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Children and Grief: When a Parent Dies
BOOK
REVIEWS
Children and Grief: When a Parent Dies. By j. William Worden. New York: Guiljord Publications. Inc., 1996. 225 pp.• $26.95 (hardcover). Children and Grief deals with the school-age child's response to the death of a parent . It features the results of the Harvard Child Bereavement Study, which is a 2-year prospective examination of bereaved children. Using results from this study, the author adds depth to the mourning process and underscores numerous factors that influence the course and outcome of adaptation to loss. The book begins with a brief description of the Child Bereavement Study itself. Children from 70 bereaved families (125 children) were matched with non bereaved control children by age. gender, grade in school. religion, and community. Semistructured interviews were conducted with each child as well as the surviving parent at 4 months, 1 year, and 2 years after the death occurred. In addition, three standardized assessment instruments were completed by each child , and six standardized instruments by each surviving parent. Descriptions of these instruments are included in an appendix to the book. After the presentation of methodology, the work is organized into three parts. Part I comprises more than half the length of the book and is titled "Children and Their Families in Mourning." This section is divided into six chapters which present results, trends. and some specific children's responses demonstrated in the Child Bereavement Study. The author attempts to integrate results from the study with material that he weaves into the text, including concise theoretical background on grief, tasks of mourning, developmental theory, and numerous references to previous studies . Descriptions of six major categories of factors that affect the course and outcome of adaptation to loss of a parent are addressed. A chapter titled "C hild ren at Risk" identifies factors that predict future emotional or behavioral difficulties. Study results indicate that, in the short term , the percentage of children in the high-risk category increases over time (between 1 and 2 years) after the loss. The author terms this a "late effect" on the child. A screening tool to identify these highrisk children was developed using data from the study and is included in the book. Worden reviews research on long-term consequences of childhood bereavement and notes that these findings are inconclusive. He presents reasons for these inconclusive results that could be helpful for the design of future studies.
J.
AM . AC AD . C H I L D AD OLE S C. P SY CHIATRY. .1 7 :2 . FEBR UARY 19 98
Assistant Editor: Dean X Parmelee, M.D.
Parr II of Children and Grief is made up of two chapters that deal with relative losseschildren may suffer.These include the death of a sibling and loss of a parent through divorce. The author delineates features that differentiate these losses from bereavement by clear headings that are thorough and clinically useful. This section is short. clear. and, despite its brevity, potentially very helpful. The final section of the work, part III, is devoted to counseling issues. intervention models, and activities. This is also very brief, but it is useful in its presentation of an overview for clinicians interested in treating children and families after a parent has died. The author reviews four different models of intervention, includes pros and cons of each model, and provides numerous references to the literature which would be helpful to clinician and researcher alike. He underscores the need to tailor treatment to goals as well as to the level of complication in bereavement. Dr. Worden makes an important distinction between children with serious emotional or behavioral difficulties and those coping adequately with loss. A list of "red flag" behaviors is included to identify children who need professional evaluation . A special section titled "Activities for Intervention" lists activities by category such as art, puppet play, memory books, storytelling activities, and games. The writer demonstrates sensitivity to confidentiality issues and frequently reiterates the need to consider the developmental stage of the child while using such modalities. A touching portion of the book is its two-page epilogue. Children in the study were asked to share advice they would give to other children experiencing the death of a parent. The wisdom. experience, and means of coping are relayed in their own words. Finally, an excellent list of suggested readings, organized by topic, is included. The author states his objectives clearly at the beginning of each chapter, and sometimes along the way. He recapitulates whichever theoretical question he is considering as he presents various information gleaned in the study. He makes use of frequent headings and provides "Points to Remember" at the end of each chapter. Even so, the large amount of information dealt with in this relatively short work, as well as the multifactorial nature of the issues being considered, leads to occasional loss of the reader's attention. The end-of-chapter summaries of specific points to remember are generally helpful, but in a few instances the summaries contain points that were not clearly made in the chapter. In these cases, the reader is left with a feeling that something has been missed.
