At least 204,000 U.S. children and teens have lost parents and other in-home caregivers to Covid-19—more than 1 in every 360 youth, according to Covid Collaborativeopens in new window, an interdisciplinary group of experts that is raising awareness and support for Covid-bereaved children.
The growing number of children facing these tragedies highlights the pressing need for clinicians to become versed in helping them cope and ultimately lead fulfilling lives, say those who study and treat these youth. Basic clinical skills can go a long way, but because childhood grief is not a big focus in graduate school training, getting extra education in the area could be really helpful.
Fortunately, most children don’t need intensive therapy for these losses; many will adjust and fare well over time without clinical intervention, said Irwin Sandler, PhD, a professor emeritus and research professor at Arizona State University (ASU) who has studied childhood grief for more than 3 decades. But a significant subset of children, about 20%, “experience serious long-term problems, including long-term development of depression and long-term higher risk of suicide,” he said. Factors associated with this elevated risk include higher rates of psychiatric disorders in the child and/or parents, child maltreatment before the caregiver’s death, a greater number of stressful events, and less family support following the caregiver’s death, research shows.
Many children who need help or treatment—often those who need it the most—lack access to these services, said Joy Osofsky, PhD, a professor of pediatrics and psychiatry at LSU Health in New Orleans. Psychologists can help to fill this gap by partnering with educators, primary-care providers, religious institutions, and other community partners to share research-based knowledge on childhood trauma and grief on a broader scale.
“It’s about training those who are in regular contact with children to recognize the signs that they need help,” said Osofsky, who coordinated child and adolescent services for the state of Louisiana following Hurricane Katrina and continues various kinds of community outreach. That may be especially pertinent with Covid: “It’s been such an unusual kind of loss,” she said, “because there’s been no real closure for so many families.”
What childhood grief looks like
Children who have lost a caregiver vary in their expressions of grief based on factors including age, their support systems, and the circumstances surrounding their caregiver’s death, said Robin Goodman, PhD, a New York-based clinical psychologist who treats childhood grief and trauma and has conducted research with bereaved families of 9/11 first responders.
That said, grieving youth share commonalities in how they think, feel, and behave, Goodman noted. Common reactions include feeling sad, helpless, lonely, isolated, nervous, anxious, guilty, and angry. Some youth can’t concentrate at school and feel worried and confused—or they withdraw or act out.
There are good reasons for these reactions, Goodman said. “Children are trying to manage an array of feelings and adapt to a life that will never be the same,” she said. In essence, the loss of a central caregiver creates profound changes in all areas of life, including their sense of self, level of security, relationships, and sense of meaning and goals. Those changes aren’t always negative, however: “We do know that the resulting changes can lead to positive personal growth,” she said.
Experts share their thoughts on how to help children deal with these serious losses and help them on the path to growth.
Choose the right intervention
While most grieving children don’t need intensive therapy, they do need some type of psychological support, Goodman said. She and colleague Elissa Brown, PhD, a professor of psychology at St. John’s University in Queens, New York, suggest that there are four categories of grieving youth and each needs a different type of care. The first is kids who are adjusting well and have a strong support system at home, at school, and with peers. For them, basic psychoeducation and family and school support may be enough. The second level is children who are functioning OK but are showing mild to moderate signs of distress. Good support groups can provide a safe place for these youth to express their feelings, develop coping skills, engage in memory making, and know they are not alone (Goodman has developed a group intervention for this purpose called Making Connections).
[Related: Evidence-based practices for childhood grief and trauma]
Children at the third level have more serious problems such as severe depression, trauma symptoms, and posttraumatic stress disorder. For them, it’s important to use more intensive evidence-based treatments that address both trauma and grief (see Evidence-based practices for childhood grief and trauma), Goodman noted. Finally, children with even more complex problems—a history of substance abuse, violence, or serious mental illness in the family, for instance—may need even more comprehensive treatment.
“It is key to understand their situation in total—who the child is—and to involve the caregivers at all levels,” Goodman said.
Tailor therapy
Specific evidence-based practices for childhood grief and trauma are the best approach if the family has sufficient mental health insurance coverage and the child’s situation calls for more intensive treatment. If you’re not specifically trained in such techniques, you can apply basic clinical skills with modifications for the age of the patient, said Christina Cammarata, PhD, clinical director of the outpatient clinical child and community program at Nemours Children’s Hospital in Wilmington, Delaware.
For example, she uses psychoeducation that she frames in young people’s terms. For instance, she tells them that “grief is kind of like a wave—it will come and go,” or, “You might be feeling really mad sometimes, you might be feeling sad, you might want to cling to your mom or dad or aunt, you might feel very worried.” The aim “is to normalize those feelings—to help the child talk about them if they want to,” she said.
Cognitive behavioral therapy techniques are key as well, including when kids express negative and unrealistic thoughts about their caregiver’s death, said Bonnie Zucker, PsyD, who has a private practice in Rockville, Maryland, and is author of Something Very Sad Happened (Magination Press, 2016)opens in new window, written for children ages 2 and 3 who have lost a parent or caregiver.
Often, these thoughts center on guilt and self-blame, Zucker said. She talks with kids about “thinking traps” they may get into—negative ways that their belief systems may have changed as a function of their loved one’s death. For example, teens tend to feel guilty about previous bad behavior or feel ashamed that their parent died right after they’d had a fight with him or her. Addressing and countering these thoughts can help young people gain more realistic, balanced thinking and move to a more positive, future-oriented mindset.
Enlist caregivers
Research shows that kids fare better when parents and other caring adults help them process their grief, Cammarata said.
“We know it makes a huge difference for children to have at least one supportive adult who can be a consistent presence for them,” she said. In sessions with children’s caregivers at her hospital, “we encourage them to be the best sort of supports that they can be, including by returning family routines to as close to normal as possible.”
