Understanding Children’s Grief: An Overview for Counselors

50
The Report Committee for Jessica Leigh Swope Certifies that this is the approved version of the following report: Understanding Children’s Grief: An Overview for Counselors APPROVED BY SUPERVISING COMMITTEE: Deborah Tharinger Allyson Jervey Supervisor:

Transcript of Understanding Children’s Grief: An Overview for Counselors

The Report Committee for Jessica Leigh Swope

Certifies that this is the approved version of the following report:

Understanding Children’s Grief: An Overview for Counselors

APPROVED BY

SUPERVISING COMMITTEE:

Deborah Tharinger

Allyson Jervey

Supervisor:

Understanding Children’s Grief: An Overview for Counselors

by

Jessica Leigh Swope, B.S.

Report

Presented to the Faculty of the Graduate School of

The University of Texas at Austin

in Partial Fulfillment

of the Requirements

for the Degree of

Master of Education

The University of Texas at Austin

May 2011

iii

Understanding Children’s Grief: An Overview for Counselors

by

Jessica Leigh Swope, M.Ed.

The University of Texas at Austin, 2011

Supervisor: Deborah Tharinger

ABSTRACT

The current report reviews the literature on grief manifestations in children.

Definitions of grief terminology and current models of adult grief are covered to give the

reader a foundational knowledge on grief. Unique manifestations of grief, developmental

needs, and tasks for reconciliation with children are explored. Finally, a sampling of

current interventions used with bereaved children is included.

iv

Table of Contents

List of Tables ......................................................................................................... vi

INTRODUCTION ........................................................................................................1

Chapter One Grief Overview ..................................................................................5

Chapter Two Adult Grief Manifestations ...............................................................9

Kubler-Ross: Stages of Grief ..........................................................................9

Yale Bereavement Study...............................................................................11

Rando's Six Processes of Mourning ..............................................................12

Shattered Assumptions..................................................................................15

Dual Process Model ......................................................................................15

Summary .......................................................................................................16

Chapter Three Children and Grief ........................................................................17

Reactions to Loss ..........................................................................................18

Developmental Progression of Understanding .............................................19

Preschool to Kindergarten/Ages 3-5 ....................................................20

Early Primary/Ages 6-8 .......................................................................20

Late Primary/Ages 9-11 .......................................................................21

Early Secondary/Ages 12-14 ...............................................................22

Late Secondary/Ages 15-17 .................................................................22

Needs of Children Who Grieve.....................................................................23

Summary .......................................................................................................25

Chapter Four Grief Counseling Approaches for Children ....................................26

Key Elements of Grief Intervention ..............................................................26

Narrative Therapy .........................................................................................26

Short-Term Trauma- and Grief-Focused Psychotherapy ..............................27

Expressive Therapies ....................................................................................29

Music Therapy .....................................................................................29

v

Scrapbooking .......................................................................................30

Play Therapy ........................................................................................30

Group Intervention ........................................................................................31

Camp Based Intervention ..............................................................................32

Systems Approach ........................................................................................33

Summary .......................................................................................................34

Chapter Five Questioning the Effectiveness of Bereavement Interventions ........36

Conclusion .............................................................................................................38

References ..............................................................................................................39

vi

List of Tables

Table 1: Rando's Six Processes of Mourning ..................................................14

1

INTRODUCTION

It is important for counselors to have a thorough understanding of grief to

adequately conduct therapy with children. The topic of death can make many adults

uncomfortable, causing them not to discuss the issue with children. Not allowing children

to process their reactions may lead to unhealthy coping mechanisms (Farber & Sabatino,

2007; Heath et al., 2008). Counselors should become educated in the manifestations and

progression of grief in adults and children and research interventions that can be used

with children struggling with their bereavement.

Grief is a person’s thoughts and feelings associated with the loss of a loved one

(Bonanno & Kaltman, 2001; Heath, et al., 2008). Grief manifests itself in a variety of

subtle or more obvious ways. These can include physical reactions such as aches and

pains, affective manifestations including anger and guilt, cognitive manifestations such as

depersonalization, spiritual manifestations such as struggling with one’s faith, and

behavioral manifestations like crying or withdrawing (Cohen & Mannarino, 2004;

Kastenbaum et al., 2002). Many mourners receive assistance in working through their

losses by turning to grief counseling. This counseling method can be provided

individually or in a group format by psychologists, clergy, counselors, or social workers

(Higgins, 2009; Wolfe, 2002).

A person who has suffered the loss of a loved one may experience a wide variety

of symptoms. He or she may have feelings of sadness, anxiety, anger, loneliness, guilt,

relief, isolation, confusion, or numbness (Kastenbaum, et al., 2002; Wolfe, 2002). The

person may express all or only some of these feelings. After a loss the person may

2

become disorganized, feel tired, have trouble concentrating, endure sleep problems, have

appetite changes, encounter vivid dreams, and/or daydreams about the loved one (Pakes,

2008; Wolfe).

In understanding significant losses from a theoretical perspective, the leading

experts tend to subscribe to particular models of grief. Kubler-Ross’s stages of grief are

popular among counselors and the general public. This model was revised during the

Yale Bereavement Study (Maciejewski, Zhang, Block, & Prigerson, 2007). Psychologist

Rando created another model of understanding grief: the six “R” processes that a

mourner must complete to achieve healthy mourning (Rando, 2002; Solomon & Rando,

2007). The Dual Process Model was created to explain the bereaved’s struggle with their

past identity and their new identity (Swan & Scott, 2009). The Shattered Assumptions

Model expounds upon many models by describing the sense of traumatic confusion felt

by many grievers. These models are discussed in detail within this paper.

Some researchers believe that children hold unrealistic ideas about death and have

more complicated forms of grief than adults (Auman, 2007). Since children are not fully

cognitively developed, experts suggest that as children grow older and reach higher levels

of functioning, they need to reprocess their grief (Kraus & Monroe, 2005; Selekman,

Busch, & Kimble, 2001). As a result, children may be in counseling to assist in healing

wounds from a death that may have occurred years earlier.

Significantly, children have their own unique response to experiencing loss

(Coleman, 2009; Robson, 2008). Depending upon their developmental stage, their

understanding and expression will be different (Eppler, 2008; Kraus & Monroe, 2005). It

3

is important for counselors to become familiar with developmentally appropriate

responses to grief, which are discussed in a later chapter.

