result of the bereavement, children may develop a variety of mental or physical complications. Bereavement in children has been associated with more frequent anxious and disruptive behaviors consistent with depression and conduct disorder (Thompson, Kaslow, Kingree, King, Bryant, & Rey, 1998).
Skinner and Wellborn (1994, 1997) suggest that parental death threatens the ability of children to meet needs for relatedness, competence, and autonomy. Further, stressors that accompany the loss of a parent may hinder satisfaction of the basic needs of positive self-worth, social relatedness, and control (Sandler, 2001). Sandler suggests that fulfillment of these basic needs is likely to promote a child's process of redefining and reintegrating oneself into a life without the physical presence of the person who has died. As a child navigates the grieving process and reintegration occurs, painful feelings decrease and recurring thoughts about the deceased are less intrusive and dominant (Shear & Shair, 2005).
The death of a parent is not an isolated trauma for children: parentally bereaved children re-experience aspects of the loss throughout their life (National Cancer Institute, 2008). The long-term effects from parental death are an important consideration for counselors. Adults who were parentally bereaved as children may present with issues that are not directly linked to but have been influenced by their loss. The Harvard Child Bereavement Study (Silverman & Worden, 1992; Worden & Silverman, 1993, 1996) documented how parental death can have a continuing impact on adult survivors.
The treatment of childhood grief presents unique challenges for both counselors and family members because the nature of the grieving process is different for children than for adults. Children understand grief differently than adults because their cognitive ability to grasp and cope with loss is still developing (Schoeman & Kreitzman, 1997); they do not react to loss in the same ways as adults (O'Toole & Cory, 1998). With limited capacity for abstract thinking, children may not fully comprehend the concept of death or understand the permanence of the loss; thus, they may not display their feelings as openly as adults.
Although the death of a loved one causes emotional trauma for children, their grief reactions may differ from the emotional responses typically seen with adults. The primary difference is that intense emotional and behavioral expressions are not continuous in children (Corr, Nable, & Corr, 1997). Rather, their grief reactions may appear more intermittent and brief than those of adults, yet the grief usually lasts longer than its behavioral expression (Fitzgerald, 1992; O 'Toole & Cory, 1998). Families often incorrectly interpret this behavior to mean the child does not really understand the loss or has already gotten over the death.
Grief reactions are intermittent because children cannot thoroughly explore all their thoughts and feelings rationally as adults can (Corr et al., 1997). A variety of emotional reactions can be expected from a grieving child, among them numbness, disbelief, yearning, anguish, anger, and guilt (Lampton & Cremeans, 2002). Children often have difficulty articulating their feelings about grief; thus, it is through their behavior that they may evince strong feelings of anger and fear of abandonment or death (O'Toole & Cory, 1998). Rather than outwardly expressed emotions and withdrawal from daily activities, grief reactions in children may manifest in psychosomatic symptoms, temper tantrums, academic failure, and other seemingly unrelated behaviors.
Bereaved children also tend not to withdraw into preoccupation with thoughts of the deceased person as adults can; instead they often immerse themselves in activities and games as a way of working out their feelings and anxieties (Corr et al., 1997; O'Toole & Cory, 1998). Play, drama, art, school work, and stories also give them opportunities to express feelings (Goldman, 1998).
Although loss is a highly individualized experience, children's grief reactions may be influenced by their age, personality, stage of development, previous experiences with death, type of relationship with the deceased, environment, the cause of death, patterns of interaction and communication within the family, stability of family life after the loss, how the needs for sustained care are met, availability of opportunities to share and express feelings and memories, parental styles of coping with stress, and the availability of consistent relationships with other adults (DeSpelder & Strickland, 1996; Fitzgerald, 1992).
Tasks of Grieving
Although children must work through the same tasks in the bereavement process as adults, the progression differs depending on the child's developmental stage (Schoeman & Kreitzman, 1997). Although several researchers have proposed tasks and stages of grief, I will highlight just one model that has wide acceptance and has been specifically applied to children's grief. Worden and Silverman (1996) assert that the normative grieving process for children incorporates specific tasks associated with common responses to loss over time. In their model, children must complete four tasks in order to experience reintegration and adaptation to the loss.
The first is to accept the reality and permanence of the loss. To accomplish this, children need accurate information about the death so they can avoid "magical thinking" or filling in the gaps with misinformation (Lampton & Cremeans, 2002). Emotional recognition and acceptance of the loss are very difficult; the process involves full recognition that the lost one will not return.
Next, children must experience the pain and the emotional aspects of the loss. Intense emotions of sadness, despair, anger, guilt, fear, loneliness, shame, and jealousy may all be part of this experience. Initially, these painful feelings may be constant. Later, they may become sporadic or intermittent, but they can surface at unexpected times, causing the child to feel out of control. Eventually, these feelings become less frequent and may be experienced mostly during anniversaries of the loss, holidays, and special events (e.g., the birthday of the lost one).
