Bereavement With Children

Clinical Child Psychology and
Psychiatry
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Bereavement: A Framework for those Working with Children

Diane Melvin and Diane Lukeman
Clin Child Psychol Psychiatry 2000 5: 521
DOI: 10.1177/1359104500005004007
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07 Melvin (to/d) 15/9/00 10:39 am Page 521
Bereavement: A Framework for Those

Working with Children
DIANE MELVIN
St Mary’s Hospital, London, UK
DIANE LUKEMAN
Thelma Golding Health Centre, UK
A B S T R AC T
This article aims to describe psychological factors which help or hinder coping with
bereavement in childhood. Children can and do cope with the death of those close
to them if they know what is happening and have the appropriate support to cope.
However, children suffering from loss are likely to be in the care of adults who are
also grieving and there is a need to support the adults and to mobilize other
resources for the child. We discuss the timing and appropriateness of interventions
from all those working with children and, in particular, for the child mental health
and other specialist services in supporting children and families through the
process of bereavement.
K E Y WO R D S
bereavement, children, intervention in bereavement, understanding of death
The context
major advances in psychological understanding during the 20th
T H E R E H AV E B E E N
century and, as we commence a new century, it is ironic that there has been an upsurge
D I A N E M E LV I N ,
Chartered Clinical Psychologist, is employed in the Department of Clini-
cal Health Psychology at St Mary’s Hospital where she works with a specialist paediatric HIV
team and family clinic. She is also employed at Great Ormond Street Hospital in the paedi-
atric liaison service. She has worked in a variety of settings in the NHS with children and
families.
DIANE LUKEMAN, Chartered Clinical Psychologist, is employed in Clinical Psychology

Services, Hounslow and Spelthorne Community and Mental Health NHS Trust and
works in a child and adolescent mental health service. She has worked in a wide range
of settings with children and families both in health and in social services.
C O N TA C T : Diane Lukeman, Thelma Golding Health Centre, 92 Bath Road, Hounslow TW3
3EL, UK.
Clinical Child Psychology and Psychiatry 1359–1045 (200010)5:4 Copyright © 2000

SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 5(4): 521–539; 014088
521

CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)
of interest in the topic of children’s bereavement – something which was more part of
the lives of children at the turn of the last century than at the present time.
The number of books, conferences and training courses on the subject of death and
bereavement which is now available could leave the impression that death has only
recently been ‘discovered’ and that bereavement is an illness or a problem that will not
go away unless treated by counselling or those with special expertise.
As clinical child psychologists in the field of mental health, together with colleagues in
this field, we are experiencing an increase in the number of enquiries and referrals of chil-
dren and young people immediately following the death of a family member. Many of the
referrals are from health and social services professionals who are expressing concern
and/or uncertainty about whether a bereaved child’s reactions are ‘normal’ and what is
the ‘best way’ to deal with the situation. Together with this, we are aware that within the
general referrals made to us about problems within families, there are likely to be some
in which death and bereavement are major issues. These may have occurred in the life-
time of the child referred or may be significant issues in the childhood of the parents.
While there is now more openness about death in families and communities, the child-
hood experience of many clinicians may have been from the era when this was not the
case. The prevailing view was that ‘children are too young to understand’. The adults’
role was to protect children from potential distress. There is now a greater acknow-
ledgement that mourning and grieving are natural processes following a death. However,
although there is more understanding about the need for children to be part of the
experience, anxieties are raised about changes in the behaviour of the child. There may
be a fearful reaction about not wanting to ‘do damage’ by saying or doing the ‘wrong
thing’. In this age of ‘experts’ on whose services we depend for repair of all our machines,
as well as for the maintenance of our health and well-being, the ‘expert’ is sought who
can deal with distressing situations and who may help to manage the child’s grief in the
‘correct’ way.
This has led us to consider the following issues:
• what are the appropriate resources for providing support to bereaved children and
their families?
• can different resources/interventions be identified which are appropriate at different
times in the process of grieving?
• when is it appropriate to refer bereaved children to child mental health services?
• should child mental health professionals be more available for consultation to those
who are in close contact with bereaved children so that they can develop ways to
support them?
• how do clinicians manage to separate their own personal experiences and their work
context?
The preparation of this article has involved much discussion of our personal experiences
of death and the sharing of a wide range of our clinical material when bereavement and
grieving were significant issues. We aim to present the outcome of these discussions in a
way that may be useful for those working with and around children who have been
bereaved.
The social and historical context

