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27 Grief and Bereavement in Children Robin Fiorelli
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Introduction Children’s Concepts of Death and Responses to Grief
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Sadness/Depression Anger Guilt and Regrets Fears Physical Complaints Bereavement Support Groups for Grieving Children Support from Schools for Grieving Children Play Therapy for Grieving Children
Infancy (to Age 2) Preschool (Age 2–4) Early Childhood (4–7) Middle Years (Ages 7–10) Preadolescent (Ages 10–12) Adolescent (Ages 13–15) Adolescent (Ages 15–18) ■
Normal Grief Reactions in Children Physical Symptoms Cognitive Symptoms Emotional Shock and Denial Sadness, Despair, and Depression Anger and Acting-Out Behavior Regressive Behaviors Fear, Anxiety, and Panic Guilt, Shame, and Self-Blame Jealousy Acceptance
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Guidelines for Helping Bereaved Children Express Their Grief
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Guidelines for Helping Grieving Teens Grieving Parents Need to Take Care of Themselves Guidelines for Children Attending Funerals and Memorial Services Explaining Burial and Cremation to a Child Ways to Commemorate the Loss with a Grieving Child Holidays and Special Anniversaries Death of a Parent or Significant Adult
Normal Grief Experience for a Teenager Complicated Grief Reactions in Children and Teenagers Preparing a Child for the Death of a Loved One
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Predeath Support How to Talk to a Child When the Death Occurs Typical Questions That Children Have About Death
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Death of a Sibling Conclusion
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INTRODUCTION Both mental health practitioners and parents alike have been misguided about how children and teens experience the loss of someone significant to them and about the most effective ways to assist a grieving child. In a systematic review of the prevailing misperceptions, Charles A. Corr listed most centrally the belief that children do not really grieve because they are too young to understand death. The reality is that children’s grief may look different than that of adults, but it shares fundamental similarities as a physical and emotional reaction to the loss of a significant loved one. The most compelling myth is that it is best to protect a child from death and also from grief. It is natural for adults to want to protect children from painful experiences. However fanciful this wish may be, children will grieve in their own unique ways and it is imperative that caring adults do not dictate or impede that process, instead, allow and even facilitate children’s expression of grief. Another myth is that funerals and memorial services are not age appropriate and children may be traumatized by the acute emotional experience at such an event. As will be discussed, current research suggests that a child should receive information about what the event will be like and then should be allowed to make up his or her own mind about participating, a decision adults should honor. Another common myth is that children are “naturally resilient” and should just “bounce back” after a loss. This is not always the case and depends on contingencies such as concurrent stressful events, the child’s understanding of the death, the child’s developmental age, and the support received by adults in their life. On the other hand, John Bolby in his work on attachment and loss concluded that children are more
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susceptible to profound emotional scarring after experiencing a significant loss. Supposing this potential exists, its realization still depends on the factors already listed, most importantly the attitudes and behaviors of adults important in their lives. Children tend to attribute physical symptoms to emotional experiences more than do adults. Many parents are familiar with the headache that appears when a child is overwhelmed with emotion or with the stomach ache that appears the morning before a school test. There is much debate about whether children really experience emotions more as a physical sensation than do adults or whether they know that adults in their lives are more apt to heed physical rather than emotional symptoms. This chapter begins by outlining children’s concepts of death and grief responses, differentiated by developmental level and chronologic age, through adolescence. The most common physical, emotional, social, and spiritual grief reactions of children and teens will be explored in depth, following which, complicated grief reactions in children and teens will be outlined. The chapter then shifts to a discussion on how to prepare a child for the impending death of a loved one, what to tell them when the death actually occurs, and the questions one might expect children to ask during this difficult time. The chapter then turns to the topic of how to assist bereaved children and teens in expressing and coping with their grief as well as where to find additional sources of support for the grieving child and teen. Suggestions for grieving parents in caring for their own grief needs are also included. How children may attend and participate in funerals and memorial services, including guidance for how to discuss burial and cremation with children, and how to help grieving children participate in memorial activities, including those on anniversaries or birthdays, are shared. Finally, two of the most significant losses for a child will be examined closely, that of a parent and that of a sibling.
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Babies do not have the cognitive capability to understand an abstract concept like death. They function very much in the present, so when someone significant dies, babies become more acutely aware of loss and separation. They also react to the emotions and behaviors of significant adults in their environment and also to any disruptions in their nurturing routine and schedule. If there is a sudden change, they feel tremendous discomfort. Therefore, in response to a loss, babies may search for the deceased and become anxious as a result of the separation. Common reactions include: irritability and protest, constant crying, a change in sleeping and eating habits, decreased activity, and weight loss.
back, for example, she or he may ask the same question again an hour later. These children often have difficulty visualizing death as separate from life, and not as something that can happen to them. Preschool children love to play “peeka-boo” games where adults in their life disappear and then reappear again. It is through these games that they slowly begin to understand the concept of “gone for good.” Because preschoolers tend to be presentoriented, their grief reactions are brief although often very intense. As these children are going through the developmental stage where they are learning to trust and form basic attachments, when a significant adult in their life dies, they become very concerned about separation and altered patterns of care. Children this age typically have a heightened sense of anxiety concerning separations and rejections because they do not have the capacity yet to use fantasy to gain control over what is happening. They also respond to the emotional reactions of adults in their life. If they sense their parents are worried or sad, they may cry or throw tantrums either because they are concerned or as a way to distract their parents from difficult emotions. Typical grief responses of the preschool child include confusion, frightening dreams and night agitation, and regressive behaviors such as clinging, bedwetting, thumb sucking, inconsolable crying, temper tantrums, and even withdrawal from others. They may search intensely for the deceased despite assurance they will not return. They also may exhibit anxiety toward strangers.
PRESCHOOL (AGE 2–4)
EARLY CHILDHOOD (4–7)
CHILDREN’S CONCEPTS OF DEATH AND RESPONSES TO GRIEF Each child is unique in his or her understanding of death and response to grief. This understanding is largely influenced by the child’s developmental level and chronologic age. There can be tremendous overlap, however, between the age groups because children and adolescents move from one developmental level to another at very different rates.
INFANCY (TO AGE 2)
When will my mommy be home? How does (the deceased) eat or breathe?
Preschool children do not comprehend the concept of “forever.” For this age group, death is seen as temporary and reversible. Even when a preschooler is told that mommy is not coming
It’s my fault. I was mad at my mother once and I told her I wish she would die and then she died. The roadrunner in the cartoon always comes back to life, so I know Daddy will too
As with preschoolers, children in the 4 to 7 age group tend to view death as temporary and
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638 reversible. They sometimes feel responsible for the death because they believe that negative thoughts or feelings they have had about the deceased caused their demise. This “magical thinking” stems from the belief that everything in their environment revolves around them and that they can control what happens. Even when children at this age are exposed to death through the media or at school, they still may believe that if you are careful enough you can avoid death. Children at this age may also connect occurrences that do not have anything to do with each other. For example, if a child bought a certain toy the day that her sister died, she may attribute the toy to causing the sister’s death, especially if the real cause of the death is not fully explained to her. Not surprisingly, therefore, children of this age group, much like their younger counterparts, may repeatedly search for the deceased or ask where they are. Repetitive questioning about the death process, such as “What happens when you die?” “How do dead people eat?” is often common. They will often express their grief feelings through play instead of verbally. Themes of family loss and death may surface as they play with dolls or action figures. They may play act the death itself or the funeral. Sometimes, children at this age appear unaffected by the death and act as if nothing happened, but this doesn’t mean that they are oblivious or that they have accepted the death. It may just signify their inability in the moment to acknowledge very painful reality. They also may model their grief reaction after the adults in their lives, feeling uncertain how to express grief feelings. Other typical responses include anger, sadness, confusion, and difficulty eating and sleeping. As with preschoolers, this age group may regress as a way to receive more nurturance and attention during this difficult time. Children who have experienced a loss at this age tend to be fearful that other loved ones will leave them as well. Sometimes they form attachments to people who resemble the deceased in some way.
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MIDDLE YEARS (AGES 7–10) Do your fingernails and hair keep growing when you die? If I smoked cigarettes, would I die?
Although children between the ages of 7 and 10 often still want to see death as reversible, they begin to see it as both final and universal. Children in this age group sometimes visualize death in the form of a tangible being such as a ghost or boogeyman. They are very curious about the details of death, cremation, and burial and may ask candid questions Even though they know death can happen to anyone and that there are many things that cause death, they still do not typically think of death as something that can happen to them or their family members, instead, to only old or very sick people. They may believe that they can escape from death through their own efforts. They also might view death as a punishment, particularly before age 9. Sometimes they are unable to comprehend how the death will affect their lives, which can become a source of anxiety. Children in the middle years often become concerned with how others are responding to the death as they become less focused on themselves and more on others. They may fear that other loved ones will die as well. Sometimes they may become overly concerned about their own health and may fear bodily harm and death. Some children in this age group may act out their anger and sadness and experience difficulties in school due to a lack of concentration. On the other hand, they may have a jocular attitude about the death, appearing indifferent, or they may withdraw and hide their feelings. Other typical responses include shock, denial, depression, changes in eating and sleeping patterns, and regression to an earlier developmental stage. This age group tends to have more coping strategies available than younger children and may fantasize how they would prevent the death from happening again as a way to gain control
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over the situation. Death is also play-acted in children at this age, for example, through war games, especially for those children who have difficulty expressing feelings verbally. Children in this age group may assume the role of the deceased in the family or the mannerisms of the deceased. They may also take on tasks or chores normally performed by the deceased, such as care for their siblings. They may idealize the deceased as a way of maintaining a bond with them.