A grief reaction can be elicited in a child by a wide range of events. A child can

have intense grief reactions to the loss of a loved one or pet, a disruption of familiar

living situations, or traumatic events (Betz & Thorngren, 2006; Cohen & Mannarino,

2004). A disruption of familiar living situations can include divorce, family financial

difficulties, or frequent moves (Heath, et al., 2008). These disruptions are sometimes

caused by a death. For example, the death a parent can result in the depletion of

monetary resources and/or the relocation of the surviving family members. This can

compound the grief experienced by the child (Heath, et al.). Clearly, grief can be

brought on by many events. For the purposes of this paper, the grief following the death

of a loved one will be focused upon.

There are multiple approaches to grief counseling with children. Narrative

therapy is used to help children to restructure their stories (Degges-White & Davis,

2010). Therapists help children externalize their anxieties surrounding the loss and create

alternative narratives (Betz & Thorngren, 2006; Salloum, Garside, Irwin, Anderson, &

Francois, 2009). Counselors work with bereaved children in support groups that allow

for the expression of emotions through a variety of methods (Heath, et al., 2008). Group

therapy can also be delivered as a camp based intervention where longer sessions can be

conducted in close succession. Research has been conducted on expressive therapies,

which have evidence of being an adequate alternative to talk therapy (Dalton & Krout,

2005; Williams & Lent, 2008). A few examples include, but are not limited to, music

4

therapy, scrapbooking therapy, art therapy, and play therapy. In chapter 4, this paper

dissects these in order to give counselors a better understanding of interventions available

to grieving children.

Counselors using grief therapies developed for children, aim for specific

outcomes. Counselors facilitate children’s struggle to accomplish reconciliation

(Wolfelt, 1995). By working through tasks, this paper later describes, children come to

accept the reality of the loss, redefine themselves without their loved one, and build and

strengthen new and existing supportive relationships (Cohen & Mannarino, 2004). When

working with children, counselors may use a variety of activities that allow them to

experience their emotions, highlight their support systems, and memorialize the missing

loved one (Cohen & Mannarino; F. B. Wood, 2008).

This report will look at grief counseling from multiple perspectives. First, a brief

overview of the grief literature to explain and define grief terms and concepts is

presented. The content subsequently transitions to focusing on adult models of grief. A

review of the ways in which children experience grief and the stages they experience,

including the relevant research that has been conducted follows. Finally, a sampling of

different grief therapy techniques and approaches used with today’s children is provided.

This paper intends to educate counselors on grief in an effort to make this topic more

comfortable for them to broach while working with children.

5

Chapter One: Grief Overview

Many terms are important to understand and clarify when discussing grief.

Within the literature there are discrepancies regarding word definitions. The definitions

for the purposes of this report are defined and described below. In addition to defining

specific terms, this chapter provides an overview of the concept of grief.

Grief and bereavement are used interchangeably to describe a person’s reaction to

the loss of a loved one (Cohen & Mannarino, 2004). Grief can affect a bereaved person’s

thoughts, behaviors, and emotions (F. B. Wood, 2008). Each person’s experience of grief

is unique. Someone grieving may become disorganized, feel tired, have trouble

concentrating, experience trouble sleeping, or daydream about the deceased

(Kastenbaum, et al., 2002; Pakes, 2008; Wolfe, 2002). Individuals can feel a variety of

emotions that include but are not limited to sadness, anxiety, anger, loneliness, guilt,

isolation, helplessness, relief, confusion, and numbness (Kastenbaum, et al.; Wolfe).

Grief can aggravate or even bring about new health impairments (Irwin & Pike, 1993;

Kastenbaum, et al.). Examples of compounded or precipitated health concerns may

include: osteoarthritis, colitis, migraine, asthma, bronchitis, ulcerative colitis, spastic

colon, urticaria, and rheumatoid arthritis (Gentry, Kennedy, Paul, & Hill, 1995).

Grief can also throw a person into a state of traumatic confusion (Gentry, et al.,

1995). People can lose the ability to accomplish many tasks, impairing their daily lives.

Many times grievers find themselves between two stages of life: who they were before

their loss and their new identity without the loved one. One example would be a wife

who becomes a widow. These people are referred to as being liminal people (Gentry, et

6

al.). This means those experiencing grief may also be experiencing a conflict of self. In

an attempt to find balance between their past and future, they may simultaneously hold

their pre-loss and post-loss identities.

In contrast to mourning is a person’s way of expressing grief through religious

and cultural rituals (Cohen & Mannarino, 2004). These are often public displays that can

include attending funerals, wearing black, putting up memorials, and participating in

wakes. Mourning enables grievers to accommodate the loss of their loved one by

undoing their ties to the deceased, internally adapting to their new life without the loved

one, and reinvesting themselves to the world (Rando, 2002). Mourning practices are

shaped by an individual’s understanding of the nature of grief. This understanding has

been learned from the societal messages they have encountered (Balk, 2003) and is

dependent on cultural influences (Kastenbaum, et al., 2002).

Frequently following mourning bereaved achieve reconciliation, a term that refers

to a person’s adjustment and acceptance of their new life without their lost loved one

(Cohen & Mannarino, 2004). A person never reaches a time when they are completely

unaffected by the loss, but most people can find a healthy way to process their grief and

reintegrate themselves into society. When a person has achieved reconciliation they are

usually accepting the loss as being real, are experiencing and expressing all of their

emotions, are finding their place in the world without their loved one, integrating the

memory of their loved one into their life, and are finding meaning in the loved one’s

death (Cohen & Mannarino).

7

However, reconciliation does not happen for all mourners. A small number of

grieving individuals become stuck in their grieving which results in complicated grief

(Zhang, El-Jawahri, & Prigerson, 2006). Typically, the bereaved experience mourning as

a series of processes, which can become complicated (Rando, 1993). This means that the

mourner experiences disbelief about the death, anger, bitterness, yearning, longing, lack

of trust, lack of perceived meaning in life, and preoccupation with the deceased (Hensley,

Slonimski, Uhlenhuth, & Clayton, 2009; Johnson et al., 2009; Maccallum & Bryant,

2010). These symptoms are more intense and longer lasting than normal grief

expressions (Zhang, et al.). According to Bonanno and Kaltman’s longitudinal study

only a small amount of bereaved individuals, 10-15% (Bonanno & Kaltman, 2001) or 10-

20% (Hensley, et al.), will experience complicated grief.