Sandler of ASU developed the Family Bereavement Program, which helps grieving children and caregivers build new and positive family structures and relationships (see Evidence-based practices for childhood grief and trauma). Not only does the program build mental health and resilience in kids, but he has found that it benefits caregivers as well—suggesting that creating and maintaining an environment that’s good for kids is also good for the caregivers. Recently, he and his colleagues launched an additional program designed specifically for caregivers: Resilient Parenting for Bereaved Families. This program helps caregivers of bereaved children gain the practical skills to create supportive family environments.
Use clear language
Many children who are grieving the loss of a parent or caregiver keep quiet because they are afraid they’ll burden others by talking about it; conversely, caregivers may not understand the best way to talk with them about it, either.
Clinicians can help by modeling clear and direct language—for example, using terms like “death” and “dying” instead of euphemisms like “passed away” or “is gone,” said Komal Sharma-Patel, PhD, a clinical psychologist who works with children and families at Children’s National Hospital in Washington, D.C.
“Simple explanations go a long way,” she said. “When parents use direct language with their children, it communicates that they are a source of information and safety.”
Consider age
Also key is understanding developmental differences among grieving youngsters and how to address them, said clinical psychologist Julie Kaplow, PhD, ABPP, executive director of the Trauma and Grief Centers in Houston and New Orleans and professor of psychiatry at Tulane University School of Medicine. For example, children younger than 6 don’t grasp that death is permanent, so they may continue to seek the person out, for example, waiting by the door or window for the person to return. When they become aware that the person is no longer present, they may react with temper tantrums, as well as regressive behaviors in their use of language, eating, and sleeping.
By school age, children begin to understand that the loss is permanent. As a result, they’re more likely to develop symptoms of depression and to express more intense distress. Some might become more concerned about the safety of caregivers or develop separation anxiety, while others might act out in school. Teens, meanwhile, may develop a sense of hopelessness or helplessness—the feeling their life is meaningless without the person there. In turn, that can lead to risk-taking behaviors and even suicidal thoughts and actions.
Take these stages into account when working with grieving kids, Kaplow advised. For example, younger children benefit from routine and structure, school-age kids may need help forming new relationships and connecting with people outside the family, and teens may need extra emotional support and space to process their feelings with peers. With teens, it’s also important to be alert to signs of suicidal thoughts or behavior, she noted.
Encourage expression
Giving young people the time and space to express their range of feelings about the death is essential, and it’s vital to teach caregivers how to do that, too. Psychologists are well suited to this task, Zucker added. “There isn’t as much opportunity to do this with school counselors, for example, where there is less time and the environment is different,” she said, though any intervention can help.
Sandler’s Resilient Parenting for Bereaved Families program encourages caregivers to listen to grieving children rather than talk at them. “We very deliberately teach listening skills,” such as how to ask open-ended questions, make eye contact, and let the child know that you are there for them. “We encourage caregivers to stay away from the quick fix, which often shuts down the conversation,” he said. These skills can help children deal with anything from grief-related conversations to everyday stressors, he added.
Caregivers should be encouraged to open up as well, Cammarata added. Ideally, caregivers should “do it in a way that is real and honest, but that doesn’t shut the child down or make the child afraid because of their emotions.”
Nurture resilience
Helping youth build inner strength is another main component of reducing grief-related distress and enhancing adaptive grief reactions, clinicians and researchers emphasized. With this in mind, Kaplow and colleagues developed a theoretically driven intervention called multidimensional grief therapy, which holds that grieving children can experience challenges in any of three areas: separation distress, or yearning for the person who died; existential or identity distress—feeling that life lacks meaning without that person; and circumstance-related distress, or becoming preoccupied with the way the person died. The model also holds that there are parallel strategies in each domain to help children adapt and grow.
An example of circumstance-related distress is a teen who is fixated on her mother’s death from breast cancer. Adaptive strategies for her might include joining a breast-cancer walk or considering a career in medicine. If a boy is suffering from existential distress, a helpful practice might be helping him identify and emulate traits that he loved in his caregiver, such as kindness or creativity.
Luckily, kids are more than willing to engage in these processes, Kaplow noted. “Kids naturally gravitate toward wanting to do something that would help prevent the kind of suffering that their caregiver went through,” she said.
Employ cultural awareness
Ask caregivers, and if age appropriate, their grieving children, to discuss their cultural and religious identities and how those may relate to commemorating the person’s death, Sharma Patel advised. Ask about grief rituals that they practice in their tradition, as well as how their cultural identity may impact their understanding of mental health, emotions, thoughts, and behaviors. “You want to integrate this understanding and conversation from the beginning, from the assessment and on into treatment,” she said.
Also important is discussing similarities and differences between what you as the therapist see as a treatment pathway and the patient’s concept of grieving, Sharma-Patel added. For example, some traditions may ask that people stay home for a period of time to grieve. However, if that time goes on too long, it’s time to explore what might be happening from a psychological perspective, she said.
The goal is “to find a middle path on giving information that’s important to the family,” she said, “while still respecting their cultural values and beliefs.”
Encourage new traditions
Finally, memorials can promote closure and prompt children and families to think about the future, said Sharma-Patel. “They can serve as both a permission to celebrate the death and the life of the person who died, as well as a permission to move forward, to be happy,” she said.
Therapists can help families think about how to craft these commemorations and modify future traditions to incorporate the memory of the deceased caregiver while creating and celebrating new hopes and directions, she said.
Memorials are useful because they’re about doing something instead of feeling stuck, Zucker added.
“People transcend grief and trauma through movement,” she said. “We want to support children to do the same.”
