INTRODUCTION
The death of a family member is an adverse event for children (Worden
1996), which may represent “a profound
psychological insult” (Raveis et al.,
1999, p. 165). Approximately 4% of children who are younger than 18
and live in the United States experience the death of a parent (Sandler et al., 2003). The death of a loved one
initiates a bereavement reaction, typically characterized by feelings of
sadness and feeling as if a loved one was taken away from the family
(Reynolds et al., 1995; Buckingham, 1996). Young children who have lost a
parent or sibling are likely to exhibit problems in emotional, social, and
behavioral functioning (Worden, 1996; Thompson et al., 1998). They may feel sadness and
anxiety during the grieving process (Raveis et al.,
1999; Sandler et al., 2003).
Community-based programs for bereaved children are becoming more
common and popular. Research on the effectiveness of community-based
programs, like hospice services, for children coping with the loss of a
loved one is needed (Armstrong-Dailey & Zarbock,
2001; Curtis & Newman, 2001; Davies, 2001). The purpose of this study was to
examine children's opinions about a hospice-sponsored grief camp.
During camp children participated in art and counseling activities
designed to improve emotional expression, build positive memories, and
improve abilities to cope with the loss of a family member. The children
completed group activities with peers who had also lost a family member.
Groups were facilitated by hospice counselors and trained volunteers. This
type of experience offers an important outlet for children, who may not
discuss their feelings with family members in order to protect them from
experiencing additional emotional distress (Reynolds et
al., 1995).
The opportunity to share feelings of grief in a supportive environment
among peers who have endured the death of a loved one may be one of the
most powerful aspects of the camp experience (Tremblay
& Israel, 1998; Christ et al., 2002).
A literature search revealed one study examining the impact of summer
camps for helping siblings of children with cancer cope with
grief related to their brother's or sister's terminal illness
(Spirito et al., 1992). These researchers
reported that participating in the summer camp improved support for
children and helped them to express, remember, and actualize their
feelings regarding their sibling's terminal illness. A literature
search revealed no similar studies assessing the effectiveness of
bereavement camps.
This pilot study contributed to the literature by providing
information about children's perceptions of the impact of a grief
camp. Interviews were used to record children's views about their
camp experience, as qualitative methods are recommended to provide
explanatory information about grief reactions (Nadeau,
1998; Christ, 2000). The study assessed
perceptions of children between 6 and 12 years of age. Children in this
age range may be at increased risk for adjustment problems following the
loss of a family member (Worden, 1996).
Children's groups focusing on interventions designed to promote
emotional expression, such as the art activities at this camp, can
facilitate opportunities for children to cope with emotions that they
might not be able to share in the home environment.
METHODS
Participants
Eighteen children (9 boys and 9 girls) attended the camp and
participated in this project. Children were in the first through sixth
grades, and had lost a parent or grandparent. Sixteen of the children were
Caucasian and 2 were African American. Nine of the children had
participated in counseling, 6 were in individual counseling and 3 were in
family counseling. Most of the children (n = 16) were making
“As” or “Bs” in school. Six children had lost
their mother, 11 had lost a father, and 1 had lost a grandparent (cause of
death varied). Parental consent and child assent were required for
participation and a university-based institutional review board approved
this study.
Camp Description
The camp was designed to provide a 3-day experience (over a weekend)
for bereaved children between the ages of 6 and 12. Campers stay overnight
and are assigned to a peer buddy, and then assigned to cabins and a
volunteer counselor. These groups stay in the same cabin. Trained
counselors from hospice and similar programs as well as trained volunteers
staff the camp. The mission of the camp is to allow children to meet in an
informal atmosphere to help reduce the sense of isolation they may feel
when coping with their grief. Another goal is to provide opportunities to
learn about the grieving process (e.g., that grieving is normal and
involves many types of emotions). Children and staff participate in
scheduled activities during camp, which include art activities, crafts,
games, and sports. Rules for the children are posted: “(1) Stay
focused on the group activity, (2) share thoughts and feelings one at a
time, and (3) no hurting other people's bodies, feelings, or
objects.”
A manual, developed by Hospice of the Bluegrass1
The training manual and questionnaires are available from the first author: Laura Nabors, Department of Psychology, Mail Location 376, University of Cincinnati, Cincinnati, OH 45221-0376, USA.
, is used to train
volunteers. Camp activities included painting feelings masks, creating a
board game and playing it while exploring questions about grief, creating
a drama in which the children learn and perform a play reviewing different
types of grief reactions, developing questions about death for a question
and answer session with a doctor, participating in ceremonies to honor the
lost loved one (e.g., memorial drumming), and writing letters to the loved
one. Other activities were nature walks, recreational games, a challenge
course, and camp evaluations.
