grappling with adaptation to parental death. Continuing a connection with the deceased parent is an important consideration, especially through dreams or creating symbolic rituals and traditions for remembering the deceased parent (planting a tree, visiting the grave on certain dates). Bereaved children should be encouraged to write down or record their thoughts and experiences pertaining to the death. They can use expressive arts (e.g., drawing, sculpting, painting) to explore their loss or organize pictures and mementos into a memory box. Older children and adolescents may find it helpful to volunteer to help others and find meaning from the loss of their parent in this way.
Counselors can prompt children to discuss the deceased parent by focusing on a favorite time together, favorite memories, or a favorite gift from the deceased (Haine et al., 2008). They can also encourage families to discuss both positive and negative emotions associated with the loss in order to strengthen the family system while normalizing the grief process for other family members.
In identifying those at risk of complicated grief, a few factors seem particularly important. Counselors should monitor the degree of disruption of the social environment following the loss of a loved one. Depending on the relationships and the deceased's role in the family, the family structure may change, so having a continuity of bonds and social supports is important to the capacity of children to deal with bereavement. Similarly, the adjustment of a caregiver appears to be associated with how the child adapts to the loss. Maintaining structure and disciplines creates a predictable environment and helps the child to feel safe and secure. Open communication about the actual loss, grief reactions, and emotional responses should be promoted. Often adults strive to "shield" and "protect" their children by avoiding conversations about the trauma. However, without accurate information, children will fill in the gaps and may blame themselves for the loss.
Other factors that may influence the severity of traumatic symptoms include the presence of pre-existing conditions or psychopathology, the level of exposure to the traumatic event, the nature of the relationship to the deceased, the cause of death, and barriers associated with experiencing trauma as a child. Barriers for children in need of treatment include the necessity to disclose the trauma to an adult, the need for parents to recognize when atypical reactions warrant treatment, and parents' willingness to seek treatment.
FUTURE DIRECTIONS FOR RESEARCH
Although it is difficult to pinpoint the aspects of current treatment models that lead to positive outcomes, researchers suggest that treatment for childhood grief should incorporate interventions for both trauma and bereavement symptoms. However, there is little information about the optimal amount of treatment for reducing symptoms, and empirical studies are also needed to determine the components of treatment interventions that are most critical in producing positive outcomes in children.
Due to the association between adjustment and social support, it seems to be important to include surviving parents in the treatment of childhood grief. A lack of parental support and attention may hinder the adjustment of children to loss (Hope & Hodge, 2006; Tremblay & Israel, 1998). The emotional distress of parents and lower levels of social support for the child predict poorer outcomes for children (Cohen & Mannarino, 1996). Inclusion of a treatment component for parents may be beneficial for resolving childhood traumatic grief. Few studies have incorporated an active parental treatment component because most research examining grief in childhood is conducted at school.
Studies examining grief in children have several methodological problems. A lack of standardized assessment measures, failure to examine the link between parent and child adjustment (Kalter et al., 2002), and heavy reliance upon parent reports of child functioning (Thompson et al, 1998) have all been trouble