233
BO O K REV IEWS
add ressed at a tim e. Each step is practiced and mastered over 1 week before the next step is practi ced. T he par ent explains the various int erventi o ns to th e child, wh at the child shou ld ex pe ct, and th e potent ial co nse q uences . These sect io ns include tran script s and vignettes of act ua l parent-ch ild situation s to help the reader understand the steps in clinical and famil y context . Part III, "C reating a Positive Cli mate for Behavior C hange," nicely balan ces th e pri or em phasis on soc ial learn ing and beh avioral interventions with famil y life. Emp hasis is o n strength ening th e relationship between parent a nd ch ild th rough FU N: friendship, unde rstanding, and nurturing. T his section aids success in th e 5-week parenting program , but it also lays th e founda tio n for prevent io n of furth er difficulties later in the chi ld's life. Emphasis is o n teach ing d fectiv e communication , social skill s, resp on sibilities, valu es, jud gment, perseverance, self-d iscipline, an d self-confidence th rou gh exper ience and example, not th rough lect ur ing . For exam ple, hou sehold tasks provide an o ppo rt unity to increase child ren's self-wo rth and problem-solvin g skills. Hou sehold structures and routines provide effective family fun ctioni ng and less nagging of the child. Fam ily trad itions and ritu als help to define un iqu ene ss of the f.lmily and to give th e child a special place and meani ng. T he parents' relat ion ship is em phasized in modeling for the child. Ti me toge ther, sharing, and confl ict resolution are discu ssed. One ent ire chapter is dedicated to improving communication skills. Another hel ps pare nts of strong-willed children to develo p mo re patience, an extremely imp ort ant step for par ent s of strong-willed child ren, who severely test th eir parents' pat ience and yet need th eir parents' pat ience more th an the typ ical child . Lack of pati ence int erferes with parents' ob jectivity and ab ility to make intelligent decisio ns. Parents arc offe red a cogni tive restructuring approac h to recon ceptualizing th eir child ren's behaviors, and gu idelines for what to do when th ey do lose th eir patience. Parent s are also encouraged to man age st ress in th eir own lives. Part IV, "So lving Some Com mo n Beh avior Pro blems : Add itio nal Recommendation s," provides so me help ful steps fo r dealing with such typ ical daily diffic ulti es as tantrums, mealt ime behavio rs, car tra vel, bedtime, lying, and sibling rivalry. Parenting the Strong-Willed Child describes a un iqu e, solid, em pi rically tested program fo r helping parents and th eir you ng childre n. It provides a co ncep tua l base, un derstandable ex p lanat io ns , and pract ical st ep s. It o ffer s opt imism to parents wh o are frustrated by their st rong-willed young child ren . Parent s not o nly learn parent ing strategies, but learn to perceive th eir ch ildr en more po sitively as the y reframe th eir behaviors and as their child ren respond to th e interventi on s. Tab les in each chapter nicely extr act core co ncepts and steps
In sum mary, this book packs a tr emendou s am ount of information in to a small package. The autho r's th orough style leads to coverage of theor y, literature review, study an d data present at ion as well as practi cal clinical suggestions for treatment of bereaved child ren. Alt ho ugh the data presentat ion becomes uncl ear at times, it seems to reflect th e multid imensio nal na tu re of th e to pic. Material fro m thi s book co uld pro vide a springboa rd fo r mo re in-dep th research or study in any of th ese areas. T he book would be appropriate for those invo lved with bere avement research as well as ph ysician s an d counselor s who work with ber eaved chil dr en. Agencie s co uld use suggested scre en ing p rocedu res a nd red flag lists to provide better-qu ality evaluat ion of bereaved families. Wo rde n's boo k presents a great deal of research data wh ich are not black and wh ite by nature. It is well-grounded in the or y, is clin ically useful, and relays th e autho r's co mpassio n fo r child ren and willing ness to hear them . Holly Perkins, M.D. G rand Rap ids, MI
Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Par ents of Two- to Six-Year-Olds.
