Treating grief in children and adolescents: a therapist's manual

This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with children and families, and access to supervision. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reformulated in our own words and never reproduced: consult the original manuals for the letter of the text.

1. The programme at a glance

Indication. Prolonged, disabling grief in children and adolescents aged 7 to 18, at least six months after the death. The programme also suits grief complicated by a violent or sudden death, with the reservation set out in section 30.

What this programme is not. Support for every bereaved child. The great majority of children get through a bereavement without treatment, with the people around them, and systematic intervention gives them nothing — the meta-analyses show it, and some universal interventions have null or negative effects. This manual is addressed to children who are unwell, lastingly, and whose functioning is impaired.

Reference models. Three converging contributions. Cognitive behavioural therapy for prolonged grief in children, evaluated by Boelen, Spuij and their colleagues (2016, 2021), which targets cognitions and avoidance. The multidimensional grief theory of Layne and colleagues, which distinguishes three forms of distress — separation, the circumstances of the death, and the impact on identity and meaning — and which underpins trauma- and grief-focused therapy for adolescents. And the grief components of Cohen, Mannarino and Deblinger's trauma-focused cognitive behavioural therapy, for cases where the death has been traumatic.

Format. Fourteen individual sessions of 50 minutes with the child, weekly, and five parallel sessions with the parent or guardian, interleaved. The sessions with the parent are not an extra: they are part of the treatment, and their omission is the leading cause of failure in the child.

Target mechanism. Not forgetting, nor acceptance understood as resignation, but four changes: that the child can think of the person who died without being overwhelmed, that they stop avoiding what recalls them, that the thoughts that weigh on them — the fault, the injustice, the worry about those who remain — are examined, and that they take up the course of their development again.

Session	Focus	What the session produces
1	Welcome, assessment, alliance	What the child knows, in their own words
2	Formulation, goals, naming feelings	Diagram drawn with the child
3	When it overflows: the tools	Three tools tried in session
4	Who this person was	First memories, written or drawn
5	Understanding the death, the facts	The unanswered questions, listed
6	The narrative, part one	Beginning of the narrative, written
7	The narrative, the hardest moments	Complete narrative
8	"I should have": the fault	Belief examined, share reattributed
9	Injustice, anger, "why"	What is said and what was not being said
10	Taking back what is avoided	Two avoidances lifted
11	What I keep	Memory object, or letter
12	What has changed for me	Identity, role, future
13	The sharing with the parent	Narrative read or told, prepared
14	Stocktake, plan, the dates that come round	Summary sheet made by the child

Parent session	Placement	Focus
P1	Before session 1	Assessment, information, their own grief
P2	After session 3	Answering questions, talking about the death
P3	After session 7	Preparing the sharing, tolerating the narrative
P4	After session 10	Routines, boundaries, school, siblings
P5	After session 13	The dates, the future, the family plan

What the child takes away. Seven printable worksheets, listed in section 33 and downloadable from this page: what I know, my feelings, my tools, my memories, my questions, my story, my plan.

What sets this programme apart from bereavement support. The target is not sadness, which is not a symptom and does not have to disappear. The target is what prevents grief from running its course: avoidance, the thoughts that weigh, and the absence of an adult able to talk about it. A child who cries for their mother two years on is doing well; a child who refuses to hear her name is not. That difference governs the whole treatment.

2. Before you start

Who this programme is for

This text is addressed to psychologists, child and adolescent psychiatrists, psychotherapists and mental health nurses trained in cognitive behavioural therapy with children. It assumes that you can conduct an interview with an eight-year-old, assess suicide risk in an adolescent, and work with a parent who is bereaved themselves.

It is not written for families. It contains guidance on what must not be said, examples of narratives of violent deaths, and criteria for non-response. Handed to a parent, it would mostly serve to alarm them.

The prior question: should you treat?

This is the most important decision in the manual, and it is taken before session 1.

Do not treat a child who is doing well. The great majority of bereaved children do not need therapy. They need an adult who answers their questions, a school that has been told, rituals they are allowed to take part in, and time. Interventions offered to all bereaved children, regardless of their state, achieve very small effects, and there are grounds for thinking they can do harm: they suggest to a child who was doing well that they ought not to be.

Treat a child whose functioning is impaired beyond six months: school refusal, withdrawal from peers, lasting regression, consistently disturbed sleep, massive avoidance of everything that recalls the person who died, thoughts of death, or separation distress that does not ease.

