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Journal of Palliative Medicine
 
J Palliat Med. 2012 August; 15(8): 931–945.
PMCID: PMC3396138

Minor Children of Palliative Patients: A Systematic Review of Psychosocial Family Interventions

Abstract

Although the whole family is affected by a parent's palliative disease, palliative care research does not yet routinely consider patients' minor children. Children's and adolescents' psychosocial functioning may be impaired during prolonged parental disease with poor prognosis. Therefore, more and more health care providers are establishing clinical initiatives for families of palliative patients with minor children. However, the number of these family interventions, as well as their theoretical and empirical backgrounds and evidence base, has yet to be determined. The purpose of this study was to systematically review structured and published interventions for this target group, as well as empirical studies on these interventions. The evidence base and impact of interventions on families were considered. Literature published between 1980 and present focusing on psychosocial family-, child- or parent-centered interventions during palliative care was retrieved from PsycINFO®, Embase, MEDLINE®, CINAHL®, and PSYNDEX databases. Five interventions met the inclusion criteria. Programs focused on different populations, had diverse empirical and theoretical backgrounds and features, and were evaluated by studies of varying methodological quality. This systematic review illustrates the lack of well designed and elaborated intervention concepts and evaluation studies in this field, highlighting the necessity of conceptual and methodological rigor to inform clinical practice on a sustainable basis in the future.

Introduction

Severe somatic disease of a parent influences the family as a whole1—not only spouses/partners,2 but also minor children.3 According to an extrapolation of data of the U.S. National Center for Health Statistics, in Western societies, 5%–15% of minor children may have a parent suffering from a severe disease.4 The point prevalence of severe somatic disease (i.e., life-threatening and/or severely influencing quality of life) in parents was 4.1% in a German representative study of N=1.950 families with at least one child aged 4 to 18 years.5 The most common diagnoses in this sample were cancer (28.8%), cardiovascular (13.7%), and diseases of the intestinal tract (12.3%). In Western societies about 4% of children experience the death of a parent before they are 18 years old.6 Children of chronically ill parents show particularly more internalizing symptoms, i.e., anxious/depressive, social, and somatic problems, than children whose parents are healthy.5,7 Nevertheless, in specialist clinical palliative care, perhaps due to limited resources, health professionals tend to focus on primary caregivers and not on the entire family.8

Anticipated parental death is a crisis for every family member.9 Both non-ill10 and seriously ill parents11 experience confusion concerning their parental competence. Child-centered parenting by healthy parents can decrease with lengthy disease of the partner.12 In turn, both influence the adaptation of children to parental loss.12,13 Poorer patient prognosis, more intensive treatment, worse functional impairment, reduced mental health, and perception of parental illness as more serious are associated with negative self-reported psychosocial functioning of children of physically ill parents.1417

Children have less cognitive capacity and coping strategies than adults to deal with such a crisis.18 The predictability and stability of everyday life can disappear. Due to psychosocial stress, healthy spouses may have difficulty adequately meeting their children's needs, which may in turn exacerbate their children's situation.12 Children fear the ill parent's death and worry about the healthy parent‘s well-being.19 They are afraid of the unknown as well as of not being able to effectively cope with the situation.20 The association between disease severity and child functioning warrants further exploration,14 and as parental palliative disease seems to play a major role in child adjustment, reviews should account for this stage of the illness.7 Although of importance, other reviews explicitly exclude parental palliative disease.3,16

Against this background, our review aims (1) to identify structured psychosocial interventions published and evaluated for families of palliative patients with minor children, (2) to analyze the evidence base of those interventions, and (3) to evaluate the impact of the interventions on families (if applicable).

Methods

Search strategy

When developing our concept of child-oriented medical family counseling towards a manualized interventional concept including special modules for families in palliative care in the context of a German multisite research project,21 this review was part of a literature search of related international interventions.

A systematic review approach2224 was adapted to observational studies and descriptions of intervention concepts. English and German publications since 1980 were identified searching the databases PsycINFO, PSYNDEX, Embase, MEDLINE, and CINAHL in March 2011. The first search included the keywords (child* OR parent* OR family OR spous*) AND (terminal* OR palliative) AND (intervention* OR counsel* OR therap*). Because couple interventions were thought to possibly contain child-related issues as well, this keyword was further integrated. To cover interventions beginning in palliative care and lasting throughout bereavement, the subsequent search added the keywords (parent* death OR death of a parent OR dying parent OR bereaved child* OR child bereav*).

Hand searches were conducted in April and May 2011 through palliative care and psychooncology journals, reference lists of relevant books, included articles, and relevant review articles. An online search of relevant websites was carried out to identify evaluated intervention concepts. The full search strategy is available upon request from the first author.

