Indication
Recommendation
Does the child show clinically elevated grief-related distress, depression, anxiety or functional impairment on objective, normed measures of functioning?
If so, assessment and treatment with a qualified mental health professional is recommended to reduce current distress and to prevent future impairment. If a child reveals suicidal ideation or intent, or engages in risky or self-harming behavior, urgent evaluation and safety planning is critical
• Consider TF-CBT, TGCT-A for children who experienced a loss with subjectively traumatic features
Does the child have one or more risk factors for heightened distress or dysfunction, or is the child asking to see a therapist?a
If so, and particularly if multiple risk factors are present, treatment aimed at ameliorating the risk, likely with a professional mental health provider, is indicated.
• Child factors: prior psychiatric disorder, especially depression or anxiety; high number of negative life events; low self-esteem; negative coping style/poor expressive coping; belief that others are accountable for the death, or that others blame the child for the death
• Consider returning to a provider who was helpful in the past, for children with pre-existing mental health issues
• Consider school-based resources and the match between the expertise and school-year availability of staff, with the child’s needs and preference for school to remain an “island of normalcy” where grief is not a focus
• Caregiver factors: poor caregiver mental health and functioning, especially depression; expression of strong emotional distress in response to the death; low levels of child-centered parenting, parental support and communication; history of bipolar disorder in the deceased parent
• When resources are limited, consider supportive interventions such as Big Brother/Big Sister programs that strengthen the child’s connection to stable, supportive adults; be careful about programs with high turnover, however, to prevent additional losses
• Family factors: low family cohesion and low adaptability
• Consider individual therapy or group supports for caregivers with significant mental health issues
• Consider individual or group parent guidance to promote positive parenting practices
• Loss factors: protracted illness, being at the scene when a sudden death occurred; parental suicide
Does the child feel generally well-supported by adults and peers in his or her day-to-day environment but overwhelmed by particular challenges at school, with friends, during activities, or at home with family? For example:
If so, consider what kinds of targeted approaches might broaden and deepen the child’s social support network, and improve coping skills in a way that takes into account the child’s unique personality, temperament, and strengths. For example:
• Difficulty on math tests that do not seem to be part of a broader drop in grades suggestive of depression, but rather an adjustment to loss of a parent who structured study time and provided “cheerleading”
• Tutoring from an older student
• An initial scheduled check-in with a school guidance counselor to increase child’s comfort with accessing that person and to develop a coping plan for managing distress during the school day
• Worry about “breaking down” in front of peers at school in response to loss reminders
• Irritation/fighting with a sibling who is grieving differently and may seem uncaring
• Parent guidance/psycho-education about normalizing a range of grief reactions, impact of developmental stage on grief, and strategies to talk with children about these differences
Even in the absence of current emotional/psychiatric dysfunction (Indication 1 in Table 9.1) or significant risk factors for future dysfunction (Indication 2), managing the cascade of changes that attend the death of a caregiver (Indication 3) can be extremely stressful for children. How numerous and significant these changes are varies widely across families, and the broader context in which they occur impacts the child’s perception of stress. For example, a child with a previous history of being bullied at school and no really close friend will likely struggle more with getting teased about a deceased parent than a child with a long-time best friend who also likes and trusts his teacher. A military-connected child whose parent’s death forces an eventual move from a military base, with its strong network of support, to a neighborhood of civilians may find the change in location challenging but the change in culture even more so.
Thus, clarifying the child’s own perception of support from home, school, and peers is a critical step in fully assessing the need for any kind of treatment.
It Takes a Village
The importance of support to parents and caregivers as they care for grieving children should not be underestimated. Providers from a range of backgrounds—mental health, medical, and educational—have much to offer parents and, indirectly, their children. Suggestions, based on clinical experience, for providing guidance to parents in supporting their children are presented in Table 9.2. For example, providers might help parents reframe efforts at self-care not as selfish, but rather as a means to facilitate children’s well-being by setting a positive example and optimizing their functioning in the parenting role. Expressing genuine interest about a parent’s experience caring for a grieving child will likely reveal opportunities for support and comfort. Given the opportunity to talk, some parents will share that they are deeply afraid that the death of a loved one might ruin their child’s life forever. Conveying that bereaved children can grow up to lead productive lives and find people to love and be loved by, can be enormously helpful to parents. Perhaps most important is the assurance that you will support them in ensuring their children thrive.
Table 9.2
Helping parents help children
Parents can | Providers can |
|---|---|
Provide praise, warmth, and consistent limits—these are critical to children of all ages | Develop comfort in screening children for distress and a rationale for recommending treatment |
Proactively identify signs that a child with a pre-existing psychological vulnerability could be relapsing. What helped in the past, and what can be done in advance to facilitate timely access to support? Internalizing symptoms are often under-recognized, especially in adolescents, so don’t set too high of a threshold for accessing support | Learn about resources in your area. Do they provide grief support for all children, or treatment for those with high levels of distress? Develop resource lists for parents. Consider training in an evidence-based approach, individually or with colleagues |
Talk with children about grief, but do not assume all negative emotion is grief-related. Even children with no loss history have bad days | Inquire about grief-related distress, and also about developmental competencies and strengths; both are indicators of functioning after a loss |
Communicate with the school: how does the child function there? What books or units may be challenging for the child (e.g., science unit on cancer) and what support can be offered? With the child, develop a plan for what to do if he/she becomes emotional during the day (visit nurse or counselor? text a parent?) | Understand and educate about trauma and loss reminders and the importance of not setting up a cycle of avoidance because it so often generalizes to new situations/settings |
Identify difficult dates for family members (e.g., major holidays, the birthday of the deceased) and know that their approach may explain heightened reactions that may otherwise seem mysterious | With parents, consider how to manage difficult dates: will the deceased be remembered aloud and is this comfortable for all family members? Are there arrangements (new location for holiday) or agreements (we will ask extended family not to ask children how they’re doing) that might help? |
For therapy-reluctant children , reframe as a way to thrive despite adversity, or an opportunity to develop skills useful in athletic and academic settings as well as close relationships. Try sharing that the primary motivation is to assuage your own uncertainty about recognizing distress, rather than a response to particular signals from the child | For therapy-reluctant parents , reframe getting their own support as one of the best ways of helping their children, not a luxury, given the strong connections between caregiver mental health, parenting, and child outcomes. Remind them that it is difficult to keep a child afloat when you, yourself are drowning |
Appendix
Family Bereavement Program
For program and training information, see https://reachinstitute.asu.edu/programs/family-bereavement
Intervention manuals for the child, adolescent, and parent programs are available from the Prevention Research Center, Arizona State University, 900 S. McAllister Ave. Room 205, P.O. Boxes 876,005, Tempe, AZ 85287–6005.
Trauma-Focused Cognitive Behavior Therapy (TF-CBT) for Childhood Traumatic Grief
Free web-based training available at CTGWeb: www.musc.edu/ctg
Free web-based TF-CBT consultation program (Funded by the Annie E. Casey Foundation) available at www.musc.edu/tfcbtconsult
For a list of certified therapists, see https://tfcbt.org/members
Trauma and Grief Component Therapy for Adolescents (TGCT-A)
Layne CM, Saltzman WR, Pynoos RS. Component Therapy for Trauma and Grief: Adolescent Version. University of California, Los Angeles; 2002.
Contact the authors for training.Related posts:
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