Further deviations from normative grieving may occur when a loss is not

universally accepted as a cause for grief. These instances are labeled ambiguous loss and

can include, but are not limited to, the ending of a romantic partnership, the loss of a job,

the diagnosis of a child with a mental or physical disability, moving, or sexual abuse

(Betz & Thorngren, 2006). Often ambiguous loss is separated into two categories: either

a loss where the person is psychologically present but not physically there or when a

person is psychologically absent while being physically present (Ambiguous Loss, 2008;

Betz & Thorngren). Often times people experiencing ambiguous loss feel a lot of

uncertainty and do not have access to many of the supports nor are they able to

participate in the mourning rituals that people who experience unambiguous loss have

8

(Ambiguous Loss, 2008). If this grief is not dealt with the stress within the individual and

the family unit experiencing the loss can be exacerbated (Betz & Thorngren).

9

Chapter Two: Adult Grief Manifestations

A great deal of research has been conducted to study adults’ experiences of grief.

This research has been used as a foundation for counseling children and adolescents.

This chapter reviews the major adult theories before covering grief manifestations with

developing children in the next chapter.

Kubler-Ross: Stages of Grief

Kubler-Ross’s stages of grief are commonly referenced in scholarly journals and

popular media. Kubler-Ross interviewed terminally ill patients to collect their thoughts

regarding their impending death (Elisabeth Kübler-Ross, 2004). Five stages of dying

were created from the data that was collected. Later these stages were turned into the

five stages of grief (Bolden, 2007). The five stages of grief are: denial, anger, bargaining,

depression, and acceptance (Maciejewski, et al., 2007). These stages can be experienced

in any order and a person can return to stages they have already encountered (Schimmel

& Kornreich, 1993).

The first stage of grief is denial. People in this stage are in a state of emotional

shock where they are experiencing problems comprehending the implications of the death

(Friedman & James, 2008; Schimmel & Kornreich, 1993). Denial may be employed by

the person experiencing grief as a psychological defense in order to minimize the

seriousness of the event (Pakes, 2008). Bereaved individuals in the denial stage

cognitively understand that their loved one is dead, but facing the reality of the death is

complicated by this sentiment.

10

Denial is followed by anger, Kubler-Ross’s second stage of grief. The anger a

person is feeling in this stage may be directed inwardly, at the loved one that has passed

away, at others in the bereaved person’s life, or at a spiritual figure (Bolden, 2007;

Schimmel & Kornreich, 1993). Active manifestations of the anger stage can include

physical or verbal aggression. This stage can also manifest as passive-aggressive

behaviors (Pakes, 2008). Family members of the bereaved may distance themselves from

the bereaved during this stage due to the rage the bereaved may be expressing.

Following anger is bargaining, Kubler-Ross’s third stage of grief. Bargaining

includes going over the events of the death of their loved one. They obsess over the

small details that they believe could have facilitated a different outcome. Many times

grievers in this stage are mentally repeating phrases similar to “what if” and “if only”

(Bolden, 2007).

The next stage of grief, according to Kubler-Ross, is depression. This feeling is

typically present throughout the grieving process, but can intensify during this stage

(Pakes, 2008). People in this stage experience feelings of profound loss and sorrow

(Schimmel & Kornreich, 1993). Symptoms of this stage include difficulty concentrating,

disturbance of sleeping and eating patterns, high fluctuation of emotions, and low levels

of energy (Friedman & James, 2008). People in this stage are not considered clinically

depressed due to the normalcy of this manifestation of grief (Higgins, 2009).

Finally, Kubler-Ross’s fifth stage of acceptance is reached when a person

experiencing the loss of a loved one has attained reconciliation. This stage is

characterized by a griever’s ability to live their life without the missing loved one, but

11

still able to memorialize the person they have lost (Bolden, 2007). The name of this stage

is misleading in that it gives off the impression that the person is completely “healed” of

their grief. However, someone who has experienced the loss of a close loved one will

most likely be processing their loss on some level throughout their life (Friedman &

James, 2008; Matthews & Marwit, 2006; Moules, Simonson, Prins, Angus, & Bell,

2004).

Yale Bereavement Study

A study conducted at Yale University is believed to be the first empirical study of

Kubler-Ross’s stages of grief (Maciejewski, et al., 2007). The Yale Bereavement Study

(YBS) evaluated the grief manifestations of a sample of bereaved individuals (Johnson, et

al., 2009). The data was evaluated in order to rename and redefine a portion of Kubler-

Ross’s stages.

In contrast to Kubler-Ross’s denial, the first stage of grief was renamed

“disbelief”. The YBS renamed this stage to better illustrate how a person understands the

reality of the death but is experiencing difficulties accepting that reality (Friedman &

James, 2008). The study found that expressions of disbelief were highest immediately

following the loss and decreased after one month (Maciejewski, et al., 2007).

Kubler-Ross’s second stage, bargaining, was renamed “yearning” to reflect a

wider expression of grief (Friedman & James, 2008). People in the yearning stage are

longing for a reunion with their lost loved one. This stage is characterized by intense sad

feelings regarding the inability to reconnect with the deceased. YBS found that yearning

12

was the stage expressed by most of the study participants and was expressed the strongest

at four months after the loss (Maciejewski, et al., 2007).

Finally, the last stage of acceptance was reframed to be conceptualized as a level

that could increase and decrease within an individual. YBS asked participants to assess

their level of acceptance throughout their grieving process (Michalski, Vanderwerker, &

Prigerson, 2006). Bereaved individuals could be in the acceptance stage while still

processing their grief in another stage (Maciejewski, et al., 2007).

The YBS framework of grief processing is helpful in highlighting the uniqueness

of the stages of grief. Individuals can become concerned when they do not fit into

Kubler-Ross’s prescribed linear stages. Each person’s progression through grief will

manifest differently depending upon multiple factors, including the relationship to the

lost loved one, nature of the death, support during their time of grieving, and previously

instilled coping factors. Also, the reframe of acceptance as a gradient allows the bereaved

to build this within his or her own timeline.

Rando’s Six Processes of Mourning

In contrast to Kubler-Ross’s stages and YBS’s revisions, Rando distinguished six

specific processes that must be undergone to achieve healthy coping (see Table 1). The

six processes facilitate the reorientation of the bereaved on three different levels. The first

level focuses on reorienting the relationship the bereaved holds with the deceased

(Rando, 2002; Solomon & Rando, 2007). The bereaved must alter their ties with the lost

loved one (Solomon & Rando). The second level focuses on the bereaved’s personal

13

adaption to the loss, including their self-identity (Rando; Solomon & Rando). The last

level involves the bereaved discovering how to adapt to living in a world without their

lost loved one (Solomon & Rando).