Over the past century there have been marked changes in mortality rates with conse-
quent differences in attitudes to death and dying (Judd, 1989). In the 19th century, two-
thirds of the population died before the age of 50; death took place at home and was
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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN
seen as a natural progression of life; it was likely to be a much more public event. The
First World War and its aftermath brought about some changes. Vast numbers of young
men were killed abroad and, in that political climate, there was little encouragement for
grieving and loss to be acknowledged openly. As medical knowledge increased with the
discovery of the first curative drugs, attitudes to death changed. Rather than thinking of
death as a natural phenomenon in the progression of life, death could now be perceived
as avoidable or the result of medical failure.
Gelcer (1983) raised some issues pertinent to these changes in attitude. She stated that
we now live in a society where the emphasis is on health, curing disease and prolonging
life. Most children and many adults may not have experienced the direct impact of a loss
in their household. Alongside this, there is another significant change: death is less likely
to occur in the home. The experience has been taken away from the family into insti-
tutional settings. This can have the effect of isolating the events from everyday life and
preventing people from expressing their natural responses.
We know that the rituals of mourning are usually determined by family and cultural
factors within the wider community (McGoldrick et al., 1991). Gelcer (1983) raised the
concern that because of the decrease in the practice of religious and institutional rituals
around death, adjustment can be more difficult for bereaved individuals. The decline in
the influence of social and religious institutions leaves uncertainty about how mourning
rituals take place. At the same time, our society has become more culturally mixed and
there are religious communities who follow different prescribed rituals attached to
mourning. This can be confusing, as members of one group are unlikely to be familiar
with the rituals and beliefs of other communities although working and living alongside
each other.
We have referred, earlier, to the silence around death. There often appears to be a
taboo around discussing death in front of children or of displaying emotions. Adults may
find their own feelings too painful and wish to protect children from distress. This may
be puzzling to children who may rarely experience death within the home but are
exposed to images of death on their television screens – death without any emotional
impact (Bertoia, 1993). Such images may influence and explain the way in which some
children behave when confronted with the death of a person close to them. Children may
appear indifferent; they may not ask questions; they may continually ask questions (to
which adults do not respond); they may act as if the dead person is still present. The lack
of appreciation of this confusion for children seems to have influenced the lack of
support for children in the recent past.
There is a general view that there is now more openness around the topic of death,
grief and bereavement processes. We have indicated that this may not be so when chil-
dren are involved. Moreover, this may carry the implicit message that if everything is
carried out as prescribed, the pain and suffering will be lessened, if not alleviated
completely. Judd (1989) described this as similar to the denial of death – the denial of
death as a painful, emotional experience. Those who do suffer may be seen as having
failed to adhere to the ‘prescription’.
The developmental perspective

For all those involved in caring for children, it is essential that ‘children’s problems,
competencies and needs be judged in the light of their requirements for further develop-
ment’ (Achenbach, 1992). Childhood is marked, in all aspects of development, by the
presence of conspicuous milestones and rapidity of change. Many child developmental
theorists view development as a series of stages and attach age levels to these stages.
523

Table 1. Children’s understanding of the concepts of death (Kane, 1979)

Age (years) Concept Explanation
3 Realization Awareness that death can happen to someone
5 Separation The dead are located elsewhere
Immobility The dead are inactive, cannot move
6 Irrevocability Death is permanent
Dysfunctionality Bodily functions cease
Universality Mortality – everyone dies
7 Causality Brought about by internal or external cause
8 Insensitivity Cessation of feeling, thinking and senses
12 Appearance Look same/different from when alive
Increasing age alone, however, does not explain the developmental process. There are
many other factors which need to be taken into account including the child’s own life
experiences. Some developmental theorists consider the child as ‘a theory builder’ – a
process whereby the child’s experiences interact with the ability to understand so each
child develops their own understanding of their experiences (Nelson, 1986). The ways in
which children who have terminal illnesses and their families develop an understanding
of the process of dying is illustrated in two studies by Bluebond-Langner (1978, 1996),
an anthropologist. Her observations, in the first study, within a ward for children with
leukaemia and, in the second, the families of children with cystic fibrosis, highlights the
importance of recognizing the coping skills which children and adults have in such situ-
ations. Moreover, it illustrates the way in which children develop in their socialization
and understanding of relationships, and are able to facilitate their own understanding of
death and that of those around them – both families and professionals.
These perspectives need to be taken into account when we consider the impact of
death on a child. Some studies have helped build up knowledge of children’s under-
standing of death. In an important study, Kane (1979) identified nine components of the
understanding of death and showed the relationship between age and understanding
(Table 1).
There has been debate about the age levels assigned to the understanding of different
components of death by Kane. Speece and Brent (1984) found that these were achieved
between the ages of five and seven years; Lansdown and Benjamin (1985) concluded that
‘while 7 or 8 remains the average age for a full development of the concept of death,
there is considerable support for the notion that children younger than this have a good
grasp of the meaning of the word . . .’. Orbach, Weiner, Har-Even, and Eshel (1994)
provided a useful overview of the studies which examine children’s understanding of
death by considering the complex relationship between cognitive, emotional and social
development and experience of death.
Some of the issues raised in the literature about children’s concepts of death are noted
below:
• methodology has been questioned – not surprisingly given the complexity of the issues
involved and the difficulties in interviewing a child population
• the concept of death is not a global one; it would appear that different components of
the concept develop separately but are linked sequentially
• we need to be aware that understanding the death of a loved person is not a single,
time-limited experience
524

