Counseling Bereaved Children and Adolescents

Description of Childhood Bereavement

Prevalence and Description of Problem

According to the children’s bereavement estimation model (CBEM; Judi’s House/JAG Institute, 2018), it is expected that 1 in 15 children will experience the death of a parent or sibling by age 18 years.

According to Harrison and Harrington (2001), 78% of children ages 11–16 years have experienced the death of a parent, close relative, or friend. Children and teens who experience the death of a parent or other loved one are more likely to exhibit depression and anxiety, engage in substance abuse, and develop conduct disorder symptoms compared to non-bereaved peers (Kaplow, Saunders, Angold, & Costello, 2010). Notably, symptoms of depression and drug use may not be present until almost two years after a parental death (Brent, Melhem, Donohoe, & Walker, 2009). Additionally, those whose parents died by suicide were three times more likely to die by suicide and were at increased risk of suicidal attempts, depression, and other mental health issues (Wilcox et al., 2010). These maladaptive behaviors are more likely to manifest with bereaved children who experience a loss that is stigmatized such as death caused by overdose or suicide (Brent et al., 2009). Despite the stated risk for children and adolescents to develop a range of severe mental health concerns following parental loss, a recent systematic review supported the effectiveness of support programs after parental loss, suggesting that brief interventions can indeed mitigate the development of such problems in children and adolescents (Bergman, Axberg, & Hanson, 2017).

Terminology

The language describing grief and loss counseling is often ambiguous due to the variety of interpretations and incorrect assumptions that the terms are synonymous (Humprhey, 2009). To better understand the grief process and help clients navigate their grief journeys, it is important to clarify terminology. Loss is “the real or perceived deprivation of something meaningful” (p. 5) and can be death-related or nondeath- related. Grief is described as the internal thoughts and emotions a person experiences as a reaction to the experience of a loss that may include death-related or nondeath-related experiences such as divorce or loss of a significant relationship (Center for Loss and Life Transition [CLLT], 2018). Mourning is the outward expression of grief and refers to socially acceptable practices (CLLT, 2018; Humphrey, 2009). Bereavement is a period of distress following the death of a significant person and always refers to death (Humprhey, 2009). When working specifically with children and adolescents, it is important for practitioners to use concrete, direct language such as death or died (Servaty-Seib, Peterson, & Spang, 2003). Euphemisms like lost or passed away can lead to client confusion and misunderstanding.

Resources:

Center for Loss and Life Transition. (2018). Grief and mourning basics. Retrieved from https://www.centerforloss.com/grief/grief-mourning-basics/

Full Circle Grief Center. (2018). Bereavement resource manual. Retrieved from http://www.fullcirclegc.org/wp-content/uploads/2018/09/FCGC-BRM-SEPTEMBER-2018.pdf

Judi’s House/JAG Institute. (2018). Understanding childhood grief in the U.S.: Children’s bereavement estimation model (CBEM). Retrieved from https://www.judishouse.org/cbem

Identification/Assessment Strategies

The Diagnostic and Statistical Manual for Mental Disorders (DSM-5; American Psychiatric Association, 2013) does not have an approved clinical diagnosis specifically for bereavement; however, persistent complex bereavement disorder (PCBD) is included in the conditions for further study. Although PCBD includes proposed diagnostic criteria for children and adults, it cannot be used for clinical diagnosis at this time.

Professional counselors should also be aware that suspected complicated bereavement can often be accompanied by comorbid disorders like post-traumatic stress disorder (PTSD), depression, and anxiety. Professional counselors should use their clinical judgment and knowledge of these co-occurring disorders when working with bereaved children.