People move through the following processes during uncomplicated mourning,

and processes may be revisited depending on the person’s unique grief process. The first

process that must be successfully completed is to recognize the loss of the loved one

(Rando, 2002; Solomon & Rando, 2007). The bereaved must be aware of the reality of

the loss of the loved one and understand the causes of the death (Rando; Solomon &

Rando). The person must acknowledge the reality of the death (Rando; Solomon &

Rando). The second process the bereaved should go through is reacting to the separation

(Rando; Solomon & Rando). The bereaved must experience the pain of the death

(Rando; Solomon & Rando). This includes feeling, identifying, accepting, and expressing

their thoughts and emotions (Solomon & Rando).

The third process a mourner should experience is recollecting and re-experiencing

the lost person and relationship (Rando, 2002; Solomon & Rando, 2007). To accomplish

healthy mourning the bereaved must realistically review and remember the relationship

(Rando; Solomon & Rando). The fourth process, according to Rando, for a person in

mourning is the relinquish phase. During this phase the person should give up the old

attachment to the lost loved one (Rando; Solomon & Rando). This includes their view of

the world that included them as a connected unit (Rando; Solomon & Rando).

Next, the bereaved should readjust to their new world post-loss without forgetting

their old world, when the deceased was alive (Rando, 2002; Solomon & Rando, 2007).

14

For this to be achieved, the mourner must develop a new relationship with the deceased,

create a new way of being in the world, and form a new identity (Rando; Solomon &

Rando). Finally, the last process is the reinvesting process. The mourner should take the

energy that they once put into the relationship with the deceased and find a place in their

new world (Rando). The mourner can put their energy into their relationships, life goals,

and other aspects of their life post-loss (Rando). If a bereaved person experiences

complications within one of the phases of mourning it can result in complicated

mourning (Rando, 1993).

Table 1

Rando’s Six Processes of Mourning

Process Objectives

1st Recognize

Become aware of the loss of the loved one

Understand the causes of the death

2nd

React

Experience the pain of the loss of the loved one

3rd

Recollect and

Re-experience

Realistically remember the relationship

4th

Relinquish

Give up old attachments

5th

Readjust

Develop a new relationship with the lost loved one

Form a new identity

6th

Reinvest

Put energy into new relationships and activities

Source: Rando 2002; Solomon & Rando, 2007

15

Kubler-Ross, Yale, and Rando’s theories have focused on the grief process in a

relatively linear way. However, new theories are being developed that look at the grief

process in a nonlinear format. The following two theories focus on how the bereaved

makes meaning after the death of a loved one.

Shattered Assumptions

According to the shattered assumptions model many people hold an unrealistic

view of the world (Swan & Scott, 2009). In order to maintain peace of mind, people tend

to block out the injustice and danger of the world. They believe that negative events

only happen to other people and that their family is safe from these occurrences.

According to this model, when a traumatic event happens, a person’s worldview is

shattered (Matthews & Marwit, 2006; Swan & Scott). This can lead to high levels of

insecurity or fear in the bereaved individual. Many will have to work to redefine their

beliefs in God or their spiritual beliefs (Matthews & Marwit). They may see the world as

a dangerous place in which their loved ones will never be safe.

Dual Process Model

Another nonlinear model that can be used in grief work is the Dual Process

Model. Strobe and Schut analyzed bereaved people’s coping mechanisms (M. S. Stroebe

& Schut, 2001). The researchers were attempting to discover how people who have lost a

loved one come to terms with their loss. The Dual Process Model provides a framework

for understanding a bereaved person’s adaptation techniques (M. S. Stroebe & Schut).

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According to the Dual Process Model, many people who lose a loved one

experience two orientations of thinking. The first way of thinking is loss orientation

(Swan & Scott, 2009), which is when the bereaved focuses on the past: their life while

the deceased was alive. They experience distress and an urge to search and reconnect

with their lost loved one (M. Stroebe, Schut, & Boerner, 2010). The second way of

thinking is restoration orientation (Swan & Scott). The bereaved in this orientation look

forward to the future and make the transition from their old identity to their new identity.

They focus on secondary stressors that arise from the loss of a loved one, such as

changing one’s identity from a wife to a widow (M. Stroebe, et al.). According to this

model, people experience complicated grief when they do not oscillate between the two

models (Leighton, 2008). If people become stuck in one orientation they block the

memories of their lost loved one or do not confront their new life post-loss.

Summary

By understanding how adults react to grief and the processes they can experience,

counselors have a better foundation for understanding children’s expressions of grief.

Once a clear comprehension of adult grief is acquired, one can start to look at the

developmental aspects of children that may uniquely impact their grieving processes.

The following chapters explore much of the recent literature regarding children and grief.

17

Chapter Three: Children and Grief

Many adults avoid talking to children about peripheral losses such as distant

family members, acquaintances, and pets. Children are not always told about deaths and

may not be taken to funerals (Auman, 2007). Due to this and their cognitive limitations,

some of those children do not have a clear understanding of death (Auman; Oltjenbruns,

2001; Selekman, et al., 2001). This can result in a decrease in grieving ability (Auman).

Since children and adolescents are still cognitively developing, their expressions and

understanding of grief are dissimilar than adults’. According to much of the literature,

children will re-experience their grief as they develop (Hung & Rabin, 2009; Kraus &

Monroe, 2005; Leighton, 2008; Oltjenbruns). This means that not only will the child be

reminded of their lost loved one as important developmental landmarks are achieved, but

they will also re-grieve the loss from a more mature viewpoint (Oltjenbruns).

A variety of incidents can elicit a grief reaction within a child. Each child’s

expression of grief will be unique. The impact of a particular death on a child will most

likely be dependent upon three factors. The first thing a counselor should look at is the

child’s cognitive developmental level (Eppler, 2008; Webb, 2003). Next, one should

consider the nature of the relationship between the child and the deceased (Webb;

Williams & Lent, 2008). Finally, the story of the death that the family and the

community tell is important (Webb). One must remember that each child will have a

unique story, expression, and internalization. This chapter examines common

precipitators of grief, reactions to grief, developmental progression of understanding, and

reconciliation needs of children and adolescents.