• influences other than age need to be taken into account such as social, cultural and
religious context, cognitive level of the child, emotional state and the nature of the
death itself
• both from the literature and clinical examples there is little doubt that the personal
experience of death can facilitate the understanding of the concepts involved (Black,
1994; Bluebond-Langner, 1978, 1996; Krasner & Beinart, 1989; Norris-Shortle, Young,
& Williams, 1993). Developmentally, children may not have reached the ‘stage’ of
understanding the permanence of death but experience has influenced that develop-
mental process.
Case example 1
David’s father was killed instantly when his motorcycle was in collision with a large lorry.
David, aged four, appeared to accept this immediately and took a very practical view. His
sister, Lucy, not yet two, did not appear to understand. She asked constantly for Daddy
and looked for him both inside and outside the house. David commented on this and his
mother explained to him how hard it might be for the baby to understand. ‘Leave it to me’
he said and took his sister to his room. After some time, she came down and said ‘Daddy
gone’. David was asked what he had said. ‘I took my toy articulated lorry and a motorbike
and put a little figure on it. I showed her how Daddy had got knocked off his bike by the
lorry. She knows now.’ Her searching behaviour reduced almost immediately.
In the earliest years, children are making connections and sorting out consistencies in
their personal and object world. The formation of attachments helps bring trust and
security to young children. They will be most dependent on others to maintain balance,
security and a routine in their lives that will enhance coping following a death. While
most passive and helpless, their more limited understanding of what has happened may
also serve to protect them from the long-term implications of the event. They may be
observed showing frequent ‘searching’ behaviour for the lost person as well as frequent
playing out of the event. Disruptions to toiletting, sleep patterns and eating may occur,
although they are usually short-lived. Periods of sadness are usually short and the natural
openness and concrete thinking of young children may serve to help them process the
event relatively quickly (Dyregrov, 1994). Even for very young children, it seems that a
clear and honest explanation of what has happened will enhance coping. Discussion still
needs to be left open as misunderstandings can still arise.
Case example 2
Adam, aged five, returned from school in a distressed state. It was difficult to establish
what the problem was but it seemed to focus on his reluctance to be in the nativity play.
He had always been outgoing and a volunteer for such activities. Careful listening by his
mother led to a possible explanation. Adam’s grandfather had died in the summer. He had
been close to Adam but had been ill for some time. There had been open discussion at
home and the children, including Adam, had been part of the mourning. Adam under-
stood that Grandad was ‘with the angels in heaven’. Adam was not prepared to be an angel
as he thought he may die. He readily accepted the part of a wise man.
As understanding increases, children may grow more puzzled and anxious over an
event which they, apparently, ‘understood’ earlier. This may result in persisting feelings
of loss or blame. In such cases it may be necessary to revisit the circumstances and
emotional impact of the death.
As the child progresses through school age, there are shifts both in emotional and
525

cognitive understanding and in the range and types of coping strategies used in stressful
situations. The child is becoming less dependent on parents and the home, and has more
contact with outside influences. Each child is able to make inner plans of action helping
to protect themselves from what has happened (Pynoos & Eth, 1984). They can also
‘undo’ or change what has happened in their dreams, fantasies and play. Taking revenge
or producing a different ending in their imagination can help counteract feelings of help-
lessness. During these years, adults demand more of them and sometimes the expecta-
tion might be that they should act ‘grown up’ and ‘not cry’. Problems commonly found
following a death include poor concentration and school work may be affected. Aggres-
sive outbursts and some regression in behaviour may also be found.
Adolescence is itself a time of transition when ambivalence and conflicts with parents
and school are commonplace. Adolescents may also have a heightened sense of their
own mortality. If a significant death occurs during this time, it is important to consider
these issues and how they may influence the way in which the impact of death is
managed. Intense feelings may be reported often with some avoidance of dealing with
them. Sometimes, magical thinking and irrational fears are reactivated. More risk-taking
behaviour may occur, but there may also be fears of losing control emotionally. The role
of friends and peers cannot be underestimated at this age.
Contributions from current psychological theories