Evaluation Procedures
Parents completed a survey during an orientation session before camp
and another after camp ended. The initial survey requested background
information (child's gender, type of loss) and required parents to
answer questions about changes in their child's emotional functioning
(e.g., sadness, worry), using 4-point Likert scales (1 for no
change and 4 for a high level of emotion) or
“yes” or “no” questions. Five parents completed a
similar survey immediately after camp ended. Four parents completed the
follow-up survey 6 months after camp ended.
During camp, children completed surveys to record their satisfaction
with two art activities designed to facilitate emotional expression:
painting feelings masks and a making their own board game about grief
reactions. A research assistant and the first author asked the children
about their satisfaction with these two activities and recorded their
responses about their level of satisfaction on 4-point Likert scales (1,
no help or satisfaction, 4, a lot of help or
satisfaction). The research assistant and the first author also
recorded why and how much the activities (using the 4-point Likert scales)
helped them cope with feelings of sadness and anxiety related to the
loss.
At the end of camp, children worked with camp staff to complete
questions to evaluate their opinions of camp. These questions were open
ended, and most of the children finished answering them in about 10 min.
Staff also recorded their ideas about what the camp meant for the
children.
Six months after camp ended, 5 of the children who attended camp
completed a follow-up survey. A research assistant administered survey
questions by telephone. Questions examined the children's views about
how camp helped them and what activities they remembered enjoying and the
reasons why these activities helped them cope with their grief (see
footnote 1).
RESULTS
Parent Report Prior to Camp
All but one of the parents reported that their family functioning was
poor and reflected a state of distress. Five of the 17 parents (29%)
reported that their child was experiencing a high degree of sadness about
their parent's death. Eight parents (47%) reported that their child
was experiencing some sadness related to the loss. Sixty-seven percent
reported that their child was experiencing significant anxiety related to
the death. Four parents (22%) reported that they believed the child's
academic performance had declined because of grief related to the death.
Sixteen of the 18 parents (89%) reported that their children's
friends remained a strong source of support for them and that their
children were still playing as often with friends as they were before the
death.
Five parents completed evaluation forms the day camp ended. They all
had positive things to say about the camp like, “I think it was very
uplifting for my child.” Another parent said that her son
“thoroughly enjoyed it and said it was great to be able to freely
express grief with others who understood it.” On rating scales,
however, no significant changes were noted in the children's levels
of sadness or anxiety.
Four parents provided information about 6 children (2 of the children
had siblings who attended camp) at a 6-month follow-up. Four of the
children were still experiencing some sadness or grief related to the
death. One child, a boy who had lost a father, experienced an emotional
low about a month after camp when he “hit rock bottom” and
talked about suicide. After being hospitalized his emotions stabilized.
Another girl lost her grandfather during the follow-up period. She had
lost her father before camp. Her mother reported that her daughter
remained withdrawn and was still experiencing a moderate level of sadness
and a high level of anxiety. All of the parents were very positive about
the camp experience, even the parent of the boy who was hospitalized,
stating that their children had a great time and “wanted to go
back.” The mother of the daughter who had experienced the loss of
her grandfather said, “I think Camp Great Escape was a very good
program for my daughter and I remember picking her up and how excited she
was.”
Eighteen of the children provided responses about their satisfaction
with the feelings mask and game activities. Fourteen of the children were
very satisfied with the feelings mask activity. Nine (50%) felt that the
feelings mask was “very helpful” and 6 (33%) stated that the
activity was helpful for expressing feelings of sadness related to their
parent's death. Most of the children (n = 16, 89%) reported
that the feelings masks were a very helpful activity for coping with
anxiety related to their loss. The children were less satisfied with the
board game. Only 28% were very satisfied with the game or found the game
“very helpful” in addressing their feelings of sadness and 2
children did not enjoy the game or find it helpful in addressing feelings
of sadness or anxiety. Eleven children (61%) thought the game was very
helpful for addressing anxiety, and 7 children thought the game was very
helpful for coping with feelings of sadness.
Children's Views of their Camp Experience
All of the children reported that camp helped them. Children provided
answers indicating that they valued the peer support and counseling
activities at camp. Quotes representing children's perceptions are
presented in Table 1.
Children's responses about camp
Counselors provided similar answers to those provided by the children
about the benefits of camp. One counselor reported, “It (camp)
helped them learn that with support they could overcome their fears and
difficulties.” Counselors also mentioned that the camp afforded the
children opportunities for emotional expression and a chance to begin to
build a positive memory of the loved one.
A research assistant completed a telephone survey with 5 children at a
6-month follow-up. The children all rated their camp experience as
“good” and “very helpful.” One 11-year-old boy
stated that participating in camp “got me over my anger.”
Another 11-year-old girl said that at camp she learned that,
“You're not the only one going through losing somebody.”