Wait, in the first few weeks, except where there is risk. The month after a death is not the time for a protocol. What is useful then: information for the parent, an answer to the child's questions, a school that has been told, and an appointment set for three months' time.

What this programme is not

It is not a treatment for post-traumatic stress disorder. When the death was witnessed, and the child has re-experiencing and a state of hypervigilance, the trauma is treated first, with a dedicated protocol. Grief comes afterwards, or alongside if you are trained in the version that integrates the two.

It is not a treatment for childhood depression. A full depressive episode is treated as such.

It is not a programme for the under-sevens. In toddlers and preschool children, the work is done almost entirely through the parent, with play and books, and the frame of this manual does not suit.

It is not a stage model. The "five stages of grief" do not describe what children go through, they have never been validated, and they do harm when presented to a family: a child who is not "at the right stage" becomes anxious, and a parent waiting for it becomes impatient. Do not use them.

How to use it

Read the whole thing before session P1. Sections 3 to 13 lay down the frame; sections 14 to 28 are worth rereading the day before each session.

Every session is described on the same frame: the objective, a step-by-step run-through, what you say, the common mistakes, and the criterion for moving on. That last point sets the pace: the programme advances by acquisition, not by calendar. With children, the gap between the two is wider than with adults.

3. What is normal, and what is not

Ordinary childhood grief

It is intense, discontinuous, and it disconcerts adults. Three features in particular.

It alternates. A child cries for ten minutes then goes off to play. That alternation is neither indifference nor denial: it is the way a child bears a pain they cannot hold for long. Parents often misread it — "he did not understand", "she does not care" — and it has to be explained to them.

It comes back in waves, over years, at anniversaries, at festivals, at milestones — starting a new school year, an exam, a first love, a birth. A child who cries for their mother at sixteen, having lost her at ten, is not relapsing: they are growing up with that loss, and they cross it again at every age with what they newly understand.

It shows itself through the body and through behaviour more than through words: stomach aches, headaches, sleep, tempers, regression, falling school results, repeated questions about details.

What causes needless worry

Saying little about the person who died. Not crying. Playing at death or funerals. Asking the same factual question ten times. Saying blunt things. Laughing at the funeral. Talking aloud to the dead person, or saying that they see or hear them — frequent, not psychotic, and not to be treated as a symptom.

What should cause concern

After six months, and lastingly:

massive avoidance of everything that recalls the person — their name, their photographs, their room, the places, the subjects;

separation distress that does not ease: the child can no longer be apart from the surviving parent, sleeps in their bed, refuses school, checks that they are alive;

fixed guilt, with an explanation in which the child is the cause;

prolonged withdrawal from peers and activities;

a drop at school that does not recover;

thoughts of death, the wish to join the person who died, or a plan;

a conviction that life no longer has any meaning, in adolescents above all;

lasting regression in a younger child: toileting, language, separation.

These are not signs of weakness, and they do not resolve on their own with time. This is the indication for this programme.

The ages, and what they change

From 7 to 9. The child understands that death is final and universal, but applies that understanding poorly to themselves and to their own family. Magical reasoning is still active: they may have had a thought that caused the death. The questions are concrete and repeated, about the body, the grave, what happens afterwards. Answer them concretely: that is what soothes.

From 10 to 12. Understanding is close to an adult's, and the worry concerns the consequences: who is going to look after me, is the other parent going to die too, are we going to move. Shame appears: the child does not want to be the one whose father died. They begin to protect the surviving parent by not talking.

From 13 to 18. The impact falls on identity and on meaning. The adolescent asks who they are without that person, what becomes of their future, and whether any of it means anything. They share with peers rather than with family, and they may take risks. Suicide risk is real here and must be assessed at every session in severe cases. Alcohol and substance use appears as an avoidance, and it has to be looked for.

4. The clinical picture

The three forms of distress

Multidimensional grief theory, proposed by Layne and colleagues, distinguishes three forms that call for different interventions. This distinction is the best formulation tool we have in children, and it organises this programme.

Separation distress. The child suffers from the absence: they look for the person, miss them, cannot bear the empty places, do not want to be apart from those who remain. It is the most visible form, and the one worked through memories, continued bonds and the gradual lifting of avoidance.