The third task is adjusting to life without the loved one. How difficult this will be depends on what the relationship between the child and lost parent was and the amount of disruption in daily life the child experiences due to the loss. The opportunity for a child's personal growth is perhaps most clearly seen in this part of the grief work.
Finally, the child must convert the relationship with the deceased from one based on continuing interactions to one based on memories. Children gradually withdraw emotional energy from the loved one and focus on establishing new relationships with others. The work of this task has been described as being able to say a final farewell to the dead person. This does not mean giving up memories; rather, this farewell releases a central attachment to the dead person so that more room and energy are available for engaging in life in the present.
Ultimately, the process outlined in this model is characterized by reconciliation, which is defined as the "process that occurs as the bereaved child works to integrate the new reality of moving forward in life without the physical presence of the person who died" (Cohen, Mannarino, Greenberg, Padlo, & Shipley, 2002, p. 309). Although most children are able to cope with the normative grieving process without complications (Boelen, van den Hout, & van den Bout, 2006; Bonanno, 2004), some who cannot successfully address these tasks may suffer complicated grief.
PARENTAL BEREAVEMENT IN CHILDHOOD
A review of the literature consistently indicates that bereavement in children is significantly related to depressive symptoms, withdrawal, and academic problems (Wolchik et al., 2006). Parental death involves a series of stressors that may affect numerous aspects of the life and functioning of children, such as a decrease in economic resources, changes in residence, loss of contact with peers, increased expectations and responsibilities, loss of time with the surviving parent, and a change in caretakers and the family system (Wolchik et al., 2006). As a result, bereaved youth report more depressive, anxious, and disruptive behaviors than nonbereaved children as well as heightened psychological and social difficulties and a higher incidence of behaviors consistent with depression and conduct disorder (Thompson et al., 1998).
From an attachment theory perspective, disruptions in a bond formed through early emotional attachment have serious implications for later social relationships and psychological adjustment (Mack, 2001). Different reactions are seen in response to permanent separation (parental death), such as sadness and depression. If children respond to parental loss with despair and sadness, in adulthood attachment-related feelings may manifest in low self-confidence or symptoms of depression.
Most research examining the impact of parental death on children has focused on long-term psychological consequences or delayed effects; only a few studies have examined the more immediate impact of parental death (within two years of loss) on the emotional well-being of bereaved children (Worden & Silverman, 1996).
Studies that examined the short-term adjustment of children have yielded mixed results. Some researchers reported that parentally bereaved children display considerable distress and significant impairments, including depressive symptoms, anxiety, aggressive and disruptive behaviors, and academic difficulties (Christ et al., 1993; Thompson et al., 1998). Other researchers have found that children who experience the death of a parent are largely indistinguishable from nonbereaved peers with regard to short-term reactions (Silverman & Worden, 1992).
About 18 months post-loss, most children are considered to be "well adjusted," particularly with regard to measures of depression and anxiety compared with nonbereaved controls (Lawrence, Jeglic, Matthews, & Pepper, 2006). However, some bereaved children do not begin to display more problems than the nonbereaved until two years after a parent's death (Worden & Silverman, 1996). Difficulties then arise, among them more anxiety and social difficulties and lower self-esteem. Children two years post-loss were also reported to be more socially withdrawn, display more aggressive behavior, experience more somatic symptoms, and report more health problems.
The mixed results in the research highlight the variability in outcomes for parentally bereaved children. This is not completely surprising considering the multitude of factors that may contribute to positive rather than negative adjustment. Sandler, Wolchik, and Ayers (2008) highlighted the notion that outcomes, both positive and negative, are not predicted by any single factor but rather by the accumulation of risk and protective factors. Most importantly, with bereaved children the developmental course of grief needs to be considered because bereavement is a process that continues over time, and throughout their lifespan these children will revisit the loss repeatedly, especially during significant life events (e.g., graduation from school, marriage, and the birth of their own children).
Factors Influencing Adjustment of Bereaved Children
Factors that may influence the adjustment of parentally bereaved children include both child-level and family-level variables (Sandler et al., 2003). Age, sex, the relationship with the deceased, the circumstances of the death, the adjustment and emotional stability of the surviving caregiver, the presence of siblings, and participation in interventions and rituals (e.g., the funeral), are consistently reported in the literature as influencing the adjustment of the parentally bereaved child (Hope & Hodge, 2006).
Specific child-level variables, such as coping efficacy and appraisal of threat, are reported to impact adjustment; in particular, fear of abandonment appears to be a salient construct for these children. Researchers have also found support for self-esteem and control beliefs as protective resources for parentally bereaved children (Haine, Ayers, Sandler, Wolchik, and Weyer, 2003).