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Reactions to Loss

Like adults and regardless of developmental stage, children and adolescents may

display a wide variety of reactions to the loss of a loved one. These reactions can

manifest in children, regardless of their developmental level. Physical reactions may

include loss of appetite, overeating, stomach aches, and headaches (Heath, et al., 2008).

Children may become clingy, regress to thumb sucking, cry more often, and have

multiple nightmares (Farber & Sabatino, 2007; Tracey & Holland, 2008). Children may

even increase their hyperactivity or experience a lack of energy (Eppler, 2008; Robson,

2008). They may become more fidgety and involved in aggressive fighting (Cohen &

Mannarino, 2008). The physical manifestations of grief will be unique to each child.

Concern should arise when the behaviors last for an extended amount of time or are

exceptionally intense (Kraus & Monroe, 2005; Rowling, 2003).

In addition to diverse physical manifestations, bereaved children and adolescents

may experience a wide variety of emotions involving more than mere sadness (Eppler,

2008). These emotions include depression, guilt, anger, moodiness, embarrassment,

anxiety, hypersensitivity, hopelessness, helplessness, shock, numbness, and even relief

(Farber & Sabatino, 2007; Heath, et al., 2008; F. B. Wood, 2008). Children may go into

a state of emotional shock where they display a flat affect (Farber & Sabatino). Problems

occur when the child cuts off one or more of the emotions (Cohen & Mannarino, 2008;

Selekman, et al., 2001).

Further, when a child loses a loved one, they can experience cognitive grief

symptoms. They may become avoidant, inattentive, confused, or preoccupied with death

19

(Heath, et al., 2008). They can be in a state of denial about the incident (Cohen &

Mannarino, 2004). Many will be distractible and start to question their beliefs (Leighton,

2008). If the death was caused by a traumatic event they may develop distorted ideas

about the event (Cohen & Mannarino, 2008). They may also believe that they were to

blame for the death.

Finally, children may express their grief in their social interactions. They

sometimes withdraw from their peers, isolating themselves in their environments (Tracey

& Holland, 2008; F. B. Wood, 2008). Bereaved children may become argumentative

with adults and other children (Cohen & Mannarino, 2004). Teachers may find them

rebellious or oppositional (Auman, 2007; Heath, et al., 2008). They may display

attention-seeking behaviors within their social networks. The physical, emotional,

cognitive, and social reactions become problematic if they persist over time without

resolution (F. B. Wood).

Children can express grief through a variety of physical, emotional, cognitive, and

social manifestations. These expressions may present differently depending upon

cognitive development. Adults, such as counselors, in these children’s lives should

monitor the intensity and duration of these grief reactions. These grief reactions may

become less persistent if a child reconciles with the loss of their loved one (Heath, et al.,

2008).

Developmental Progression of Understanding

Even though many reactions are consistent throughout development, a child’s

ability to understand loss is dependent upon their development level. As a child matures,

20

their reactions manifest differently. Researchers separate developmental subgroups

several ways. For the purposes of this chapter, childhood development is sectioned into

five developmental stages. The sections are Preschool to Kindergarten (approximately 3

to 5 years in age), Early Primary (approximately 6 to 8 years in age), Late Primary

(approximately 9 to 11 years in age), Early Secondary (approximately 12 to 14 years in

age), and Late Secondary (approximately 15 to 17 years in age). This section will

examine each in detail.

Preschool to Kindergarten/Ages 3-5

At this stage of children’s development, children struggle greatly with assuming

an outsiders’ viewpoint (Rowling, 2003). They are not able to grasp the finality of death

(Kraus & Monroe, 2005; Selekman, et al., 2001). They do not understand that when a

loved one dies they are not going to “wake up”. Since this age has not developed abstract

thinking, they see heaven as being a place they can physically visit (Rowling).

Statements like, “they have gone to heaven”, can be very confusing to this age group.

Many grievers in this developmental stage will display sadness, aggression, and

regressive behaviors (Kraus & Monroe; Selekman, et al.). This age group may have

more intense, but shorter, reactions to grief in comparison to other age groups. Children

in this age group experiencing grief need help understanding death and dispelling their

fears.

Early Primary/Ages 6-8

21

As children move into this stage they have a better understanding of the finality of

death, but may still be misplacing blame on themselves for the death (Kraus & Monroe,

2005; Selekman, et al., 2001). Death is seen as an entity, like a boogie man or the Grim

Reaper, which can be tricked or avoided (Rowling, 2003). Children, between ages six

and eight, can become obsessed with outsmarting their physical manifestation of death.

If these children’s emotional needs are not met they may try to find ways to fill them with

food or other materials (Rowling). When processing their grief, bereaved children at this

developmental stage may display temper tantrums, increased anxiety, and clinginess

(Rowling; Selekman, et al.). These children can benefit from reassurance about life, clear

expectations about the funerals, and allowances to express their emotions through

nonverbal avenues (Rowling).

Late Primary/Ages 9-11

In contrast to the earlier stages, this age group is likely to seek detailed

information about the nature of the death (Kraus & Monroe, 2005; Rowling, 2003).

Some of these questions may be perceived as gruesome. Due to the increase in cognitive

ability, these bereaved children may be using more elaborate defenses (Rowling). These

defenses can include denial and repression of feelings. At this age children are also able

to compare their life pre- and post-loss, increasing their understanding of the

bereavement they experienced (Rowling). Children in the late primary stage can start to

identify with others, which can result in grief reactions to people outside their immediate

family (Rowling). Some of the behaviors this age exhibits include being defiant,

22

possessive, and aggressive (Selekman, et al., 2001). Their reactions may appear more

subdued than those of younger children (Kraus & Monroe).

Early Secondary/Ages 12-14

As children enter the early secondary stage they become aware of the personal

and social implications of the death (Rowling, 2003). They may see how the loss will

make them different from their peers, as in being outside the norm in losing a parent.

They may become avoidant towards information pertaining to the death and expressions

of grief displayed by their loved ones (Kraus & Monroe, 2005). These children may

display signs of low self-esteem (Rowling). They may also become withdrawn, anxious,

and depressed (Selekman, et al., 2001). Many times they will develop health problems

(Rowling). Children in this stage of development may have poor educational

performance due to their inability to concentrate (Kraus & Monroe; Rowling).

Late Secondary/Ages 15-17

Finally, children at the late secondary level have a more developed understanding

of the future implications of the loss of their loved one (Kraus & Monroe, 2005).