PREADOLESCENT (AGES 10–12) None of my friends could ever relate to what it’s like losing their Dad. While I know that Grandma is not coming back and I will miss her, I don’t understand why my Mom is so upset about it
Preadolescents conceive of death in much the same way as children in the middle years with a few additions. Preadolescents are in the process of establishing their own identity, increasing their independence from their parents and other adults and increasing their dependence on their peer group. In understanding death, preadolescents attempt to understand both the biologic and emotional process of death. They are, however, more able to understand the facts surrounding the death of someone than they are the feelings surrounding the death. It is common for preadolescents to want to cover up their feelings about their loss so as not to appear “different” from their peer group. They fear that expressing sad feelings may be seen as a sign of weakness (particularly for boys). For this reason, they may appear removed and indifferent. Preadolescents may also express their grief feelings in uncharacteristic ways such as through anger outbursts, irritability, and bullying behavior. Feelings may also be exhibited through physical complaints, moodiness, changes in sleeping and eating patterns, indifference toward schoolwork, or isolation from their peers. They may
639 show concern for practical issues after the death such as how the household will survive without the deceased or how they personally will be taken care of. They also might have questions regarding religious and cultural beliefs related to death.
ADOLESCENT (AGES 13–15) These years are often marked by stressful physical changes. Boys are usually a little slower to mature than girls in this age range, but the stress of change is ever-present—from radical growth spurts to facial skin problems. Teens in this age range are seeking to establish their unique identity, often separate from parents and family. They are beginning to think about spiritual and philosophical ideas for the first time in truly abstract ways. And, they generally experience powerful and deep emotions that they may feel no one can understand. One of the difficult tasks a grieving teenager faces is integrating loss into his or her current emotional life. This integration can be compounded by physical and hormonal changes. Grief may be expressed by frequent headaches or stomach aches, or through feeling sad and depressed. Another common reaction is for middle teens to manifest their grief in mood swings and outbursts of anger. Some teens withdraw to a safe place, such as a bedroom, where the anger may be acted out by pounding on a wall or beating a pillow. Some may act out the anger through inappropriate social behavior, pouting, or aggression toward others. Grades may decline in part due to sleep disturbances, which are often combined with depression and a general feeling of meaninglessness. It is not unusual for middle teens, both girls and boys, to want a special “friend,” such as a teddy bear to hug and sleep with during this time. It may be important for a caregiver to protect this information from other family members and friends, especially in the case of a boy. The teenager also may want to wear a special article
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640 of clothing that belonged to the deceased. He or she may adopt certain mannerisms or behaviors associated with the deceased loved one, or idealize his or her relationship with the deceased. Being tolerant of what may be seen as “childish” or immature behavior allows middle teenagers to process the loss in their own, personal and important ways.
ADOLESCENT (AGES 15–18) Adolescents in the 15 to 18-year-old age group are in the process of becoming young adults. They want to be treated with respect and collegiality. Providing assistance to grieving adolescents, therefore, can be complicated by the fact that although they may be young adults, they do not have the full experience of adulthood. They are also in the process of differentiating and distancing themselves from the parental figures in their lives. The peer group is their major authority—and how they are seen and judged by their peers is of primary importance to them. These older teens often become sullen and noncommunicative. Their anger may be expressed through exaggerated conflict with parental figures, pushing hard to overturn formerly understood limits. They may become insecure about the future, question the meaning of life, and question or abandon the family’s belief system. They may have sleep problems, such as recurrent or disturbing dreams and insomnia. Sometimes they regress and become immature and childish, or they mask their fears with jokes and sarcastic remarks. Sometimes, older adolescents who suffer a loss may idealize the deceased loved one. They may adopt mannerisms, habits, and preferences of the deceased. They may want to wear certain items of clothing, especially a hat, shirt, or jacket that belonged to their special loved one. Or they may react by feeling abandoned and angry at unfulfilled expectations in their relationship with the deceased.
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NORMAL GRIEF REACTIONS IN CHILDREN We now examine more in detail the typical and normal grief reactions that children and adolescents experience during the grief process. Some grief reactions with children occur immediately and others may occur at a later point. In general, children’s grief tends to manifest in physical and behavioral expression rather than verbal expression. In addition to developmental level and chronologic age, the main factors that influence how a child grieves are the relationship with the person that has died, the nature of the death (when, how, and where the person died), the child’s own personality, previous experiences with death, religious, and cultural beliefs, input from the media, and above all, what they are taught about death and grief from adults and the availability of family, social, and community support. The more common physical, cognitive, and behavioral reactions that may occur to children during the normal grief process are listed in Table 27–1 and are discussed below.
PHYSICAL SYMPTOMS I don’t feel good. I feel sick to my stomach. Last night I dreamed that Johnny came back to visit me. He was all grown up, though, and he had a mean look and wanted to hurt me.
Chief somatic complaints of a grieving child include headaches, stomach aches, fatigue, lack of energy, muscle aches, tightness in the throat, difficulty breathing (especially when they first learn about the death), skin rashes, change in eating patterns (lack of appetite or excessive appetite), change in sleeping patterns (both falling asleep, staying asleep, and sometimes prolonged sleeping), odd and frightening dreams, hyperactivity and hypersensitivity (especially if
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TABLE 27–1. Normal Grief Reactions in Children REACTION
EXAMPLES Muscle aches Throat tightness Skin rashes Hyperactivity Hypersensitivity
Changes in eating habits Difficulty breathing Changes in sleep habits Odd and frightening dreams
Physical symptoms
Headache Stomach ache Fatigue Lack of energy
Cognitive symptoms
Inability to concentrate Obsessed with or preoccupied with deceased Preoccupation with the death, or the meaning of death Carrying objects owned by the deceased Repetitively looking at photos of the deceased Visual hallucinations of the deceased Adopting deceased’s roles or physical mannerisms Emotional shock Anger and acting out Denial Regressive behavior Sadness, despair Fear, anxiety, panic Depression Jealousy Guilt, shame, self-blame Acceptance
Behavioral changes
the loss was traumatic). Most of these physical symptoms are temporary and go away with time when the child begins to receive adequate grief support. Some children develop physical symptoms that resemble the symptoms of the illness that they observed in the deceased. This may be a child’s attempt to stay connected in some way with the deceased or a way to express his or her own fear about getting sick. When children receive a great deal of attention for their physical symptoms, they may exaggerate the “sick role” as a means to obtain socially acceptable attention for their grief feelings.
COGNITIVE SYMPTOMS I couldn’t focus on my school work today. I don’t remember one thing that I learned. My Dad was the best father in the world. He never even once got mad at me When I went to sleep last night, my Mom came and sat in the chair by my bed.
Many bereaved children describe an inability to concentrate for any length of time after a significant loss. Their thoughts seem to be taken up with the death and loss of their loved one. Rabbi Earl A. Grollman discusses how children idealize the deceased as a way of coping with their loss. In an attempt to counter unhappy thoughts, the child may become obsessed with only the positive qualities of the deceased. Some older children become preoccupied with “why” the death happened, may want to know all the facts surrounding the death, and may search for the “meaning” of the death. Some children search for their lost loved ones with the hope of finding them. They may seek out places they used to go together. Other children become temporarily preoccupied with memories of the deceased, asking other adults to tell stories about the deceased over and over again, carrying objects of the deceased around with them, and looking at photos repetitively. Visual hallucinations of the deceased are also common and are experienced as very real to the
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642 child. Sometimes they can be comforting and other times terrifying. Identification with the deceased by incorporating mannerisms or taking on the deceased’s roles such as disciplining the other children are also common. All these behaviors are an attempt by the bereaved child to reconnect and relate to his or her deceased loved one. They should all be viewed as a normal part of the grief process unless they persist unnaturally long or cause a great deal of distress for the child.
EMOTIONAL SHOCK AND DENIAL I don’t believe you. My mother will come back. You are wrong. Even though it’s a year later, I still can’t believe that Grandma is gone.
Usually, when the realization of the death is too overwhelming, the child temporarily denies that it happened. Denial of the death is not unusual, but it can be difficult for adults to endure. It should be viewed as a protective mechanism; a way for the child to comprehend painful information at the speed with which they are ready. Denial is most common in the first few months following the death, but may reappear at different times throughout the grief process.
SADNESS, DESPAIR, AND DEPRESSION I don’t want to live without my Dad.
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ANGER AND ACTING-OUT BEHAVIOR I hate you and wish you had died instead of Dad. I hate school. I hate my friends. I hate my family. I hate my life. I hate everything.
It is often easier for children to feel mad, then to feel sad and children typically strike out with anger at the people with whom they feel closest and most safe. There are many reasons why grieving children feel angry. They may feel angry at the person who died for leaving them, angry at God, at others in their family, and at the doctor for not doing more to save their loved one. They may be angry at themselves because they believe they caused the death (magical thinking) or that they did not do enough to prevent the death. Anger often originates from feelings of helplessness and lack of control. There are some bereaved children that channel their anger by defying authority, rebelling against everything and by displaying somewhat antisocial tendencies. Antisocial behavior in a bereaved child is often an attempt to keep themselves away from any close relationships and the possibility of being “abandoned” again. It is important to note that anger expression generally is more socially acceptable among boys than girls. Younger children are often more physically expressive and direct when they are angry. They throw things, hit and kick, and have tantrums. Anger outbursts are often set off by seemingly unimportant triggers in bereaved children.
I miss my Mommy and I want her back.
There are many different ways that children exhibit feelings of sadness and despair following a loss. They may express it verbally, nonverbally through a depressed demeanor, through tears, or by becoming withdrawn, isolated, and quiet. Children sometimes react in total despair and are inconsolable when they first learn the news of the death. The full realization of the loss does not happen all at once, but as it does, sadness, loneliness, and depression can follow.
REGRESSIVE BEHAVIORS It is very common for bereaved children to regress in some way to an earlier developmental or chronologic age. Death of a loved one can cause complete disruption in their routine and in their sense of safety, and regression to a time in their life where they felt more secure and familiar should be seen as a healthy adaptation to a traumatic situation. Usually, regressive behaviors are temporary and subside with time as the child
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receives appropriate grief support. It is important that adults in a grieving child’s life find a balance between allowing the regression and gently expecting the child to return to his or her former level of functioning. Examples of regressive behaviors include bedwetting and thumb sucking, difficulty separating from significant others, demanding attention, regressing from prior advances toward independence, difficulty with developmentally appropriate tasks, needing to sleep in parent’s bed, needing to be held or rocked, reverting to fantasies of an earlier age, talking in baby language, giggling inappropriately, and inability to function with peers.
