Mapping interventions for children and young people experiencing bereavement, loss and grief

Read the executive summary of this report here.

Introduction

During the COVID-19 pandemic children and young people have experienced major changes in their lives, changes which can include experiences of bereavement, loss, and grief due to the loss of those close to them1 and major changes in their lives more generally. 

Whilst experiencing bereavement itself is common in childhood2, the experience of bereavement during the COVID-19 pandemic may have been intensified by not being able to be with family and friends, not being able to be with the person when they pass away, or to attend the loved ones’ funeral for example1 . Understanding how to support children and young people to cope with bereavement, loss, and grief during these times is particularly important as children and young people begin to return to school and they experience changes to their lives once more. Moreover, children and young people’s experiences of bereavement, loss, and grief often differ from that of adults, as their understanding of death and loss, and adaptive behaviours are dependent upon their developmental stages3. As a result, we need to ensure that the correct supports are in place for children and young people, as life begins to shift back to ‘normal’, or the ‘new normal’. In considering which support and approaches to adopt, we require an understanding of the evidence-base underlying such approaches. As such this overview seeks to descriptively outline both the types of interventions as well as the principles underpinning interventions for children and young people experiencing bereavement, loss, and grief.

Approach to reviewing literature

To identify relevant articles for inclusion in this overview, we adopted a structured search strategy based on searches within the Web of Science and PsychInfo databases. We also reviewed the webpages of bereavement charities including Hope Again, Childhood Bereavement Network, Child Bereavement UK, and Grief Encounter to locate any links to additional studies which had been conducted.

Inclusion criteria

Due to the scope of this study, we included articles that:

  • Systematically reviewed studies of intervention effectiveness – we therefore included systematic reviews, scoping reviews, or rapid reviews of the literature, and
  • Were published from 2010 onwards to ensure that the literature was reflective of the support required by children and young people in modern times, and
  • Focused on children and young people, with a predominant focus on the 0-18 age-range.

A framework to structure the review 

In scoping this overview, we identified two frameworks4,5 which were helpful to our goal of descriptively mapping the evidence of interventions. Both frameworks illustrate that there are several different levels of support required by those who have experienced bereavement, loss, and grief. The framework developed by the Irish Childhood Bereavement Network5 has a pyramid structure that maps 4 levels of needs/supports for children and young people against whether they will be required by most (universal), some (targeted), or few (specialist) children and young people experiencing bereavement, loss, and grief. The 4 levels are summarised in Table 1. Similarly, in Akerman and Statham’s framework (Figure 1), levels of support move from universal information and guidance about how children grieve, to outreach and specialist support for those who have been traumatised or are particularly vulnerable4.

Based on these frameworks, we structure this descriptive overview of interventions across three levels including: (1) primary support (for most or all children and young people experiencing grief), (2) secondary support (for some children and young people who are vulnerable and experience grief symptoms over time), and (3) tertiary support (for the few children and young people who experience complex grief). 

Brief description of studies reviewed 

Studies included in this overview varied in several ways, including the population of children and young people targeted, the intended outcomes, the intervention settings, the type of bereavement, and the methodological approach used. 

Primary intervention models 

Overall, there is little evidence from the studies included in this overview that refer specifically to the effectiveness of primary intervention models. However, several of the studies do refer to the value in supporting the protective factors for children and young people’s mental health and emotional wellbeing overall as promising primary intervention approaches. Two well-evidenced primary intervention models through which to strengthen children and young people’s mental health and emotional wellbeing are:

  1. supporting the protective factors around children and young people’s mental health and wellbeing (an example given in the literature is supporting positive parenting)
  2. whole school approaches to emotional wellbeing.
Supporting positive parenting

According to the studies reviewed, well-evidenced protective factors relate to family relationships in terms of supporting positive parenting, quality of relationships within the family, and social supports4, 7, 8. Studies have for example identified that positive parenting has been shown to be a protective factor across both high and low levels of exposure to postbereavement stressors and subsequent mental health problem11. This study suggests that positive parenting leads to reduced mental health problems, particularly for parentally bereaved children in several ways, including:

a. Positive parenting can create an environment that supports children’s needs and developmental goals

b. Positive parenting reduces negative reinforcement and punishment and thus reduces negative caregiver-child relationships

c. Positive parenting can promote social skills in dealing with conflict resolution and problem solving

d. Positive parents can help develop the child’s individual resources such as coping mechanisms to support their mental health and wellbeing

Whole-school approaches to emotional health and wellbeing 

The literature reviewed also emphases the role of the school environment, in ensuring that there are whole-school approaches to emotional wellbeing9 . First this means that the mental health and wellbeing curriculum should, in part, focus on psychoeducational components such as normalising grief and providing education on grief terminology as well as developing coping mechanisms more generally9 . Secondly, the literature emphasises the need for developing a whole school approach to supporting children and young people experiencing bereavement that is proactive, not reactive. We outline practical and evidence-based examples of what this might look like below.