Theories of the bereavement process
The following are recurring (and interrelated) themes which have led to present-day
thinking and which still drive ideas about the nature and timing of help.
• The stage or phase model of bereavement.
This model suggests that there is a consistent and continuous order to the process,
including a timing component and emotional tasks for each stage. The implication is
that difficulties will arise if a person becomes ‘stuck’ in a particular phase and that
different approaches to intervention are needed during different stages (Bowlby-
West, 1983; Kubler-Ross, 1969; Worden, 1991).
• Death as a severe stress or trauma necessitating professional intervention.
Death is a stressful event which usually causes problems and difficulties, especially for
children. It is often considered in the same arena as mental illness. This leads to the
view that children experiencing death, regardless of the circumstances or natural
support network, will need therapy or counselling to support them through the grief
and bereavement processes. The media emphasis on the presence of counselling
services in the aftermath of disasters, perhaps, has promoted this view.
• Task theory.
This is based on the concept of grief work. Worden (1991) identifies four goals for
counselling based on the four tasks of mourning: to increase the reality of the loss, to
help deal with expressed and latent affect, to help overcome impediments to readjust-
ment after the loss, to encourage saying an appropriate goodbye and moving on
(Fredman, 1997). Some bereavement programmes from hospice care have highlighted
the important task of including and involving children in tasks and rituals around the
death of a loved one as part of this task completion (Baker et al., 1992; Bell, 1992;
Hemmings, 1992; Pennington & Stokes, 1998).
While each of these models provides helpful ideas for understanding reactions to grief,
they can lead to a rather prescriptive approach to the provision of help. The sense that
there is a right way of doing it for everyone can lead to feelings of failure or regret if
526

some tasks were not possible or not achieved. At this time of uncertainty, those involved
may feel more comfortable working within a particular framework. Bereaved children
may feel that general ideas are being superimposed over their own thoughts about what
would (or did) help them during their own personal experience of death. We believe that
this does not take account of individual differences in responding to stress and the role
of natural support networks.
Case example 3
A referral was received from a health visitor requesting help for Catherine, a nine-year-
old-girl and her family. Catherine was described as being unhappy, moody and uncooper-
ative. The health visitor indicated that she had concerns, as this was a reconstituted family
– Mr and Mrs D had married some five years earlier after each lost their first partner by
death from cancer. Catherine was the daughter of Mr D’s first marriage. There was one
other child in the family – Susan, the daughter of Mrs D and her first husband. The assess-
ment highlighted predictable issues. Catherine, whose mother had died, appeared to be
showing marked signs of loss and separation. Her care prior to and following the death of
her mother had been inconsistent. There had been a split between her father and her
maternal grandparents and that contact had been lost. Mr D admitted his great difficulty
in talking to Catherine about her mother. Mrs D spoke about her experiences with her
own daughter when her father was dying and after. The parents began to become aware
of the differences for each girl. While the experience of meeting and becoming committed
to each other had felt very positive for the parents, they began to talk about how differ-
ent the experience may have been for the girls who could not replace their dead parents.
There was loss of members of extended families and some confusion with the girls as to
which relatives ‘belonged’ to whom. The discussion helped the parents to think about ways
round that which they decided to work on themselves with their daughters.
Family system theories

There is a growing body of knowledge about family psychological processes, which can
contribute to our understanding of the process of bereavement for children. Much of
children’s understanding of the world around them, their patterns of behaviour and their
coping styles are processed through the family The influence of early experiences may
not only be about death, but also around any loss or separation – family moving away,
marital separation and other family conflicts. Events and the family’s construction of
these may not be shared with the children in a way that makes sense. Family myths and
the views and style of transmitting information will play a part here. In addition, the loss
for each member of the family may be very different, emotionally. The loss of a father
– irreplaceable for a child – may be different in quality from the loss of a partner who
may be replaced in time.
Kissane and Bloch (1994) stated that ‘. . . the family virtually always constitutes the
most significant social group in which grief is experienced . . .’ and that, therefore, a
systemic perspective is appropriate when assisting the bereaved. Walsh and McGoldrick
(1991) noted the importance of understanding family myths and stories in helping with
grief. ‘The pain of death touches all the survivor’s relationships with others, some of
whom may never have even known the person who died’. This can be understood in the
way that some people react to the reporting of deaths or disasters affecting those far
removed from their family or social circle. It is also important to consider losses tempo-
rally within families. The death of a significant member of a family prior to a new
member joining that family through birth or marriage can have an important effect on
the way that a death is processed and understood in the family.
527