Inclusion criteria and assessment of study quality

Articles were included based on these criteria:

Population: Parents with palliative-stage disease; Minor children (<18 years)

Intervention: Psychosocial interventions (e.g., counseling, psychotherapy, support groups); family, child, and parent-centered interventions; interventions delivered in any setting and by any method; content and/or time structured and formally described interventions

Outcome: Any psychosocial outcome (e.g., symptomatology, quality of life)

Studies: Evaluation studies of any quantitative or qualitative study design (with adjacent quality assessment); published since 1980; published in peer-reviewed journal or edited book; published in English (representing international research standards) or German language (author's mother tongue)

In accordance with our study questions, publications exclusively on child bereavement were excluded. Dissertation abstracts, case studies, anecdotal reports, and comments were excluded as well.

After the first elimination of studies based on title and abstract (see Fig. 1), the raters included/excluded and assessed publications independently, based on the full texts and according to a checklist requiring a decision based on each inclusion criterion (yes/no). The two trained raters were the first author (FK) and a master's psychology student with advanced methodological skills (JCG). If there were divergent assessments, consensus was achieved by discussing inclusion criteria.

FIG. 1.
Flow chart of the literature search procedure.

According to a systematic review of tools for quality assessment of observational studies,25 critical appraisal checklists provided by Cardiff University26 were utilized. They were chosen because different study types are evaluated according to one common and comparable procedure. Depending on study design, raters assess specific aspects of study aims/focus, method, population, and results; they provide concluding ratings according to predefined questions. In our review, both raters independently evaluated whether or not there was evidence for the respective questions or whether there was unclear evidence. Afterwards, discordant assessments were discussed and a concluding decision was made.

Study quality will be reported, but due to small sample sizes of heterogeneous studies, no minimum-quality criterion was set for inclusion. Two independent raters assessed study quality, then discussed their findings. Interrater reliability reached a Kappa coefficient of K=.75, which can be categorized as good.27 Data extraction and report are based on prominent publications in the field.16,28,29

Results

While in total, 5 interventions described in 24 publications fulfilled the inclusion criteria and were included in this review, many interventions identified during the literature search did not fulfill the inclusion criteria. Exclusions involved not being structured by time and/or content,3047 not being focused on palliative care or exclusively focused on bereavement,4871 focused on early-stage cancer7273 or recurrent breast cancer,74 not including minor children/parents,7578 or not being evaluated in an empirical study7983 (listed regarding first inclusion criterion that did not fit). For reasons and corresponding numbers of exclusions dependent on the stage of the process, see Figure 1.

Psychosocial family interventions

Table 1 gives an overview of intervention concepts including brief characterizations. Interventions were developed in the United States,84,85 mainly in Australia,86 or predominantly in Europe.87 During a conjoint European project (COSIP), three independent modifications of an intervention were developed in collaboration between partner centers.8890

Table 1.
Interventions for Families of Palliative Patients with Minor Children

Interventions addressed adolescents89 or children and adolescents.84,8790 They focused on parental physical illness,88 cancer,89,90 terminal cancer,84,97 terminal illness,86 or HIV/AIDS.91 Although one program was predominantly developed for adult patients and their families, we included it because one of its topics involves the “needs of younger children.”91 The COSIP interventions were not exclusively designed for families in palliative care.8890 Yet as in most other interventions,84,86,91 they include anticipatory/adaptive grief as one intervention goal. This and further intervention aims (parenting competence, active coping, communication) capture the concerns of families mentioned above. All authors indicated that developmental issues are a crucial determinant of counseling.

Theoretical and empirical backgrounds were diverse, and intervention development more or less explicated (see Table 1 and Fig. 2). Important indications were illness severity,84,87 family functioning,86 or disease disclosure/parental death in the course of the intervention.91 The most frequent recurrent intervention aims were parenting competence,8691 anticipatory/adaptive grief,84,86,8891 active coping,8691 and communication.84,8890 Intervention goals are also related to important risk and protective factors of psychosocial adaptation of minor children in cancer families, such as familial communication and functioning, parental psychological functioning, and coping strategies.1416, 93, 94

FIG. 2.
Features of intervention concepts (multiple answers).

Programs were described as needs oriented,8691 preventive,84,8688 or brief and focused84,86,8890 by their authors. Regarding number of sessions, the length of interventions varied between short8690 and long.84,91 In all cases, individual and group sessions were offered, except in one case86 of exclusively family sessions. All interventions were face-to-face, one provided regular telephone contacts,84 and four were also conducted in the family home.84,86,89,90 One intervention did not include the ill parent on a regular basis.84

In three interventions, an unpublished manual,87 verbal descriptions,84 or a published practical guide88 describing the intervention were mentioned. If the authors had published a treatment manual,86,91 intervention techniques and tailoring to the treatment unit were elaborated, and both training and supervision were mandatory. Otherwise, authors listed training87 or regular supervision.84,88,89 Therapists' backgrounds were mainly in social work, family therapy, and psychology or psychiatry (see Fig. 2).

