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To cite this Article Christ, Grace H. , Raveis, Victoria H. , Siegel, Karolynn , Karas, Daniel and Christ, Adolph E.(2005)
'Evaluation of a Preventive Intervention for Bereaved Children', Journal of Social Work in End-Of-Life & Palliative Care,
1: 3, 57 — 81
To link to this Article: DOI: 10.1300/J457v01n03_05
URL: http://dx.doi.org/10.1300/J457v01n03_05
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Evaluation of a Preventive Intervention
for Bereaved Children
Grace H. Christ, DSW
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Grace H. Christ, DSW, is on the faculty at the Columbia University School of Social
Work.
Victoria H. Raveis, PhD, Karolynn Siegel, PhD, and Daniel Karus, MS are on the
faculty at the Joseph L. Mailman School of Public Health of Columbia University,
New York, NY.
Adolph E. Christ, MD, is Professor Emeritus at the State University of New York,
Health Science Center in Brooklyn, NY.
Address correspondence to: Grace H. Christ, DSW, Columbia School of Social
Work, 606 West 116th Avenue, New York, NY 10027.
This work was supported in part by grants from the National Institute of Mental
Health (RO1-MH41967), the American Cancer Society (PRB-24A), the Van
Ameringen Foundation, the Society of Memorial Sloan-Kettering Cancer Center and
The Soros Foundation’s Project on Death in America.
Journal of Social Work in End-of-Life & Palliative Care, Vol. 1(3) 2005
Available online at http://www.haworthpress.com/web/JSWEL
2005 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J457v01n03_05 57
58 JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
provide sufficient help to retain families for later evaluation. The level of
general support and referral for other treatments, if adequately done,
may be sufficient to blur differences in standardized psychopathology
measure scores between any two interventions. It may only be in the spe-
cifically targeted intervention area that differences can be expected to be
significant in adequately resourced families. [Article copies available for a
fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail
address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.
com> © 2005 by The Haworth Press, Inc. All rights reserved.]
BACKGROUND
Lin et al., 2004) linking parental death and loss to later psychopathology
that may have confounded earlier studies. The recognition of the impor-
tance of life events (Dohrenwend & Dohrenwend, 1974; Holmes & Rahe,
1967), later refined to stressful life events and their interaction with social
support (Compas, Slavin, Wagner, & Vannatta, 1986; Compas, Wagner,
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Slavin, & Vannatta, 1986; Lin & Ensel, 1984; Monroe, Connell, Bromet, &
Steiner, 1986) in the onset of depressive symptoms, provided important
perspectives of the greater complexity required to study the role of paren-
tal bereavement to adult depression. Of the numerous stressors that have
been identified, the role of support and communication from the surviv-
ing parent have emerged as singularly important (Bifulco, Brown, & Har-
ris, 1987; Bifulco, Harris, & Brown, 1992; Breier, Kelsoe, Kirwin,
Wolkowitz, & Pickar, 1988; Harris, Brown, & Bifulco, 1986; Harris,
Brown, & Bifulco, 1987; Mireault & Bond, 1992; Raveis, Siegel, &
Karus, 1999; Saler & Skolnick, 1992, Sandler, Tremblay, & Israel,
1998).
Numerous clinical interventions designed to mitigate the adverse ef-
fects of such a tragedy as parental death have been described (Furman,
1974; Furman, 1981; Zambelli, Clark, Barile, & de Jong, 1988), but few
have been evaluated formally, and even fewer have included a compari-
son or control group (Tremblay & Israel, 1998). Only two published in-
tervention programs, in addition to the present one, have used control or
comparison groups. None of these interventions have focused exclu-
sively on expected death from disease and none have intervened with
children before the death occurs. This paper reports on the evaluation of
the relative efficacy of a parent guidance intervention (treatment) com-
pared to a telephone monitoring (comparison) intervention for bereaved
children that begins during the parent’s terminal illness and continues
for 6 months after the death.
and again two years later. Relying exclusively on parents’ reports, the
investigators found that children whose families had participated in the
treatment group had fewer behavioral and learning problems and a
lower incidence of depression and sleep or health problems. They also
found that children in the treatment group spent more time talking and
crying about the dead parent and that crying was associated with fewer,
less serious behavioral problems, especially among children older than
five years. The exclusive reliance on parents’ reports and the lack of
details about the content of the intervention have been identified as
significant limitations of this study (Tremblay & Israel, 1998).