Multiple family-level variables, such as the adjustment of the surviving caregiver and the quality of care received by the child after the loss, are substantially related to how children cope (Kalter, Lohnes, Chasin, Cain, Dunning, & Rowan, 2002). The surviving parent may be ill-prepared for managing his or her own reactions as well as the reactions of the child. Typical responses to the death of a spouse include feelings of guilt, anxiety, sadness, and preoccupation with thoughts of death or the deceased. Negative relations with the surviving caregiver has been shown to be more predictive of maladjustment for bereaving children than other factors; a positive adjustment of the surviving parent is necessary for a more positive adjustment of the child (Hope & Hodge, 2006).
Helping the surviving parent to implement positive parenting practices and foster a positive parent-child relationship is consistently regarded as important to the adjustment of parentally bereaved children (Sandler et al., 2008). Caregiver warmth includes displaying a positive regard toward the bereaved child, conveying acceptance, expressing affection, fostering open communication, and providing emotional support (Haine, Ayers, Sandler, & Wolchik, 2008). Additional support for both children and surviving parents (e.g., support groups, grief groups) may be beneficial to promote adjustment among grieving children and their families. The fact that bereaved children will likely experience a range of emotions like sadness, anger, guilt, and anxiety (Silverman & Worden, 1992; Worden, 1991) makes open communication imperative. More openness and frequency of communication is associated with less depression and anxiety in bereaved children (Hope & Hodge, 2006).
Adaptation to parental death can be facilitated by providing accurate information about the grief process (Corr, 1995) to decrease any maladaptive cognitions that may disrupt adjustment (e.g., feeling responsible for the death because of an argument beforehand). Educating children about death and bereavement may help reduce anxieties while also normalizing the grief process (Hope & Hodge, 2006).
Given the multiple changes associated with parental death, a stable environment is very important for positive adaptation (Haine et al., 2008). Implementing consistent discipline and routines, facilitating discussions of feelings, and appropriately interpreting acting-out behaviors may be beneficial to bereaved children's adjustment (Hope & Hodge, 2006). An environment with a predictable routine, clear and specific rules and expectations, and consistent follow-through has been associated with fewer mental health problems among parentally bereaved children (Worden, 1 996). Similarly, ensuring that a child's basic needs are met, helping children identify personal strengths, and promoting strong connections and social support for bereaved children are important.
Clearly, there are a number of factors that may influence the adjustment of parentally bereaved children. As a result, when working with these children and their families, counselors should consider influences from various levels (individual, family, environmental) in each child's life.
TREATMENT FOR PARENTALLY BEREAVED CHILDREN
Although studies of the use of empirically supported interventions with this population are few, some clinically relevant information comes from projects like the Family Bereavement Program (FBP; Sandler et al., 2003) that reiterate the importance of increasing children's understanding of their grief experiences.
Although researchers have examined intervention programs for bereaved adults, little is known about effective treatments for facilitating the grieving process in children, particularly children experiencing complicated or traumatic grief (Boelen et al, 2006). More research is necessary for gaining a better understanding of the consequences and outcomes associated with childhood grief, as well as the components of effective treatment (Thompson et al., 1998).
Because "grief refers to the child's personal experience of the thoughts, emotions, and behaviors associated with the loss" (Lampton & Cremeans, 2002, p. 468), a cognitive-behavioral approach might be most effective. According to Stubenbort and Cohen (2006), treating children with complicated grief requires treatment of both trauma and grief symptoms. Similarly, successful outcomes are associated with the inclusion of surviving family members in the treatment process. Trauma-focused cognitive-behavioral therapy (TF-CBT) is a manualized treatment approach for children and their parents drawn from extensive work with trauma survivors. Cognitive-behavioral techniques have been used successfully to treat sexually abused children (Cohen & Mannarino, 1996; Cohen et al., 2000) and bereaved adults and children after an airline disaster (Stubenbort, Donnelly, & Cohen, 2001).
Dunning (2006) suggests that promoting adjustment of parentally bereaved children involves interventions that frame the concept of death cognitively, affectively, and behaviorally. The cognitive frame emphasizes the sharing of accurate and factual information about the death to avoid "magical thinking" and unnecessary responsibility-taking by the child. Information should be presented to children in language appropriate to their cognitive development. The affective frame involves talking with bereaved children about the negative feelings associated with the loss and helping them identify and label their feelings appropriately. Finally, the behavioral frame involves such topics as children understanding their own behaviors and the behaviors of adults. For example, witnessing the surviving parent crying or expressing anger or frustration can be a source of distress and misunderstanding for children. Counselors will want to communicate openly with bereaved children about challenges they may experience in school and other social milieu. Counselors can also develop a plan with children on how much to tell, who to tell, and how to answer questions about their loss. Such planning may help alleviate worries and uncertainty for grieving children as they adjust to their loss.