Persistent Complex Bereavement Disorder (PCBD) Checklist – Youth

The PCBD Checklist is an empirically supported assessment that measures the five diagnostic criteria for PCBD in the DSM-5 (APA, 2013; Kaplow et al., 2018). This 39-item instrument can be used for children and adolescents ages 8-18 years who experienced the death of someone with whom they shared a close relationship at least six months before administration (Criterion A). Criterion B subscale (Cronbach’s = .85) has seven items that address persistent longing for and preoccupation with the deceased. The Criterion C subscale (Cronbach’s = .93) is 22 items that assesses the reactive distress and social/identity disruption due to the death. Each of these two subscales uses a Likert-type scale from 0 (not at all) to 4 (all of the time) to determine the youth’s reaction during the previous 30 days. Criterion B is met if at least one symptom is reported at a 3 or 4 and present longer than six months. Criterion C is met if at least six symptoms are reported at a 3 or 4 and last longer than six months. The PCBD also includes a traumatic bereavement specificer for adolescents who experienced a traumatic death like suicide or homicide. Functional impairment in the school, family, and social domains are also assessed in Criterion D. Criterion E assess that grief reactions are different or inconsistent with cultural, religious, and age- appropriate norms. The PCBD Checklist can be purchased for $3.00 per administration. A single-page scoring sheet and a testing manual are included with the purchase.

To purchase this instrument or for more information, visit https://www.reactionindex.com/as-uc-pcbd-y.html

Bereavement Risk Assessment Tool (BRAT)

The BRAT is an evidence-based bereavement assessment that is used to anticipate complicated grief reactions prior to a client’s loved one’s death (Victoria Hospice, 2018). Thus, it can be used with clients whose significant others are currently in palliative or hospice care. This is a 40-item psychosocial assessment that considers four risk factors such as existing mental health conditions, previous bereavements, concurrent stressors, and circumstances involving the expected death (Rose, Wainwright, Downing, and Lesperance, 2011). The BRAT also assesses 36 client protective factors such as social support, religious/spiritual support, and kinship. The total BRAT score provides a 5-level risk estimation with no risk (level 1) to high risk (level 5). When collapsing the risk levels into low and high risk, the BRAT has good inter-rater reliability with a Fleiss’ kappa of 0.63 and intra-class correlation of 0.66 (95% CI: 0.5-0.9) (Rose et al., 2011). Limitations of this assessment include subjectivity of some of the items and further studies are needed on its use with a variety of bereaved populations. The strengths of this assessment are that it can be used in a variety of settings by any number of professionals, is a precipatory tool to identifying complex bereavement issues, and includes a section about addressing children and adolescents. The BRAT manual and electronic files are available to purchase for $35.

To view a sample report from this instrument, visit https://www.victoriahospice.org/sites/default/files/ bereavementriskassessmenttool2008_0.pdf

To purchase this instrument or for more information, visit http://www.victoriahospice.org/health- professionals/publications-professionals#BRAT

Intervention Strategies

It is important to note that the aforementioned assessments specifically deal with complicated grief and anticipatory grief, respectively. The interventions below, however, can be used with all types of bereavement and levels of grief intensity. Because grief can vary greatly among individuals, it is up to the discretion of the practitioner to choose appropriate interventions.

Remembrance Activities

Whereas previous grief and loss models encouraged separation and disconnection from the deceased, contemporary grief and loss models emphasize the importance of maintaining a connection to deceased loved ones (Humprhey, 2009). Remembrance activities help children and adolescents maintain that bond. In a 2011-2012 national poll, 71% of bereaved children and adolescents indicated that they honored their loved ones by keeping photos or special items of them (National Alliance for Grieving Children, 2018). Creating memory boxes to keep photos or tokens of the loved one is a way to keep cherished belongings together. Professional counselors can work with clients on creative arts activities including journals, picture frames, t-shirts, and quilts. Additionally, organizations such as the American Foundation for Suicide Prevention and Full Circle Grief Center provide a space for online memorials for clients to honor their loved ones. Art with Heart and The Center for Loss and Life Transition have a variety of resource books with remembrance activities, which may be helpful for practitioners to purchase.

Resources:

American Foundation for Suicide Prevention. (2018). Create a new quilt square. Retrieved from https://afsp.org/find-support/ive-lost-someone/digital-memory-quilt/create-a-new-quilt-square/

Art with Heart. (2018). Grief resources. Retrieved from https://www.artwithheart.org/shop/

Center for Loss and Life Transition. (2018). Books and resources to help kids and teens. Retrieved from https://www.centerforloss.com/bookstore-category/for-adults/books-resources-to-help-kids-teens/

Full Circle Grief Center. (2018). Full circle grief center memory wall.