FEAR, ANXIETY, AND PANIC Are you going to die when you go to sleep tonight like Grandma did? Who is going to take me to school now that Daddy died?
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GUILT, SHAME, AND SELF-BLAME It’s all my fault that Janey died. I told her I wished she was dead when she broke my doll and now she is dead. I never liked my brother. He always teased me. Now I feel so guilty because he died.
Bereaved children sometimes believe they are responsible for the death, especially if they had ever wished the deceased dead. Some children feel guilty if they experience relief that the person has died, even though this is very normal reaction, especially if their loved one had been suffering. Other children feel guilty because they had a difficult relationship with the deceased. Frequently interrelated to self-blame is a sense of helplessness and worthlessness. If grieving children feel helpless, they may try to gain some control by thinking what they would have done differently to change the situation.
JEALOUSY
I think I’m going to get cancer too.
Children often react with fear and panic when they lose someone significant to them and may be afraid of the intensity of their own feelings. They become concerned about how other grieving adults will fare. They worry as well about the changes in care-giving and nurturance that come with the loss. Some grieving children become concerned that someone else close to them will die and that they will have to feel that pain again. In some cases, these children withdraw from other important adults so as not to repeat the hurt. Bereaved children often feel afraid of becoming sick or of dying themselves. They may become afraid of the dark, of sleeping alone and of being separated from or abandoned by other significant adults. Unfortunately, this is especially true if a parent has died and the other parent is somewhat detached from the child because of the parent’s own grief reaction.
I can’t go to the Father/Daughter dance because I don’t have a father. I hate when all the kids at school talk badly about their parents. They should feel lucky they HAVE parents.
It is very common for bereaved children to feel like they have been short-changed in some way, especially if the loss is that of a parent. It becomes particularly difficult for them during holidays such as Mother’s or Father’s Day, at their birthdays or graduations, and when they receive awards, because all these events serve as continual reminders to them of their loss. Feeling jealous that other children have parents is very common.
ACCEPTANCE When Dad first died I thought my life was over. Now I feel like I’m starting to look forward to things again.
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644 J. William Worden, a leading expert in grief and loss, describes the process by which a child begins to accept a significant loss. Acceptance of the loss comes gradually as does the understanding that the death is final. Most children describe a kind of “new normal” as they begin to adjust to the loss. They still think about their loved one that died and understand that their life has been changed, but they begin to reconstruct a life without their loved one in it. In the case of the death of a parent, they begin to feel secure that they will be taken care of and will have their needs met. They realize there are other significant adults available for support. Older children sometime state that going through a grief experience allowed then to learn to feel more compassion toward others and more tolerance for other problems and challenges in their own lives. Alan Wolfelt, another leading expert on children’s grief, calls the healing process that grieving children go through “reconciliation.” He says that reconciliation happens when a whole and healthy person emerges from grief. The person recognizes that life will be different without the presence of the significant person who has died. Reconciliation is a process not an event, and it does not occur all at once—it is a slow, painful process. The most notable changes during the child’s “reconciliation” process include a return to stable eating and sleeping patterns, a renewed
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sense of energy and well-being, a subjective sense of release from the person who has died, increased thinking and judgment capabilities, the capacity to enjoy life experiences, a recognition of the reality and finality of the death, and the establishment of new and healthy relationships.
NORMAL GRIEF EXPERIENCE FOR A TEENAGER By the end of high school, 20% of today’s students will have lost one of their parents; 90% will have experienced the death of a close relative or loved one. Add to this that 1 in every 1,500 secondary school students dies each year, and we can see that death and the resulting grief following death is a part of everyday life for many teenagers. Recognizing and providing constructive ways for teenagers to express their grief will help prevent prolonged or unresolved grief and depression. Grief is as unique as the people who experience it, but there are some reactions to grief that we all feel and that are considered normal or typical grief reactions. For teens who experience the death of a loved one, these typical grief reactions, listed in Table 27–2, often resemble those described
TABLE 27–2. Normal Grief Experiences for Teenagers Assuming mannerisms, traits, or wearing clothes of the deceased. Emotional regression and even bed-wetting, which can be most upsetting for teenagers. Needing to repeat again and again stories of their loved one Saying nothing at all Becoming overly responsible (the “new” man or woman of the house), which distracts them from their own feelings by taking care of everyone else. The need to integrate the loss into their budding identity Anger and lashing out at others that can happen at any time for no real reason Intense anger at the deceased for dying, and later feelings of guilt for being angry. Mood changes over the slightest things; unexpected outbursts or crying. A feeling that the loss is not real and did not happen at all
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earlier for children, albeit in a somewhat older age context. Teenagers experience their loss at different times in their development and the first and second year may be the most difficult. Part of normal development for a teenager is to reintegrate what they have learned about their loss into their current developmental stage. Special days and important times may serve as reminders of their absent loved one. The process of integrating the loss may resurface on these special days. For example, a high school senior wore his deceased father’s shirt to his graduation exercises. A 19year-old bride proposed her first toast to her deceased grandmother, a most significant figure in her life.
COMPLICATED GRIEF REACTIONS IN CHILDREN AND TEENAGERS Prior to her mother’s death from liver cancer, Sarah had been doing well in school, was captain of the gymnastic team and had several close friends. As Sarah and her Mom were very close, it was expected that Sarah would have a difficult time adjusting to her Mom’s death, although everyone remarked how “well” Sarah was coping as her mother was dying. Her father explained, “She seemed to hold it all together so well.” Even after the death, Sarah returned to school and to her normal routine fairly quickly. “Then all at once everything started to fall apart. It was as if she finally understood that her mother was really gone.” Sarah started missing school and her grades began to slip. She lost interest in gymnastics and quit the gymnastic team. She had trouble getting out of bed and began saying that she wished she were dead. She rejected her peers’ attempts at helping her and stopped answering the phone. Her Dad noticed that she stopped caring about her appearance and that she even looked disheveled. At first, her Dad was patient and thought it would pass. He was so involved in his own mourning that he didn’t seem to notice just how serious her depression had become. He finally called the school
645 counselor who referred him to a grief specialist who worked with children. Sarah was reluctant at first, not believing that anything would help. Finally, she agreed to go, began to express her anger and sadness, and over the course of several months began to resume her normal activities and functioning.
Thus far, the emotional, physical, and behavioral grief responses that have been described are normal expressions of grief in children and adolescents. A child may experience some or all of these reactions or may show no overt reaction at all. However, if any of these typical responses to grief are prolonged, extreme, pervasive, affecting the child’s ability to function normally in school or with their peers, or in providing self-care, like in the case with Sarah, the grief would now be considered “complicated.” Examples of complicated grief reactions are listed in Table 27–3. When a bereaved child exhibits any of these behaviors, immediate professional advice and assistance should be sought. There are many community sources that provide support for grieving children including school guidance counselors, pediatricians, clergy, mental health practitioners, and hospice bereavement personnel. Further discussion of how to manage complicated grief reactions in children and teenagers can be found below.
PREPARING A CHILD FOR THE DEATH OF A LOVED ONE PREDEATH SUPPORT If an adult can prepare a child or teen for the death of a loved one, it is important to do so as soon as possible before the death occurs. First, asking a child what he or she knows about a loved one’s illness allows the adult to discover any misperceptions that the child may have, and assists the adult in knowing where to start from in educating
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TABLE 27–3. Complicated Grief Reactions in Children and Teenagers BEHAVIOR Suicidal thoughts and behaviors
Prolonged sleep disturbances Persistent personality changes
Aggressive behavior Excessive or inappropriate guilt Extreme fatigue or loss of energy on a prolonged daily basis Extreme withdrawal or isolation
Pervasive fantasies that interfere with normal functioning Phobias that interfere with functioning Hypervigilance
Persistent assumption of mannerisms of the deceased
EXAMPLES “I just want to kill myself” Giving away valued possessions Preoccupation with suicidal themes in media Desire to be with deceased loved one Self-punishment ideation or behaviors Insomnia Nightmares Neat, well-groomed child abandons bathing, grooming, and dressing habits Eating habits change: too much or too little Extrovert turns into introvert Optimist becomes pessimist Pleasant child becomes a bully Secure child becomes anxious and afraid Dangerous risk-taking behaviors Behavior dangerous to others Child ruminates how she or he caused death of loved one Inability to get out of bed that lasts more than 10 d Inability to socialize with others Despair Depressed affect Belief that loved one will return, especially if she or he is good Fear of getting sick Fear of dying Avoiding anything having to do with death Checking on other parent constantly Checking themselves and others for symptoms that mirror those experienced by the deceased Hyperalertness in a car if loved one died in a car accident Assumption of chores and responsibilities of deceased that are not developmentally appropriate
Preoccupation with the deceased to the point that it interferes with normal function Drug and/or alcohol use
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the child about the illness and prognosis. It is imperative that the adult presents the information in a gentle and calm manner, allowing the child to voice questions and concerns. Children can usually absorb only a little information at a time. It is important to look for “teachable moments”—moments when the child seems open to learning. It should be explained that all living things must die. The adult could show the child plants and insects that have died and tell them that because people are living things, they die too. Explain that the changing seasons are another example of the cycle of life and death. The child should be told that the images they see of death in television cartoons are not always authentic and that death is irreversible. The adult can explain to the child that people usually live a long life, but that sometimes when someone develops a very serious illness, he or she dies before becoming old. The adult can also explain that doctors usually help people live long healthy lives, but that sometimes even doctors cannot stop some people’s bodies from malfunctioning. Using several adjectives like “very, very sick” or “very, very old” helps the child distinguish between someone with a common cold versus someone with a terminal illness and between their parents, who may seem old to them, and elderly people. The child should be reassured that this is not a punishment, or God’s fault or anyone’s fault, but that sometimes it just happens. She or he can also be reassured that death is usually not painful and that it is almost always quiet. When a loved one is dying, if a child is old enough to understand what is happening and both the child and the dying person would like to see each other, the child should be allowed to visit the loved one. The child should be prepared beforehand about what she or he might see or hear and what feelings might be experienced. The child should be told what the loved one might look like, and the setting, including medical equipment if applicable, should be described. Depending on the age of the child, it may be advisable to keep the visit short. Visiting with a dying loved one might be a way for a child to
647 understand the reality of the death, and a way for important communication to take place between the child and the loved one. The key is that the visit must be the child’s choice. If the child does not want to visit, a supportive adult should attempt to elicit why the child is resistant, but the child’s wishes should be honored. Throughout the illness, a child should be told about changes in a loved one’s condition as they arise. A child should be allowed to care for a loved one in a way that he or she chooses, be it through writing cards or bringing a glass of water or tissues. Sometimes, caring for a dying loved one allows a child to feel less helpless.