Related evaluation studies

Table 2 summarizes characteristics of evaluation studies and their main results. Studies were mainly quantitative and cross-sectional (see Fig. 3). Three studies87,89,95 did not incorporate a control group, three compared the intervention with standard care/absence of counseling,90,96,97 and one with telephone monitoring.98 Sampling was either convenience87,89,90,95 or randomized.9698 Recruitment took from six months95 to five years,96,98 and participation varied from 44%–57%87,95,96,98 to 72%–89%.89,90,97 There were studies with smaller,87,90,95 medium sized,89,98 and larger samples.96,97

FIG. 3.
Features of evaluation studies (outcomes, design, approach; multiple answers; RCT, randomized controlled trial).
Table 2.
Evaluation Studies on Interventions for Families of Palliative Patients with Minor Children

Two research projects investigated therapist fidelity.97,99 Participants versus nonparticipants or completers versus noncompleters were compared by three research groups.89,90,100 Reasons for nonparticipation were family- or disease-related burden or refusal of individual family members.89 Parents in the counseling group were older, more often single,92 and reported more emotional distress.90

Study quality was diverse. Independent of design, and referring to the critical appraisal checklists,26 there were four studies of higher89,90,96,97 and three of lower87,95,98 methodological quality.

Studies considered contentment, experiences with, or implementation of the intervention more often than psychosocial outcomes (see Fig. 3). Children mentioned fear of parental death and an inability to talk to their parents about their concerns.87 Adolescents especially experienced communication with healthy fathers as problematic.98 When families participated in a program supporting parenting, children perceived improved parental competence and communication.98

Altogether, participating families indicated that they were satisfied with counseling.90,95,97,98 In one study,95 therapists were more critical than family members, whereas in another study91 there were no differences between therapists' and family members' ratings. In a further study, medical staff gave a more cautious evaluation.89

In one study, mothers reported higher levels of depressiveness90 at baseline. In the pre-post counseling comparison, parent- and child-reported depressiveness decreased.90 Another study96 highlighted that relationships with children were worse in dysfunctional families with parents with higher depressiveness scores. Female and older adolescents of HIV/AIDS patients reported more emotional distress.97 Parental emotional distress predicted emotional distress in adolescents, and, if the mother was ill, adolescents reported more emotional distress and risky sexual behavior.97 Parental physical health predicted adolescent problem behavior and parental death was associated with more emotional distress and adolescent problem behavior.97

According to a one-group pre-post measurement, parent-reported family functioning improved after counseling.90 In family-focused grief therapy (FFGT), families had different benefits from therapy.96,101 Precategorized “sullen” and “intermediate” families tended to benefit more from FFGT, whereas members of “hostile” families benefited more from individual psychotherapy. Furthermore, the most distressed family members improved significantly. Correspondingly, Christ and colleagues102 proposed a categorization of high-risk, vulnerable, and resilient families based on their clinical experience.

In counseling for parents with AIDS/HIV and their adolescent children,103,97 although both groups profited in various domains, positive effects seemed to last for the first two years, primarily for the program's duration. At six years104 there were still positive effects in the intervention group, although only evident in secondary outcomes.

Discussion

Few interventions with various backgrounds

There is a small number of structured, published, and evaluated interventions for families of palliative patients with minor children. Their theoretical and empirical background varies, as well as the comprehensibility of their design. Furthermore, in the field of interventions for children of cancer patients, programs are seldom developed according to evidence-based or theory-driven frameworks.16 Our review reveals that successful interventions begin in palliative care and last throughout bereavement.84,86,91 Publishing manual-based interventions is a means of quality management, as authors describe important aspects of their interventions more thoroughly. Number of treatment sessions varied in accordance with different populations and conceptualizations. One research group offered booster sessions, but did not control for participation.97 Therefore, our findings support the conclusion of other authors who stress the necessity of an investigation of effective “doses” of support in family caregiver palliative care research,8 also with due regard to minor children.

In accordance with empirical results regarding risk factors,7,15,16 participating parents were more often single,89 emotionally more distressed,90 and children mentioned fear of parental death.87 Therefore, it is promising to support the most distressed subgroups and to respect resilience in well-functioning families.89,105 It needs to be defined whether psychosocial burden means symptomatology, limited functioning, decreased health-related quality of life, or family functioning.89 Kissane and colleagues (2007)100 propose routine screening of family functioning to facilitate recognition of high-risk families. The authors prefer individual therapy for members of hostile families in the light of potential negative effects within the scope of a preventive model.

Defining the appropriate time point for screening is very important, because parental palliative disease is not a single event but a phase of familial transition.10 Self-assessed need hints at individual shock and psychosocial burden, and should coincide with offering support.89 Periodic assessment and clinical experience are important further ways of determining distress.89 Consistent with the fact that “there is no one-size service that fits all”106(p. v), research should unravel effective aspects of treatment.29

Diverse evidence base

As there is only a handful of methodologically sound studies,89,90,96,97 the evidence base of child-centred interventions in families with parental palliative disease is rather low. This also applies to studies on children of cancer patients in general, where intervention studies are mostly poorly constructed.28,94 Methodological shortcomings include widely used cross-sectional designs, lack of control groups, heterogeneous questionnaires that cannot be easily compared, inconsistent treatment exposure, and overall, rather low participation rates.

