J. William Worden, PhD, ABPP, is a Fellow of the American Psychological Association and holds academic appointments at Harvard Medical School and the Rosemead Graduate School of Psychology in California. He is also co-principal investigator for Harvard's Child Bereavement Study, based at Massachusetts General Hospital. He is the author of Personal Death Awareness; Children & Grief: When a Parent Dies; and is co-author of Helping Cancer Patients Cope. His book Grief Counseling & Grief Therapy: A Handbook for the Mental Health Practitioner, now in its fourth edition, has been translated into 12 languages and is widely used around the world as the standard reference on the subject.
 
Q. You have played an instrumental role in the Harvard Child Bereavement Study. Can you briefly describe that project and what impact it has had on what we know about children and loss?
 
A. Dr. Phyllis Silverman and I were co-directors. Our goal was to develop a study of bereaved children that would the most effective study to date. We met with our first group in 1987 and followed each group longitudinally for two years. A few components of the study are particularly significant:

• We interviewed both parents and children in families where one parent had died; up to that point, most studies on bereaved children had only interviewed the surviving parent.
• We chose children ages 6—17 from communities in the Boston area representing a wide range of backgrounds and demographics.
• We matched each bereaved child with one non-bereaved child as a control.

One of the most significant findings from our work has been that many of the negative consequences associated with the loss of a parent do not appear in children for as long as two years after the death. Even hospice care, which has always been strong in offering bereavement support, generally focuses on the first year after the death.
 
Q. What implications does that finding have for hospices and other organizations that work with bereaved children?
 
A. One of the main objectives that has come out of the study has been to develop a screening instrument that can be used 4-6 months after the death to predict which children will not be doing well two years out. On average, we find that about 20% of children will need intervention after two years. This average contrasted significantly with the average for the control group, which was closer to 9—11%.
 
Donna Schuurman of The Dougy Center has used our screening instrument in her enrollment and they found that their programs did indeed primarily reach those 20%. Utilizing the instrument and the findings from the study does not mean that we recommend excluding 80% of children from bereavement support, nor do we want programs to wait for two years until those kids really need help. The screening instrument can help serve as an indicator, 4-6 months after the loss, of which kids might need help later on, and offer those interventions now.
 
In my book Children and Grief: When a Parent Dies, I write that there are basically three approaches of how we have helped kids in times of loss:

1. We can take a sort of traditional approach—“it’s tough for every kid to lose a parent” and offer all bereaved children some sort of intervention. But what we found from the Harvard study is that not all kids need it, and it is not cost-effective.
2. We can wait to see that a child is really in trouble—acting out, failing in school—and then step in.
3. Using our findings and instruments, we can develop an early prediction of potential problems and hopefully use a more preventative mental health approach.

Q. Is there one factor that seems to be a strong predictor for children who might have trouble coping after the loss of a parent?
 
A. It is very clear that the one variable that most strongly affects the functioning of a child after loss is the functionality of the surviving parent. If that parent is depressed, if he or she is not able to maintain a consistency within the home with regards to homework, discipline, etc., that child is going to have a much more difficult time adjusting to the loss.
 
Q. So does that mean that programs should focus more on helping the surviving parent?
 
A. That’s an interesting philosophical issue. It certainly may be more appealing to funders and community members to offer programs for children, rather than adults. Some of the work may just be in re-thinking what type of support is offered. For instance, I once oversaw a fairly traditional men’s bereavement program, and attendance was very low. We made a change and focused more on “skills for single parents,” and were able to reach out and really help those men.
 
Irwin Sandler’s group in Tempe, AZ has developed an intervention to identify poorly functioning parents, with the hope that by identifying these parents, the children will then also benefit.
 
Q. What changes have you seen in professional beliefs about children and loss since you entered this field?
 
A. In the last 15—20 years, I have definitely seen an increased interest in the issues facing bereaved children. There has been much more written in the literature on intervention, and some wonderful books for kids have been written as well.
 
The Harvard study was really a spawning ground for the concept of “continuing bonds,” which is now a strong theme in bereavement. The phenomenon was clearly prevalent with the children we interviewed, so we developed some questions to pursue the concept as the study went on. In children, we do not see the need for continuing bonds as a predictor of a problem. The existence of these bonds did not have negative consequences for most children.
 
Q. What are some fundamental components of how children grieve that may differ from grief in adults?
 
A. Based on the research, a great deal of the differences depends on age and development. I generally break it down into three categories:
 

1. Pre-schoolers/young children: For about the first year after the death, it is very common for this age group to show major regression to earlier developmental stages, in areas such as toilet-training or even language.
2. School-age: One finding in the Harvard study that has always fascinated me was how many children this age somaticize grief—headaches and stomach aches are very prevalent. Some children this age may also revert to clinging behavior. This is not to say that it would be unusual for a school-age child who has just lost a parent to want to stay close to the surviving parent at first. With intervention, there is always that fine line between supporting the child’s wishes and promoting a behavior that may not be healthy. Aggression can also be a factor with this age group, especially with boys. In these cases it is critical that the school personnel are aware of, and sensitive to, the child’s circumstances.
3. Adolescents: In general, the grief you see with adolescents is fairly similar to that of adults.

I am often asked the question, “Do young kids grieve?” Some professionals say that for a person to experience grief, that person must be capable of understanding certain abstractions about death, mortality, etc. My belief is that, even if a child is not able to grasp abstractions, he or she will respond to separation, and that is grief. And even very young children will pick up on the “vibes” of a family that is in crisis, or dealing with loss.
 
Q. What role can schools play in helping children cope with loss?
 
A. In the Harvard study, we found for the most part that schools have been doing a good job in helping kids. For many young people, the most important intervention is simply having patient adults who are willing to help kids find ways to talk about the loss, and being willing to listen. While some kids in our study reported that they did not want to talk, very few kids reported that a teacher wouldn’t let them talk.
 
Many schools are now partnering with hospices and other community groups to provide bereavement support in the school. The only advice that I would stress is that schools should not offer “mixed” groups for children dealing with divorce and children dealing with the death of a parent.
 
Q. In your work with the Harvard study, what role did the funeral play for the children?
 
A. Most children we interviewed attended their parents’ funeral. Attending the funeral can help the child feel important at a time that he or she may feel displaced by what is happening around them. In some cases, children can be encouraged to participate in the funeral, which can help them feel included.
 
In general, I like to see the child given an educated choice. They should be told what they will see, what they should expect. For very young children, up to five years of age, the parent can generally decide what would be best. One suggestion that can help is to “assign” an adult friend to accompany the child to the funeral, in case the child has second thoughts.
 
Q. It has been found that up to 20% of young people who are grieving may require more intensive intervention. Beyond the more obvious behaviors, like self-destructive acts, what are some more subtle warning signs that a young person is struggling and needs more help?
 
A. One significant concern is when a child exhibits significant, sudden changes in behavior. Of course, short-term changes may be normal. But if the changes are persistent, or striking—for example, the usually social child doesn’t want to be around anyone—this may be cause for concern.
 
A few “red flag” signs that may indicate the need for further assessment by a mental health professional are:

• If a child cannot speak about the dead person, or leaves the room when the person’s name is mentioned;
• A child whose aggression becomes destructive, especially if this is new or unusual behavior;
• A child who develops persisting anxiety;

Again it is important to look at these in the context of the death; many of these behaviors may be typical soon after the death, but if they continue they may be more serious.
 
In any of these situations, I would urge professionals to take the time to listen well; to be patient and really develop relationships with the children they work with, so they can offer them the best support through this challenging time.