Distress related to the circumstances. The child is preoccupied with how the death came about: what they saw, what was kept from them, what was done or not done, who is responsible. It is recognised by insistent questions about details, and it is worked through the narrative and through the examination of beliefs.

Existential and identity distress. The child, and above all the adolescent, is affected in who they are and in what they expect of life: I am not the same, I have no future, nothing means anything, I do not deserve to be happy. It is the least often spotted form, the most closely linked to suicide risk, and it is worked in sessions 12 and 13.

Most children show all three, in varying proportions. Rate them at assessment: it is the proportions that decide how much room each part of the programme will take.

What keeps grief stuck

Avoidance. This is the central factor, as in every anxiety disorder. The child avoids the reminders — the name, the photographs, the room, the house, the anniversary — and each avoidance prevents the discovery that they can think about it without being destroyed. Adults, in good faith, join in: the photographs are put away, the name is no longer spoken, the subject is changed.

The thoughts that weigh. Three families recur. The fault: I could have, I said something terrible, it happened because I wished it. Injustice and anger: it is not fair, I was lied to, someone should have done something. And anticipation: the others are going to die too, I am going to be left alone, I will not manage.

The silence of adults. This is the maintaining factor specific to childhood. A bereaved parent who cannot talk, who cries as soon as the subject comes up, or who lied about the circumstances, leaves the child alone with their own hypotheses — which are always worse than the reality. The child, for their part, keeps quiet to protect the parent. This pact of mutual silence is extremely common, and it is a direct target of treatment.

The breakdown of routines. A bereaved child whose meals, bedtimes, school and activities have fallen into disorder is unwell independently of their grief. Restoring routines is one of the most effective interventions, and it goes through the parent.

The state of the surviving parent. This is the best known predictor of how the child fares. A parent who is depressed or in severe prolonged grief cannot support their child, and their own treatment is part of the child's care plan.

Epidemiology, in two useful figures

About 4 to 7 % of children lose a parent before eighteen, and a far larger proportion lose a close grandparent, a brother or sister, or a friend.

Among bereaved children, a minority develop full prolonged grief: estimates run from 10 to 20 %, with higher rates after a violent or sudden death, or a death by suicide. It is that minority this programme concerns.

5. The model that guides this programme

Why this one

Three lines of work converge, and this programme assembles them.

The cognitive behavioural model of prolonged grief (Boelen et al., 2006; Spuij et al., 2013) attributes the blockage to three mechanisms: insufficient integration of the reality of the loss into autobiographical memory, negative beliefs about oneself, the world and the future, and avoidance strategies — avoidance of reminders, but also rumination and proximity seeking. This model has been specifically adapted and evaluated in children and adolescents, with good results.

Multidimensional grief theory (Layne et al.) supplies the three-domain formulation set out in section 4, and the treatment principle that follows from it: you do not attack at the same point depending on the dominant form.

The grief components of trauma-focused therapy (Cohen, Mannarino and Deblinger) contribute two elements that are essential in children: the gradual narrative, written or drawn, as a way of approaching what is unbearable in small doses; and the joint parent-child work, with a prepared sharing of the narrative.

The five levers

Lifting avoidance. Gradual, concrete, and negotiated: the photographs, the name, the room, the places, the subjects.

The narrative. It is not a catharsis, it is a work of ordering: what happened, in what order, with the facts corrected where the child had got them wrong.

The beliefs. The fault above all, then injustice, then anticipation.

The continued bond. The aim is not to detach the child from the dead. It is to turn a bond made of absence and pain into a bond made of available memories. A child who can talk about their father and laugh is doing better than a child who no longer talks about him.

The parent. Their capacity to talk about the death, to bear their child's grief, and to hold the routines. Without this lever, the other four do not hold.

What the model implies you should not do

Do not aim for the end of grief. The aim is not that the child should stop being sad, nor that they should "move on". Say so to the child and the parent in session 1: nobody here will ask you to forget, and there is no moment at which one is supposed to have finished.

Do not force the narrative. A child made to tell their story before they have regulation tools leaves the session dysregulated and does not come back. Session 3 comes before session 6 for that reason.

Do not reassure about what you do not know. To "is Mum going to die too?", the honest answer is bounded, not reassuring at any cost.

Do not work without the parent. A child treated alone, who goes home to a house where the name is forbidden, loses their gains between sessions.

Do not use the stages of grief. They describe nothing and they create false expectations.

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