In one study, patients refused participation because of organizational and disease-related burdens,89 which is perhaps a core feature of the population studied and may require flexibility on the part of therapists and researchers. Sampling bias arises from convenience sampling87,89,90,95 and clinical personnel that potentially screened out more dysfunctional families.86 Furthermore, certain subgroups participated less, such as avoidant families,86 or fathers and Spanish-speaking mothers in another study.97 Depending on parental disease, samples were of higher86,89 or lower97 socioeconomic status.

Researchers relied on self-report data and often used additional self-established measures. A great deal of effort was invested in large-scale studies, but most comparisons were nonsignificant, perhaps due to poor sensitivity of the applied measures. Given the deteriorating physical condition of the palliative patient, the focus on improvement of most instruments should perhaps be reconsidered, since psychosocial stabilization is an important treatment goal in itself in these families. Likewise, resilience is still rarely taken into account in studies on families of palliative patients with minor children.

Most participants were satisfied with the interventions.90,9598 Although social desirability is quite likely, contentment with a program is an important prerequisite for building a therapeutic working alliance. The evaluation studies included in this review indicate that the identified interventions for families of palliative patients and their minor children tend to improve communication, depressiveness, and family functioning.90,9698 Nevertheless, due to theoretical and methodological weaknesses, these findings should be considered in the context of the respective evidence base.

Conclusions

Parental palliative disease can be a particularly critical situation for dependent children, and long-lasting illness is associated especially with internalizing child symptoms.7,16 Although there is a variety of family, child and parent-centered concepts, only five structured and published interventions met our inclusion criteria. As presented, successful interventions already begin in palliative care and last throughout bereavement, transferring interventions into manual-based forms adds to quality management, and supporting the most distressed subgroups presents an adequate approach.

As with research on interventions for cancer families with minor children,3,4,15,28 there is a lack of well-designed and elaborated intervention concepts and evaluation studies in palliative care. Future empirical studies are facing the tasks of screening for high-risk families and individuals according to self-assessed need and clinical assessment; of study recruitment against the background of physical deterioration of the patient; of defining appropriate outcome criteria (e.g., stability, resilience); and of selection and development of sensitive outcome measures. Stringent development of specific interventions for families of palliative patients with minor children is necessary and needs to be theoretically clear, empirically substantiated, clinically sensible, and supported by methodologically sound intervention studies. This can help to explain and establish what and why psychosocial professionals do what they do.

Acknowledgments

We would like to thank Doreen Kopper for her assistance with literature search and acquisition, and Monica Blotevogel for English copyediting. The study is part of the German multisite research project “Psychosocial Services for Children of Parents with Cancer” supported by German Cancer Aid (Deutsche Krebshilfe, grant #108303). In this multisite project the following institutions and principal investigators are collaborating:

  • Dept. of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Centre Hamburg-Eppendorf (Prof. Georg Romer);
  • Inst. of Medical Psychology, University Medical Centre Hamburg-Eppendorf (Prof. Uwe-Koch-Gromus);
  • Dept. of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, Charité University Medical Centre, Berlin (Prof. Ulrike Lehmkuhl);
  • Dept. of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Centre, Leipzig (Prof. Kai v. Klitzing);
  • Inst. of Medical Psychology, University Medical Centre, Leipzig (Prof. Elmar Brähler);
  • Dept. of Psychosomatic and General Clinical Medicine; University Medical Centre, Heidelberg (Prof. Wolfgang Herzog);
  • Dept. of Child and Adolescent Psychiatry, University Medical Centre, Heidelberg (Prof. Franz Resch);
  • Dept. of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, Otto-von-Guericke University, Magdeburg (Prof. Hans-Henning Flechtner).

Author Disclosure Statement

No competing financial interests exist.

