The death of a loved one in childhood and adolescence is associated with increased emotional problems, including elevated depression, anxiety and posttraumatic stress, as well as somatic complaints and behavioural problems [1, 2]. From among all children who experience such a loss, an estimated 5% to 10% go on to experience clinically significant psychiatric problems. Such problems include major depression, posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD) [3, 4].
PGD encompasses several symptoms, including separation distress, preoccupation with thoughts about the lost person, a sense of purposelessness about the future, numbness, bitterness, difficulty accepting the loss and difficulty moving on with life without the lost person [5, 6]. Empirical studies have shown that PGD symptoms can be reliably assessed in children and adolescents . PGD symptoms can be distinguished from normal grief, depression and anxiety, including PTSD, and are associated with significant concomitant internalizing and externalizing problems [7–10].
Few effective interventions for bereaved children and adolescents are available. On the basis of a meta-analysis of 13 controlled studies examining the effectiveness of bereavement interventions with children, Currier et al.  concluded that interventions available at the time were not more useful than undergoing no intervention. Indeed, a number of controlled studies have been conducted on the treatment of bereaved children, including studies examining family interventions for bereaved children , music therapy in groups , group therapy for children  and group therapy for children bereaved by the suicide of a relative . These studies are limited by the fact that they did not articulate the theoretical basis of the intervention tested , focused on generic indices of distress rather than on symptoms of grief [12, 15] or did not randomly allocate participants to treatment and control groups [13, 14].
In the past decade, several promising lines of research have greatly advanced our understanding of bereavement interventions for children. The first and most extensive line of research concerns the family bereavement program (FBP), developed by Sandler and colleagues [16, 17]. The FBP is a group-based program that targets family-level variables (for example, parenting skills) and child-level variables (for example, coping skills) that promote resilience. The FBP was found to reduce immediate and long-term emotional problems in children confronted with parental loss. A second promising intervention is the trauma and grief component therapy (TGCT) developed by Layne et al. . TGCT is a group treatment for adolescents confronted with loss in the context of a civil war. This treatment proved to be effective in terms of reducing grief, depression and anxiety symptoms [2, 18]. A third important line of research concerns the work of Cohen and colleagues [19, 20] on cognitive-behavioural therapy for childhood traumatic grief (CBT-CTG). This treatment approach explicitly focuses on the alleviation of the emotional condition termed childhood traumatic grief, which is defined as a combination of traumatic and grief stress reaction, among children exposed to deaths that occurred under traumatic circumstances (for example, motor vehicle accidents, suicide, homicide). Two uncontrolled studies showed that children who underwent CBT-CTG reported significant improvement in CTG and PTSD symptoms [19, 20].
Notwithstanding the importance of these three research lines, they still leave room for further study and refinement of treatment options for children confronted with the death of a loved one. For instance, the FBP and TGCT are limited to a group-based format, which may yield practical problems; for example, clients may have to wait until there are enough children for a group and may be less effective because it is less well-adjusted to an individual child’s circumstances. In addition, all three approaches are limited by their focus on restricted groups, such as parentally bereaved children (FBP) or children exposed to traumatic deaths (TGCT and CBT-CTG), making these approaches less suitable for use with other groups of bereaved children. The impact of these treatments on PGD symptoms, as currently defined [5, 6], is unknown.
Given the need for effective therapy for PGD symptoms in children and adolescents, we developed a nine-session protocolized cognitive-behavioural treatment that is administered in combination with five sessions of parental counselling. This treatment is called Grief-Help. It is based on a cognitive-behavioural model of processes that interfere with adjustment to loss. Two pilot studies of this treatment have been done.
The first was a multiple-baseline study of six bereaved children and adolescents, which showed that the intervention coincided with reductions in symptoms of PGD, depression, PTSD and (parent-rated) internalizing and externalizing problems . The intervention proved to be feasible, as both children and parents evaluated the treatment positively. That is, all participating children and parents gave favourable scores regarding their satisfaction with each session, the contact with their therapist and the information they received, attesting to the feasibility of this treatment approach. Results showed that after treatment there were reductions in symptoms of PGD, depression, posttraumatic stress and parent-rated internalizing and externalizing problems. Averaged across the six participants, reductions in scores on the outcome measures were all statistically significant, and all pretreatment to posttreatment effect sizes were large (Cohen’s d > 0.8).
The second pilot study was an open trial conducted with ten children and adolescents . We conducted this study to evaluate the potential effectiveness of Grief-Help therapy among children confronted with losses other than the loss of a parent or sibling and to investigate whether the program is effective when the loss occurred more than 12 months prior to initiation of treatment. In this study, patients significantly improved from pretreatment to posttreatment, with large improvements observed in self-rated PGD and bereavement-related posttraumatic stress (effect size (ES) > 0.8) and small to moderate improvements in depression and parent-rated internalizing and externalizing problems (0.2 < ES < 0.8). Additional analyses focused on predictors of treatment outcomes suggested that Grief-Help therapy might be less effective for children and adolescents who are further removed in time from the loss and for those confronted with loss due to suicide. Taken together, Grief-Help therapy appears to be a promising treatment, and controlled evaluation is clearly indicated.
This randomised controlled trial seeks to examine the effect of cognitive-behavioural Grief-Help therapy for children with emotional problems following the death of a loved one. Participants are randomly assigned to one of two treatment conditions: (1) cognitive-behavioural Grief-Help therapy combined with parental support or (2) a control treatment consisting of nondirective supportive counselling combined with parental support. Participants are asked to complete questionnaires before and after treatment and at three follow-up assessment points.
This treatment trail has three goals. First, we want to compare the effects of cognitive behavioural Grief-Help therapy with the effects of supportive counselling by measuring the reduction of PGD symptoms and other emotional problems, including depression and PTSD. Our second goal is to gain knowledge about variables that are expected to mediate the effects of Grief-Help therapy, such as maladaptive cognition, avoidance behaviours and positive parenting (warmth, involvement and autonomy-granting). We also want to generate knowledge about variables that moderate the effectiveness of Grief-Help therapy.
We hypothesize that the Grief-Help group will show a greater reduction of PGD symptoms and other emotional problems (for example, depression, PTSD symptoms) than the supportive counselling group immediately after treatment and at each follow-up point (three, six and twelve months later). Furthermore, we expect that this reduction will be mediated by a change in maladaptive cognitions and behaviours as well as by increases in positive parenting. We consider the following factors to be possible moderators: demographic variables, severity of symptoms before treatment, time since loss, cause of death, child personality and psychopathology symptoms in parents. We will use state-of-the art statistical techniques to analyse temporality, causality and mechanisms of change.