Adolescents may experience an initial stage of numbness. This numbness stage is often

followed by an array of emotions that can include: sadness, anger, bitterness, and

hopelessness (Kraus & Monroe; Selekman, et al., 2001). Many times these adolescents

can be overwhelmed by the various emotions they experience. To cope with these

emotions, adolescents in this stage of development will participate in reckless behavior.

These behaviors can include drug use, reckless driving, and unsafe promiscuous acts

23

(Rowling, 2003; Selekman, et al.). Grievers in this cognitive stage need help maintaining

their sense of control and should have their privacy respected (Rowling).

A child’s understanding and reaction to the death of a loved one will change as

they develop. As children mature, they may use more elaborate defense mechanisms to

cope with the grief they are experiencing. Even though many developmental coping

mechanisms exist, there are also grief reactions that are not completely bound to a child’s

maturity.

Needs of Children Who Grieve

In addition to understanding what grief can look like in children, counselors must

also understand what their needs are. A helpful model for this is Wolfelt’s Reconciliation

Tasks. The first task is to acknowledge that the death is a reality (Cohen & Mannarino,

2004; Heath, et al., 2008). This involves confronting the fact that the person is gone and

will not return (Wolfelt, 1995). Adults need to work with the grieving child to help make

the unreal real. Participation in the funeral can help children accomplish this task (Heath,

et al.).

After acknowledging the death, the second reconciliation task is to face the pain

of the loss with support (Cohen & Mannarino, 2004; Heath, et al., 2008). The pain and

emotional aspects of the death need to be experienced (Wolfelt, 1995). This task requires

the bereaved to express the wide range of thoughts and emotions that accompany grief.

The child needs to participate in memorializing activities so that they are better able to

face and share memories of the lost loved one (Heath, et al.).

24

Following facing the pain, Wolfelt’s third task is to reframe the child’s

relationship with the deceased. The bereaved needs to convert their relationship from a

connection in the present to a relationship with the memory of their lost loved one

(Wolfelt, 1995). The child should not be encouraged to give up all ties with the

deceased, but rather to find a healthy way to memorialize the loved one. According to

The Dual Process Model, they need to find a healthy way to oscillate between the loss

orientation and the restoration orientation (M. Stroebe, et al., 2010).

After reframing, the fourth task of mourning is to develop a new self-identity

without the lost loved one (Wolfelt, 1995). The child needs to redefine themselves in the

absence of the deceased (Heath, et al., 2008). The child may begin to question their self

worth (Wolfelt). They also may experience doubts about the future and their new

identity without the loved one.

Finally, Wolfelt’s last reconciliation task is to form meaning around the death

(Cohen & Mannarino, 2004). To complete this task the child needs to make sense of the

loss of the loved one and find new significance in their life after the death. When

attempting to complete this task, children may question their religious beliefs (Wolfelt,

1995). The counselor needs to be attentive to the children and be with them during this

time to help them discover meaning in their loss (Wolfelt). People find meaning by

believing a lost loved one has gone on to a better life, their suffering has ended, or their

death could bring about change.

The literature has taken Wolfelt’s five reconciliation tasks and added one more to

be used specifically with children. The added task is to build and strengthen new and

25

existing long-term supportive relationships (Cohen & Mannarino, 2004). Children need

to experience the comfort of a continuing or supportive adult presence in their life

(Heath, et al., 2008). The child can be gently questioned to discover the identity of their

confidants and with whom they would feel comfortable talking.

A counselor can assist children in acknowledging the reality of the death, face the

pain that results, reframe their relationship with the deceased, develop a new self-identity,

form meaning around the death, and strengthen their support network. By helping a child

successfully navigate the reconciliation tasks, a counselor can renew a child’s resources

for living (Wolfelt, 1995).

Summary

Children’s understanding and display of grief varies significantly from adults.

Counselors should be aware of the manifestations of grief that may be expressed through

emotional, physical, behavioral, or social outlets. There are specific needs that a

counselor can assist students in meeting to achieve reconciliation. The next chapter

samples interventions counselors can use to assist children in adequately coping with

their grief.

26

Chapter Four: Grief Counseling Approaches for Children

Key Elements of Grief Intervention

Many times adults avoid processing grief with children. Whether this is due to

their own fear of death, unresolved grief from their past, or some other reason, it can have

negative impacts on children who have experienced the loss of a loved one. Death should

be discussed with children in a developmentally appropriate, clear, and direct manner

(Coleman, 2009; Selekman, et al., 2001). Adults may feel that it is inappropriate to cry

when talking to children. However, Selekman, Bush, and Kimble (2001) assert that

adults’ grieving serves to give children permission to show their own emotions.

This chapter will sample grief counseling approaches used with children

experiencing grief. It is important for counselors to become familiar with a variety of

approaches that are available to use with bereaved children. The child’s developmental

needs and preferences of expression should be considered when choosing an intervention.

Narrative therapy, trauma- and grief-focused psychotherapy, group interventions, camp-

based interventions, music therapy, scrapbooking, and play therapy will all be discussed

in this chapter.

Narrative Therapy

A primary method is Narrative therapy. Narrative therapy encourages a child to

share their story, including their past, present, and future. This approach helps the child

work with the counselor to verbalize their reactions to the death and attempt to construct

meaning (Betz & Thorngren, 2006; Leighton, 2008; Salloum, et al., 2009). Afterwards,

27

the counselor reflects the child’s narrative to allow the child to restructure the story as

they see appropriate (Leighton). Counselors help clients externalize problems, elaborate

their story with rich descriptions, explore outcomes, and develop alternative narratives

(Degges-White & Davis, 2010; Salloum, et al.). Some researchers believe that clients

with shorter narratives may be blocking off memories of a trauma, such as a loss of a

loved one (Beaudreau, 2007).

One specific technique under narrative therapy is Biblionarrative. Biblionarrative

therapy is used with children to allow them to talk and write about dramatic life events

(Eppler & Carolan, 2005). To create a Biblionarrative, the counselor works with the

client to gather life information while highlighting strengths, such as successful coping

techniques, throughout the process. When working with bereaved children, the counselor

touches upon the basic circumstances surrounding the death during the interview. The

Biblionarrative includes a description of the relationship with the lost loved one. This

approach allows the child to have multiple options of expression (Pomerantz, 2007).