By Rex Forehand, Ph.D., and Nicholas Long, Ph.D. Chicago: Contemporary Books, 1996, 256 pp., $ 12.95 (soficover). Str ong-willed tem peram ent is a well-recogni zed cons truct in child hoo d development. Stro ng-willed child ren are at risk for multiple behavioral distu rbances and psychi atr ic d isorders such as oppositional de fiant d isorder and atte ntio n-deficit / hyperactivity disorder. T hey exhaust their parents, teac hers, and other care providers and may increase th eir own risk for abu se. Parenting the Strong-Willed Child provides a 5-week, well researched and clinically tested appro ach to th ese youngsters. T he book is geared to pa rents , but it is relevant to all mental health therapists and ed ucato rs working with yo ung childre n. The book is di vided into four parts. Part I, " Understand ing Your St rong-Willed C hild," provi des a co nce ptu al base for unde rstanding strong-willed child ren . Temperam ent is th e found ation fo r children's beh avioral repertoir e, bu t social learning establ ishes spec ific behaviors. Parent s are generally un aware of how th eir respo nses to their childre n's behaviors may ignore positive behaviors and reinforce negat ive o nes. Parenting skills may then mai nt ain o r resolve child ren's difficult behavi ors. By developing more effective parenti ng skills, parents ma y then influence their ch ildren's experience and thereby th eir socia l learni ng. Part II, "Add ressing Strong-Willed Behavior: A Five-Week Program ," describes th e five-step program: atte ndi ng, reward s, ignoring, giving d irections, and tim e-outs. O ne behavior is
234
.I .
AM . AC A l> . C H Il. l> All() l. E SC. \' SYC HI AT RY. .17 :~ . H IIR UARY
I '}~ H
REVIEWS
Children and Grief: When a Parent Dies. By j. William Worden. New York: Guiljord Publications. Inc., 1996. 225 pp.• $26.95 (hardcover). Children and Grief deals with the school-age child's response to the death of a parent . It features the results of the Harvard Child Bereavement Study, which is a 2-year prospective examination of bereaved children. Using results from this study, the author adds depth to the mourning process and underscores numerous factors that influence the course and outcome of adaptation to loss. The book begins with a brief description of the Child Bereavement Study itself. Children from 70 bereaved families (125 children) were matched with non bereaved control children by age. gender, grade in school. religion, and community. Semistructured interviews were conducted with each child as well as the surviving parent at 4 months, 1 year, and 2 years after the death occurred. In addition, three standardized assessment instruments were completed by each child , and six standardized instruments by each surviving parent. Descriptions of these instruments are included in an appendix to the book. After the presentation of methodology, the work is organized into three parts. Part I comprises more than half the length of the book and is titled "Children and Their Families in Mourning." This section is divided into six chapters which present results, trends. and some specific children's responses demonstrated in the Child Bereavement Study. The author attempts to integrate results from the study with material that he weaves into the text, including concise theoretical background on grief, tasks of mourning, developmental theory, and numerous references to previous studies . Descriptions of six major categories of factors that affect the course and outcome of adaptation to loss of a parent are addressed. A chapter titled "C hild ren at Risk" identifies factors that predict future emotional or behavioral difficulties. Study results indicate that, in the short term , the percentage of children in the high-risk category increases over time (between 1 and 2 years) after the loss. The author terms this a "late effect" on the child. A screening tool to identify these highrisk children was developed using data from the study and is included in the book. Worden reviews research on long-term consequences of childhood bereavement and notes that these findings are inconclusive. He presents reasons for these inconclusive results that could be helpful for the design of future studies.
J.
