Therapy on Parentally Bereaved Children and Adolescents

Franklin, Harris & Allen-Meares (2006) state death is a universal experience. Every year hundreds of thousands of children in the United States encounter the death of a parent, grandparent, or other close relatives. Abuhegazy (2017) states statistics indicate approximately 1 in 20 children will experience a death of a parent before the age of 18 in the United States and one-third of American children spends the first 18 years with only one parent. Not specified in that figure are the accounts of loss of other family members such as siblings or stepparents. For school-aged children a parent or caregivers’ death can be overwhelming. Fitzgerald (1992) stated children who grieve the death of a parent or caregiver can experience that grief over many years without the intensity of early grief. The child or adolescent will be in touch with the grief when significant events occur such as winning a game, making honor roll, and having a first date. This process can continue into adulthood reminding them of what they have lost as big events approach such as graduation, marriage, the birth of babies, and all the moments they would have wanted to share with the person that passed. The topic of grief is relevant because all families and children are affected by a loss. Children and adolescents experience a vast array of loss and unruly changes throughout their lives. Grief and loss occur in many forms, situations, and does not exempt any group. Even in the event of death children and adolescents are expected to behave their best intellectually, socially, emotionally, and behaviorally at school. However, a reaction to a loss can affect a student’s ability to bring success academically and behaviorally. Actions speak louder than words when it comes to children because many behavior changes are often signs of their grief. Schools are a crucial place for the development of children and adolescents. School social workers specifically work with students who have experienced a lot of stressful events and are essential to improving the social-emotional well-being of these students. Quinn-Lee (2014) suggests that even though grief is a family issue, it can affect the child while they are in school, especially since children spend most of their time in school. School social workers need knowledge of crisis interventions, grief work, and treatment for post-traumatic stress.

The grief that loss brings about can come from the death of a loved one, divorce or separation, or other disruptive changes but the focus of this paper is on the loss of a loved one. The different types of loss can cause grief in children and adolescents to happen. Regardless of the kind of loss, one persistent characteristic every loss is accompanied by is grief.

Theories

Bronfenbrenner’s ecological systems theory looks at a child’s development within the framework of the relationships that form their environment. The theory explains how everything in a child’s environment can affect how the child grows and develops. Bronfenbrenner defined different levels of the environment that shape a child’s development, including the microsystem, mesosystem, exosystem, and the macrosystem. Rasheed, Rasheed, and Marley (2011) state the microsystem is the small, direct environment the child lives in. The microsystem includes any direct relationships such as family or caregivers, peers, neighborhood, and their school. How the groups communicate with the child will influence how the child grows. The next level is the mesosystem, represents how the different parts of the child’s microsystem work together for the well-being of the child. The primary relationship in the meso level for children is how parents interact with the school. The exosystem level includes other people and places that the child may not deal with personally with but have a significant effect on them, such as extended family members, parents/caregiver’s workplace, neighborhood, etc. For example, if a child’s parent loses their job that can negatively affect the child if the parents are unable to pay rent or buy groceries. The final level is the macrosystem. This level is the greatest and most remote set of people to a child but still has a significant influence on the child. The macrosystem includes government, cultural value, the economy, etc. These can also affect a child either positively or negatively. Bronfenbrenner outlines influences from multiple system levels that can affect the way a child grieves. Death can affect all levels of a child's environment. The death of a parent or caregiver directly affects the child’s microsystem. The child loses the immediate relationship with that person, which then affect all the other relationship in the microsystem. A disruption in the child’s environment across most levels can affect the way the child grieves. For example, the now single parent could also be affected by the loss of the loved one and disrupt the child’s micro and meso level by not interacting with the child or working together with part of the child’s microsystem. The death of a parent or caregiver can also affect the child’s exsosystem if for example the parent that passes was the primary income. This now negatively affects the child because a parent or caregiver is not unable to pay for rent or groceries. Death affecting all these levels can cause more stress on the child’s life making it hard for them to grieve because of all the other things going on in their environment now. The goal of ecological systems theory is to enhance the individual and family’s connection to supportive networks to improve functioning and attain resources. The social worker can use this theory to help connect the family to the support networks to address all the possible new stressors within each level. Along with helping with support networks the social worker can present therapy for the grieving child and family.