Eppler and Carolan (2005) found, when conducting a study on Biblionarratives, that 50

percent of their participants preferred writing, while 33 percent preferred talking. Each

child is going to have their preferred method of communicating, which expresses a

unique perspective and mode of expression that can reveal as much as the content of their

discourse.

Short-Term Trauma- and Grief-Focused Psychotherapy

28

In contrast to Narrative therapy, short-term Psychotherapy tends to focus on the

“here and now” by using techniques such as psycho-education, instead of using

externalizing approaches. Researchers have found that using short-term, trauma-focused

grief intervention lowered children’s experience of traumatic grief and the occurrence of

PTSD symptoms (McClatchey, Vonk, & Palardy, 2009; Saltzman, Pynoos, Layne,

Steinberg, & Aisenberg, 2001). The trauma- and grief-focused psychotherapy outline is

composed of psycho-education, skill-building, and process-oriented components. These

interventions focus on five areas, which include the traumatic experience, the trauma and

loss reminders, the posttraumatic adversities, the connection between the trauma and the

grief, and resuming cognitive development (McClatchey, et al.).

Saltzman, Pynoos, Steinberg, and Aisenberg (2001) conducted a study with the

goal of determining the results of a trauma and grief focused group psychotherapy

program conducted in a school. The program attempted to screen for students who had

experienced a severe trauma or loss that resulted in impairing distress. Once students

were accurately identified, the clinicians followed a psychotherapy manual that focused

on traumatic experiences, reminders of trauma and loss, the interplay of trauma and grief,

post-trauma adversities, and developmental progression (Denzine, 2008; Saltzman, et al.,

2001; Social Learning Theory, 2001). The treatment resulted in a significant decrease in

posttraumatic stress scores, no significant decrease in depressive symptoms, significant

decrease in complicated grief symptoms, and higher academic scores (Saltzman, et al.).

There have been additional studies conducted evaluating the impact of trauma/grief-

focused brief psychotherapy using the specific treatment model explained above

29

(Goenjian et al., 1997; Layne et al., 2001; Möhlen, Parzer, Resch, & Brunner, 2005).

This intervention is one of the most successfully researched one available (Rosner, Kruse,

& Hagl, 2010).

Expression Therapies

Younger children’s language abilities are still being developed and may prevent

them from fully benefitting from the interventions previously discussed. In order to meet

the needs of these children, counselors have attempted to create strategies that allow for

expression in alternate forms. Some alternative therapies utilize artistic expression, in

order to bridge the gap between adults and young children developing language skills. A

few of the therapies that utilize artistic expression are reviewed below.

Music Therapy

Music is one therapy that attempts to incorporate artistic expression into mental

healing. One study analyzed the results of a music therapy intervention that worked with

children to create songs to express their grief (Dalton & Krout, 2005). The therapy

focused on five grief process areas: understanding, feeling, remembering, integrating, and

growing (Dalton & Krout). The approach was grounded in the assumption that children

would need to understand the cause of the loss, then explore their feelings, remember the

good and bad memories of the lost loved one, begin to make a plan for their future

without the loved one, and then discover their own personal growth from the loss (Dalton

& Krout). The researchers found that the seven-week songwriting-based music therapy

treatment group resulted in noticeable decreases on a thirty point self-statement grief

30

process scale (Dalton & Krout). This study has been reviewed and found to be very

successful (Rosner, et al., 2010). More studies should be conducted to further support

this intervention.

Scrapbooking

Distinct from other expressive therapies, Scrapbooking utilizes objects that the

bereaved associate with the lost loved one. This intervention allows children to bring in

artifacts that serve as reminders of the loved one in order to engage in memorializing

activities (Williams & Lent, 2008). This intervention is also referred to in the research as

a memory book or collage (Buxbaum & Brant, 2001; Webb, 2003). The reminders the

children use are not required to be the actual artifact, but can be photographic in order to

prevent damage to the original objects. While the artifacts are added to the scrapbook,

the therapist engages the child in a dialogue regarding the object and its connection to the

lost loved one. The scrapbook can be used to facilitate dialogue between the child and

other family members. After the scrapbook is complete, the therapist can use it as a tool

to refer to during therapy (Williams & Lent).

Play Therapy

Many therapies, such as Narrative, assume that children will be able to articulate

their emotions, however many children’s typical form of communication is not

verbalization. The younger the child, the more likely they are to be more comfortable

communicating through play. In play therapy, the therapist joins the child in the

metaphors used to attempt to lower the child’s anxieties surrounding the topic of death

31

(Webb, 2003). Expressing emotions through play helps the child develop their

understanding of the loss (Glazer, 1998). This approach functions under the assumption

that the client will use play to explore their feelings in a displaced way (Webb).

Group Intervention

The interventions reviewed above are often used in an individual setting. While

individual counseling has the benefits of giving the child one-on-one attention, group

therapy can have its own therapeutic benefits. Group therapies can be especially

effective with bereaved children (Buxbaum & Brant, 2001; Heath, et al., 2008; Selekman,

et al., 2001). Facilitators should construct groups that include children that are

experiencing similar coping difficulties due to the loss of a loved one. Information

regarding the group members’ cultural beliefs about death, grief, and mourning need to

be gathered as well in order to incorporate those beliefs into the group (Heath, et al.;

Selekman, et al.).

Group therapy allows the members to share their experiences with others and

receive normalizing feedback (Buxbaum & Brant, 2001; Selekman, et al., 2001). Groups

also help facilitate the normalizing process by educating members on the grief process

(Buxbaum & Brant; Selekman, et al.). Members are provided with a safe environment in

which to express their feelings regarding the loss (Buxbaum & Brant). Children may

need opportunities to release energy while in the group through activities such as games,

walking, and drawing (Heath, et al., 2008).

32

Salloum (2008) conducted a study to evaluate the effectiveness of a school based,

time-limited grief and trauma group intervention for elementary aged children. The

group included survivors of homicide victims and children who had witnessed extreme

violence within their community (Salloum, 2008). Group members participated in group

therapy attempting to reduce traumatic symptoms. The goal of the therapy was to allow

the children to process their grief without complications stemming from the trauma of

their loss. Salloum (2008) found that the group members who had not witnessed the loss,

scored lower on a posttraumatic stress reaction index after treatment. Given this evidence,

there are inherent benefits to group counseling with bereaved children.