HOW TO TALK TO A CHILD WHEN THE DEATH OCCURS Ideally, a child or teen should be told in a gentle and caring way about the death as soon as it occurs, by someone they trust and feel close to. It might be helpful to prepare the child for the news by saying, “I’m afraid I have some bad news.” The explanation should be kept simple, avoiding euphemisms such as, “passed away,” “expired,” “went away,” or “went to sleep.” These euphemisms may cause the child to believe the person will come back or wake up, or conversely, may cause the child to be afraid to go to sleep at night. A suggested approach might be, “Daddy has died. He was very, very sick. Daddy had a disease that made him very weak and he was not able to get better. Daddy is now unable to move, feel, talk, eat, or hurt anymore.” By being direct, the child’s confusion and fantasies about what happened are usually diminished. When a child is told about the death of a loved one, she or he needs to be allowed a lot of time for expressing reactions and feelings, as well as for raising questions and concerns. By sharing their own feelings with a child, adults can help normalize what the child might be feeling. The child should also be made aware of what others in their environment may be feeling and thinking and should be reminded that sadness, anger, and
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648 fear are all normal feelings when someone dies. It is also important that the child is told what funeral arrangements or rituals will happen next, so they know what to expect. They should be reassured by being told specifically what will happen to them and how they will be taken care of.
TYPICAL QUESTIONS THAT CHILDREN HAVE ABOUT DEATH It is important that the questions posed by children and adolescents are answered in a specific, straightforward, and brief fashion, and reflect the developmental level of the child. Children can usually absorb only bits of information at a time so it is important to pay attention to their cues. Checking to see if a child has understood what has been said is also critical. Adults unsure of the meaning behind a child’s question should probe further by asking what the child meant or knows about the topic. Children often repeat the same questions merely as a way to assimilate the answers. It is also okay for adults to tell the child they do not know the answer to a specific question. Some of the most common questions children ask are the following: Why did daddy die?: It is important to probe further to assess whether they are asking this question because they feel sad, angry, or guilty about the death. If so, it is imperative to allow the child to express those thoughts and feelings. The child should be reassured that death does not seem fair. It may also be that they are asking about the physical process of death. When is mommy coming back?: It is okay to tell a child in a gentle loving way that people who die do not come back; that as much as she or he may want mommy to come back, she can’t because she is dead. Sometimes, it is reassuring for a child to know that she or he can always hold onto feelings and memories about a loved one and that in that way, the
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loved one will always be with him or her. It may also be reassuring for a child to know that the feelings of sadness that he or she is experiencing about a loved one being gone will go away over time. Where is daddy now?: Before answering this question, it is helpful to know where the child thinks daddy is. The adult’s response would then be based on that belief. If the child believes daddy is in heaven, because that is the family’s spiritual belief, than that belief should be validated. Also, to minimize confusion, it might be helpful to remind the child about the burial, for example, that the loved one was placed in a casket underground. Will you die too?: It is important when answering this question to give reassurance and support and also to answer honestly. An example would be: “I will die sometime but I hope to be here a long time yet. I do not have any serious illnesses.” Sometimes when a child asks this question, she or he is afraid of losing another loved one. A clarifying question might be,” Are you worried that I won’t be here to care for you?” How long will I live?: A response might be that no one knows how long they will live, but that no one lives forever. The child should be reassured that most people live until they are old and that many old people are not worried about death.
GUIDELINES FOR HELPING BEREAVED CHILDREN EXPRESS THEIR GRIEF A hundred years ago death was much more a natural part of a child’s experience. Grandparents often lived with families, so children witnessed them growing older and dying. Modern medicine
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has made strides in reducing infant and child mortality and has prolonged life expectancy for the elderly, so children witness fewer deaths. More and more elderly die in nursing homes and hospitals, outside the home environment. The exclusion of death from children’s lives requires us to teach them explicitly about death and grief. In Mourning and Melancholia, Sigmund Freud outlined his belief that young children did not have the capacity to mourn. He believed that only as a child developed into an adolescent did they acquire the ego capacity to grieve. More contemporary research has concluded that children do in fact have the capacity to experience and express grief, but it is often more intermittent and drawn out over a longer period of time than with adult grief. General guidelines for helping children express their grief are presented in Table 27–4, whereas guidelines that address some of the most common specific feelings that children experience are listed in Table 27–5.
TABLE 27–4. General Guidelines for Helping Grieving Children Express Grief Allow children to express grief in their own ways. Do not pressure children to resume normal activities before they are ready. Allow children to feel that it is OK to talk about death and grief. Be available to listen. Let children know that having and expressing feelings are normal. Avoid expressions that suppress grief. Gently intervene if the child is taking on the role of a bereaved adult. Grieving adults should not hide feelings from children. Allow children to express religious and spiritual concerns. Allow children to remain in familiar surroundings. Avoid sending children away.
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649 The grieving process helps people heal from their pain. Pain is a natural reaction when we lose someone close and children are capable of accepting pain of loss directly and openly. When adults try to protect children from such pain, they are usually, in reality, trying to protect themselves. The most important thing to remember in helping children cope with the death of a loved one is to allow them to express their grief in their own way and in their own time. It is important not to pressure children to resume their normal activities if they are not ready. Children tend to have “grief bursts” followed by play and normal activities. Children may not be able to succinctly verbalize what they are feeling and instead may demonstrate their feelings through their behavior and play. They may laugh or play at a time that feels inappropriate to an adult. Children need to feel that it is okay to talk about death and grief. However, if a child does not want to talk about grief, adults also need to respect that desire. Adults should let the grieving child know that they are available to listen and help and that any feelings they have, such as anger, sadness, fear or regret, are normal. Hugging and touching helps the grieving child feel secure in expressing emotions and also reassures the child that he or she is loved and will be cared for. Alan Wolfelt feels that if grieving children are ignored, they may suffer more from the sense of isolation that from the loss itself. Messages relayed to a grieving child such as “Don’t cry. You need to be strong,” “You’re the man in the family now,” or “Be a good girl. Your mommy needs your help now more than ever,” suppress grief expression in children and set up unfair expectations of them. Adults should gently intervene if they observe a child taking on the roles and tasks of a bereaved adult. Grieving children should not be allowed to take on the role of the “confidante” or partner of one parent if the other has died. It is important that adults not hide their own feelings of grief from a bereaved child. If they do, they teach them that experiencing these
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TABLE 27–5. Guidelines for Managing Specific Expressions of Grief EXPRESSION Sadness/depression
Anger
Guilt and regret
Fear
Physical complaints
SUGGESTED ACTIONS Draw memories of the deceased and show to others Show photographs and describe keepsakes to others Develop a memory scrapbook Engage in physical activity Allow child to dissipate anger with various activities Ask children about their anger Ask the child to suggest ways of responding to anger Maintain household rules and chores Write a letter or draw a picture describing “unfinished business” with the deceased Write a note about feelings of guilt and tie it to a helium balloon in order to “let it go” Create puppets so that child puppet can talk to puppet of the deceased Help child identify fears Provide repetitive reassurance that all will be OK Spend time alone with child and reassure that s/he is special and loved Ask about other possible feelings, symptoms, or emotions Remind the child why the death occurred Pediatrician visit to reassure child
feelings are not okay, that they are something to be ashamed of or to be kept to oneself. It is also true that grieving adults should not grieve profusely and at length in front of a child as it might frighten and worry the child. Religion is an important source of strength for many adults and children during the grief process. Children takes things literally, so explanations such as “It is God’s will” or “Bonnie is happy in heaven” could be frightening or confusing rather than comforting, particularly if religion has not played an important role in the child’s life. It’s important to inquire how the child perceives what is explained about the death. It is also important that children be allowed to express their religious and spiritual concerns. Parents may be tempted to “send children away” when there is a loss—either to protect them
from painful feelings or because it is difficult to care for them while grieving themselves. During the grieving period, children are often most comforted by familiar surroundings and routines, and separation may increase their fears about abandonment.
SADNESS/DEPRESSION Grieving children that are sad or depressed require a lot of support and attention so that they can express their sad feelings and work them through. Helen Fitzgerald, a well-known children’s grief therapist, recommends several techniques for helping a depressed grieving child. She suggests having the child draw good and bad memories of the deceased and share them with
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others. The child could also could show photographs and describe keepsakes to others and develop a memory scrapbook. For a child that feels so despaired about a loss, it might be helpful to ask the child to fantasize how life might be different if she or he was not so sad. Encouraging the child to engage in physical activity is another useful technique with a depressed child. Johnny was very withdrawn and depressed for several months after the death of his mother. Finally, his grief counselor suggested he make a “God box” where he could write down all his sad feelings and put them in the box and God would help him feel better. He wrote a new note almost every day and soon his father noticed that he seemed more cheerful.