Retrieved from http://www.fullcirclegc.org/memories/

Grief.com. (2018). Grief and the holidays. Retrieved from https://grief.com/grief-the-holidays/

Bibliotherapy

Bibliotherapy is a powerful tool to help children and teens process death and can be used in conjunction with individual counseling (Briggs & Pehrsson, 2008). Death can be a difficult concept to understand, especially for younger clients. However, children respond well to fictional characters and stories, which help with the abstract concept of death (Arruda-Colli, Weaver, & Wiener, 2017). Books can also be a useful tool to help parents and professional counselors explain more stigmatized losses such as overdose and suicide in appropriate language. For teens, bibliotherapy can be a useful strategy to ease into death discussions, especially for those who are hesitant to openly share. Using stories and characters affected by death of a loved on also provide children with a model of grieving and helps to normalize the grief experience. In a meta-analysis of children’s books (ages 6–12 years) addressing bereavement, Arrunda-Colli et al. analyzed 210 books and noted some interesting demographic information that practitioners may find useful depending on their clientele. For example, over 90% of books were in English and had either animals or children as the main characters. The main types of death were grandparent and pet loss, and the majority of characters were white/Caucasian with an underrepresentation of minority populations.

Resources:

Centering Corporation. (2018). Children and teen grief resources. Retrieved from https://centering.org/free-grief-books/children-and-teen-resources.html

Full Circle Grief Center. (2018). Grief resources. Retrieved from http://www.fullcirclegc.org/grief-resources/#

What’s Your Grief. (2018). 64 children’s books about death and grief. Retrieved from https://whatsyourgrief.com/childrens-books-about-death/

Grief Groups

Group counseling can be a powerful tool for helping children and adolescents process death. In addition to the benefits of universality of experience and peer support (Jacobs, Schimmel, Masson, & Harvill, 2012), group counseling interventions can reduce posttraumatic stress symptoms (Salloum, 2008) and suicidal ideation (Sandler, Tein, Wolchik, & Ayers, 2016). Family grief groups that include parents, guardians, and other significant adults can also be useful by addressing the grief of the entire family and providing adults with education and resources to understand and help children grieve. Professional counselors can use their local resources to find bereavement support groups for children. Schools, hospitals, religious institutions, and police departments are common places that may offer bereavement support groups if practitioners do not have a local grief support center. Although the majority of grief support groups are conducted in-person, some groups can be facilitated online or through social media sites. It is important for professional counselors to work with clients on vetting these groups as they may not always be conducted by licensed professionals.

Resources:

Grief.com. (2018). Grief.com support group directory. Retrieved from https://grief.com/grief-support-group-directory/ 

Suicide Postvention for School Counselors

Suicide is the second leading cause of death among children and adolescents ages 10-24 years behind unintentional injury and has increased during the past few years (Suicide Prevention Resource Center, 2018). After a Suicide: Toolkit for Schools provides templates for releasing a community statement, tips talking with staff and students after a suicide, activities for helping students cope in the immediate aftermath, and strategies for memorializing the deceased student. This toolkit is endorsed by the American School Counselor Association, National Association of School Psychologists, and the National Association of Secondary School Principals. Because suicide is heavily stigmatized (Hanschmidt, Lehnig, Riedel- Heller, & Kersting, 2016; Sheehan et al., 2018), it may be helpful to use this toolkit and organizational endorsements to help advocate for directly addressing suicide in schools. Additionally, the Coalition to Support Grieving Students has a variety of resources for all school personnel to support students after a suicide or other type of significant death. Resources are also provided in English and Spanish.