Case example 4
James was nearly three years old when his mother died following a period of illness. His
father involved him in what was happening and had been able to support his needs, both
emotionally and practically. James returned to normal routines and daily life quite quickly.
When he was six, his father sought help as he felt James was now ‘worried’ about his
mother’s death and becoming upset when they talked about her. Further discussion with
the father indicated that this upset happened at the time he had formed a close relation-
ship with a new partner and there had been some talk about marriage and ‘a new mother’.
James said he had a mother, even though she was dead and did not want another one. He
had also become more clingy to his father.
Narrative theory
There is an increasing interest in developing ideas using stories and narratives both to
understand personal and family life changes (including secrets and losses) and for use as
therapeutic techniques in clinical practice in both adult and child work (Book, 1996; J.
Crocker, personal communication, 1996). Narrative approaches have been used, more
recently, to help the bereaved child (Gersie, 1991). Children can be helped to make sense
out of what initially seems senseless. If there is no attempt to help them develop a narra-
tive or include the death in their existing life narrative, there is a risk that the death and
surrounding events may become ‘separated off’ and not integrated into everyday func-
tioning.
Children’s narratives involve not only real events but also a mixture of reality and
fantasy, past and present (Riches & Dawson, 1996). Because a story can have different
endings, a bereaved child may be able to fantasize or dream, for a time, that the loss has
not happened. This may bring comfort and act as a protective function allowing gradual
adjustment and adaptation. Adults may need to be aware of the child’s story for if this
does not move on or if fantasy interferes with everyday functioning, then the negative
effects of denial may outweigh the protective effects.
Visual and auditory images may accompany the stories and the dreams that form part
of the narrative around the death of a loved one. Reports of seeing the dead person and
talking to them are occurrences commonly reported by both adults and children follow-
ing the death of a loved one (Zambelli, Clark & Hodgson, 1994). It may be that such
images represent a kind of transitional object helping the process of adjustment, especi-
ally if a death has occurred unexpectedly with no opportunity for preparation or antici-
patory grief. As grieving progresses, the interest in ghosts usually begins to fade.
Special circumstances surrounding a death

There are particular circumstances that may mean that the usual resources of the child,
or of the family system, are overwhelmed or cannot deal adequately with the demands
created by the death and its aftermath. It is in these situations that referral to outside
agencies may be most needed.
Sudden and traumatic deaths

After a death which occurs as a result of aggressive or traumatic circumstances, such as
war, terrorism, horrific accidents or murder, when strong emotions of panic, fear or
blame surround the event, access to expert help may be required. The child’s natural
coping mechanisms may be inhibited or distorted, particularly if the child has been a
witness to or directly involved in the events (Black, Harris Hendricks, & Kaplan 1992;
528

Dyregrov, Randalen, Lwanga, & Mugisha, 1987; Yule & Williams, 1990). Deaths in such
circumstances often enter the public arena and police investigations or legal proceedings
can take a long time, serving to prolong or hamper the grieving process. After some
violent deaths, urgent access to a service with expertise in talking with children can
provide appropriate debriefing and assess for the presence or likelihood of post trau-
matic stress (Black et al., 1992; Dyregrov, 1991).
Suicide
Suicide, while directed at the self, also leaves those touched by the life of the person
attempting or succeeding in such acts feeling anguish, self-blame or self-reproach
(Dunne, McIntosh, & Dunne-Maxin, 1988). The accompanying guilt and shock can be
so consuming that the processes of grieving and bereavement are inhibited as the nature
of the death stands in the way of adjustment and memories. There may be extra stres-
sors on the child which include trying to make sense of what has happened and the
confusing and erratic responses of others in their family and support networks. These
can range from secrecy and social stigma about the death to ambivalent or negative
remarks about the victim as anger is mixed with grief. Family communication can be
distorted and the family can find themselves isolated from personal and social support
(Walsh & McGoldrick, 1991). Higher rates of psychiatric disturbances have been
reported in children whose parents committed suicide than in other cases of parental
death (Dowdney et al., 1999).
Adolescents can be particularly vulnerable to the consequences of suicide, not only
when a family member is involved, but also when they lose a member of their peer group
or wider acquaintance. At this time of transition between childhood and adult life,
expressing feelings can be difficult and they may put their own grief ‘on hold’ (Pennells,
Smith, & Poppleton, 1992; Valente, Saunders, & Street, 1988). Rates of suicidal ideation
and suicidal behaviour are high and rising in young people themselves (Asen, 1998;
McClure, 1994). A suicide in the family or in a close contact may increase vulnerability
in this age group as it can fuel feelings of rejection (Hawton, 1986).
Accessing mental health agencies attached to clinics or hospitals may not be welcomed
or seen as appropriate by adolescents. However, such services may be in a key position
to train or support youth workers, school counsellors and others who come into direct
contact with young people. They may be in a better position to reach young people either
troubled by suicidal ideas themselves or affected by the effects of a death by suicide.
Parental death
The death of a parent, especially when they have been the main carer, is likely to disturb
the daily structure of a child’s life and may leave a child feeling vulnerable and also
perhaps in need of extra support from outside the network of personal resources in
family and friends. Young children may be concerned about how the practical aspects of
their life will continue; adolescents about the responsibilities and how to express their
needs at such a time of transition for them (Heinzer, 1995). Surviving parents may be
emotionally unavailable to their children, being preoccupied with their own grief.
Parental death for children of divorced/separated parents The issues around the death of a
parent when the parents are divorced or separated can be very complex. Children may
be suffering from the loss of their parent but the remaining parent may feel detached
emotionally from that process. The ambivalence of the relationship which existed
between the parents may make it difficult for the surviving parent to assist the grieving
process for the children. Other partners (and stepchildren) may be involved. If the parent
529