Schuurman (2003) highlights practical suggestions for children grappling with adaptation to parental death. Continuing a connection with the deceased parent is an important consideration, especially through dreams or creating symbolic rituals and traditions for remembering the deceased parent (planting a tree, visiting the grave on certain dates). Bereaved children should be encouraged to write down or record their thoughts and experiences pertaining to the death. They can use expressive arts (e.g., drawing, sculpting, painting) to explore their loss or organize pictures and mementos into a memory box. Older children and adolescents may find it helpful to volunteer to help others and find meaning from the loss of their parent in this way.
Counselors can prompt children to discuss the deceased parent by focusing on a favorite time together, favorite memories, or a favorite gift from the deceased (Haine et al., 2008). They can also encourage families to discuss both positive and negative emotions associated with the loss in order to strengthen the family system while normalizing the grief process for other family members.
In identifying those at risk of complicated grief, a few factors seem particularly important. Counselors should monitor the degree of disruption of the social environment following the loss of a loved one. Depending on the relationships and the deceased's role in the family, the family structure may change, so having a continuity of bonds and social supports is important to the capacity of children to deal with bereavement. Similarly, the adjustment of a caregiver appears to be associated with how the child adapts to the loss. Maintaining structure and disciplines creates a predictable environment and helps the child to feel safe and secure. Open communication about the actual loss, grief reactions, and emotional responses should be promoted. Often adults strive to "shield" and "protect" their children by avoiding conversations about the trauma. However, without accurate information, children will fill in the gaps and may blame themselves for the loss.
Other factors that may influence the severity of traumatic symptoms include the presence of pre-existing conditions or psychopathology, the level of exposure to the traumatic event, the nature of the relationship to the deceased, the cause of death, and barriers associated with experiencing trauma as a child. Barriers for children in need of treatment include the necessity to disclose the trauma to an adult, the need for parents to recognize when atypical reactions warrant treatment, and parents' willingness to seek treatment.
FUTURE DIRECTIONS FOR RESEARCH
Although it is difficult to pinpoint the aspects of current treatment models that lead to positive outcomes, researchers suggest that treatment for childhood grief should incorporate interventions for both trauma and bereavement symptoms. However, there is little information about the optimal amount of treatment for reducing symptoms, and empirical studies are also needed to determine the components of treatment interventions that are most critical in producing positive outcomes in children.
Due to the association between adjustment and social support, it seems to be important to include surviving parents in the treatment of childhood grief. A lack of parental support and attention may hinder the adjustment of children to loss (Hope & Hodge, 2006; Tremblay & Israel, 1998). The emotional distress of parents and lower levels of social support for the child predict poorer outcomes for children (Cohen & Mannarino, 1996). Inclusion of a treatment component for parents may be beneficial for resolving childhood traumatic grief. Few studies have incorporated an active parental treatment component because most research examining grief in childhood is conducted at school.
Studies examining grief in children have several methodological problems. A lack of standardized assessment measures, failure to examine the link between parent and child adjustment (Kalter et al., 2002), and heavy reliance upon parent reports of child functioning (Thompson et al, 1998) have all been troublesome. Considering the frequency of parental death and its potential for traumatic impact on the psychological development of children, research is needed to better understand the consequences and outcomes associated with it and factors that moderate various reactions (Thompson et al., 1998).
Many researchers have examined the efficacy of treatment techniques for children who have been exposed to a variety of traumas. Therefore, examining the efficacy of interpersonal and cognitive-behavioral therapies for children experiencing normative and traumatic grief around parental loss should be a chief research goal. Similarly, studies are needed to determine the effectiveness of current treatment models for decreasing symptoms and increasing the adaptive functioning of children (Cohen & Mannarino, 2004).
The loss of a parent can have a devastating effect on the life of a child. When the grieving process is complicated, an inability to adequately navigate the normal tasks of bereavement can lead to negative psychological effects for children. Counselors who are sensitive to the importance of critical factors during the grieving and adaptation process for parentally bereaved children can provide valuable clinical services to families and child survivors. Creating a safe place for children and family members to mourn and providing an opportunity to build skills to manage stress are essential. Counselors should follow up with bereaved children for long periods of time because of the potential for delayed effects following parental death (Worden & Silverman, 1996). Finally, counselors should remain sensitive to the continuing and life-long nature of parental bereavement, particularly surrounding common life transitions for children as they grow into adulthood and beyond.
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Robyn A. Howarth is affiliated with The University of Iowa. Correspondence concerning this article should be directed to Robyn A. Howarth, Department of Psychological and Quantitative Foundations, The University of Iowa College of Education, 361 Lindquist Center, Iowa City, Iowa 52242-1529. E-mail: firstname.lastname@example.org.