Family systems theory examines the family-wide connotation of death, the transactional processes in family adaption over time, and the variables of risk and resilience. The loss of a family member is a loss for the entire family, affecting all members, relationships, and the family as a functional unit. Walsh and McGoldrick (2013) shared, from a family system orientation, bereavement is viewed in terms of transactional processes affected by the experiences of previous losses and involving those who die and their survivors in a shared multigenerational family life cycle. Death can disrupt a family’s functional equilibrium. Death involves multiple losses in numerous relationships, functional roles, and the family unit. Rasheed, Rasheed, and Marley (2011) stated in the integration of systems and developmental theory that death is considered a horizontal stressor for families. These stressors reflect the life cycle transitions. The death of a parent or loved one can be a highly stressful event for children. Although the children need support the reverse can happen because of the change in family systems and roles. Many children’s caregivers are struggling with their own grief. The caregiver must also deal with the stress of being a single parent, sole provider, and coping with their loss. This can mean less time, attention and support for the children from the remaining parent or caregiver. In some events, children may never get to grieve appropriately with all the new changes that are happening within the family.

Developmental theories

John Bowlby provides a reason for the human tendency to develop secure attachments. He views attachment as a mutual relationship that occurs because of long-term interactions, starting in infancy. Bowlby suggests that grief is a typical response to separation. John Bowlby initiated a focus in psychoanalytic research on the nature of early attachment relationships and loss. Scott (2007) stated Bowlby was one of the first to research childhood bereavement. Bowlby’s attachment theory is one of the many approaches that provided the foundation for bereavement counseling. In Bowlby’s research with young children and their mothers, he studied the impact of separation and situations that caused fear or anxiety. He determined that fear is brought on by such as darkness, sudden movements, or separation. Bowlby examined young children’s response to temporary or permanent loss and noted expressions of sadness, anxiety, and grief that accompany such loss. Some research suggested that there may be a link between attachment and grief response. Bowlby describes stages of separation for infants that were comparable to those of grief. Attachment behaviors are natural behaviors that have as their goal of maintaining contact with another individual. The purpose of attachment behavior is to keep the bond with the loved one. Death is a disruption in the attachment the child has with their parent/caregiver. This is recognized and generally has a process of grief that follows. Stroebe, Stroebe, and Schut (2018) explain Bowlby’s four-stage grief process that includes numbness, yearning, despair, and reorganization. Numbness is the phase in which there is a sense the loss is not real. During this time there is a sign of physical distress where many people shut down emotionally. The phase of yearning shows an awareness of the void left in life from the loss. Despair is when acceptance of the change occurs. One feels hopelessness, despair, as well as anger and question during this stage. Finally, reorganization is when one’s life starts to become restored. How can anyone expect a child or adolescent to go through these stages and get to the stage of reorganization without support from someone such as the school social worker? Without the guidance or support from the social worker, the child could be suck in the numbness and yearning stage. Children develop different cognitive skills throughout life, as a child gets older, their cognitive skills develop and become more advanced. Piaget’s researched four stages of development. They are sensory-motor, pre-operational, concrete operational, and formal operational. A child’s understanding of death develops as the child grows older and their cognitive abilities are developed. A young child may have difficulty comprehending death because their cognition is still evolving. Slaughter (2005) stated, the pre-operational and concrete operational receive the most focus on bereavement for children. In the preoperational stage, children are building on the knowledge that was learned through their physical means in the sensorimotor stage. Children in the pre-operational stage may have less of an understanding of death than the children in the concrete operational stage. The children in the pre-operational stage do not have the cognitive ability to understand death is irreversible and universal. Slaughter (2005) shared, children believe death is temporary and relate death to concrete things such as the dead having closed eyes. When the child transition to the concrete operational stage, the child understands the dead is gone. Fitzgerald (1992) states, during each stage of development that child comprehends death differently. However, Pulaski (1980) reported, because of object permanence can be seen in young children, it can be expected that children will note when someone is missing. Death should be addressed because young children can notice this change in their lives. The children may not understand the difference, but they know something is different. As stated before children believe death is temporary and children who notice a change only see it as temporary. Children are thought to be in Piaget’s preoperational stage during that time. During the preoperational stage, children believe in regard to centration. This explains why children are only able to consider one facet of death at a time. In the first stage of understanding death, children realize it has happened but is unable to understand it is not reversible. Children in the concrete operational and formal operation stages can understand death better as they grow older. An example of this change is children will transform their thinking from specific and concrete to more abstract thinking. Talking to a child about death depends on their cognitive development and their understanding of death. Pulaski (1980) shared concrete operational are school-aged children, and school-age children have an increased understanding of causality, are less egocentric and have an increased understanding of time than in earlier stages.

