Grief in children

3

1INTRODUCTION TO INTEGRATED

GRIEF THERAPY FOR CHILDREN (IGTC)

Most young people experience the death of at least one loved one atsome point in childhood (Harrison & Harrington, 2001). Approximately 4%of children (through age 18) in Western countries experience the death of aparent (Garmezy & Masten, 1994; Harrison & Harrington, 2001; SocialSecurity Administration, 2000), which is considered one of the most stress-ful events a child can experience (Yamamoto et al., 1996). Many more expe-rience the death of another loved one, such as a grandparent, other familymember, or friend.

Children vary widely in how they respond to the death of a loved one.Much of this variance is influenced by developmental stage, with a 5-year-old’s cognitive, emotional, and behavioral responses differing greatly from an18-year-old’s. The variance in how children respond is also influenced by fam-ily factors, such as the family’s functioning prior to and after the death andthe child’s relationship to the surviving caregiver. Further variance occurs onthe basis of individual child factors, such as temperament, access to and useof social support, and coping style. With such a wide range of responses fromchild to child, it is impossible to describe any single timetable or series ofstages that grieving children necessarily follow.

11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 3

Nonetheless, certain responses are common among bereaved children.For example, bereaved children are likely to experience confusion, sadness,anger, and worry. For most children, these feelings lessen over time, particu-larly when they have the support of trusted adults and peers with whom theycan talk and share their feelings. Other children seem to have a more difficulttime, experiencing psychological distress and social isolation that persist forseveral months or longer.

Those children who do suffer from significant or prolonged distressfollowing the death of a loved one may be affected in a myriad of ways,including depressed mood, irritability, and significant anxiety about thehealth and safety of surviving family members (Abdelnoor & Hollins, 2004;Cerel, Fristad, Verducci, Weller, & Weller, 2006; Dowdney, 2000; Genevro,Marshall, Miller, & Center for the Advancement of Health, 2004). Theymay also exhibit behavioral problems, a decline in school performance,and/or social withdrawal (Luecken, 2008). Finally, emerging evidence sug-gests that early parental loss may be linked to physical health problems laterin life (Luecken, 2008). It is estimated that 20% of bereaved children arelikely to have problems significant enough to require clinical intervention(Dowdney, 2000).

Children’s difficulties following a significant loss may be related to theinherent stress of grief as well as problems adjusting to corresponding changesin the family system. For example, many parentally bereaved children livewith the surviving parent, who may remain single or may eventually remarry.Other bereaved children live with grandparents or extended family members,particularly when both parents have died or when the deceased parent wasalready a single parent as a result of divorce or other circumstances. Still otherchildren enter foster care or are cared for by other nonrelatives.

Despite the good intentions of the larger family or community, bereavedchildren often must also deal with the challenge of responding to a socialcontext in which peers as well as adults may not know how to interact withthem. Bereaved children often feel isolated and different from their peers,and they may feel that they are treated differently at school or in social set-tings. Complicating matters further, when the loss is that of a parent or otherimportant adult role model, the child loses a guide to help negotiate variousemotional and developmental challenges so that others are needed to stepinto these roles.

Given the widespread occurrence and potential for trauma and othernegative physical and mental health consequences of losing a loved one inchildhood, it is important for every clinician who works with children tounderstand how best to help them cope with these types of loss experiences.To meet this need, this book offers an evidence-based model of treatment—called integrated grief therapy for children (IGTC)—that can be applied to var-

4 FOUNDATIONS OF TREATMENT

11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 4

ious symptoms and circumstances with bereaved children. IGTC goes beyondother child therapy approaches by not only addressing specific presentingsymptoms, such as depression and anxiety, but also attending to the child’sareas of strength and fostering resilience. Although most of the interventionsin IGTC are cognitive–behaviorally based, the theoretical framework alsointegrates principles from family systems work, interpersonal therapy, andnarrative approaches.

This book contains everything needed to successfully implement IGTC,including instructions for specific components of the therapy, sample dialoguesto illustrate concepts, and activity handouts that therapists can photocopyand use in sessions. The primary intended audience for this book is thetherapists, social workers, psychologists, psychiatrists, and other profession-als who provide mental health services to children and families. However,caregivers of bereaved children can also benefit from the book. The remain-der of this chapter defines some basic terminology, outlines the componentsof IGTC, and explains how the book is organized.

TERMINOLOGY

For simplicity and clarity, throughout the book we refer to the currentprimary caregiver as the parent, although we acknowledge that the personmay be another relative or adult who is responsible for the bereaved child.Furthermore, we use the term children to include those of early childhood agethrough adolescence, roughly ages 4 through 20, unless otherwise noted. Forchildren younger than the age of 4, the recommendations and interventionsgeared toward parents and caregivers may be used.

