Get Help Now!  (312) 655-7700
 

Newsletters & Articles


LOSS Program Office
721 N. LaSalle Street
Chicago, IL 60654

Main Line: (312) 655-7283
Fax Line: (312) 948-3340

Featured this Month:

Grief and Family Development: When Children Refuse Counseling
Wednesday, August 07, 2013 by Deborah R. Major, Ph.D., L.C.S.W

Lately, we have heard parents express concerns over what they should do if children refuse counseling following a family member’s suicide. We understand that concern, given the research that examines the characteristics of child survivors of suicide.* We recently heard about an adult survivor who lost a parent as a child and who told her mother at the time that she did not want to attend counseling. Today this same survivor is asking her mother why she was not made to attend counseling anyway, recognizing in retrospect how much she needed it. This story speaks to the gradual accretion of developmental competence and maturity around decision-making, competence that young children do not have, which adds to the complexity of helping them make good choices. These situations are complex, and while we want to promote the responsible exercise of self-determination, there is no recipe that will insure that promoting children’s self-determination will also promote what is in their best interests.

As you consider how to respond to your children’s objections, you will want to ask yourself if they are sufficiently mature to make such decisions. In the United States children under the age of twelve have not been allowed to make decisions involving medical treatment because they are presumed to lack the maturity, judgment and developmental competence to do so. With few exceptions, we look to parents to make informed decisions and to consent to treatment on their behalf, because of the duty to protect them and our responsibility to make decisions in their best interests. As children mature, we gradually allow them to have more input into how they spend their time. If children are developmentally on track, we start to encourage their participation in the consent process at age 12; not by surrendering the decision making power to them, but by asking for their assent, which gives them the opportunity to express their wishes about the treatment, but parents retain the responsibility for making the decision.

As children enter adolescence, we begin to think more seriously about their rights to make autonomous decisions, or at least to be relatively free from coercion in treatment decisions. The problem is that the acquisition of maturity and developmental competence in children is quite variable, with some children taking much longer than others to acquire the skills necessary to participate in an informed consent process. Maturity isn’t something that children magically acquire at age 12, at age 14 or even at age 18, although these are all ages that have been identified by the courts as having legal significance. In Illinois there is something called the mature minor doctrine, in which minors are considered to be mature and able to consent to or refuse treatment under certain circumstances. However, not all states adhere to the doctrine, and even those that do, do not give complete decision making power to the minor without parental oversight. The courts struggle, just as parents do, with how to balance the duty to protect developmentally immature minors while respecting their quest for privacy, autonomy and self-determination. You will want to ask yourself what evidence you have that your children have been making decisions that are in their best interests and that demonstrate good self-caretaking.

Part of our role as caregivers involves helping children to develop good self-caretaking and the ability to be reflective. Like other complex skills, children need to practice these in order to strengthen them. To help them practice, you begin by allowing them to make minor decisions that do not have significant consequences. You observe the outcomes; discuss the process, providing encouragement and age-appropriate information. But it is also crucial to consider the seriousness of the situation that raised the need for counseling in the first place, and the impact of that event on their self-concepts, relationships and on their meaning systems. If you are aware that a traumatic event has placed your children in serious distress, that may not be the best time to ask if they think they need counseling for that distress. Consider the frame of mind that would give rise to their response. If you believe strongly that the response is well-grounded and you know that your child has a history of making solid self-caretaking decisions, then you might place more trust in the response. On the other hand, if your child has a history of making questionable decisions, you will want to think very carefully about how you ask for input and the trustworthiness of the input your receive.

Consider the ways in which serious trauma compromises everyone’s decision-making abilities, regardless of age or maturity level. You do want children to know that their views are important and that you take them seriously, but you may not want to let them make the final decision. Ideally you want the decision making process to be shared until you are certain that children have less need of your authority. The older the child is, the more complex this shared process becomes. Older teens are often viewed as having sufficient intelligence and understanding to make these decisions. Developmentally they are exploring evolving issues of identity as individuals with significant independence from parents. Even if you are convinced that your 16-year-old needs counseling, if your older teen feels strongly that it would be a waste of time, he will be more aware of your motive to make him comply, and less aware of what he may really need. In such instances, we cannot coerce compliance, nor would we want to do so, unless the situation poses such a high degree of urgency or risk that it warrants involuntary intervention. In the absence of high risk, you may be better off just trying to keep your older teen engaged in an open relationship with you. If you can foster that engagement, cooperation may improve over time, making it more likely that he will be open to the idea of using counseling in the future. You can also model the self-caretaking behavior that you believe is optimal, for example, by seeking counseling support for yourself. As you get the support you need, you may find that you can also be more emotionally available to your children. Their awareness of your availability may prompt them to seek you out for support, and as they do so you will have increased leverage to help them make decisions that are more in line with their self-interest.


References


Cerel, J., Fristad, M., Weller, E., & Weller, R. (1999). Suicide-bereaved children and adolescents: II. Parental and family functioning. Journal of the Academy of Child & Adolescent Psychiatry, 39(4), 437-444.

Cerel, J., & Roberts, T.A. (2005). Suicidal behavior in the family and adolescent risk behavior. Journal of Adolescent Health, 36, 352.e8-352.e14.

Dyregrov, K., & Dyregrov, A. (2005). Siblings after suicide—“The Forgotten bereaved.” Suicide and Life-threatening Behavior, 35(6), 714-724.

Pfeffer, C., Martins, P., Mann, J., Sunkenberg, M., Ice, A., & Damore, J., et al. (1997). Child survivors of suicide: Psychosocial characteristics. Journal of the Academy of Child & Adolescent Psychiatry, 36(1), 65-74.