Certain aspects of grief are virtually universal. However, the bereavement process can vary depending on one’s culture. The counseling/ social work profession has begun to recognize the significance of an individual’s cultural perspective. Today the bereaved are viewed as unique individuals whose grieving process is altered by many cultural factors. Additionally, knowing the rules and roles of one’s culture such as ethnicity and geographic location can be powerful forces in molding thoughts, feelings, and behaviors during a time of grief. Each society has traditions and rituals that provide structure to the grief experience. It is essential that the social worker identifies the client’s unique cultural influences and consider their influence on the grieving process instead of working from stereotypes.

Overview of interventions

Abuhegazy (2017) shares, intervention models for helping bereaved children and adolescents is not much, some target the child, others target the parents or both, some intervene through group therapies, grief programs, support groups, and cognitive behavior groups. Although there are many interventions used for bereavement, there a few that are deemed effective. There is no universally agreed on intervention for bereavement. In this section will give an overview of interventions that have been used to help with grief but are not limited to only grief work. There are many types of interventions used for those who are experiencing the loss of a loved one. A few interventions include an array of approaches such as grief therapy, peer counseling, support groups, play therapy, individual therapy, and family therapy. Childhood bereavement is not limited to these specific interventions. Franklin, C., Harris, M., & Allen-Meares, P. (2006) state, peer support and discussion groups are one of the best techniques for adolescents because they are more comfortable talking with peers about death than adults. The groups offer individuals an important opportunity to be with others as they grieve. For many, finding a group that is experiencing the same issues can be important. Groups provide members with safety and support and normalizes and validates their reactions to the loss. Play therapy is growing in popularity throughout the western world, but the ideas of play are not a new thing. Children do not like to sit and talk with adults. Playing is a way that makes sense in their world. It can be challenging for children to share what is bothering them, play can encourage children to communicate. Play allows the children to use their imaginations to safely express thought and feelings. This type of therapy can be helpful for younger children during the grieving process.

Along with play therapy, art therapy has also been found to be effective with the population of children and adolescents. Art therapy can also be used in support for children by sharing and healing of their experiences with loss. Children respond well to art therapy because they can express themselves through drawing. Art related interventions have been proven to be a valid form of support for children to express themselves and cope with the grieving process. An example of art therapy is memory books. Franklin, Harris & Allen-Meares (2006) share bereaved children use memory work to create a physical way to remember their feelings and share them. Memory books are a collection of thoughts and feelings through drawings and writing that allows the child to re-experience memories in a safe way. Along with memory books children can make memory boxes that may contain special pictures and objects to remind them of their person who died. There are many other ways to use creative therapies as interventions.

Effective and efficient interventions

The death of a parent is an immensely stressful life event for children and adolescents. While the children and adolescents at this time need support, the contrary can happen because of changes in the family system and family roles. When a parent or caregiver dies, the children and remaining family need support and advice in their grieving process. The question is what kind of help are most useful for the children and their families. Bergman, Axberg, and Hanson (2017) focused on the effects of support interventions for children who are parentally bereaved. The reason for this in-depth focus is that it is recognized that there are difficulties for children who lose a parent and caregiver. The closer relationships can have heightened feelings of loss and bereavement. Bergman, Axberg, and Hanson (2017), present findings from a systematic review of empirical studies evaluating the effectiveness of supportive interventions. The interventions reviewed in this study are bereavement groups for inner-city kids, camp activities at camp magic, writing for recovery, family therapy, parent guidance program, and the family bereavement program. Most interventions were directed to both the children and the caregivers. The results from this review differ from other studies because it focuses solely on parentally bereaved children. The overall results indicate that even relatively brief supportive interventions can keep children from developing more problems after the loss of a parent or caregiver. The interventions may help prevent mental health problems and traumatic grief after the loss of a parent. The family bereavement program showed results of positive effects for both children and caregivers. The studies of the program also stated some children and families might require more intensive interventions or more support as the intervention itself is brief. Many populations are not amenable to the current interventions because of personal and cultural beliefs, socioeconomic status, and many other factors that affect their ability to receive proper help. For many parents if the intervention is not offered through the child’s school the child does not participate. The study above does not look at factors such as poverty. The interventions shared above would possibly require transportation, fees, and insurance to be able to participate.

In conclusion, there is no one grief intervention that is agreed upon by professionals. Future research is vital in the area of child and adolescent bereavement. It should be recommended for researches to look at the possible factors that make populations not amenable to the current interventions. More research is needed to provide strong evidence-based platform for what kinds of interventions are most helpful for bereavement children and adolescents.