Bereavement refers to the objective experience of losing a loved one bydeath, whereas grief refers to the subjective reactions that people have tobereavement, including the set of emotional, cognitive, behavioral, and phys-ical manifestations and signs of distress that may follow the death of a lovedone. Mourning is the formalized expression of grief that is practiced by a soci-ety or specific cultural group. This includes memorial services, funerals,wakes, and other rituals (Genevro et al., 2004).

IGTC

The IGTC model was developed on the basis of several main beliefs, ortreatment principles, and consists of three phases of treatment. This sectionoutlines each of these guiding treatment principles and phases of treatment.

INTRODUCTION TO INTEGRATED GRIEF THERAPY FOR CHILDREN 5

11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 5

Treatment Principles

IGTC comprises seven treatment principles that serve as a foundationfor all clinicians working with grieving children and their families. We dis-cuss each principle in turn.

Principle 1: The Process of Grieving Looks Different From Person to Person—There Is No One Right Way to Grieve

When faced with the death of a loved one, people respond in highlyindividualized ways. For example, some bereaved children find comfort inopenly talking about the deceased, whereas others prefer to maintain theirmemories in a more private fashion. Contrary to commonly held assumptions,research indicates that people who are grieving do not necessarily follow anyparticular set of stages and that responses to loss vary greatly from person toperson (Weiss, 2008; Wortman & Silver, 2001).

Given the importance of individual differences in the grieving process,clinicians working with the bereaved must tailor their approach to the needsof the individual. It may be argued that this is especially true when workingwith children, who may face additional challenges depending on their ageand cognitive development, such as potential confusion about death itself.For many children, the loss will bring about changes that will alter the courseof their lives, and they will experience an array of responses and feelings thatmay (or may not) accompany such change, including sadness, guilt, ambiva-lence, fear, and relief, to name a few. The IGTC approach therefore serves asa guide containing a multitude of options from which the clinician canchoose aspects that are most relevant for the individual child.

Principle 2: Whenever Possible, Use Evidence-Based Interventions to Guide Treatment

It is our belief that when certain interventions or approaches have beenfound effective in treating a given problem or disorder, then those are theinterventions that should be used. Fortunately, the child therapy literaturehas expanded significantly over recent decades so that a growing body ofresearch is available regarding what types of treatment approaches may behelpful for specific disorders and symptom areas. This is particularly true foranxiety, for which there is perhaps the most significant amount of treat-ment outcome data for children (for reviews, see Scott, Mughelli, & Deas,2005; Silva, Gallagher, & Minami, 2006). There is also evidence regardingwhich approaches are most effective in helping children with posttraumaticstress disorder (PTSD), depression, and behavior problems (for reviews, seeChristophersen & Mortweet, 2001; Target & Fonagy, 2005). Our approach


11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 6


to working with bereaved children who are experiencing problems related toPTSD, anxiety, depression, and behavior problems, as detailed in Part II ofthis book, is therefore largely based on the existing literature.

Unfortunately, there continues to be a scarcity of evidence regardingthe efficacy of treatments designed specifically for grieving children, and thosetreatments that have been studied have almost exclusively been group-basedrather than individual approaches (Currier, Holland, & Neimeyer, 2007).Some of these group approaches have contributed greatly to the child grieftherapy literature, such as the Family Bereavement Program (Sandler et al.,1992, 2003), whose outcomes highlight the importance of including the par-ent in treatment for bereaved children. This has, in turn, informed the IGTCapproach, which similarly focuses on parenting skills to promote resilienceamong grieving children.

Not all bereaved children are in need of treatment, and interventionsappear to be most beneficial with children who exhibit adjustment difficul-ties or other problems after the loss (Currier et al., 2007). Research indicatesthat when bereaved individuals who are experiencing significant distressreceive treatment, outcomes tend to be favorable, with effect sizes compara-ble with those seen in psychotherapy for other psychological difficulties(Currier, Neimeyer, & Berman, 2008). These findings support our belief thatnot all bereaved children require a full course of IGTC, which has beenspecifically designed to allow clinicians to select interventions based on thechild’s given needs.

We feel strongly that more research is needed in the area of individualtherapy for bereaved children, but we also know that clinicians need guidancefor how to work with such children based on what we know to be effective sofar. Our model therefore attempts to incorporate the given body of literatureinvolving bereaved children (albeit limited) while also drawing from the exist-ing general child treatment literature as well as our own experience with andunderstanding of this population.

Principle 3: Collaboratively Identify Goals and Determine How to Reach Them

It is important that the therapist present a plan for treatment based onactively discussing goals with the child, and, in some cases (in particularwhen younger children are involved), the parent. Such discussion not onlyallows the child some sense of control (which is often disrupted in the faceof major loss) over the treatment but also provides a sense of structure andmomentum that helps the child and therapist know and agree on what hasbeen accomplished and what work remains. The implication is that a discus-sion of treatment goals is ongoing, rather than a single occurrence at the startof therapy.