Learning to cope with change/loss using a curriculumbased approach

Evidence-based example: The UK Resilience Programme One evidenced programme mentioned in Akerman and Statham’s study4 is the UK Resilience Programme, which has been shown to have short-term effects on children and young people’s ability to deal with difficult and stressful situations as indicated through decreased depressive symptom scores15. The UK Resilience Programme (a UK implementation of the Penn Resiliency Program) is a schools based programme that aims to improve children’s psychological well-being by building resilience and promoting accurate thinking and coping mechanisms15. The intervention involves 18 hours of workshops and focuses on teaching cognitive-behavioural and social problemsolving skills based on the Activating-Belief-Consequences model. This model assumes that beliefs about events mediate their impact – the programme therefore encourages participants to identify and challenge unrealistic beliefs, use evidence to make better appraisals of situations, and to use coping mechanisms when faced with difficult situations15.

Developing a whole-school approach to dealing with bereavement

Alongside a curriculum based approach, schools should also have in place specific actions and processes to support children and young people with bereavement4,7,8. Akerman and Statham4 outline what a promising primary intervention whole-school approach might involve. Defining a primary approach to be proactive in nature, they state that a whole system to support those experiencing bereavement should involve:

a. Policies that outline the school’s approach to supporting those children and young people experiencing bereavement, e.g. in how to support effective communication with families of children and young people experiencing bereavement

b. Training, support for and designation of staff to support children and young people experiencing bereavement. An example of such training is the ‘Lost for Words’ programme, a training programme developed for those who work with children and young people to provide them with an insight into the experiences of children who have suffered loss, such as being bereaved

c. The provision of school counselling and peer support mechanisms more generally, and the provision of space in schools, e.g. a quiet room, so children and young people can have some time to themselves if they are feeling down

d. Good links with local community organisations and services that can support children and young people experiencing bereavement

Secondary intervention models  

In terms of secondary interventions, i.e. those that support children and young people experiencing grief, and in particular those who may be more vulnerable to the symptoms of grief over time, several of the studies point to the importance of grieving as a family process and the need to have support centred on the family4, 7, 9. It should be noted that family/parent/ caregiver intervention components were also common within interventions for 3-5 year olds: this included companion An overview of evidence-based interventions parent groups, filial therapy, and parentchild sessions8. Moreover, the literature also highlights the value of peer support based programmes to help children and young people communicate about and validate their experiences7, 9. Similarly, group interventions, and in particular group therapy, have been found to be beneficial for children bereaved by suicide10. Based on this literature, we outline practical and evidence-based examples of what this might look like below.

Supporting grieving as a family process

Evidence-based example: The Family Bereavement Programme Two of the studies included in this overview reference ‘The Family Bereavement Program’ as a promising intervention model that has undergone several evaluations4, 7 and which centres of grieving as a family process. The programme involves 14 professionally-led sessions including separate and concurrent groups for caregivers, children and adolescents, joint activities for children and their caregivers, and individual family meetings7 . The sessions focus on improving positive caregiver-child relationships and communication, increasing positive activities, and developing and using effective coping mechanisms as examples7 .

Other evidence points to the use of activity-based approaches to support children and young people who have experienced bereavement. For example, one study highlights the value of musictherapy interventions6, owning the success of such approaches to music playing a large part in contemporary youth culture. For young children, play-therapy has also been highlighted at promising8 with it being a commonly used approach in supporting children dealing with parental separation and ongoing family issues more generally. One study concluded that relatively brief secondary support interventions can prevent children from developing more severe problems after the loss of a parent7.

Tertiary interventions models 

Intervention models were on the whole considered effective in cases of higher ‘symptom severity’6, 7 with specialist interventions considered helpful for those children and young people showing significant negative impacts from their experiences of bereavement4. Trauma/grief-focussed school-based brief psychotherapy was considered effective in one study but only for a An overview of evidence-based interventions very specific subgroup of young people suffering grief with co-morbid PTSD6. In this intervention model, studies have demonstrated effectiveness for those children and young people exposed to traumatic experiences such as major disasters12, war13, and community violence14. Below, we describe some of the evidence of such approaches in two different intervention settings: schools and residential camps.

Trauma/grief focussed brief psychotherapy

Evidence from schools-based interventions: Trauma/grief focussed school-based psychotherapy programmes involve individual and group components that have a therapeutic focus on processing trauma. This means that activities focus on dealing with reconstructing and reprocessing trauma, trauma reminders, additional post-trauma stressors, the interplay of trauma and grief, and the developmental impacts on the child/ young person12. Outcomes associated with this intervention approach included evidence of reduced severity of PTSD (12), reduced psychological distress13, and reductions in post-traumatic stress and complicated grief symptoms14.