with whom the children lived dies, the disruption in family living arrangements may be
very marked for the children, surviving parents and their families (Hildebrand & Daniel,
1997).
Parental mental illness The short- and longer term effects on the emotional and social
development of the child of growing up with a parent who has a serious mental illness
have been documented (Cassell & Coleman, 1995; Cummings & Davies, 1994). Attach-
ment responses may be particularly vulnerable. Furthermore, children may feel confused
or embarrassed by or responsible for aspects of the behaviour of their parent(s). If the
parent dies, the already vulnerable child may be faced with extra and conflicting
emotions including blame and relief. Access at some stage to a mental health service may
provide a means to express and deal with some of these confusing feelings and help with
longer term adjustment.
Death from inherited and transmitted conditions

The presence of a life-threatening illness in a member of a family can produce feelings
of guilt and blame in other affected family members. This may be particularly so in
conditions which have a genetic origin, for example sickle cell or haemophilia, or which
are transmitted directly from one person to another, for example sexually transmitted
diseases and HIV infection. Parents who feel their child’s or their partner’s death was
their fault because they ‘passed on’ a condition may find that these feelings complicate
or inhibit the bereavement and adjustment process. Specialized support may be neces-
sary and appropriate. Others in the family, especially children affected (but not infected)
by the condition, may feel responsible for what has happened and may wonder if they
did enough to help or prevent the death.
HIV infection is one such condition in which secrecy, confusion and fear of disclosure
can also accompany feelings of guilt or blame (Melvin & Sherr, 1995; Siegel & Gorey,
1994). Children’s upset at a death from AIDS in the family can be exacerbated because
they may not be included or informed about what is happening and many may have
already suffered other losses and changes without explanation. Furthermore, the
nature of transmission of the HIV virus through sexual contact or from mother to child
means there are often several persons in one family group who may die from the illness.
These factors together may place HIV-affected children in need of access to outside
support.
Issues of difference
Attitudes to death and the rituals surrounding the death and mourning and the child’s
role vary in different ethnic and religious groups (McGoldrick et al., 1991). A death in
a family may disrupt traditional activities. Imber-Black (1991) describes the way in which
the death of a family member led to dysfunctional behaviour around the celebration of
Christmas.
If a family is living away from their culture of origin, particularly if newly arrived and
isolated from others of their community, its members may experience an additional sense
of loss and bewilderment. These feelings may arise from being separated from familiar
and supportive systems and from the different formalities surrounding the management
of a death in the new culture. Children may not understand the way the adults they love
are behaving or what is expected of them. Furthermore, they may have little support
from the wider community or peer group at school who may be from different cultures.
Access to someone who can help them make sense of what is going on around them may
provide the best support to bereaved children in such a situation.
530

Case example 5
Betty was six years old when her mother died following a long illness. Her mother was
from Africa but Betty had lived all her life in London. She had been staying with her aunt
during the last months of her mother’s life and was going to be cared for by this aunt in
the future. She had been told her mother was ill and had been able to visit her and talk to
her mum (and say goodbye). Betty attended the funeral which was also attended by friends
and relatives, many from Africa. During the service some of the women started to wail
loudly in traditional fashion. This made Betty a little concerned but she was reassured
when the other people were not upset by it. A few days later at school her teacher noted
that she was playing in the home corner with one of the dolls and shouting loudly and
getting some of the other children to join in. She asked her what she was doing. Betty
replied: ‘I’m playing dying’. Her teacher knew that Betty’s mother had just died and
thought she was very distressed or very angry about it. She wondered if Betty needed
special help to cope.
Pre-existing mental health issues of the child

Highly anxious or depressed children or those dealing with multiple losses are likely to
be in need of immediate help. While similarities exist in the presentation of a bereaved
child, one who is depressed and one suffering from post-traumatic stress, the approaches
to care and management differ. The opinion of a child mental health worker can facili-
tate the process of adjustment and shorten the emotional suffering of some children.
Children with special needs