In the second study, a family bereavement group program, Sandler
and associates (1992) studied a cognitive behavioral intervention at the
Prevention Research Center, Arizona State University, funded by the
National Institute of Mental Health. The intervention was based on their
previously tested interventions of a family advisor program with be-
reaved families. The intervention tested the efficacy of approaches in-
volving training in parenting skills to reduce stress and build the coping
capacities of bereaved children and parents. It was delivered in 11 group
sessions with bereaved parents and 11 parallel group sessions with the
children. Ninety families (135 children and adolescents and their care-
givers) were randomly assigned to the intervention, and 66 families
(109 children and their caregivers) were assigned to a comparison group
involving self-study with printed materials.
All the families were referred to the bereavement program by family
service, health, and mental health agencies that were providing mental
health services to the families. Sandler and associates suggest that their
method of accrual may have accounted for the greater numbers of men-
tal health problems reported when the study began than has been found
in other child bereavement studies (Worden, 1996).
Unique to this cognitive behavioral approach was the opportunity for
participants to practice skills in groups with peers before applying the
skills at home. The manual-based treatment groups for parents aimed to
modify identified mediators of positive mental health outcomes for
children who had suffered a major loss: for example, by establishing
positive parent-child relationships; stable, positive routines; and effec-
tive discipline. Another goal was to protect children from life-event
stressors associated with the loss of a parent. To accomplish this goal,
Peer-Reviewed Papers 61
from responses following the death. This clinical experience was con-
firmed by the finding, previously reported, that children were signifi-
cantly more anxious and depressed during the pre-death period than at
the 7- and 14-month post death follow up (Siegel, Karus, & Raveis,
1996; Siegel et al., 1992).
METHODS
Sample
A total of 275 families meeting the criteria for the bereavement inter-
vention were identified. The eligibility criteria were as follows: the fam-
ily was intact; both parents lived in the home, one of whom was being
treated at a major urban cancer center; the family spoke English; the
family lived within two hours of the cancer center, and the family had at
least one child aged 7 to 17 years with no history of serious emotional
disturbance. There was no significant difference in rates of retention in
the two intervention groups.
Two hundred twelve (72%) of the 275 families who met all eligibility
criteria agreed to participate and to be randomly assigned to one of two
interventions. One hundred eighty-four of these, (87%) completed one
of the interventions, and of these, 104 (56%) completed the initial and at
least one post-death evaluation. After eligible families were informed
that they would be randomly assigned to one of the two interventions
and the interventions were described to them, well parents who agreed
to participate were asked to sign the consent forms, and assent to partici-
pate was obtained from their children, the family was assigned to the
psycho-educational intervention (75%) or to the telephone supportive
intervention (25%).
A comparison group of 556 non-bereaved children aged 7 to 17 years
from 434 families from a suburban school system was also selected for
the study. Like the bereaved children, these non-bereaved children
completed the depression (CDI), anxiety (STAI) and self-esteem (SEA)
measures. The median family income in the community from which the
children came ($63,275) was comparable to that of the bereaved sample
Peer-Reviewed Papers 63
($68,902). The control group was large enough to allow a group match
with children in the intervention sample on age, gender, and number of
children in the household.
Recruitment
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INTERVENTIONS
tional child and/or family interviews were scheduled. The forms for
each session and their definition are summarized in Table 1.
After the final interview, the social worker initiated bi-monthly to
monthly telephone contacts as needed with the surviving parent until
the final post-death psychological assessment was completed about 14
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months after the death of the parent. If significant family crises emerged
either during the mental health clinician’s final assessment or the social
worker’s final telephone contact, additional telephone contacts were
scheduled. When necessary, individual parent, child and/or family sess-
ions were offered.
Interventionist training and supervision was an integral part of the
project. Each of the 6 social workers who formed the intervention team
had at least five years’ post-masters experience working in a medical or
mental health setting. The social workers received extensive written and
verbal descriptions about the goals of the intervention, their role in
meeting these goals, the types of material that would be elicited from
children and parents, and the type and quality of notes that would be
kept after each scheduled and unscheduled contact. Ongoing training
was provided through weekly individual and group supervisory meet-
ings. The first author coordinated and supervised the clinical program.