AM . AC AD . C H I L D AD OLE S C. P SY CHIATRY. .1 7 :2 . FEBR UARY 19 98
Assistant Editor: Dean X Parmelee, M.D.
Parr II of Children and Grief is made up of two chapters that deal with relative losseschildren may suffer.These include the death of a sibling and loss of a parent through divorce. The author delineates features that differentiate these losses from bereavement by clear headings that are thorough and clinically useful. This section is short. clear. and, despite its brevity, potentially very helpful. The final section of the work, part III, is devoted to counseling issues. intervention models, and activities. This is also very brief, but it is useful in its presentation of an overview for clinicians interested in treating children and families after a parent has died. The author reviews four different models of intervention, includes pros and cons of each model, and provides numerous references to the literature which would be helpful to clinician and researcher alike. He underscores the need to tailor treatment to goals as well as to the level of complication in bereavement. Dr. Worden makes an important distinction between children with serious emotional or behavioral difficulties and those coping adequately with loss. A list of "red flag" behaviors is included to identify children who need professional evaluation . A special section titled "Activities for Intervention" lists activities by category such as art, puppet play, memory books, storytelling activities, and games. The writer demonstrates sensitivity to confidentiality issues and frequently reiterates the need to consider the developmental stage of the child while using such modalities. A touching portion of the book is its two-page epilogue. Children in the study were asked to share advice they would give to other children experiencing the death of a parent. The wisdom. experience, and means of coping are relayed in their own words. Finally, an excellent list of suggested readings, organized by topic, is included. The author states his objectives clearly at the beginning of each chapter, and sometimes along the way. He recapitulates whichever theoretical question he is considering as he presents various information gleaned in the study. He makes use of frequent headings and provides "Points to Remember" at the end of each chapter. Even so, the large amount of information dealt with in this relatively short work, as well as the multifactorial nature of the issues being considered, leads to occasional loss of the reader's attention. The end-of-chapter summaries of specific points to remember are generally helpful, but in a few instances the summaries contain points that were not clearly made in the chapter. In these cases, the reader is left with a feeling that something has been missed.
233
BO O K REV IEWS
add ressed at a tim e. Each step is practiced and mastered over 1 week before the next step is practi ced. T he par ent explains the various int erventi o ns to th e child, wh at the child shou ld ex pe ct, and th e potent ial co nse q uences . These sect io ns include tran script s and vignettes of act ua l parent-ch ild situation s to help the reader understand the steps in clinical and famil y context . Part III, "C reating a Positive Cli mate for Behavior C hange," nicely balan ces th e pri or em phasis on soc ial learn ing and beh avioral interventions with famil y life. Emp hasis is o n strength ening th e relationship between parent a nd ch ild th rough FU N: friendship, unde rstanding, and nurturing. T his section aids success in th e 5-week parenting program , but it also lays th e founda tio n for prevent io n of furth er difficulties later in the chi ld's life. Emphasis is o n teach ing d fectiv e communication , social skill s, resp on sibilities, valu es, jud gment, perseverance, self-d iscipline, an d self-confidence th rou gh exper ience and example, not th rough lect ur ing . For exam ple, hou sehold tasks provide an o ppo rt unity to increase child ren's self-wo rth and problem-solvin g skills. Hou sehold structures and routines provide effective family fun ctioni ng and less nagging of the child. Fam ily trad itions and ritu als help to define un iqu ene ss of the f.lmily and to give th e child a special place and meani ng. T he parents' relat ion ship is em phasized in modeling for the child. Ti me toge ther, sharing, and confl ict resolution are discu ssed. One ent ire