References

1. Rolland JS. Parental illness and disability: A family systems framework. J Fam Ther. 1999;21:242–266.
2. Pitceathly C. Maguire P. The psychological impact of cancer on patients' partners and other key relatives: A review. Eur J Cancer. 2003;39:1517–1524. [PubMed]
3. Diareme S. Tsiantis J. Romer G. Tsalamanios E. Anasontzi S. Paliokosta E. Kolaitis G. Mental health support for children of parents with somatic illness: A review of the theory and intervention concepts. Fam Syst Health. 2007;25(1):98–118.
4. Worsham NL. Compas B. Ey S. Children's coping with parental illness. In: Wolchik SA, editor; Sandler IN, editor. Handbook of Children's Coping: Linking Theory and Intervention, Issues in Clinical Child Psychology. New York: Plenum Press; 1997. pp. 195–213.
5. Barkmann C. Romer G. Watson M. Schulte-Markwort M. Parental physical illness as a risk factor for maladjustment in children and adolescents: Epidemiological findings from a national survey in Germany. Psychosomatics. 2007;48(6):476–481. [PubMed]
6. Pearlman MY. Schwalbe KD. Cloitre M. Managing behavior problems in grieving children. Grief in childhood. In: Pearlman MY, editor; Schwalbe KD, editor; Cloitre M, editor. Fundamentals of Treatment in Clinical Practice. Washington DC: American Psychological Association; 2010. pp. 123–145.
7. Sieh DS. Mejer AM. Oort FJ. Visser-Meily JMA. Van der Leij DAV. Problem-behavior in children of chronically ill parents: A meta-analysis. Clin Child Fam Psychol Rev. 2010;13:384–397. [PMC free article] [PubMed]
8. Hudson P. Payne S. Family caregivers and palliative care: Current status and agenda for the future. J Palliat Med. 2011;14(7):1–6. [PubMed]
9. Bugge KE. Helseth S. Darbishire P. Parents experiences of a family support program when a parent has incurable cancer. J Clin Nurs. 2009;18(24):3480–3488. [PubMed]
10. Siegel K. Raveis VH. Bettes B. Mesagno FP. Christ G. Weinstein L. Perceptions of parental competence while facing the death of a spouse. Am J Orthopsychiatry. 1990;60(4):567–576. [PubMed]
11. Altschuler J. Dale B. On being an ill parent. Clin Child Psychol Psychiatry. 1999;4(1):23–37.
12. Saldinger A. Porterfield K. Cain AC. Meeting the needs of parentally bereaved children: A framework of child-centered parenting. Psychiatry. 2004;67(4):331–352. [PubMed]
13. Christ GH. Siegel K. Christ AE. Adolescent grief: It never really hit me..until it actually happened. JAMA. 2002;288(10):1269–1279. [PubMed]
14. Huizinga GA. Visser A. Van der Graf WTA. Hoekstra HJ. Stewart RE. Hoekstra-Weebers JEHM. Family-oriented multilevel study on the psychological functioning of adolescent children having a mother with cancer. Psychooncology. 2011;20:730–737. [PubMed]
15. Visser A. Huizinga GA. van der Graaf WTA. Hoekstra HJ. Hoekstra-Weebers JEHM. The impact of parental cancer on children and the family: A review of the literature. Cancer Treat Rev. 2004;30:683–694. [PubMed]
16. Osborn T. The psychosocial impact of parental cancer on children and adolescents: A systematic review. Psychooncology. 2007;16:101–126. [PubMed]
17. Visser A. Huizinga GA. Hoekstra HJ. Van der Graf WTA. Hoekstra-Weebers JEHM. Parental cancer: Characteristics of parents as predictors for child functioning. Cancer. 2006;106:1178–1187. [PubMed]
18. Saldinger A. Cain A. Kalter N. Lohnes K. Anticipating parental death in families with young children. Am J Orthopsychiatry. 1999;69(1):39–48. [PubMed]
19. Christ GH. Siegel K. Freund B. Langosch D. Hendersen S. Sperber D. Weinstein L. Impact of parental terminal cancer on latency-age children. Am J Orthopsychiatry. 1993;63(3):417–425. [PubMed]
20. Saldinger A. Cain A. Porterfield K. Managing traumatic stress in children anticipating parental death. Psychiatry. 2003;66(2):168–181. [PubMed]
21. Romer G. Kühne F. Bergelt C. Möller B. Seelische Gesundheitsvorsorge für Kinder krebskranker Eltern. Manualisiertes Interventionskonzept kindzentrierter medizinischer Familienberatung [Mental healthcare for children of parents with cancer. Manualized interventional concept of child-oriented medical family counselling] Psychotherapeut. 2011;56(5):400–408.
22. Higgins JPT, editor; Green S, editor. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006] The Cochrane Library. Vol. 4. Chichester, UK: John Wiley; 2006. p. 6.
23. Kunz R. Khan KS. Klejnen J. Antes G. Systematische Übersichtsarbeiten und Meta-Analysen. Bern, CH: Huber; 2009.
24. Bausewein C. Simon S. Serie: Methodik in der palliativmedizinischen Forschung - Systematische Übersichtsarbeiten. Palliativmedizin. 2010;11(5):202–205.
25. Sanderson S. Tatt ID. Higgins JPT. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: A systematic review and annotated bibliography. Int J Epidemiol. 2007;36(3):666–676. [PubMed]