In the area of work with people with learning difficulties, there has been a lack of
acknowledgement that they too understand and suffer from loss and bereavement
(Cochrane, 1995; Oswin, 1992). It is only more recently that the emotional requirements
of children with special needs have begun to be considered (Cathcart, 1995; Sanderson,
1996; Sinason, 1992). A child with special needs, especially those affecting learning and
communication, may require approaches or interventions beyond the knowledge of their
usual carers. They may have difficulties expressing their feelings or express them in less
socially acceptable ways. Providing explanations and support by those with experience
of treating the emotional and behavioural needs of children to those adults familiar to
the child can often be the most effective way of making progress.
Moderating factors
Within all the systems surrounding the child there are moderating factors serving to
influence the impact of a death on the child and modify the subsequent processes of
grieving and bereavement. These moderating factors can be crucial in determining
whether and when referral for outside support is necessary for a child and/or the family
following a death.
The past two decades have seen a radical shift in approaches to understanding chil-
dren’s reactions when faced with difficult or upsetting situations. Psychological
approaches to work in some fields of paediatrics, disability and child mental health have
moved away from deficit-centred models (e.g. predicting rates of ‘maladjustment’) and
replacing them with approaches which consider coping styles and resilience (Heiney,
Hasan, & Price, 1993) These models seek ways of predicting why some children have
resilience, for example, adjust more readily than others to stresses. There appears to be
a triad of factors found in resilient children: genetic and constitutional factors, a
531

supportive family milieu, and external social support systems available to parents and
children (Garmezy, 1985). Fonagy et al. (1994) argued that resilient children are securely
attached children and that this attachment is part of the moderating process.
Eiser (1993), in her book about childhood chronic illness, described models put
forward to describe coping in childhood and adolescence. These models suggest two
main kinds of coping.
1. The child attempts to control or change some aspect of the environment or individual
(problem focused/ approach focused).
2. The child attempts to regulate or manage the negative emotions associated with the
stressor (emotion focused/ avoidance).
Both kinds of coping are appropriate and may be useful at different times, both devel-
opmentally for the child and during the process of grieving. It is helpful to consider
whether a child has access to a wide range of coping strategies, both in the thinking and
in the feeling dimensions. There can be a tendency for one approach to be valued over
another, for example in some families open expression of feeling is not expected from
children; in other families, grief is seen as being appropriately expressed by public
displays of distress.
In considering death and bereavement, the influences which appear to reduce the
impact of a death and the likelihood of both immediate and longer term disturbing reac-
tions in the child include:
• the availability and effective use of social support from family, friends and others
• the re-establishment of life patterns
• the development of new, intimate relationships
• the provision of crisis intervention, including the giving of inappropriate information
and explanations (Rutter & Rutter, 1992).
Some specific examples of the moderating factors, from the different systems surround-
ing the child, which have been found to be protective are outlined in Table 2.
Intervention
The death of a loved one brings about not only feelings of loss, but also has practical
effects. Moderating factors can affect these two interrelated components of the child’s
emotional security and attachments. Interventions which enhance or promote attach-
ments and security for the child (dealing with the lack), as well as giving means of
expressing and understanding the death (dealing with the loss), help to reduce the like-
lihood of future or prolonged disturbance in the child.
We have discussed earlier some of the factors which influence decisions about inter-
ventions. It is likely that the most appropriate form of support will be from the adults
already in the child’s life, including family members. The ability to express feelings and,
in turn, to be given an open explanation of what has happened seem to be core features
of good adjustment following a death (Dyregrov, 1994). Crocker (personal communi-
cation, 1996) noted that being excluded from the rituals of mourning and from partici-
pation in the discussions around it, creates a sense of inexplicable silence.
It is important, however, to remember that the adults around a bereaved child may
also be grieving and lack the resources to make themselves available to the child. They
may be fearful, too, of any signs of distress or unusual behaviour in a child or of showing
their own distress to children. (I was upset when my favourite aunt died and I could not
532