11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 7

The importance of collaboration in identifying goals is illustrated by the case of Lila, a 17-year-old girl whose father died 1 year before Lilaentered therapy. Lila felt overwhelmed by the changes she was facing dur-ing her senior year of high school and by the choices she needed to makeregarding college applications. Over the course of therapy, there were timesduring which these decisions were impacted by the loss of her father; forexample, she did not wish to attend a college that was farther than a shortcar ride away so that she could be available to help her mother with her littlesister. There were other times, however, that Lila looked to her therapistfor guidance about issues that were unrelated to her grief and were more uni-versal to adolescents her age. It was important that Lila’s therapist under-stand what she was looking for in therapy so that they could together movetoward those goals.

Principle 4: Build on the Parent–Child Relationship

On the basis of our experience as well as current research (for a review,see Luecken, 2008), the outcomes of the bereaved child are significantlyrelated to the functioning of the surviving parent or caregiver. The inclusionof a surviving parent or caregiver is therefore instrumental in working withbereaved children. The loss of a loved one impacts a whole family and ofteninfluences the relationships between family members as a result. Our belief isthat bolstering the child–parent relationship is one important component inhelping the child to grieve and manage the consequences of a major loss. Thismay be done in a variety of ways, each of which is described in detail in laterchapters, including psychoeducation for the parent around children’s reactionsto loss, increasing communication between child and parent, and improvingparenting skills.

Principle 5: Create and Implement a Treatment Plan Consistent With the Child’s Style, Family Culture, and Temperament

As discussed previously, it is important to tailor the approach to theindividual. Specificity works in terms of both content (i.e., areas to be addressedthrough treatment) and process (i.e., how the clinician addresses the childand presents him- or herself and the treatment). In other words, not onlyis it important to choose which interventions to utilize based on the needsof the child, but it is equally important to choose how to present thoseinterventions based on the child’s personality, temperament, age, abilities,likes, and dislikes. For example, whereas a 16-year-old boy may feel com-fortable raising his own issues for discussion, a 6-year-old boy might requirea more structured environment, including elements of play and art. Similarly,two 10-year-old girls might respond to the same therapist very differently,


11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 8

with one preferring to express herself through art and the other preferring toexpress herself through talking and storytelling. The important principle hereis that there are multiple ways to engage children, and the therapist shouldtake the time to figure out what works best for the individual child.

In the same way, when including the parent in treatment, the parent’sstyle as well as the parent–child relationship must be taken into account.Often, therapists are surprised when a child who was fully engaged during anindividual session seems to suddenly clam up when the parent is invited toparticipate in the session. For this reason, any inclusion of the parent shouldbe fully discussed with the child prior to a joint session. Such discussionshould include getting the child’s input about what to share with the parentas well as who (i.e., the child or therapist) should share it.

Principle 6: Provide Clear Expectations for Therapy

Bereaved families seeking therapy are struggling with profound lifechanges and may not be experienced with what therapy typically involves. Itis important for the therapist, who is often being looked to for guidance, tooffer a safe place in which the child’s most private thoughts and feelings maybe comfortably revealed. Likewise, it is important for the therapist to discloseto both the child and parent where he or she is coming from, both in termsof the general approach to treatment (e.g., “I know you said you would liketo be able to talk to each other about what happened, and I am here to helpyou do that”) and professional responsibilities, including issues of confiden-tiality and its limits. Issues of confidentiality are particularly important to dis-cuss in a clear way, again with both the child and parent, when the parentwill have some role in the treatment process.

Principle 7: Build on Strengths of the Child and Family to Provide Skills That Will Continue to Help Them Over Time

Many of the books currently available regarding clinical practice withchildren tend to focus on diagnostic issues and how to get relief in key problemareas. Although there is an important place for this type of deficit-basedapproach, and, in fact, we do include several types of interventions aimed atcommon problem areas in Part II of this book, we also feel that the strengthsof a child are equally important as a focus in therapy for bereaved children.By focusing on and bolstering the strengths of the individual child and his orher family and by using community resources, resilience may be fostered. Thefundamental idea is to enhance the child’s and family’s quality of life by notonly reducing problems and symptoms but also by increasing positive inter-actions and building on what the child and family are already doing to helpthemselves. In this way, the child will learn how to cope with the loss of a loved


11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 9

one and will be more prepared to adapt to the significant life changes associ-ated with such a loss.