27. Grouven U. Bender R. Ziegler A. Lange S. Der Kappa-Koeffizient [The kappa coefficient] Dtsch Med Wochenschr. 2007;132:e65–e68. [PubMed]
28. Niemelä M. Hakko H. Räsänen S. A systematic narrative review of the studies on structured child-centred interventions for families with a parent with cancer. Psychooncology. 2010;19:451–461. [PubMed]
29. Hodges LJ. Walker J. Kleiboer AM. Ramirez AJ. Richardson A. Velikova G. Sharpe M. What is a psychological intervention? A metareview and practical proposal. Psychooncology. 2011;20:470–478. [PubMed]
30. Adams-Greenly M. Moynihan RT. Helping the children of fatally ill parents. Am J Orthopsychiatry. 1983;53(2):219–229.
31. Adams-Greenly M. Beldoch A. Moynihan R. Helping adolescents whose parents have cancer. Semin Oncol Nurs. 1986;2(2):133–138. [PubMed]
32. Black A. Wood D. Family therapy and life threatening illness in children or parents. Palliat Med. 1989;3(2):113–118.
33. Black D. Family intervention with families bereaved or about to be bereaved. In: Papadatou D, editor; Papadatos C, editor. Children and Death. Washington, DC: Hemisphere Publishing Corp.; 1991. pp. 135–143.
34. Blackford KA. Strategies for intervention and research with children or adolescents who have a parent with multiple sclerosis. Axone. 1992;14(2):50–54. [PubMed]
35. Chowns G. ‘No, you don't know how we feel’: Groupwork with children facing parental loss. Groupwork An Interdisciplinary Journal for Working with Groups. 2008;18(1):14–37.
36. Christ GH. Christ AE. Current approaches to helping children cope with a parent's terminal illness. CA Cancer J Clin. 2006;56(4):197–212. [PubMed]
37. Dunning S. As a young child's parent dies: Conceptualizing and constructing preventive interventions. Clin Soc Work J. 2006;34(4):499–514.
38. Kennedy C. McIntyre R. Worth A. Hogg R. Supporting children and families facing the death of a parent: Part 1. Int J Palliat Nurs. 2008;14(4):162–168. [PubMed]
39. Kennedy C. McIntyre R. Worth A. Hogg R. Supporting children and families facing the death of a parent: Part 2. Int J Palliat Nurs. 2008;14(5):230–237. [PubMed]
40. Lewandowski J. A parent has cancer: Needs and responses of children. Pediatr Nurs. 1996;22(6):518–521. [PubMed]
41. Lewis FM. Strengthening family supports. Cancer and the family. Cancer. 1990;1(65):752–759. [PubMed]
42. Lydon A. Hennings J. Ryan Woolley: Evaluation of a British child bereavement service: The user's perspective. Palliat Support Care. 2010;8:297–303. [PubMed]
43. Lewis PG. Lippman JG. Helping Children Cope with the Death of a Parent: A Guide for the First Year. Westport, CT: Praeger Publishers/Greenwood Publishing Group; 2004.
44. Rauch PK. Muriel AC. Cassem NH. Parents with cancer: Who's looking after the children? J Clin Oncol. 2002;20(21):4399–4402. [PubMed]
45. Segal J. In: Helping Children with Ill or Disabled Parents: A Guide for Parents and Professionals. Simkins J, editor. London: Kingsley; 1996.
46. Saldinger A. Cain AC. Porterfield K. Lohnes K. Facilitating attachment between school-aged children and a dying parent. Death Stud. 2004;28(10):915–940. [PubMed]
47. Veach TA, editor; Nicholas DR, editor; Barton MA, editor. Cancer and the family life cycle: A practitioner's guide. New York: Brunner-Routledge; 2002.
48. Cable D. Book review: Remembering My Special Person: An Activity Book for Children Experiencing the Death of a Loved One. Am J Hosp Palliat Care. 1998;15(1):61.
49. Carroll ML. Griffin R. Reframing life's puzzle: Support for bereaved children. Am J Hosp Palliat Care. 1997;14(5):231–235. [PubMed]
50. Corr CA. Support for grieving children: The Dougy Center and the hospice philosophy. The staff of the Dougy Center. Am J Hosp Palliat Care. 1991;8(4):23–27. [PubMed]
51. Costa L. Holliday D. Helping children cope with the death of a parent. Sch Couns. 1994;28(3):206–213.
52. Gersten JC. Beals J. Kallgren CA. Epidemiology and preventive interventions: Parental death in childhood as a case example. Am J Community Psychol. 1991;19(4):481–500. [PubMed]
53. Goldman L, editor. Life and Loss: A Guide to Help Grieving Children. Bristol, UK: Routledge; 2000.
54. Grollmann EA, editor. Bereaved Children and Teens. A Support Guide for Parents and Professionals. Boston: Beacon Press; 1995.
55. Heiney SP. Lesesne CA. Quest. An intervention program for children whose parent or grandparent has cancer. Cancer Pract. 1996;4(6):324–329. [PubMed]
56. Hilliard RE. The effects of music therapy-based bereavement groups on mood and behavior of grieving children: A pilot study. J Music Ther. 2001;38(4):291–306. [PubMed]
57. Hoke LA. A short-term psychoeducational intervention for families with parental cancer. Harv Rev Psychiatry. 1997;5(2):99–103. [PubMed]
58. Holland J. How schools can support children who experience loss and death. Br J Guid Counc. 2008;36(4):411–424.