The social work interventionist filled out a lengthy 10-14 page
semi-structured form following each interview session. Different forms
were developed for each pre-death and post-death interview that reflected
the intent of that interview. These ten forms and their sub-headings were
developed not as headings for a semi-structured interview, but rather to
remind interviewers about the general topic areas that should be covered
and to serve as a pedagogic guide for the interventionists. Table 1 lists the
ten forms. As indicated in the table, a number of them might require two
or more sessions to complete. For example, one major heading in the
child’s post death session form (Form 7) is titled “evaluation,” and has 13
sub-headings (e.g., “child’s adaptation,” “school performance and behav-
ior,” “coping strategies”), some with additional subheadings (e.g., “pro-
cess of being informed,” “changes to the family life style”). Another
example is the final pre-death parent interview form (Form 6) titled
“Preparation for death and issues related to loss,” which has 15 subhead-
ings (e.g., “discuss severity of parent’s illness,” “explore what each child
knows and believes about the parent’s death,” “educate parent about
value of children’s participation in rituals such as wake, funeral, burial”).
These notes were used to aid in the supervisory process, but were also in-
tended to facilitate a qualitative analysis (Christ, 2000). Detailed written
notes were kept of all telephone contacts with or about the family.
Peer-Reviewed Papers 67
*1a-n indicates that the same form may be used for more than one interview.
Measures
your well parent makes it easy for you to discuss things that are bother-
ing you? (2) How often do you feel that your well parent really listens to
you? (3) How often does your well parent want to hear what you think
about things that are going on in the family? and (4) How often does
your well parent ask questions to make sure he/she really understands
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Analysis
could have been correlated with each other, and the impact of a particu-
lar parent or family characteristic on outcome measures could be artifi-
cially inflated. Therefore, the data from families with more than one
age-eligible child were weighted so that each family received an equal
unit weight. Six percent of the study children were Hispanic of any race,
4% were black, and 7% of children were from racially mixed families.
Minority families were eliminated from the reported quantitative analy-
ses because, although they differed significantly from whites regarding
socioeconomic status, they represented only a small proportion of the
total sample (16%), with an insufficient number of families of any one
minority to analyze separately.
Qualitative methods provided a comprehensive description of chil-
dren’s experience of a parent’s death and informed interpretations of
quantitative results. The results of the qualitative analysis have been
reported (Christ, 2000).
RESULTS
T11 Initial psychological testing; T22 Retesting at 8 months after death; T33 Retesting at 14
months after death; TG14 Parent-guidance intervention; TG25 Telephone monitoring inter-
vention
another region of the United States around the time the intervention was
completed; others had recently remarried or were engaged and believed
that their own and their children’s investment was in the present and the
immediate future, not in the past. Some children, especially the adoles-
cents, refused to retake tests they had previously completed. No finan-
cial incentives were offered to encourage participation in evaluation
sessions.
Forty-eight percent of the study children were girls, and 58% of the
surviving parents were mothers. A series of analyses were undertaken
to determine the role of the surviving parents’ gender, the children’s age
and gender in relation to emotional distress. Multiple regression analy-
ses showed that girls with a surviving father experienced significantly
less decrease in state anxiety and depressive symptoms after the death
between Time 1 and Times 2 and 3. Ten percent of the variance in state
anxiety score change from pre-death to post-death was accounted for by
being a girl with a surviving father. Four other independent variables
were also entered (child age group (7-11, 12-18), length of the ill par-
ent’s survival, number of pre-death interviews and number of post-
death interviews, but did not reach significance and did not contribute to
explained variance (r = .275, beta = .278, R2 = .10, p = .01). Similarly,
10% of the variance in depressive symptoms score change from
pre-death to post-death when compared to other children was ac-
counted for by being a girl with a surviving father. Four other inde-
72 JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
pendent variables were also entered (child age group (7-11, 12-18),
length of the ill parent’s survival, number of pre-death interviews and
number of post-death interviews) but did not reach significance and did
not contribute to explained variance (r = .277, beta = .325, R2 = .10, p =
.01).