ANGER It is sometimes easier for a child to feel mad rather than sad or guilty. Anger is not always rational and it can escalate by feeding upon itself. Anger does need to be expressed, however, and adults can be helpful in teaching grieving children how to express anger in constructive ways. Unexpressed anger can turn into depression or into anger that is out of control. Children generally tend to express their anger physiologically. Instead of asking an angry child to “calm down” it may be more useful to allow them to dissipate their anger in other ways such as running, exercising, scribbling on paper, ripping paper, singing, and sculpting play dough. It is important to not try to deal with the cause of anger until the intensity has decreased. Adults can ask children questions about their anger at a time when they are not angry. It might be helpful to ask questions like, “What usually leads to your feeling angry?” or “How does your body tell you that you are becoming angry?” Examining these precipitating factors usually diminishes the intensity if the anger and gives the child a sense of control by learning what triggers an angry response. It is helpful to ask the child what he or she thinks are more appropriate ways to respond to
651 angry feelings. It is also appropriate for an adult to set a limit with an angry bereaved child who is acting out. “It’s not okay to hit me but you can hit this pillow.” Maintaining household rules and chores actually increases the sense of normalcy and security for a grieving child. Stephen had been very close to his grandfather and when he died, his parents noticed he began bullying his younger siblings and picking fights at school. They called his football coach who suggested that Stephen might “work out” some of his aggression by staying after practice and “ramming” the dummy players. After two weeks of “extra” practices, Stephen was much less aggressive with other children.
GUILT AND REGRETS Some children have regrets about negative aspects of the relationship with the deceased or regrets about things that did not happen or were not said prior to the death. Examples might be: “I never told my mother I loved her,” “I lied to my father and never told him the truth,” “I was mad at my Mom the day she died,” or “I didn’t have a chance to say goodbye.” Helen Fitzgerald describes some techniques that are useful with children in helping them work through feelings of guilt and regret. One suggestion is to write a letter to or draw a picture for the deceased describing their “unfinished business.” Another suggestion is to have the child write a note about what she or he feels guilty about, tie the note to a helium balloon, and then release the balloon into the sky. For younger children, she suggests making two puppets and drawing one puppet face as the child and the other as the deceased person. The child puppet could tell the puppet of the deceased what they feel guilty about or what they regret about the relationship. After her mother’s death, Emily’s father noticed that she seemed very preoccupied and unable to focus on her schoolwork. After several months, he referred her to the school counselor who had
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652 experience in working with bereaved children. When she suggested Emily write letters to her mother, Emily seemed relieved to be able to “communicate” with her mother in this way. Emily then asked the counselor to read the letters. They were full of ways that Emily believed she could have prevented her mother’s death. After several of these letters and the counselor’s educating Emily on the nature of her mother’s serious illness, Emily began to relax and was able to focus on her school work again.
FEARS It is important to help fearful children identify what they are afraid of specifically and then to address each fear individually. Children who are fearful generally need repetitive reassurance that they will be OK. It is also important that a parent or other significant adult spend time alone with and focused on the grieving child, reassuring the child that they are special and loved. Both of Anwar’s siblings had been killed in an automobile accident. Anwar was terrified of riding in a car for months after their death and was also afraid that someone else close to him would die. His parents and family provided a great deal of love and support during this time. His father decided to help him confront his fear of riding in the car by taking incremental steps. First they sat in the car for a long time as Anwar expressed sorrow about his loss and his anger at the driver that hit the car. Later, his father backed out of the driveway reassuring Anwar that he was safe. The next day he drove down the street assuring Anwar about how accomplished a driver he was. Soon Anwar was able to ride in a car again without fear.
PHYSICAL COMPLAINTS When grieving children routinely have physical complaints like headaches and stomach aches, it is sometimes helpful to ask what other feelings they may be having as well. They may not disclose their emotions right away, but they may begin to make their own connection between their physical and emotional concerns.
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If the physical complaints mirror those of the deceased, it is helpful to remind a child why the death happened. A visit to the pediatrician may also be advised, so the child can hear reassurance from the doctor that nothing is wrong with them. Jose complained of headaches for weeks after his father’s death. He was the oldest son and felt he had to be “strong” for his other siblings and for his mother, so he expressed very little emotion. Two months after his father’s death, his uncle asked Jose if he wanted to visit the cemetery. When they arrived, Jose began to cry when they came to the grave. He and his uncle spent several hours while Jose talked to his father and reminisced with his uncle. After that, Jose no longer complained about headaches.
BEREAVEMENT SUPPORT GROUPS FOR GRIEVING CHILDREN Child bereavement support groups are among the most successful ways to provide support to a grieving child, particularly for older children. Donna L. Schuurman, Executive Director of the Doughy Center, an agency that specializes in the grief and loss issues of children, suggests that children should be grouped by age and developmental level in grief groups. She also suggests that mixing death types and relationships to the deceased are acceptable but that children experiencing different losses (i.e., divorce, death) should not be mixed in the same group. Children support groups are typically less structured than adult groups and usually incorporate play time. One of the most important reasons that bereavement groups are helpful is that grieving children discover in the group that there are other children whose experiences are similar to theirs. Being in a peer group with other bereaved children helps normalize their experience and reactions, helps then to understand that their feelings are important, and allows them to feel hopeful by listening to other children who are coping successfully. In bereavement support groups, children learn that they can express themselves in healthy ways and also learn tips from one another
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about how to deal with similar emotions and circumstances.
SUPPORT FROM SCHOOLS FOR GRIEVING CHILDREN Children spend a great deal of time in school and both teachers and peers can be an important source of support for a grieving child. Teachers and school counselors should be told about the progress of the illness while the child’s loved one is still alive and of the death when it happens. The teacher should be aware of what the child knows about the illness and could be given advice on how best to support the child. Teachers can also help by monitoring the child’s emotional state and behaviors in the time following the death. The school may need to alter assignments or provide extra instructional assistance for a grieving child. The teacher should share with the child’s classmates’ information about the death and also provide guidance on what they can do and say and how they might be helpful when the grieving child returns to the classroom. Children could be prompted to say, “I was sorry to hear about your sister,” or “I felt sad when I heard about your father dying.” Welcome back posters or sympathy cards are very appropriate. It is important to remember that some children spend more time processing their loss with peers than with other adults. On the other hand, some children, especially older children, do not want to feel different than their peers and may be hesitant to share their loss as it might single them out as different from others.
PLAY THERAPY FOR GRIEVING CHILDREN A child’s play is often the main avenue through which a grieving child expresses his or her grief, particularly younger children. When young children are trying to comprehend death, one can often observe rituals where they bury animals and insects in the ground or use dolls and action
653 figures to play out the both the dying and grief processes. Through play, children can take apart traumatic experiences and replay them in a way that is comforting to them, and they can do this in relative safety, one step removed from reality. If parents or teachers find that a child’s play has taken on a rigid, sad, or repetitive character, they should talk openly with the child about what is being experienced. Many grief therapists who work with young grieving children use play therapy to assist the child in coming to terms with their loss. The advantages of play therapy are that young children tend to have a limited verbal ability for describing their feelings, they tend to have a limited emotional capacity to tolerate stress and the pain of loss, they have a shorter attention span, and finally, young children communicate their feelings, wishes, fears and attempted resolutions to their problems through play. The goals of therapy for the bereaved child are to help facilitate the mourning process and to help clarify any cognitive confusion the child may have about the death.
GUIDELINES FOR HELPING GRIEVING TEENS Table 27–6 presents the “Bill of Rights for Grieving Teens.” Written by a grieving teenager, this document, is, in essence, guidelines for how to assist teens who are bereaved. The most important thing an adult caregiver can do for grieving teens is to be available to them. Availability means being approachable, nonjudgmental, caring, and appropriate. Letting them know you are there to talk at any time and letting them know you will hear what they are saying, no matter what it is, will make all the difference in your ability to be a helpful presence for teenagers who have suffered a loss. Do not assume they will come to you to talk. You will need to ask if they want to talk. And, if a grieving teen asks, “What do you want to talk
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TABLE 27–6. Bill of Rights for Grieving Teens A grieving teen has the right . . . . r To know the truth about the death, the deceased, and the circumstances r To have questions answered honestly r To be heard with dignity and respect r To be silent and not tell you her or his grief emotions and thoughts r To not agree with your perceptions and conclusions r To see the person who died and the place of death r To grieve any way he or she wants without hurting self or others r To feel all the feelings and to think all the thoughts of his or her own unique grief r To not have to follow the “Stages of Grief” as outlined in a high school health book r To grieve in one’s own unique, individual way without censorship r To be angry at death, at the person who died, at God, at self, and at others r To have his or her own theologic and philosophic beliefs about life and death r To be involved in the decisions about rituals related to the death r To not be taken advantage of in this vulnerable mourning condition r To have irrational guilt about how he or she could have intervened to stop the death Written by teenagers at the Dougy Center (http://www.dougy.org/grief-resources/bill-of-rights/); Reprinted with permission of the Doughy Center, Portland, OR.