Table 2. Protective moderating factors

Child
Ability to form an internal image or representation of dead person (Lohnes & Kalter, 1994) or
maintain memory or link (Silverman & Worden,1992). Children who are able to express themselves in
words, drawings, etc.; girls are often more able to do this than boys (Dyregrov, 1994).
Parental
A replacement figure who can fill some of the role that the dead person had in the care of the child.
This is especially important following a mother’s death where practical, as well as emotional, needs
have to be met (Saler & Skolnick, 1992). If the care role is taken by the surviving parent, it helps if
there existed a good prior relationship and if they are not overwhelmed by their own grief (Lohnes &
Kalter, 1994).
Family
Flexibility in family roles and a more open level of communication within family (Mahon & Page,
1995). Stage in the life cycle of the family and if there are no other transitions and changes in family’s
situation or lifestyle (Walsh & McGoldrick, 1991).
Friends
Maintenance of contact with other children at home and school is important, especially if there is
also parental grief (Zambelli & De Rosa, 1992). For adolescents these may be the main support
network.
School
Schools which provide both open discussions about life and death in general for its pupils, as well as
individual support if a death occurs (Dyregrov, 1994). Easy availability of counselling and debriefing for
the school staff and pupils is important if traumatic accidents or deaths have affected school pupils or
staff (Cornish, 1998).
Community
Access to culturally appropriate role models in the surrounding community can lessen a child’s
confusion about the behaviours and rituals surrounding a death. This is particularly so for children in
families living out of their country or culture of origin (McGoldrick et al.,1991). Children’s coping with
grief and bereavement is facilitated by a more open attitude to discussing death.
understand why the adults were not crying or being upset. Now I realise that they were
– but not in front of me.)
Table 3 summarizes some of the interventions that have been explored and the settings
in which they may take place. This is set alongside a time-line indicating at what time in
the process of bereavement this intervention may take place. We agree with Baker et al.
(1992) that describing reactions over time ‘. . . by no means implies that these reactions
evolve in a simple linear fashion . . . .’ and have tried to indicate this in the diagram.
Figure 1 offers a pathway for assessing the need for referral and intervention.
Conclusions
We have attempted to provide an understanding of bereavement and its clinical appli-
cations in work with children. We have indicated, in Table 3 and Figure 1, the factors
which need to be considered before making referrals of bereaved children to
professional services. From these arise some guidelines for good practice.
• In thinking about helpful approaches, it seems essential to start with the premise that
death is not abnormal and that most of the upset felt around the death of a loved one
533

Table 3. Interventions
Time/level of intervention Examples
General education – Children’s books (see list in Fredman, 1997)
information generally available Good Grief programmes (Ward & Associates, 1996a, 1996b)
Preparatory/anticipatory work Groups in hospices (Zambelli & DeRosa, 1992)

when a death is expected Information-giving (Rosenheim & Reicher, 1985)
Work Books (Heegard, 1991)
Following a death Consultation to adults (Turner, 1997)

Family support
(Heiney et al., 1993)
Staff support
(Fredman, 1997)
Community outreach
Bereavement counselling (CRUSE)
Following death in special Post-traumatic stress counselling (Black, et al., 1992;

circumstances Dyregrov, 1991; Dyregrov et al., 1987; Udwin, 1993).
At a later stage Groups (Krasner & Beinart,1989;

Bisson & Cullum, 1994;
Lohnes & Kalter, 1994)
Winston’s Wish (Pennington & Stokes, 1998;
Stokes & Crossley, 1996)
Referral to child and adolescent mental health
services for individual and /or family work
When things are not moving Family therapy (Gelcer,1983; Kissane & Bloch, 1994;
on/unresolved issues Sutcliffe, Tufnell, & Cornish, 1998)
Individual psychotherapy (Judd, 1989).
The dotted lines indicate that the divisions are not fixed and there can be overlap.
Many of the examples of the interventions may be used at any stage, singly or in combination.
is an understandable and normal response. However, the circumstances around the

event need to be taken into account.
• There are recognized dangers in conceptualizing death and bereavement as patho-
logical with a need for treatment or intervention by experts in order to be able to cope
with it.
• Taking an extreme normalizing view may also be unwise. It can mean that some chil-
dren are left to cope alone with the unimaginable – the feeling that it is their fault if
they are not managing.
• The event of the death and the circumstances around it need to be set against back-
ground factors: age, maturity, previous experience, existing networks.
• If professional help is being considered, it is least likely that it will be appropriate for
the child alone to be referred. It is more probable that there is need for consultation,
support and advice for the adult(s) caring for the child.
• Finally, there is a need for professionals to recognize the impact arising from the
interaction between their own bereavement experiences and those of their client
groups.
534

Figure 1. Map for assessing need for referral/appropriate intervention
535
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539

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Clinical Child Psychology and

Bereavement: A Framework for those Working with Children

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Bereavement: A Framework for Those

DIANE LUKEMAN, Chartered Clinical Psychologist, is employed in Clinical Psychology

Clinical Child Psychology and Psychiatry 1359–1045 (200010)5:4 Copyright © 2000

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

The social and historical context

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

The developmental perspective

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

Table 1. Children’s understanding of the concepts of death (Kane, 1979)

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

Contributions from current psychological theories

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

Family system theories

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

Special circumstances surrounding a death

Sudden and traumatic deaths

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

Death from inherited and transmitted conditions

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

Pre-existing mental health issues of the child

Children with special needs

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

Table 2. Protective moderating factors

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

Preparatory/anticipatory work Groups in hospices (Zambelli & DeRosa, 1992)

Following a death Consultation to adults (Turner, 1997)

Following death in special Post-traumatic stress counselling (Black, et al., 1992;

At a later stage Groups (Krasner & Beinart,1989;

is an understandable and normal response. However, the circumstances around the

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

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CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 5(4)

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MELVIN & LUKEMAN: BEREAVEMENT WORK WITH CHILDREN

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