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+ p ⱕ .10 * p ⱕ .05
1CDI: Children’s Depression Inventory; 2 STAI: STAIC & STAIY state and trait anxiety T
scores; 3SEI:Self Esteem Inventory; 4 CBCL: Child Behavior Check List social competence
scale; 5 CBCL: behavior problem measure; 6 POPM: Perception of Parenting Measure;
7GCM: General Communication Measure part of POPM; 8 IDRCM: Illness and Death Re-
lated Communication Measure part of POPM; 9 Tp.d.: T2 or T3 evaluation after death; 10 :
Change from T1 to T2 or T3; 11 TG1: Parent Guidance Intervention; 12 TG2: Telephone
Monitoring Intervention
74 JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
DISCUSSION
Thirdly, it could also be argued that the child report measures were not
sufficiently sensitive to bereavement-related distress as experienced by
children in an adequately resourced middle class population. Only during
the intense crisis atmosphere of the terminal illness of the parent was the
distress in our sample sufficient to be reflected in higher depression
scores. Our own post death T-scores on the CDI are 45. Findings from
two recent studies of untreated bereaved children have also reported low
depression (CDI) scores similar to our own. Raveis et al. (1999) evalu-
ated untreated bereaved children 3 to 14 months after the parent’s death
and reported CDI T-scores of 44.3 (S.D. 7.8). Saldinger et al. (1999) re-
ported on 2 groups 8-36 months after the parent’s death; children whose
parent died suddenly, (CDI-T scores of 47.9), and those whose parent had
an expected death (CDI-scores of 43.6). Lack of sensitivity of the mea-
sure to these situations has been suggested as one explanation. Measures
of psychopathology may be inadequate for the measurement of children’s
grief, mourning, sadness and the more subtle, but clinically important be-
havioral changes such as temporary decrease in ability to concentrate in
school. Newer measures being developed that assess the presence of nor-
mative and complicated grief in children and that take into account trau-
matic stress symptoms (Layne, 2000) may discern different patterns.
Fourth, while providing alternative treatments in the same institution
increases the likelihood that the groups before treatment are similar on
important demographic characteristics and have similar treatment experi-
ences, it also heightens the awareness of all staff in the institution about
the stresses inherent in the situation and they are more likely to perceive a
need for intervention. Referrals for counseling were recommended by a
broad range of hospital staff and other families. The families who were
positive about the help they were receiving in the experimental interven-
tion spoke freely about this to their physicians, to the social workers on
the medical units, and to other families.
The data from both interventions showed that the death of a mother
emerged as a greater risk factor than the death of a father, especially for
adolescent girls. Surviving fathers may require more intensive interven-
tion, not only to help them with higher levels of depression (Siegel,
Karus, Raveis, Christ, & Mesagno, 1996) but also to help them adapt to
complex role changes required to reconstitute relationships with chil-
Peer-Reviewed Papers 77
dren without the mother’s day-to-day presence. One explanation for the
lower anxiety and depression scores after the parent’s deaths could be
that they reflect the effective therapy provided to adults and children
through both interventions. This interpretation of our results is sug-
gested by Saldinger et al. (Saldinger, Cain, Kalter, & Lohnes, 1999),
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who believed that the improvement of depression (CDI) scores after the
parent died in our sample was likely influenced by the effect of the
interventions before the death.
These results and the parents’ positive responses to the parent-guidance
intervention are also encouraging. The psycho-educational approach and
parent guidance model that informed the intervention content and design
was effective for these families. For the small but important group of chil-
dren whose depression and anxiety scores did not improve after the death,
the parent-guidance intervention was not sufficient to ameliorate their dis-
tress. We concluded that these children who were not reconstituting in a
timely way may require more intensive services than parent guidance can
offer. Parent’s suggestions for availability of counseling over a more ex-
tended length of time and with more direct intervention with children are
useful. Longer term follow-up of bereaved children may help to understand
the various contexts in which children reflect delayed or compromised re-
constitution.
CONCLUSION
An important finding from this study was that both children and par-
ents valued and felt helped by an educational and supportive intervention,
not only after the death, but also during the terminal illness of a parent.
Our experience demonstrated that children could be interviewed during
this difficult time without increasing their anxieties. We found that it is
possible to engage families despite all the turmoil and demands that were
placed on them. Most practitioners have acknowledged that although the
period of the parent’s terminal illness is filled with anxiety and distress
for all families, especially those with young children, it has been difficult
to structure an intervention families can use. No previous interventions
during the parent’s terminal illness have been formally evaluated. We
think two factors contributed to the positive reception to this intervention.
(1) The choice of offering services in the home was welcomed at such a
crisis filled time. It offered the possibility of limiting further drain on the
families’ own resources, resources that are generally overextended when
a parent is dying. (2) Focusing on parent education, developing better
78 JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE
ing surviving fathers. Forty percent of our surviving parents were fathers,
about the ratio of all younger adult parents treated in this institution.
Many parents indicated they wanted the intervention to extend beyond
the 6 months post death period, and they also wanted more intervention
directly with their children. Families improved with both interventions.
However the intervention that was specifically aimed at communication
resulted in enduring effects on the parent child relationship. This is con-
sistent with findings that have emerged across several other studies; that
the specific behaviors that are the focus of the intervention can be altered.
In our study, parent child communication and parent competence distin-
guished between the two groups and continued to improve over.
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