The children remembered participating in the feeling masks activity and
enjoying it, and they also mentioned benefiting from memorial activities
involving rituals. The girl who had lost her grandfather during the
follow-up period completed the survey via mail. She reported that at camp
she learned that “everybody gets born and at some time they have to
pass away.” She rated her camp experience as good and said that
attending camp was very good (4) at helping her deal with her sadness over
her father's death and O.K. (3) in helping her cope with worry
related to losing her father.
Questions for the Doctor Session
Children were divided into two groups, one for older children (ages 9
to 12) and one for younger children (ages 6 to 8) to explore questions
about death. Ten children participated in the “older” group.
The question of most interest was “What happens after a person
dies?” The older children wanted explanations about changes to the
body after death, such as, “Why is the skin a funny color after a
person dies?” The younger children wanted to know about the medical
changes that cause death (e.g., the heart stops). Other questions were
“Can dead people come back to life?” and “Can I catch
what they had and die too?”
DISCUSSION
Results for this pilot study indicated that the children appreciated
and were involved in the camp experience, can be successfully approached,
and are responsive to questions about their experience. They valued
opportunities to share with others who had gone through similar
experiences in a supportive environment (Worden,
1996; Worden & Monahan, 2001). The
children also enjoyed the art activities as opportunities to express
feelings they might not otherwise be able to process. Several studies have
shown art activities to be an effective method for helping children
process intense emotional reactions (Reynolds et al.,
2000).
Parents also reported that their children benefited from participating
in the camp. A few of the parents also came to camp and observed some of
the activities, and the popularity of the camp experience for parents has
led Hospice of the Bluegrass to begin developing a family grief camp.
Involving the children and their families in rituals to explore feelings
about the loss and create a memory of the loved one are important
activities to facilitate coping throughout the grieving process (Rando, 1985). Involving parents may improve young
children's abilities to adjust to the loss of a loved one (Hurd, 1999). Improving parent–child
communication between the surviving child and parent, so that the child
can express his or her feelings in an open way, can further enhance the
child's ability to cope with the loss (Sandler et
al., 2003).
Findings also indicated that most of the children were experiencing
feelings of sadness and anxiety related to the loss of their mother or
father (Reynolds et al., 1995; Buckingham, 1996; Worden,
1996; Raveis et al., 1999). However,
these feelings did not appear to cause a change in relationships with
friends. Activities with friends may serve as a protective factor for
children who have lost a parent. More research is needed on protective
factors for these children (Worden, 1996).
Follow-up interviews revealed that one child experienced a significant
emotional reaction after the camp and another went through another
significant loss experience. Parents were provided with referrals at camp
and the mother of the boy who expressed suicidal thoughts reported that he
received appropriate treatment and began to improve, in terms of his
emotional functioning. The researchers contacted the parents of the boy
and girl who had experienced further emotional stress to ensure that they
were receiving or had received appropriate services. Study results
indicated that it is important to keep in contact with children who have
lost a family member, because some may experience overwhelming emotions at
some point after the loss or may experience other events that trigger
memories of the previous loss (Thompson et al.,
1998). Researchers need to continue to improve knowledge about
factors related to severe changes in children's behavior, such as
suicidal thoughts, following parental loss.
Children's questions for the doctor were consistent with existing
literature reflecting children's concepts and understanding of death.
Some children in the younger group were still learning about the finality
of death, in terms of the cessation of physical or biological functioning.
Most of the older children, however, understood that death was
irreversible and indicated nonfunctionality (Speece
& Brent, 1987). Similar to Melear's (1973) report, children in the younger age group asked
questions about whether the deceased was still experiencing pain. They
also were inquisitive about the biological processes that were involved in
the death experience for their loved one. Older children asked more
questions about what happens to the person after death. Therapeutic
interventions, such as the “Questions for the Doctor” session,
allow children to explore their understanding of a loved one's death.
This is important because young children may misunderstand the causes of
death and mistakenly blame themselves for the loss of a loved one (Christ et al., 2002).
CONCLUSION
This pilot study provided information supporting the benefit of grief
camps for children, and results can be used to seek funding for these
types of programs. The camp fulfilled its mission of creating a supportive
environment for children to process grief experiences with peers who had
similar experiences. On the other hand, the study was a pilot project
using a small sample and relied primarily on qualitative data and data
from self-report measures without well-established psychometric
properties. More studies are needed to determine outcomes for children who
participate in grief camps. Others have written about the benefits of
hospice services and proposed that more research is necessary to support
the positive effects of these services in helping children and families
cope with grief (Armstrong-Dailey & Zarbock,
2001; Davies, 2001). Consequently,
longitudinal research to assess whether improvements in psychosocial
functioning are related to therapeutic experiences, like camps and other
grief support groups, is needed to determine factors related to adjustment
and coping for children who have lost a family member. Children and family
members were responsive to our efforts to learn about their perceptions
and track the children's progress, suggesting that evaluations such
as this project are possible and may be beneficial in assisting
practitioners in evaluating children's progress following grief camp
experiences.