Camp-Based Intervention

Many child focused interventions are confined to traditional counseling settings

such as schools and private practices. In contrast, grief interventions conducted in a

camp environment have the unique ability to provide assistance for longer sessions and in

closer succession. The American Camping Association has conducted research that

supports the positive benefits of camping. They found that camping can increase a

child’s self confidence and self-esteem (Thurber, Scanlin, Scheuler, & Henderson, 2007).

Children develop and improve social skills. Camps help children become more

independent in addition to forming effective leadership skills (Directions: Youth

development outcomes of the camp experience, 2005). The environment has also shown

that children become more adventurous and increase their willingness to try new things

(Directions: Youth development outcomes of the camp experience).

33

Many grief therapy camp-based groups develop positive coping mechanisms

through the tenets of social learning and social norms theories (Farber & Sabatino, 2007).

Social learning theory is an approach that focuses on the interplay between an

individual’s personality and their environment (Denzine, 2008; Social Learning Theory,

2001). Social norms is a term that refers to the unspoken rules that dictate how

individuals are expected to act in different situations (Hagman, Clifford, & Noel, 2007).

Social learning theory posits that a person’s environment affects their thoughts and

actions (Social Learning Theory; P. B. Wood, Gove, Wilson, & Cochran, 1997).

According to this theory, the individual’s environment can be affected by the individual

(Social Learning Theory). The camp setting allows group members to learn from others

who are participating in the activities (Farber & Sabatino). The children use others to

construct meaning about the death they experienced and the acceptability of grief (Farber

& Sabatino).

McClatchey, Vonck, and Palardy (2009) collected data from camp-based

intervention. The counselors used a mixture of structured therapeutic activities and play

activities to attempt to help the participants process their grief (McClatchey, et al., 2009).

The researchers screened camp members to discern those who were at risk of

experiencing grief or PTSD symptoms (McClatchey, et al.). The results of the studies

indicated that these participants were significantly less likely to experience extreme grief

or PTSD symptoms (McClatchey, et al.). In summary, this is a new, promising approach

to grief therapy that needs to be explored further.

Systems Approach

34

When counselors provide interventions with bereaved children they should not

overlook the child’s contextual factors. Many experts believe the attainability of healthy

mourning can be mitigated by the support structures surrounding the child (Cicchetti &

Rogosch, 1997; Saldinger, Porterfield, & Cain, 2004; Van Horn, 2010). A child could be

supported by important people in their life including, but not limited to, family,

neighbors, and community members. It is believed that a child needs the commitment of

at least one supportive, trusted adult (Cicchetti & Rogosch; Van Horn).

Research suggests that children will experience healthier adjustment to their loss

if they are engaged in a positive caregiver-child relationship (Wolchik, Yue, Tein,

Sandler, & Ayers, 2008). It is important for counselors to not only offer support to the

bereaved child, but also to their caregiver who may be experiencing their own grief. The

grieving caregiver may be less emotionally available to the child, lowering their ability to

convey hope (Saldinger, et al., 2004; Van Horn, 2010). These grief manifestations in the

caregiver can result in less stability in the child’s life, which can increase maladaptive

reactions to grief (Saldinger, et al.). Counselors can support caregivers to positively

impact children by communicating the child’s experience of the loss to the adult,

educating the caregiver of the developmental needs of the bereaved child, and connecting

the caregiver with assistance to help with daily problems (Van Horn).

Summary

Many interventions are available for use with bereaved children. The sampling of

grief interventions showed multiple approaches that have been researched for bereaved

35

children. Counselors should examine the system in which the child belongs to determine

if there are structures that need support. Because this was not an exhaustive review of the

research, other interventions that were not reviewed are currently being used.

36

Chapter Five: Questioning the Effectiveness of Bereavement

Interventions

It should be noted that some scholars in the bereavement field have debated the

effectiveness of bereavement interventions. Some experts believe that grief work can

have detrimental consequences. Currier, Holland, & Neimeyer analyzed data collected

from thirteen grief therapy intervention studies (Currier, Holland, & Neimeyer, 2007).

The studies that they reviewed compared a group of children who received a group grief

therapy intervention with a group of children who received no treatment. Their results

found that, on average, children who participated in the group interventions did not show

a higher level of healthy adaption to bereavement (Currier, et al.). It should be noted that

the studies that attempted to select only children who were considered a higher-risk of

experiencing coping difficulties showed greater improvement (Currier, et al.).

In contrast to Currier, Holland, and Neimeyer’s (2007) findings, Rosner, Kruse,

and Hagl (2010) conducted a meta-analysis that found more promising results. The meta-

analysis studied twenty-seven interventions for bereaved children and adolescents. The

researchers found that the interventions had little to moderate treatment effects (Rosner,

et al., 2010). This is more promising than the findings listed from the previous study.

Although the studies reported little follow-up data, the data found suggested that

treatment effects were persistent over time (Rosner, et al.).

There are other issues inherent in the attempt to provide services for bereaved

children and adolescents. It has been argued that there are barriers to finding appropriate

participants for services (Saltzman, et al., 2001). Some researchers believe that many

37

studies use unproductive screening tools to identify students who could benefit from

interventions (Saltzman, et al.). Acquiring permission from the important adults in the

children’s lives has also been identified as a barrier (Saltzman, et al.). In order for more

conclusive data to be collected, a higher number of participants in research studies will be

required. Patient participation is directly influenced by parental approval. The

researchers need to find a way to appeal to the parents of grieving children so that further

progress can be made in this field.

38

Conclusion

Grief work with adults, adolescents, and children is pivotal to help facilitate

growth towards healing. Children are especially at a disadvantage due to their lower

levels of development and, consequently, require special attention. Counselors’ work

with children can benefit from having a clear understanding of adults’ reactions,

manifestations, and progression of grief. Understanding adult grief can bolster the

counselors understanding of the developmental progression of grief. This, in turn, helps

counselors become more attuned to the differing needs of children.

It is important for children to be given opportunities to express their grief. A wide

range of approaches such as narrative therapy, trauma- and grief-focused psychotherapy,

music therapy, scrapbooking, play therapy, group interventions, and camp-based

interventions may be used to help children reach reconciliation. Counselors can use these

approaches to create an environment conducive to healing while setting up interventions

for students who need more focused attention.

More research is required in order to determine the benefits of different

interventions. Adequate screening techniques should be developed to ensure that

children who will benefit from counseling are identified for services. A consensus within

the research community on the best approach to use with grieving children seems far-

fetched now. Hopefully, the publication of more quantitative studies can help to support

the approaches that are successful.

39

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