Phases of Treatment

Keeping in mind the basic treatment principles, the clinician adminis-ters three phases of IGTC (see Figure 1.1). In the first phase, he or she assessesthe grieving child to determine what needs must be met, what symptoms mustbe addressed, and what resources can be drawn upon to build resilience. Thisphase is critical for customizing the treatment plan to meet the unique needsof the child. As discussed previously, some children will present with minordifficulties, whereas others will face one or more significant prolonged symp-toms. Similarly, children vary in their circumstances and preferences and willtherefore require customized interventions to develop coping skills and buildresilience. The first phase ends with determining goals for treatment andpreparing the child and parent for the work ahead by presenting basic skillsthat will serve as building blocks for the therapy.

The second phase is to address any presenting symptoms or problems,such as depression, PTSD, anxiety, or behavior problems. Clinicians shouldaddress these symptoms prior to focusing on grief and resilience (the thirdphase) because these symptoms have the most impact on the child’s daily life.However, if a child does not present with specific clinical symptoms but never-theless wishes to benefit from grief-focused treatment, then the second phasemay be largely omitted.

The third phase of treatment is to focus more on the loss itself and thegrieving process while fostering resilience in the child. One important com-


Phases of treatment

Address presenting symptoms:

Depression PTSD Anxiety Behavior problems

!

!

!

!

Assess grieving children and teachbasic coping skills

Address grief and build resilience:

Teach coping skills Make memories

Foster resilience

!

!

!

and integrate past and present

Figure 1.1. Model of integrated grief therapy for children. PTSD = posttraumaticstress disorder.

11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 10

ponent of this phase is helping the child maintain a connection to the deceasedin a way that brings comfort and security while also helping the child to useadditional resources, such as the support of other loved ones and their ownstrengths and coping skills. This continued connection with a lost loved oneis thought to be especially important for bereaved children and is in line withother researchers and practitioners who have recognized the importance ofmaintaining relationships or bonds between bereaved persons and theirdeceased loved ones (Field, 2008; Klass & Walter, 2001; Malkinson, 2001;Silverman, Nickman, & Worden, 1992; Weiss, 2008).

Within each phase of IGTC, the clinician is encouraged to use thoseaspects of the treatment that are most relevant and make the most sense forthe given child who presents for therapy. For example, a 9-year-old boy whohas refused to sleep in his own bed at night and has discontinued many of hisafter-school activities since the death of his mother may benefit from inter-ventions to address depression and anxiety (second phase of IGTC). Follow-ing some symptom improvement, the clinician might then help the boy talkto his father about ways that he would like to preserve his mother’s memory(third phase of IGTC).

ORGANIZATION OF THE BOOK

The book is organized into three parts that mirror the three phases ofIGTC. Part I introduces the IGTC model, reviews its empirical and theo-retical basis, and presents the first phase of treatment. The current chapterlays out the basic tenets of IGTC. Chapter 2 reviews the current literatureon bereavement in childhood, including risk and protective factors, clini-cal outcomes, and findings regarding working with bereaved families intherapy. Chapter 3 further details the first phase of IGTC, provides guide-lines for the assessment of bereaved children, and outlines the basic skillsof treatment.

Part II focuses on the second phase of IGTC, administering interven-tions to bereaved children who present with clinically significant problems.This phase of treatment is organized around four major symptom clusters thatare most relevant for grieving children: depression (Chapter 4), PTSD(Chapter 5), anxiety (Chapter 6), and behavior problems (Chapter 7).

Part III focuses on helping children to move forward by increasing skillsand bolstering strengths. Chapter 8 describes how children understand andcope with loss and learn to thrive despite the loss. The chapter also includesguidelines for presenting these concepts to the child and his or her caregiver,as well as information for parents about how to talk with and help their


11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 11

grieving children. Chapter 9 presents interventions for improving children’scoping skills to address thoughts and feelings related to grief. Chapter 10focuses on facilitating grieving by preserving memories and integrating theloss into the child’s current life. Finally, Chapter 11 describes how to fosterresilience by strengthening the parent–child relationship and by helping thechild to further build on the skills learned throughout the course of treatment.Because therapy termination requires preparation and sensitivity, the chap-ter also describes how to terminate therapy once treatment goals have been met.

Throughout the book, the text is supplemented with case examples,therapist scripts, dialogues, and activities to illustrate the use of IGTC tech-niques. Handouts are provided to make many of the strategies ready for useby the clinician. Activity handouts are presented in the chapters in whichthey are first introduced, each on a separate page so that they may be easilyphotocopied and provided to the child and/or parent for use in and betweensessions. Clinicians should feel free to create their own handouts and activi-ties based on the needs of the individuals they are working with. In fact, weencourage the clinician’s creativity throughout the IGTC approach, with anunderstanding that the treatment is most effective when it is tailored tomatch the style of the therapist and the unique needs of each bereaved child.


11909-01_CH01-rev.qxd 1/18/10 2:29 PM Page 12

Grief in children

Documents

Transcript of Grief in children