about?” tell him or her. Be open and address your own feelings or difficulties regarding your loved one’s death. Be honest. Avoid euphemisms such as, “passed on” or “left us.” Use the deceased person’s name or family role (like mother, grandmother, etc.). It’s also OK to say, “I don’t know” if she or he asks you a difficult question. Don’t pretend to understand something that you don’t; your teenager likely will learn that you don’t, if he or she doesn’t pick up on it immediately. Then be open to just listening. Ask leading questions that invite your teenager to talk to you. Review the conversation, asking your teenager to summarize what you discussed. This provides opportunities to clarify if there are misconceptions or misunderstandings. If you are unable to talk about death with your teenager, find someone else who feels comfortable talking about it, like another relative, another bereaved teen, or a professional, such as a social worker, faith practitioner, or school counselor. Share your own thoughts, concerns, and feelings. Acceptable expressions of grief will be
demonstrated by your example. Give your teenagers permission to grieve by allowing them to see you grieve. Telling stories, reading, and writing poetry and journaling are all useful means of expressing one’s grief. These things could be shared with others or not. Share and discuss religious beliefs with your teenager. If your teenager has spiritual questions you can’t answer, admit it and seek the assistance of your faith professional (minister, priest, rabbi, imam). Try not to react negatively if your teenager is expressing faith or beliefs that are different from the accepted family practice. Older teens especially will be developing their own faith practices to prepare for future losses. This may require some religious “experimentation” on the older teen’s part. Refer him or her to your local faith professional. Being an adult companion to a bereaved teen, especially if you are a parental figure, may make you the focal point of anger and, perhaps, cruel remarks. This can be especially difficult to tolerate if you are experiencing your own grief. Try
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not to engage the teenager in a way that will result in building barriers, but shift the focus to the underlying pain the teenager is trying to mask with these remarks. The bereaved teen may not be approachable at the moment that the remarks are made; you may want to establish a time to talk in the future and describe what you want to talk about when making your “appointment.” Times before, during and immediately after a death are disruptive. Try to re-establish a routine, with appropriate expectations and limits, as soon as possible. Teenagers as well as younger children need the reassurance and sense of security that comes from structure, rules and limits. The main difference in an older teen is that you should be open to negotiate the rules and limits appropriate to the teen’s age. Remembering your own fears and anxieties during this period of your life may help you be less rigid and more reasonable in negotiating rules and limits. Teens need to be allowed to mourn intermittently. Two teenagers who were present for the home death of their father were seen playing video games within an hour of his death. Some family members wondered if this was “appropriate” behavior. It was fortunate that a hospice professional was present to reassure the family that this was normal, and that teenagers need to be given room to mourn in their own ways. Sometimes the overwhelming nature of the loss requires teenagers to “take a break” from their mourning and engage in whatever may distract them from the loss. Also be ready for mood swings and emotional expressions at unexpected times. Be prepared for resurfacing of emotions on special days or anniversaries, such as birthdays, holidays, and the anniversary of the death. The secure presence of some understanding, caring and appropriately affectionate adult role models can make all the difference to a teenager’s experience of and ability to cope with his or her grief. Remember that each teenager’s grief is unique. Let him or her teach you what the loss means and then help the teenager to his or her own meaning as he or she grows up with this loss.
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655 In most cases, teenagers who have experienced the death of a loved one will not need professional help. Continuing to live a routine life in a loving caring environment of friends, family and community will provide the support and refuge they need to learn to live with their loss and prepare for future losses life undoubtedly will put in their way. However, in some situations, professional help is needed. After any experience of violent death, whether that violence is manmade (such as murder, an act of war or mob violence) or natural (such as flood, tornado, earthquake, or hurricane), the evaluation of a caring family-oriented healthcare professional may be appropriate. In these situations, the possibility of long-term complications, such as posttraumatic stress disorders, should be addressed. Always seek professional help and evaluation if the teen has developed symptoms that are of a concern to you. Grief is often expressed through behavior. Your teenager needs to hear that you care about him or her even if the teen is acting out. If grief is severe or prolonged, don’t hesitate to seek grief counseling for your teenager. Family and friends can provide a wealth of support, when relationships are established that are trusting and appropriate. Individual counseling can help address personal issues. Child and family counselors are a primary source of assistance to the whole family in grief. Support groups can help your teenager feel less isolated and different from other teens. Peer groups are usually more authoritative than parents during the teen years. A well-facilitated youth group can help immensely with teenagers’ grief. When seeking grief counseling for a bereaved teen, the first place to go to obtain appropriate help should be the teenager’s primary healthcare provider. The family healthcare provider can make appropriate referrals to mental health providers or recommend other interventions that may be necessary. The provider may also help access any insurance benefits that may be available, or make referrals to public health resources.
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656 The teenager’s school may be another important resource, as a large part of a teenager’s time is spent at school. If a teenager is having a difficult time with his or her grief, the school staff, such as teachers and the guidance counselor should be involved. They can be invaluable allies in helping a teenager with his or her grief. In addition, guidance counselors often know about community resources. Inform the teenager’s school guidance counselor and teachers of the death, and how close your teenager was to the deceased. Ask teachers and guidance counselors to provide you with feedback if they see any changes—good or bad—in your teenager’s behavior or performance at school. Watch for academic decline. Grieving teenagers may not be well-rested due to insomnia or interrupted sleep patterns. They may have trouble concentrating in class or completing homework. Offer assistance and, if necessary, see if the school can recommend a tutor. There are also many resources in the general community. A growing number of communities have bereavement centers with programs for children and teenagers. Also, many communities have self-help phone numbers or help hotlines that may list bereavement services available in your community for children and teenagers. Some communities will have a public mental health center, and these centers often will help to evaluate and refer teenagers who are having a difficult time with bereavement, especially when they are depressed, despondent, or unusually angry. Another source of community help for bereavement care is your local hospice provider—even when the deceased was not a hospice patient. Hospices generally provide resources and referrals for bereavement care at no cost. Youth groups that are either recreational, such as the YMCA or Scouts, or religious youth groups, may be a useful resource to assist the grieving teen, as participating teenagers receive nurture and distraction from their routine in a wholesome environment. Some of these youth groups may even provide direct access to coun-
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selors who can address and assist with grief recovery. One’s local temple, church, or mosque, and the local minister, rabbi, pastor, imam, or other spiritual counselor is another important resource to consider if you are looking for help with bereavement. Many local faith groups provide bereavement groups and pastoral counseling that address issues of bereavement from a spiritual point of view. The internet can provide a wealth of information and support for grieving teenagers. Keep in mind that while there is also a lot of inappropriate information on the internet, there are reputable sites that provide an opportunity to read information and write or start your own blog (a web site with short entries and links to personal or other websites on a particular subject, i.e., bulletin boards). Libraries and book stores offer reading in the area of grief and grief recovery.
GRIEVING PARENTS NEED TO TAKE CARE OF THEMSELVES Although this chapter focuses on the care of bereaved children, one would be remiss in not at least touching on the need for grieving parents to care for themselves while caring for bereaved children. Many parents find this particularly challenging, which is why it is imperative that adults make a special effort to get the support and assistance they need so that in turn they can attend to the grief needs of their children. Some adults, however, do find it particularly therapeutic to give to a grieving child, because it can be healing to provide assistance to someone else. To ensure the best possible interactions can occur between grieving parents and children, several suggestions are provided in Table 27–7. A full discussion of bereavement care for adults can be found in Chapter 17.
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TABLE 27–7. Suggestions for Grieving Parents r Take time for themselves to sort out their own concerns, doubts, and fears. It is hard for an adult to be reassuring to a child when they have their own unresolved fears. r Take care of their physical health—rest, eat right, exercise moderately, and avoid alcohol and drugs. r Keep a grief journal, read books about grief, and join a bereavement support group. Many grief experts also suggest waiting on making any major life decisions. r Take people up on their offer to help and support. Relatives and friends can run errands, take care of the children, or assist with the final arrangements. It is very important not to become isolated. r Allow the child to care about them as well as long as the child doesn’t become consumed with care. r Have someone they can share the responsibility of providing emotional grief support to the child.
GUIDELINES FOR CHILDREN ATTENDING FUNERALS AND MEMORIAL SERVICES Therese Rando, a well-known grief and loss expert, explains that rituals allow structure for important events that happen throughout our lives, including death. A funeral offers a controlled time where individuals can emotionally and physically ventilate their feelings. Funeral rituals generate social support and offer opportunities to find meaning, by applying spiritual and philosophical understandings to loss. Funeral rituals are most effective when they are personal and involve participation from friends and family. When the death of a loved one occurs, adults are faced with difficult choices about whether to include children and teenagers in death rituals such as funerals and memorial services. As a general guideline, children should be allowed to attend a wake, funeral, and burial if they want to. Children can also be involved in the funeral planning. Joining family members for these ritu-
als gives them a chance to receive grief support from others and a chance to say goodbye in their own way to the deceased. Children should never be forced to attend a funeral or memorial service. It is important, however, to understand the children’s reasons for not wanting to attend, so any fears or questions can be addressed. Questions that might assist adults in understanding a child’s fears or concerns might include: “What is the thing you are most afraid of about the funeral?” or “What do you think you might feel if you were to go to the memorial service?” Always prepare children for what will happen at any death ritual. Describing the funeral process step by step (what they will see, how other people might react, how they might feel) can help allay children’s anxieties about the event. It is important to reiterate that crying or not crying are both OK. Extra attention and affection from adults may be necessary so children do not feel forgotten or neglected, remembering not to embarrass a teenager in front of his or her peer group. It is helpful to make arrangements with a trusted adult so a child could leave the funeral or memorial service early if he or she wishes.
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658 Children should never be forced to view or touch the body; they need to be given a choice that will be respected. If they are going to view the body, it is helpful to remind them that death is final and to describe how the body might look. An explanation could go like this: “Sally will be lying in a wooden box called a casket. She will look like she is sleeping, but she is not. She is dead. Her chest will not rise and fall because she is not breathing.” For some children, touching the body may satisfy their curiosity, be a way of saying goodbye, or be an expression of love. If a child decides to touch the body, he or she should be told that the body will feel cold and hard. Some children, however, do not need to touch or see the body to know that the death is real. If a child does not want to see or touch the body, an adult could relay that the body was seen and that the deceased was not living or breathing. Children should be asked if there is anything they would like buried with their loved one. It is often comforting for the child to place a small gift, a drawing, a letter, or a picture of themselves in the casket.
EXPLAINING BURIAL AND CREMATION TO A CHILD If the deceased will be buried, it is helpful to explain to children in detail what that means so they will not develop fantasies about where their loved one was put to rest. An explanation may go like this: “The casket will be sealed shut and then taken to a cemetery where there are several other bodies buried under the ground (or placed in a hole in the wall of a building called a mausoleum). They have to be placed there because, like with a dead squirrel, their body will begin to decompose because it is no longer living.” It is sometimes difficult for a child to understand cremation. When describing it, it is important to remind the child that the dead person no longer feels anything, so it is not painful. If the child wants to view the body before a cremation, most mortuaries can arrange for this. When de-
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scribing cremation to a child, it might be helpful to say: “Cremation happens at a place called a crematory. There they use heat to change the body into ashes. These ashes are usually placed in a special box and the family decides what they want to do with the ashes.”