Underpinning principles of interventions

Findings presented in this overview highlight key underpinning principles of evidence-based interventions focussed on dealing with bereavement, loss and grief. These are that support for children and young people focuses first and foremost on the individual circumstances of the child/young person. Alongside this, interventions have been shown to be effective when they are family-centred and involve elements of peer support/ group work. Moreover, the evidence presented highlights the important role that schools play as a vehicle for education around emotional health and wellbeing generally, and as mediators of support for those children and families requiring more targeted support. 

Implications for practice and policy

PRACTICE

  • Those supporting children and young people should be mindful that each child responds differently to bereavement and that support should ultimately focus on their individual circumstances, particularly their family context. Specific consideration should be given to children and young people who might be considered vulnerable to experiencing more negative impacts of bereavement. Some evidence suggests that those from disadvantaged backgrounds, including single-parent, economically inactive, low-earning, and low educational attainment, are more likely to experience the death of a close family member2. Moreover, attention should be paid to those that experience a traumatic bereavement, e.g. are bereaved by suicide2. Alongside this, those working with children and young people who have experienced bereavement should also consider their familial, cultural, social, and economic contexts and how these may affect how a child/young person experiences grief and loss2.
  • Similarly, those working with children and young people should involve the family circle, particularly parents/ carers, in the provision of support. An example of a well-evidenced programme with a family-centred focus is ‘The Family Bereavement Programme’.
  • Those developing support for children and young people should consider An overview of evidence-based interventions the value of peer support for those experiencing bereavement. The sharing of similar experiences and expressing emotion with peers can provide a way for children and young people to make sense of what they have been through. An example of a well-evidence programme with a central peer support component is the ‘Seasons For Growth’ Programme.

POLICY

  • Overall, there is lack of evidence of specific effective primary policy intervention models. However, the evidence presented here highlights the value of primary intervention approaches, particularly in terms of incorporating learning on bereavement, loss, and grief into the curriculum. In this respect, policy should support a focus on primary intervention on bereavement and grief, particularly in schools, where the inclusion of this topic within the curriculum on emotional wellbeing will equip children and young people with understanding of grief terminology, normalise the concept of grief, and help them to develop coping strategies they can draw upon in the future. Moreover, with a wider understanding and normalisation of the concepts of bereavement and grief, schools can become better sources of social support for those children who do experience a bereavement.
  • For secondary/tertiary intervention, policy should endorse a more holistic approach to supporting those who have experienced a bereavement through developing systems of support that facilitate communication between schools, families, and wellevidenced secondary/specialist support services. Such an approach will ensure that those struggling with grief/complicated grief will receive the right support, in the right place, and at the right time. We envisage that such a system might look like that depicted in Figure 2.

Limitations

There are methodological limitations of individual studies included within the systematic reviews included in this overview. These include: evaluation followup times are not long or studies are cross-sectional6, 7, 9; a lack of sufficient measurement tools for preventative interventions4 and as such, milder forms of distress are likely to remain hidden in studies where focus is on clinical levels of difficulty4; variation in outcome measurement tools8; little focus on younger, pre-school age children7 where there is often an assumption that very young children are too young to grieve; limitations to the use of parental reports about children experiencing bereavement7 ; empirical studies commonly have low sample numbers8; and empirical studies usually involve mixed aged groups making it difficult to disaggregate findings by ages and stages.8 An overview of evidence-based interventions There are also limitations to the review approach taken within this overview. The studies included use different approaches to systematically reviewing empirical studies and different analyses e.g. one study uses quantitative metaanalyses6 and another uses qualitative enquiry models rooted in metaethnography9 . It is therefore difficult to make direct comparisons between the findings of the included studies. Many of the studies focus specifically on close familial bereavement, not bereavement as a wider concept and experience. Duncan is the exception where broad criteria for the bereavement experience (death of a loved one) was used9 .

Overall, a narrow focus on death of a parent/sibling perhaps limits our understanding of effective primary intervention strategies with respect to bereavement that would aim to improve overall understanding of the concepts of grief and loss. 

Conclusions

This overview sought to map the evidence of effectiveness of support for children and young people experiencing bereavement, grief, and loss to provide guidance to those working with children and young people during this particularly challenging time. We identified several systematic and structured reviews of such evidence which we have discussed in terms of well-evidenced primary, secondary, and tertiary intervention models, as well as discussing principles or components underpinning such interventions. Whilst there is little specific evidence on primary intervention models, this overview identifies that there are several An overview of evidence-based interventions well evidenced secondary and tertiary intervention approaches, and that those with significant negative psychological impacts from their experience of bereavement can benefit from specialist, or tertiary, support. In our analysis of principles or components underpinning such support, we find that there is a role for policy and practice to embrace multidisciplinary systems of support for children and young people experiencing bereavement in terms of valuing the role of schools, peer support, and consideration of family context, as swell as involvement of family, within the support provided to children and young people. 

References

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