59. Lohnes KL. Kalter N. Preventive intervention groups for parentally bereaved children. Am J Orthopsychiatry. 1994;64(4):594–603. [PubMed]
60. Lutzke JR. Ayers TS. Sandler IN. Barr A. Risks and interventions for the parentally bereaved child. In: Wolchik SA, editor; Sandler IN, editor. Handbook of Children's Coping: Linking Theory and Intervention, Issues in Clinical Child Psychology. New York: Plenum Press; 1997. pp. 215–243.
61. Mark BS. The death of a parent: The spirit of healing through individual and group therapy. In: Lanham MD, editor; Jason A, editor. The Handbook of Infant and Adolescent Psychotherapy: New Directions in Integrative Treatment. Vol. 2. Northvale, NJ: Aronson; 1997. pp. 319–331.
62. McGlauflin H. What one small hospice learned from its grieving children's program. Am J Hosp Palliat Care. 1994;11(2):36–39. [PubMed]
63. Moyer JA. Bannock bereavement retreat. A camping experience for surviving children. Am J Hosp Care. 1988;5(2):26–30. [PubMed]
64. Pearlman MY. Schwalbe KDA. Cloitre M. Grief in Childhood: Fundamentals of Treatment in Clinical Practice. Washington, DC: American Psychological Association; 2010.
65. Pfeffer CR. Jiang H. Kakuma T. Hwang J. Metsch M. Group intervention for children bereaved by the suicide of a relative. J Am Acad Child Adolesc Psychiatry. 2002;41(5):505–513. [PubMed]
66. Sandler IN. Ayers TS. Romer AL. Fostering resilience in families in which a parent has died. J Palliat Med. 2002;5(6):945–956. [PubMed]
67. Sandler IN. Ayers TS. Wolchik SA, et al. The family bereavement program: Efficacy evaluation of a theory-based prevention program for parentally bereaved children and adolescents. J Consult Clin Psychol. 2003;71(3):587–600. [PubMed]
68. Sontag MA. Nadig J. Henry L. The Children's Grief Workshop: Social work practice in hospice. Am J Hosp Palliat Care. 1994;11(3):23–29. [PubMed]
69. Traeger J. Supporting your grieving child. J Palliat Med. 2011;14(1):116–117. [PubMed]
70. Tonkins SAM. Lambert MJ. A treatment outcome study of bereavement groups for children. Child Adolesc Social Work J. 1996;13(1):3–21.
71. Walsh-Burke K. Family communication and coping with cancer: Impact of the We Can Weekend. J Psychosoc Oncol. 1992;10(1):63–81.
72. Davis Kirsch SE. Brandt PA. Lewis FM. Making the most of the moment: When a child's mother has breast cancer. Cancer Nurs. 2003;26(1):47–54. [PubMed]
73. Lewis FM. Casey SM. Brandt PA. Shands ME. Zahlis EH. The enhancing connections program: Pilot study of a cognitive-behavioral intervention for mothers and children affected by breast cancer. Psychooncology. 2006;15(6):486–497. [PubMed]
74. Northouse LL. Walker J. Schafenacker A. A family-based program of care for women with recurrent breast cancer and their family members. Oncol Nurs Forum. 2002;29(10):1411–1419. [PubMed]
75. Duggleby W. Wright K. Williams A. Degner L. Cammer A. Holtslander L. Developing a Living with Hope Program for caregivers of family members with advanced cancer. J Palliat Care. 2007;23(1):24–31. [PubMed]
76. Johnson JL. Norby PA. We Can Weekend: A program for cancer families. Cancer Nurs. 1981;4(1):23–28. [PubMed]
77. McIntyre R, editor. Nursing Support for Families of Dying Patients. London, UK: Whurr Publishing; 2002.
78. Rosenbaum E. Garlan RW. Hirschberger N. Siegel AL. Butler LD. Spiegel D. The Life Tape Project: Increasing family social support and symbolic immortality with a brief existential intervention for cancer patients and their families. Omega (Westport) 2006;53(4):321–339.
79. Bedway AJ. Smith LH. “For kids only”: Development of a program for children from families with a cancer patient. J Psychosoc Oncol. 1996;14(4):19–28.
80. Call DA. School-based groups: A valuable support for children of cancer patients. J Psychosoc Oncol. 1990;8(1):97–118.
81. Greening K. The “Bear Essentials” program: Helping young children and their families cope when a parent has cancer. J Psychosoc Oncol. 1992;10(1):47–61.
82. Gunther M. Crandles S. Williams G. Swain M. A place called HOPE: Group psychotherapy for adolescents of parents with HIV/AIDS. Child Welf. 1998;77(2):251–271. [PubMed]
83. Taylor-Brown J. Acheson A. Farber JM. Kids Can Cope: A group intervention for children whose parents have cancer. J Psychosoc Oncol. 1993;11(1):41–53.
84. Christ GH. Siegel K. Parental death: A preventive intervention. Recent Results Cancer Res. 1991;121:426–431. [PubMed]
86. Kissane DW. Bloch S. Buckingham, UK: Open University Press; 2002.
87. Bugge KE. Helseth S. Darbyshire P. Children's experiences of participation in a family support program when their parent has incurable cancer. Cancer Nurs. 2008;31(6):426–434. [PubMed]
88. Romer G. Haagen M. Kinder körperlich kranker Eltern. Göttingen: Hogrefe; 2007.