WAYS TO COMMEMORATE THE LOSS WITH A GRIEVING CHILD During the grieving process, there comes a time to bring emotions into perspective, modify patterns of thinking, develop a new awareness of the loss and the importance of life, and start to free oneself from the profound pain of grief. This change, and it can be a significant one, is facilitated by the act of commemoration. Commemorating a loss can be a public or private event, elaborate or simple. The important thing with a grieving child is that the ritual should be planned with the child’s consent and is not imposed. The child could be asked to actively participate by sharing ideas for commemorating the deceased. A helpful way to commemorate a loss is to visit the cemetery or final resting place of the deceased. It may be a means for the child to say goodbye or to satisfy natural curiosity. As with funerals, it is important to describe to children beforehand what they will see and how they may feel at the cemetery, and allow them to ask questions. Often families take flowers, pictures, small gifts, or notes to place on the grave. It is helpful if adults share their feelings while visiting the grave to give permission to the children to share as well. It is also helpful to process afterwards any thoughts and feelings about the visit. Phyllis Silverman, William Worden, and others have described how bereaved youngsters often maintain a connection of some type to the deceased person who they loved, such as a parent. They may believe the parent is somehow with them when they are awake. There are many rituals and activities that children enjoy doing that enhance a positive connection to the deceased. Adults should allow grieving children ample
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opportunity to share their memories of their loved one and adults should talk about the deceased person as often as possible. Viewing photo albums, telling stories, visiting special places where they went with their deceased loved one, having memorable possessions of their loved one are all important commemorative activities. There are many creative ways to commemorate the loss as well. One is to write letters to the deceased. The letters could be kept in a special place, could be shared, or could be burned in a ceremony. The burning of letters is especially significant if there was unfinished business in the relationship, particularly with older children. Artwork can be very therapeutic for grieving children as it allows them a nonverbal channel to express themselves. It is important to allow children the choice about whether or not to share their artwork with others. Some children may choose to write about their emotions and memories in a poem, story, or journal. Other creative ideas include making a scrapbook or photo album, making a treasure box where mementos of the deceased can be stored, planting memorial trees or plants, and donating money to charity in their loved one’s name.
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659 Mother’s and Father’s Day can be particularly difficult for children that have lost a parent. They may choose to commemorate their loss by visiting the cemetery or visiting a special place where they have positive memories of their parent. If they are supposed to participate in an activity with the parent, for example, a Mother’s Day celebration, they may choose to take a “substitute mother” to the event. As the first anniversary of the death approaches, children often find themselves reliving very intensely the last days of their loved one’s life. Children often need extra reassurance and support during this anniversary. It is also important that the adults in their life share their own feelings about the anniversary and memories about the deceased. Children often choose to celebrate the birthday of their deceased loved one. They might make a birthday gift for their deceased loved one, or bake a cake and light birthday candles. The celebration could include sharing memories about past birthdays with their loved one. A visit to the cemetery might be a special way to allow a child to say “happy birthday” to their deceased loved one. Other holidays may be commemorated in a similar fashion, by giving gifts, sharing memories of the deceased, and developing special rituals.
HOLIDAYS AND SPECIAL ANNIVERSARIES Holidays and special anniversaries can be very difficult for grieving children and adolescents, especially during the first year. Holidays and anniversaries serve both as a reminder of the loss and of pleasant memories of the deceased. It is sometimes difficult for children to watch others enjoy the holiday, when for them it just brings up the void they feel. Often, the anticipation of the holiday can be worse than the holiday itself. It is important to let bereaved children know in advance that they might experience some painful feelings during the holiday or anniversary. It is also helpful to plan with them in advance ways to make these events more tolerable. Holiday rituals that included their loved ones could be altered and new rituals developed.
DEATH OF A PARENT OR SIGNIFICANT ADULT Parents naturally love their children and children depend upon parents for survival and stability. Silverman believes that what a child experiences as lost along with the death, how they talk about their deceased parent or significant adult, and how they understand his or her place in their lives, can be even more critical than age-specific understanding of death. The death of a parent or significant adult seems to be more difficult if the death was sudden or if the child lacks a solid replacement figure. Some children fantasize that their parent will return, and others have the wish to die so they can be reunited with their deceased parent. Usually,
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660 this is a fleeting desire rather than true suicidal ideation. Children expressing these wishes, however, should be questioned more deeply, and an investigation made as to whether they do have a specific plan and means available to carry out their wishes. Silverman describes the accommodation and adaptation to the loss of a parent or significant adult that a bereaved child experiences throughout his or her life. These children tend to revisit the meaning of their parent’s death over and over again at different developmental stages. They also re-experience the loss at events such as graduation, marriage, and the birth of a child. Some bereaved children idealize their parent or significant adult as a way to keep their pleasant, comforting memories of them alive. This can be adaptive unless it gets in the way of a child expressing angry feelings toward the parent for “leaving” or for any “unfinished business” in the relationship. It is important that surviving parents allow the idealization of the deceased parent, but also stress with children how much they love them and reassure them of their care and support.
DEATH OF A SIBLING When a sibling dies, the surviving child reacts to both the loss of the sibling and to the change in behavior and grief process of his or her parents. The grief response of siblings may be longer or shorter than parents and they may have a different understanding of the death. Siblings are often asked numerous questions about their brother’s or sister’s death from their peers and from other adults. This can feel overwhelming to a child. An ill child often receives more attention from parents than their siblings who are well. The surviving children often believe they will get more attention from their parents after the death of their sibling and then are disappointed when those expectations are not met. Surviving children may also grapple with identity and role issues after the
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loss. “Am I still a little brother?” or “Who’s going to take out the garbage now?” Sometimes, grieving parents are overprotective of the remaining siblings, concerned that they may die or become ill as well. Other parents place unreasonable expectations or demands on the remaining siblings, for example, asking them to take on the responsibilities and roles of or to have the same attributes as the deceased sibling. It is important that parents avoid being either overprotective or overpermissive with grieving siblings, despite the temptation. Care should be taken to not make comparisons between the deceased child and any siblings, as it may lead the surviving children to feel inadequate. Care should also be taken not to assign inappropriate responsibilities to a child that the deceased sibling used to have, especially responsibilities that are not developmentally appropriate. For all these reasons, grieving siblings need a lot of reassurance from their parents that they are loved for who they are and that they will be cared for and supported. They need to be reminded that they did not cause their brother’s or sister’s death. They also should be encouraged to share memories and hold keepsakes of their deceased sibling and to participate in family rituals related to the deceased child.
CONCLUSION Bereaved children and adolescents are unique in that they experience the pain of loss earlier than other people, earlier than they are expected to. Bereaved children are also unique in that they may not completely comprehend the meaning of “gone for good,” instead, may hold onto an inner representation of the deceased. Children who are grieving the loss of a parent or significant adult differ from other children in that they lose the innocent belief that their parents will be there to care for them forever. Surviving siblings or children whose young friends have died are forced
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to face the fact that young people sometimes die earlier than they are supposed to. This chapter outlines the typical emotional, physical and behavioral manifestations of children and adolescent grief and offers guidelines for interventions that adults can provide to grieving children. When adults really listen to grieving children and take their cues for action from them, adults learn that what grieving children most need is unconditional love, reassurance that they will be cared for, inclusion in the mourning process, and availability to work through their grief. Adults also can be comfortable that the community at large can play a significant role in the positive outcome of a grieving child. When adults talk openly and honestly with children about death, especially before the child ever faces a loss and if children are given the straight facts about death, they begin to understand death as a natural part of life, instead of something to be feared or something that happens to others and never to them or their families. This affords children the time necessary to be able to face the reality of death and to properly mourn, and as a result, attain a positive outcome to their grief process.
BIBLIOGRAPHY Bolby J: Attachment and Loss: Loss, Sadness and Depression-Volume III. New York, Basic Books, 1980. Cline, KD: A Family Guide to Helping Children Cope. California, American Cancer Society, 1988. Corr CA: Eight myths about children, adolescents and loss. In: Doka KJ, ed. Living With Grief, Washington, DC, Hospice Foundation of America, 2000, p. 33. Corr CA: What do we know about grieving children and adolescents?. In: Doka KJ, ed. Children, Adolescents and Loss: Living With Grief. Washington, DC, Hospice Foundation of America, 2000, p. 28. Doka KJ, ed: Children, Adolescents and Loss: Living with Grief. Washington, DC, Hospice Foundation of America 2000. Doka KJ: Using ritual with children and adolescents. In: Doka KJ, ed. Children, Adolescents and Loss: Liv-
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661 ing with Grief. Washington, DC, Hospice Foundation of America, 2000, p. 154. Doka KJ, ed: Children Mourning, Mourning Children. Washington, DC, Hospice Foundation of America, 1995. Dyregrov Atle: Grief in Children: A Handbook for Adults. London, Jessica Kingsley Publishers, 1990. Fitzgerald H: The Grieving Child. New York, Simon & Schuster, 1992. Grollman Earl: Bereaved Children and Teens: A Support Guide for Parents and Professionals. Boston, Beacon Press, 1985. Grollman EA: Grieving children: Can we answer their questions?. In: Doka KJ, ed. Children Mourning, Mourning Children. Washington, DC, Hospice Foundation of America, 1995, p. 21. Huntley T: Helping Children Grieve. Augsburg, Augsburg Fortress, 1991. Kroen WC: Helping Children Cope with the Loss of a Loved One. Minneapolis, MN Free Spirit Publishing, Inc, 1996. Osterweis M, Solomon F, Green M, eds: Bereavement: Reactions, Consequences and Cure. Washington, DC, National Academy Press, 1984. Pennells Sr., M, Smith, SC: The Forgotten Mourners: Guidelines for Working with Bereaved Children. London, Jessica Kingsley Publishers, 1995. Seibert D, Drolet JK, Fedro JV: Helping Children Live with Death and Loss. Carbondale, IL, Southern Illinois University Press, 2003. Schuurman DL: The use of groups with grieving children. In: Doka KJ, ed. Children, Adolescents and Loss: Living with Grief. Washington, DC, Hospice Foundation of America, 2000, p. 175. Silverman P: When parents die. In: Doka KJ, ed. Children, Adolescents and Loss: Living with Grief. Washington, DC, Hospice Foundation of America, 2000, p. 221. Silverman P, Nickman S, Worden W: Detachment revisited: The child’s reconstruction of a dead parent. In: Doka KJ, ed. Children, Adolescents and Loss: Living with Grief. Washington, DC, Hospice Foundation of America, 2000, p. 131. Walsh, F, McGoldrick, M: Living Beyond Loss: Death in the Family, 2nd ed. New York, W.W. Norton, 2004. Webb NB: Play therapy to help bereaved children. In: Doka KJ, ed. Children, Adolescents and Loss: Living with Grief. Washington, DC, Hospice Foundation of America, 2000, p. 78.