Resources:

Coalition to Support Grieving Students. (2018). Crisis and special circumstances. Retrieved from https://grievingstudents.org/modules/crisis-special-circumstances/

Suicide Prevention Resource Center. (2018). After a suicide: A toolkit for schools. Retrieved from https://www.sprc.org/resources-programs/after-suicide-toolkit-schools

The Dougy Center: National Center for Grieving Children and Families. (2018). Supporting children and teens after a suicide death. Retrieved from https://www.dougy.org/docs/TDC_Supporting_Children  Teens_After_a_Suicide_Death_2018.pdf

Camp for Bereaved Children and Adolescents

Comfort Zone Camp (CZC) is a bereavement camp for children and adolescents ages 7–17 years (or 18 years if in high school) who have experienced the death of a parent, primary caregiver, or sibling. At no cost to families, CZC provides three-day sleep away camps for adolescents as well as single-day family grief programs to children and families. CZC has locations in California, Massachusetts, New Jersey, North Carolina, and Virginia and can help with travel costs to any of the locations. At the three-day camp, children and adolescents are paired with a Big Buddy, who is a same-gender adult with similar types of interests, hobbies, and potential loss-types. This camp provides children and adolescents an opportunity to connect with one another over a similar experience and facilitate the healing process.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).Arlington, VA: American Psychiatric Press.

Arruda-Colli, M. N. F., Weaver, M. S., & Wiener, L. (2017). Communication about dying, death, and bereavement: A systematic review of children’s literature. Journal of Palliative Medicine, 20, 548–559. https://doi.org/10.1089/jpm.2016.0494

Bergman, A. S., Axberg, U., & Hanson, E. (2017). When a parent dies: A systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliative Care, 17, 1–15. https://doi.org/10.1186/s12904-017-0223-y

Brent, D., Melhem, N., Donohoe, M. B., & Walker, M. (2009). The incidence and course of depression in bereaved youth 21 months after the loss of a parent to suicide, accident, or sudden natural death. American Journal of Psychiatry, 166, 786–794. https://doi.org/10.1176/appi.ajp.2009.08081244

Briggs, C. A., & Pehrsson, D. E. (2008). Use of bibliotherapy in the treatment of grief and loss: A guide to current counseling practices. Adultspan Journal, 7(1), 32–42. https://doi.org/10.1002/j.2161-0029.2008.tb00041.x

Center for Loss and Life Transition. (2018). Grief and mourning basics. Retrieved from https://www.centerforloss.com/grief/grief-mourning-basics/

Hanschmidt, F., Lehnig, F., Riedel-Heller, S. G., & Kersting, A. (2016). The stigma of suicide survivorship and related consequences—A systematic review. PLoS ONE, 11(9), 1–16. https://doi.org/10.1371/journal.pone.0162688

Harrison, L., & Harrington, R. (2001). Adolescents’ bereavement experiences. Prevalence, association with depressive symptoms, and use of services. Journal of Adolescence, 24, 159-169. https://doi.org/10.1006/jado.2001.0379

Humprhey, K. M. (2009). Counseling strategies for loss and grief. Alexandria, VA: American Counseling Association.

Jacobs, E. E., Schimmel, C., Masson, R. L., & Harvill, R. L. (2012). Group counseling: Strategies and skills(7th ed). Boston, MA: Cengage.

Judi’s House/JAG Institute. (2018). Understanding childhood grief in the U.S.: Children’s bereavement estimation model (CBEM). Retrieved from https://www.judishouse.org/cbem

Kaplow, J. B., Layne, C. M., Oosterhoff, B., Goldenthal, H., Howell, K. H., Wamser-Nanney, R...Pynoos,

R. (2018). Validation of the persistent complex bereavement disorder (PCBD) checklist:

A developmentally informed assessment tool for bereaved youth. Journal of Traumatic Stress, 31, 244-254. https://doi.org/10.1002/jts.22277

Kaplow, J. B., Saunders, J., Angold, A., & Costello, E. J. (2010). Psychiatric symptoms in bereaved versus nonbereaved youth and young adults: A longitudinal epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1145-1154. https://doi.org/10.1016/j.jaac.2010.08.004

National Alliance for Grieving Children. (2018). National poll of bereaved children and teenagers. Retrieved from https://childrengrieve.org/awareness/national-poll-of-bereaved-children-teenagers

Rose, C., Wainwright, W., Downing, M., & Lesperance, M. (2011). Inter-rater reliability of the Bereavement Risk Assessment Tool. Palliative and Supportive Care, 9(2), 153–164. http://doi.org/10.1017/S1478951511000022

Salloum, A. (2008). Group therapy for children after homicide and violence: A pilot study. Research on Social Work Practice, 18, 198–211. https://doi.org/10.1177/1049731507307808