89. Schmitt F. Manninen H. Santalahti P. Savonlahti E. Pyrhonen S. Romer G. Piha J. Children of parents with cancer: A collaborative project between a child psychiatry clinic and an adult oncology clinic. Clin Child Psychol Psychiatry. 2007;12(3):421–436. [PubMed]
90. Thastum M. Munch-Hansen A. Wiell A. Romer G. Evaluation of a focused short-term preventive counseling project for families with a parent with cancer. Clin Child Psychol Psychiatry. 2006;11(4):529–542. [PubMed]
91. Rotheram-Borus MJ. Murphy DA. Miller S. Draimine BH. An intervention for adolescents whose parents are living with AIDS. Clin Child Psychol Psychiatry. 1997;2(2):201–219.
92. Romer G. Saha R. Haagen M. Pott M. Baldus C. Bergelt C. Lessons learned in the implementation of an innovative consultation and liaison service for children of cancer patients in various hospital settings. Psychooncology. 2007;16:138–148. [PubMed]
93. Wong M. Looney E. Michaels J. Palesh O. Koopman C. A preliminary study of peritraumatic dissociation, social support, and coping in relation to posttraumatic stress symptoms for a parent's cancer. Psychooncology. 2006;15:1093–1098. [PubMed]
94. Su Y. Ryan-Wenger NA. Children's adjustment to parental cancer. A theoretical model development. Cancer Nurs. 2007;30(5):362–381. [PubMed]
95. Paschen RS. Evaluation eines präventiven Beratungskonzeptes für Kinder körperlich kranker Eltern. Psychotherapeut. 2007;52:265–272.
96. Kissane DW. McKenzie M. Bloch S. Moskowitz C. McKenzie DP. O'Neil I. Family focused grief therapy: A randomized, controlled trial in palliative care and bereavement. Am J Psychiatry. 2006;163(7):1208–1218. [PubMed]
97. Rotheram-Borus MJ. Stein JA. Lin YY. Impact of parent death and an intervention on the adjustment of adolescents whose parents have HIV/AIDS. J Consult Clin Psychol. 2001b;69(5):763–773. [PubMed]
98. Christ GH. Raveis VH, et al. Evaluation of a preventive intervention for bereaved children. J Soc Work End Life Palliat Care. 2005;1(3):57–81. [PubMed]
99. Chan EK. O'Neill I. McKenzie M. Love A. Kissane DW. What works for therapists conducting family meetings: Treatment integrity in family-focused grief therapy during palliative care and bereavement. J Pain Symptom Manage. 2004;27(6):502–22. [PubMed]
100. Kissane DW. Lichtenthal WG. Zaider T. Family care before and after bereavement. Omega (Westport) 2007;56(1):21–32. [PubMed]
101. Kissane DW. McKenzie M. McKenzie DP. Forbes A. O'Neil I. Bloch S. Psychosocial morbidity associated with patterns of family functioning in palliative care: Baseline data from the Family Focused Grief Therapy controlled trial. Palliat Med. 2003;17(6):527–537. [PubMed]
102. Christ GH. Siegel KF. Mesagno FP. Langosh D. A preventive intervention program for bereaved children: Problems of implementation. Am J Orthopsychiatry. 1991;61(2):168–178. [PubMed]
103. Rotheram-Borus MJ. Lee M. Leonard N. Lin Y-Y. Franzke L. Turner E. Lightfoot M. Gwadz M. Four-year intervention outcomes of an intervention for parents living with HIV and their adolescent children. AIDS. 2003;17(8):1217–1225. [PubMed]
104. Rotheram-Borus MJ. Let M. Lin YY. Lester P. Six-year intervention outcomes for adolescent children of parents with the human immunodeficiency virus. Arch Pediatr Adolesc Med. 2004;158(8):742–748. [PubMed]
105. Harding R. Higginson IJ. What is the best way to help caregivers in cancer and palliative care? A systematic literature review of interventions and their effectiveness. Palliat Med. 2003;17( 1):63–74. [PubMed]
106. Monroe B. In: Brief Interventions with Bereaved Children. Kraus F, editor. Oxford University Press; New York: 2010.
107. Visser A. Huizinga GA. Hoekstra HJ. Van der Graf WTA. Gazendam-Donofrio SM. Hoekstra-Weebers JEHM. Emotional and behavioral problems in children of parents recently diagnosed with cancer: A longitudinal study. Acta Oncol. 2007;46:67–76. [PubMed]
108. Rotheram-Borus MJ. Lee MB. Gwadz M. Draimin B. An intervention for parents with AIDS and their adolescent children. Am J Public Health. 2001a;91(8):1294–1302. [PubMed]
109. Kissane DW. Lichtenthal WG. Family focused grief therapy: From palliative care into bereavement. In: Stroebe MS, editor. Handbook of Bereavement Research and Practice: Advances in Theory and Intervention. Washington DC: American Psychological Association; 2008. pp. 485–510.
110. Kissane DW. A model of family-centered intervention during palliative care and bereavement: Family Focused Grief Therapy (FFGT) In: Baider L, editor; Cooper CL, editor; Kaplan De-Nour A, editor. Cancer and the Family. 2nd. Chichester, UK: Wiley; 2000. pp. 175–197.
111. Kissane DW. Bloch McKenzie M. McDowall AC. Nitzan R. Family grief therapy: A preliminary account of a new model to promote healthy family functioning during palliative care and bereavement. Psychooncology. 1998;7(1):14–25. [PubMed]

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