Coping with loss
BACP Children, Young People and Families, December 2020

COVID-19 emerged while I was conducting research on religious education’s contribution to children’s ability to cope with loss, just when I was about to start interviewing children. The impact of the pandemic on children will now be included in my research, given that they are confronted with and have to cope with it daily. Facing death has become a very real concern, with significant mental health issues already being experienced including depression, anxiety, stress, and suicidal ideation. The impact on life-satisfaction, happiness and self-esteem is clear. This article takes two perspectives:

• Comparison with another world-changing event: the terrorist attacks of 11 September 2001, known as 9/11

• What can we do now to help children?

Lessons from history

Sadly, there have been many disasters we could look to in recent history. Aberfan, in October 1966, was one of the first globally reported major events of its kind, in which 144 people died, mostly children, following the catastrophic collapse of a colliery coal tip; and the 2004 Boxing Day tsunami, which had a major impact across the world because of the scale of the disaster in which 228,000 people died. I chose 9/11 because death was witnessed in real time, and there is a considerable body of post-event research, and as such evidenced major physical and mental outcomes. The evidence gives an insight into effects over time and shines a light on issues we might face if reproduced post-COVID-19, pointing to the role of counsellors and psychotherapists in addressing these issues. While reading this, please reflect on what is currently happening with COVID-19.

Statistics on 9/11

• 17% of children knew someone bereaved¹
• 41% of children saw a parent crying, and 32% had parents who witnessed the disaster²
• 35% of children had one or more stress symptoms, while 47% were worried about their own safety or the safety of loved ones.³

The most common symptoms observed in young children were post-traumatic play, re-experiencing (including disaster-related dreams), and hyperarousal (including sleeping difficulty and irritability).³

A high proportion of school children had a probable mental disorder six months later, suggesting that the pervasive effects of natural and man-made disasters on children can endure months and even years after the event.⁴

High levels of job losses had an impact on family cohesion and wellbeing, forecast to continue for a long time; significant, given the high level of COVID-19-related job losses.^5,9

Effect on children

9/11 left an untold number of bereaved children facing grief, complicated by the traumatic nature of the death,⁵ as has COVID-19. It took a heavy psychological toll: children experienced chronic nightmares, fear of public spaces, severe anxiety and other mental health problems.¹ Influential factors for prospective mental health problems were exposure to the event, perceived life disruption, loss or separation from family members, personal injury, and witnessing injuries or death.³ Children from areas of lower educational attainment or limited economic resources were also substantially exposed.³

– Claude M Chemtob

Claude M Chemtob stated, ‘We know children don’t ask for help on their own, and we know that parents and teachers are not particularly good at knowing which kids are hurting silently. We also know with children that when their problems are not detected, they can continue to have problems for more than 20 years after’.⁶

Dr Spencer Eth agreed, ‘Those kids affected and untreated will go on to have potentially lifelong difficulties directly related to 9/11: educational handicaps, substance abuse, and antisocial behaviour’.⁶

After 9/11, Hispanic students were disproportionately affected by psychological problems, researchers estimating that 13.8% suffered posttraumatic stress disorder (PTSD), compared with 9% of non-Hispanic blacks and 9% of Asians.⁷ This mirrors findings on COVID-19’s impact on BAME people.⁸

Media impact

The immediacy of people witnessing 9/11 unfold was a major contributor to consequent mental health problems. While playing an essential role in communicating disaster information, media coverage had the potential to powerfully affect those viewing.⁹ Sufficient to produce symptoms in children, routine TV news was a significant source of fear reactions and sleep disturbances in preschool and elementary (primary) school-age children. In future post-disaster conditions, major school associations and paediatric organisations advised limiting young children’s exposure to news about disasters through television and other media.³ They said that parents should monitor children for dramatic changes in media viewing habits. Intense distress following viewing of 9/11, and identification with trauma victims, were seen as potential risk factors.¹⁰ The increasing influence of social media and being constantly online, and the incidence (partly linked to social media) of bullying, may affect children’s willingness to seek help, placing reliance on professionals to identify and address problems being experienced.