Reprinted from Obelisk January 2011 edition


Archives:

Grief and Family Development: When Children Refuse Counseling
Wednesday, August 07, 2013 by Deborah R. Major, Ph.D., L.C.S.W

Lately, we have heard parents express concerns over what they should do if children refuse counseling following a family member’s suicide. We understand that concern, given the research that examines the characteristics of child survivors of suicide.* We recently heard about an adult survivor who lost a parent as a child and who told her mother at the time that she did not want to attend counseling. Today this same survivor is asking her mother why she was not made to attend counseling anyway, recognizing in retrospect how much she needed it. This story speaks to the gradual accretion of developmental competence and maturity around decision-making, competence that young children do not have, which adds to the complexity of helping them make good choices. These situations are complex, and while we want to promote the responsible exercise of self-determination, there is no recipe that will insure that promoting children’s self-determination will also promote what is in their best interests.

As you consider how to respond to your children’s objections, you will want to ask yourself if they are sufficiently mature to make such decisions. In the United States children under the age of twelve have not been allowed to make decisions involving medical treatment because they are presumed to lack the maturity, judgment and developmental competence to do so. With few exceptions, we look to parents to make informed decisions and to consent to treatment on their behalf, because of the duty to protect them and our responsibility to make decisions in their best interests. As children mature, we gradually allow them to have more input into how they spend their time. If children are developmentally on track, we start to encourage their participation in the consent process at age 12; not by surrendering the decision making power to them, but by asking for their assent, which gives them the opportunity to express their wishes about the treatment, but parents retain the responsibility for making the decision.

As children enter adolescence, we begin to think more seriously about their rights to make autonomous decisions, or at least to be relatively free from coercion in treatment decisions. The problem is that the acquisition of maturity and developmental competence in children is quite variable, with some children taking much longer than others to acquire the skills necessary to participate in an informed consent process. Maturity isn’t something that children magically acquire at age 12, at age 14 or even at age 18, although these are all ages that have been identified by the courts as having legal significance. In Illinois there is something called the mature minor doctrine, in which minors are considered to be mature and able to consent to or refuse treatment under certain circumstances. However, not all states adhere to the doctrine, and even those that do, do not give complete decision making power to the minor without parental oversight. The courts struggle, just as parents do, with how to balance the duty to protect developmentally immature minors while respecting their quest for privacy, autonomy and self-determination. You will want to ask yourself what evidence you have that your children have been making decisions that are in their best interests and that demonstrate good self-caretaking.

Part of our role as caregivers involves helping children to develop good self-caretaking and the ability to be reflective. Like other complex skills, children need to practice these in order to strengthen them. To help them practice, you begin by allowing them to make minor decisions that do not have significant consequences. You observe the outcomes; discuss the process, providing encouragement and age-appropriate information. But it is also crucial to consider the seriousness of the situation that raised the need for counseling in the first place, and the impact of that event on their self-concepts, relationships and on their meaning systems. If you are aware that a traumatic event has placed your children in serious distress, that may not be the best time to ask if they think they need counseling for that distress. Consider the frame of mind that would give rise to their response. If you believe strongly that the response is well-grounded and you know that your child has a history of making solid self-caretaking decisions, then you might place more trust in the response. On the other hand, if your child has a history of making questionable decisions, you will want to think very carefully about how you ask for input and the trustworthiness of the input your receive.

Consider the ways in which serious trauma compromises everyone’s decision-making abilities, regardless of age or maturity level. You do want children to know that their views are important and that you take them seriously, but you may not want to let them make the final decision. Ideally you want the decision making process to be shared until you are certain that children have less need of your authority. The older the child is, the more complex this shared process becomes. Older teens are often viewed as having sufficient intelligence and understanding to make these decisions. Developmentally they are exploring evolving issues of identity as individuals with significant independence from parents. Even if you are convinced that your 16-year-old needs counseling, if your older teen feels strongly that it would be a waste of time, he will be more aware of your motive to make him comply, and less aware of what he may really need. In such instances, we cannot coerce compliance, nor would we want to do so, unless the situation poses such a high degree of urgency or risk that it warrants involuntary intervention. In the absence of high risk, you may be better off just trying to keep your older teen engaged in an open relationship with you. If you can foster that engagement, cooperation may improve over time, making it more likely that he will be open to the idea of using counseling in the future. You can also model the self-caretaking behavior that you believe is optimal, for example, by seeking counseling support for yourself. As you get the support you need, you may find that you can also be more emotionally available to your children. Their awareness of your availability may prompt them to seek you out for support, and as they do so you will have increased leverage to help them make decisions that are more in line with their self-interest.


References


Cerel, J., Fristad, M., Weller, E., & Weller, R. (1999). Suicide-bereaved children and adolescents: II. Parental and family functioning. Journal of the Academy of Child & Adolescent Psychiatry, 39(4), 437-444.

Cerel, J., & Roberts, T.A. (2005). Suicidal behavior in the family and adolescent risk behavior. Journal of Adolescent Health, 36, 352.e8-352.e14.

Dyregrov, K., & Dyregrov, A. (2005). Siblings after suicide—“The Forgotten bereaved.” Suicide and Life-threatening Behavior, 35(6), 714-724.

Pfeffer, C., Martins, P., Mann, J., Sunkenberg, M., Ice, A., & Damore, J., et al. (1997). Child survivors of suicide: Psychosocial characteristics. Journal of the Academy of Child & Adolescent Psychiatry, 36(1), 65-74.



Reprinted from Obelisk January 2011 edition