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662 Wolfelt A: Helping Children Cope with Grief. Bristol, Accelerated Development, 1983. Wolfelt A: A Child’s View of Grief: A Guide for Caring Adults. Houston, TX, Service Corporation International, 1990. Worden, JW: Children and Grief: When a Parent Dies. New York, Guilford Publications, 2001.
RESOURCES FOR GRIEVING CHILDREN Books for Children Aliki: The Two of The. New York, Harper Publisihers, 1987. Blackburn LB: The Class In Room 44-When A Classmate Dies. Omaha, NE, Centering Corporation, 1991. Boulden JJ: Saying Goodbye. Weaverville, CA, Boulden Publishing, 1992. Brown, LK, Brown MT: When Dinosaurs Die: A Guide to Understanding Death. Boston, Little, Brown Books, 1996. Brown MW: Dead Bird. New York, Harper Collins, 1995. Buchanan-Smith D: A Taste of Blackberries. New York, Harper Collins, 1992. Buscaliglia L: The Fall of Freddie the Leaf. Austin, TX, Holt, Rinehart and Winston, 1982. Clifton L: Everett Anderson’s Goodbye. Austin, TX, Henry Holt & Company, Inc., 1988. DePaola T: Nana Upstairs, and Nana Downstairs. New York, Penguin Young Readers, 2000. Douglas R: Rachel and the Upside Down Heart. New York, Penguin Group, 2006. Fassler J: My Grandpa Died Today. New York, Behavioral Publications Co., 1971. Harris RH: Goodbye Mousie. New York, Margaret K. McElderry Books, 2001. Hazen, Barbara Shook: Why Did Grandpa Die? New York, Random House Children’s Books, 1985. Heegaard M: When Someone Very Special Dies. Minneapolis, Woodland Press, 1998. Johnson J, Johnson M: Tell Me, Papa. Brooklyn, Center for Thanatology, 1980. Krementz J: How it Feels when a Parent Dies. New York, Knopf, 1991. Levine Jennifer: Forever in My Heart. Burnsville, NC, Compassion Books, 1992. McNamara Jill: My Mom is Dying. Minneapolis, Augsburg Fortress, 1994. Parker MB: Jasper’s Day. Tonawanda, NY, Kids Can Press, 2002.
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Romain T: What on Earth Do You Do When Someone Dies?. Minneapolis, Free Spirit Publishing, 1999. Schwiebert P, DeKlyen C: Tear Soup. Portland, OR, Grief Watch, 1999. Shavatt D, Shavatt E: My Grieving Journey Book. Mahwah, NJ, Paulist Press, 2001. Simon N: The Saddest Time. Park Ridge, IL, Albert Whitman, 1986. Van-Si L, Powers L: Helping Children Heal From Loss. Portland, OR, Portland State University, 1994. Viorst J: The Tenth Good Thing About Barney. New York, Atheneum, 1972. Wilhelm H. I’ll Always Love You. New York, Dragonfly Books, 1988. Winsch JL: After the Funeral. Mahwah, NJ, Paulist Press, 1995. Wolfelt A: Healing Your Grieving Heart: 100 Practical Ideas for Kids. Ft. Collins, CO, Companion Press, 2000. Yolen Jane: Granddad Bill’s Song. New York, Penguin Young Readers, 1998. Zalben Jane: Pearl’s Marigolds for Grandpa. New York, Simon & Schuster, 1997.
Books for Teens: Blume J: Tiger Eyes. New York, Random House, 1982. Fitzgerald H: The Grieving Teen: A Guide for Teenagers and Their Friends. Wichita, KS, Fireside (also available in downloadable digital edition), 2000. Fry VL: Part of Me Died, Too: Stories of Creative Survival among Bereaved Children and Teenagers. New York, NY, Dutton Books, 1995. Gootman M: When a Friend Dies: A Book for Teens About Grieving and Healing. Minneapolis, Free Spirit Publishing, 2005. Gravelle K: Teenagers Face to Face with Bereavement. Englewood Cliffs, NJ, Silver Burdett Press, 1989. Grollman EA: Straight Talk about Death for Teenagers: How to Cope with Losing Someone You Love. Boston, MA, Beacon Press, 1993. Grosshandler-Smith J: Coping when a Parent Dies. New York, Rosen Publishing Group, Inc, 1995. Hughes L: You Are Not Alone: Teens Talk About Life After The Loss of a Parent. New York, Scholastic, Inc., 2005. Kolf JC: Teenagers Talk about Grief. Grand Rapids, MI, Baker. Publishing Group, 1990. Krementz J: How it Feels When a Parent Dies. New York, Knopf, 1988.
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Myers E, Adams K: When Will I Stop Hurting? Teens, Loss, and Grief. Lanham, MD, Rowman & Littlefield Publishers, Inc., 2004. Meyers K: Truth about Death and Dying. New York, Facts on File, Inc., 2005. Samuel-Traisman E: Fire in My Heart, Ice in My Veins: A Journal for Teenagers Experiencing a Loss. Omaha, NE, Centering Corporation, 1992. Wolfeldt A: Healing Your Grieving Heart for Teens: 100 Practical Ideas. Fort Collins, CO, Companion Press, 2001.
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Internet Resources: http://www.centerforloss.com/. http://kidsaid.com/. http://www.newhope-grief.org/teengrief/. http://www.wnyafn.com/teengrief/. http://www.dougy.org/. http://www.centeringcorp.com/catalog/index.php. http://www.compassionbooks.com/store/. http://santaclaracountylib.org/kids/lists/death dying grieving.html.
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SELF-ASSESSMENT QUESTIONS 1. All of the following are myths associated with children and grief in this culture EXCEPT? A. It is best to protect a child from experiencing grief B. Children should only be allowed to attend funerals and memorials if they choose to C. Children do not have the capacity to really understand death and grief D. Children are more resilient than adults and quickly “bounce back” after a loss 2. All of the following are considered typical grief reactions for infants and toddlers (until about age 4) EXCEPT: A. Anxiety related to the separation from a major attachment figure B. Understanding that death is final and irreversible. C. Irritability, protest, and crying D. Changes in eating and sleeping patterns E. Do not envision that death is something that can happen to them 3. All of the following are considered the important factors that influence how a child and teenager respond to grief and loss EXCEPT: A. Developmental level and chronologic age B. Nature of the relationship with the person that has died C. Child’s own personality D. What they are taught about death and grief from adults E. Whether they know how to read or not 4. Which of the following behaviors exhibited by a child to the loss of a significant loved one is most likely to require trained, professional help to resolve? A. Memory difficulties B. Searching behavior C. Difficulty concentrating
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D. Preoccupation with memories of the deceased E. Idealization of the deceased 5. According to Alan Wolfelt, all of the following characteristics indicate that a child is beginning to adjust to the loss of a significant loved one EXCEPT: A. Return to stable eating and sleeping patterns B. Decision to forget their loved one and move on C. Increased thinking and judgment capabilities D. Establishment of new and healthy relationships. 6. Which of the following is considered a complicated grief reaction in a teenager? A. Assuming mannerisms, traits or wearing clothes of the deceased. B. Emotional regression and even bed-wetting, which can be most upsetting for teenagers. C. Becoming overly responsible (the “new” man or woman of the house) D. Prolonged sleep disturbances, including insomnia and nightmares E. Needing to repeat again and again stories of their loved one 7. All of the following are considered behaviors associated with complicated grief in a child or teenager EXCEPT: A. Excessive rumination about having caused the death B. Extreme withdrawal, isolation, and inability to socialize with others C. Pervasive fantasies that get in the way of normal functioning D. Anger and lashing out seemingly for no reason E. Persistent assumption of the mannerisms of the deceased, including those not developmentally appropriate
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9-780-7817-XXXX-X MCGH172-Kinzbrunner
Chapter 27
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Grief and Bereavement in Children
8. All of the following are considered appropriate interventions in preparing a child for the death of a loved one EXCEPT: A. It is important to wait to tell the child until just before the loved one dies so the child does not carry unnecessary anxiety prior to the death. B. The child should be told that the images they see of death in television cartoons are not always authentic and that death is irreversible C. The adult should use adjectives like “very very old” or “very very sick” to help the child distinguish between getting a cold and someone with a terminal illness D. If the child is old enough to understand what is happening and both the child and the dying person would like the visit, the child should be allowed to visit. E. If the child does not want to visit, a supportive adult should attempt to elicit why the child is resistant, but the child’s wishes should be honored. 9. All of the following are helpful interventions by an adult who is trying to help a grieving child EXCEPT:
November 16, 2010
665 A. Assure the child with specifics about how his or her care giving needs will be met. B. Keep the child in their environment and continue their routine as much as possible C. Tell the child that God wanted their loved one and that is why he or she died can be comforting to a child. D. Adults should not use children as their sole support during their grief. E. Respect a child’s desire to not talk about their grief 10. All of the following are helpful interventions that an adult can use with a grieving child who is angry EXCEPT: A. Be direct and ask the child to “calm down.” B. Help the child dissipate the anger by running or exercising C. Involve the child in art work such as scribbling, ripping paper, sculpting dough, etc. D. Ask questions like, “What usually leads to your feeling angry?” “How does your body tell you that you are becoming angry?” E. Ask the child what he or she thinks are more appropriate ways of responding to angry feelings.
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P1: OSO/UKS
P2: OSO/UKS
MCGH172-27
9-780-7817-XXXX-X MCGH172-Kinzbrunner
QC: OSO/UKS
T1: OSO November 16, 2010
666
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