chapter is dedicated to improving communication skills. Another hel ps pare nts of strong-willed children to develo p mo re patience, an extremely imp ort ant step for par ent s of strong-willed child ren, who severely test th eir parents' pat ience and yet need th eir parents' pat ience more th an the typ ical child . Lack of pati ence int erferes with parents' ob jectivity and ab ility to make intelligent decisio ns. Parents arc offe red a cogni tive restructuring approac h to recon ceptualizing th eir child ren's behaviors, and gu idelines for what to do when th ey do lose th eir patience. Parent s are also encouraged to man age st ress in th eir own lives. Part IV, "So lving Some Com mo n Beh avior Pro blems : Add itio nal Recommendation s," provides so me help ful steps fo r dealing with such typ ical daily diffic ulti es as tantrums, mealt ime behavio rs, car tra vel, bedtime, lying, and sibling rivalry. Parenting the Strong-Willed Child describes a un iqu e, solid, em pi rically tested program fo r helping parents and th eir you ng childre n. It provides a co ncep tua l base, un derstandable ex p lanat io ns , and pract ical st ep s. It o ffer s opt imism to parents wh o are frustrated by their st rong-willed young child ren . Parent s not o nly learn parent ing strategies, but learn to perceive th eir ch ildr en more po sitively as the y reframe th eir behaviors and as their child ren respond to th e interventi on s. Tab les in each chapter nicely extr act core co ncepts and steps
In sum mary, this book packs a tr emendou s am ount of information in to a small package. The autho r's th orough style leads to coverage of theor y, literature review, study an d data present at ion as well as practi cal clinical suggestions for treatment of bereaved child ren. Alt ho ugh the data presentat ion becomes uncl ear at times, it seems to reflect th e multid imensio nal na tu re of th e to pic. Material fro m thi s book co uld pro vide a springboa rd fo r mo re in-dep th research or study in any of th ese areas. T he book would be appropriate for those invo lved with bere avement research as well as ph ysician s an d counselor s who work with ber eaved chil dr en. Agencie s co uld use suggested scre en ing p rocedu res a nd red flag lists to provide better-qu ality evaluat ion of bereaved families. Wo rde n's boo k presents a great deal of research data wh ich are not black and wh ite by nature. It is well-grounded in the or y, is clin ically useful, and relays th e autho r's co mpassio n fo r child ren and willing ness to hear them . Holly Perkins, M.D. G rand Rap ids, MI
Parenting the Strong-Willed Child: The Clinically Proven Five-Week Program for Par ents of Two- to Six-Year-Olds.
By Rex Forehand, Ph.D., and Nicholas Long, Ph.D. Chicago: Contemporary Books, 1996, 256 pp., $ 12.95 (soficover). Str ong-willed tem peram ent is a well-recogni zed cons truct in child hoo d development. Stro ng-willed child ren are at risk for multiple behavioral distu rbances and psychi atr ic d isorders such as oppositional de fiant d isorder and atte ntio n-deficit / hyperactivity disorder. T hey exhaust their parents, teac hers, and other care providers and may increase th eir own risk for abu se. Parenting the Strong-Willed Child provides a 5-week, well researched and clinically tested appro ach to th ese youngsters. T he book is geared to pa rents , but it is relevant to all mental health therapists and ed ucato rs working with yo ung childre n. The book is di vided into four parts. Part I, " Understand ing Your St rong-Willed C hild," provi des a co nce ptu al base for unde rstanding strong-willed child ren . Temperam ent is th e found ation fo r children's beh avioral repertoir e, bu t social learning establ ishes spec ific behaviors. Parent s are generally un aware of how th eir respo nses to their childre n's behaviors may ignore positive behaviors and reinforce negat ive o nes. Parenting skills may then mai nt ain o r resolve child ren's difficult behavi ors. By developing more effective parenti ng skills, parents ma y then influence their ch ildren's experience and thereby th eir socia l learni ng. Part II, "Add ressing Strong-Willed Behavior: A Five-Week Program ," describes th e five-step program: atte ndi ng, reward s, ignoring, giving d irections, and tim e-outs. O ne behavior is
234
.I .
AM . AC A l> . C H Il. l> All() l. E SC. \' SYC HI AT RY. .17 :~ . H IIR UARY
I '}~ H