l approach might be most effective. According to Stubenbort and Cohen (2006), treating children with complicated grief requires treatment of both trauma and grief symptoms. Similarly, successful outcomes are associated with the inclusion of surviving family members in the treatment process. Trauma-focused cognitive-behavioral therapy (TF-CBT) is a manualized treatment approach for children and their parents drawn from extensive work with trauma survivors. Cognitive-behavioral techniques have been used successfully to treat sexually abused children (Cohen & Mannarino, 1996; Cohen et al., 2000) and bereaved adults and children after an airline disaster (Stubenbort, Donnelly, & Cohen, 2001).
Dunning (2006) suggests that promoting adjustment of parentally bereaved children involves interventions that frame the concept of death cognitively, affectively, and behaviorally. The cognitive frame emphasizes the sharing of accurate and factual information about the death to avoid "magical thinking" and unnecessary responsibility-taking by the child. Information should be presented to children in language appropriate to their cognitive development. The affective frame involves talking with bereaved children about the negative feelings associated with the loss and helping them identify and label their feelings appropriately. Finally, the behavioral frame involves such topics as children understanding their own behaviors and the behaviors of adults. For example, witnessing the surviving parent crying or expressing anger or frustration can be a source of distress and misunderstanding for children. Counselors will want to communicate openly with bereaved children about challenges they may experience in school and other social milieu. Counselors can also develop a plan with children on how much to tell, who to tell, and how to answer questions about their loss. Such planning may help alleviate worries and uncertainty for grieving children as they adjust to their loss.
Schuurman (2003) highlights practical suggestions for children 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.
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