Counselling considerations

Post 9/11, healthcare professionals’ interventions varied widely and depended largely on their comfort zone, particularly in the areas of bereavement and religion, an echo of findings in research in the UK on counsellors and psychotherapists’ experience.¹⁷ The research also suggested that they need to tackle this responsibly, especially in the aftermath of a disaster. Any professional involved with young children and their families should recognise that catastrophes can provoke serious negative reactions, including PTSD. To protect against possible functional impairment, early identification and treatment of depression and strengthening of family resilience were recommended.¹¹ Teachers and school-based counsellors were advised to pay attention to young children showing signs of social withdrawal and regression,¹² as PTSD may manifest with subtle symptomology. Fear of ongoing threat affected both the severity and duration of psychological symptoms, which for COVID-19 could relate to the length of time it impacts on society. Counsellors and psychotherapists should be prepared to assist children with trauma-related symptoms of stress over the medium to long term.⁹

The availability of social support was significant in the aftermath of disaster.¹³ The majority of parents had talked to their children about 9/11 for an hour or more, and the availability of a supportive parent or family member was the most important factor distinguishing traumatised children who had good developmental outcomes from those with who didn’t.¹³ This gives a pointer to counsellors and psychotherapists when advising parents or family members as to children’s support during COVID-19.

Professionals involved with young children and their families should recognise and assess grief reactions in bereaved children and adolescents and examine the impact on their functioning. An understanding of Continuing bonds¹⁴ is helpful in assisting bereaved children properly resolve grief and enabling them to develop and maintain a continuing healthy bond with the deceased. Yielding positive benefits for children with traumatic grief, it recommends communicating about and maintaining an emotional connection to the person who has died, for example by talking regularly about them, and through the use of creative activities such as collecting objects for memory boxes.

Current COVID-19 research findings

These map closely to the findings of 9/11 research. In a survey by the mental health charity YoungMinds of 2,111 participants up to 25 years of age, with a mental health illness history in the UK, 83% said the pandemic had made their condition worse; 26% said they were unable to access mental health support; and findings suggested that peer support groups and face-to-face services had been cancelled, and support by phone or online could be challenging for some young people.¹⁵ 

Social distancing and school closures are likely to result in increased loneliness in children and adolescents, with social contacts curtailed by containment measures. With well-established links between loneliness and mental health problems in children and adolescents, research finds that social isolation and loneliness increase the risk of depression and possibly anxiety.¹⁵ The length of loneliness appears to be a predictor of future mental health problems, of particular relevance in the COVID-19 context, as the Government considers imposing further lockdown measures and the implementation of social distancing in schools.

When adults talk to children, the information provided needs to take into account the child’s age and level of understanding. Sensitive and effective communication about life-threatening illness has major benefits for children and their family’s long-term psychological wellbeing. Listening to what children believe about COVID-19 transmission is essential; providing children with an accurate explanation that is meaningful to them will help to ensure that they do not feel unnecessarily frightened or guilty. Honesty offers not only an understandable explanation for what children are observing, but also grants permission for children to safely talk about their own feelings. Normalising their emotional reactions and reassuring children about how the family will look after each other help to contain anxiety.

‘Empowering adults to communicate with children about illness and death has the potential to mitigate the short-term and long-term psychological effects. Sensitive and effective communication… has major benefits for children and their family’s long-term psychological wellbeing’.¹⁶

What we can do now

When interviewing teachers and headteachers for my research, two often-repeated statements stood out, ‘I don’t know what to say’ and, ‘I am scared I will do more harm than good’. Death remains a taboo subject for many reasons, and talking to children about it is a challenge shared by parents and teachers – and counsellors – alike.¹⁷ While there is actually a great deal of very good and effective help available, many people don’t know that, and/or don’t know how to access it. Faced with a need to do something quickly for the schools taking part in my research, I have compiled a COVID-19 schools support pack, guiding readers to some of the best resources freely available, together with material I have developed over the years in key areas such as, ‘What should I say?’ and perhaps more importantly, ‘What shouldn’t I say?’. It has sections specific to children, staff and parents, and books that can be downloaded for children. While the pack is aimed primarily at primary schools, much of it is generic and can be used across the educational spectrum. It contains information sourced from a number of leading bodies who provide direct guidance and support on coronavirus in the area of education, bereavement care and healthcare. These bodies are credited when their information is used: it is open-access information and website addresses are given, should users wish to make direct reference to the material.

At the time of writing, children across the UK have recently returned to school, and with that more issues will emerge around helping children cope with loss that they have been confronted with directly or indirectly. For example, in schools with pupils who have a family member or acquaintance who has died of COVID-19, they, their fellow pupils, parents and staff, will all have been affected in some way, and will need an appropriate level of support. Whether and how they are affected, and what support they need, will only be known over time, but some immediate relief can be gained through using the information contained in the pack. We are constantly learning about COVID-19 and its effects on children, parents and schools, and as such, the pack is a work in progress which will be regularly updated. To help with this, I am seeking input from counsellors and psychotherapists: if you know of or have developed resources, I would welcome hearing from you so that they can be added to future issues.

This article was written in September 2020. © Michael Coombes