Grief and Loss for Children

1. Grief and Loss for Children Mary Hildreth and Melanie Hickey Bereavement Coordinators Iowa Hospice

2. Objectives Define loss, mourning, grief and bereavement. Distinguish between anticipatory grief, normal grief, complicated grief and disenfranchised grief and how it can be different for children. Learn about treatment interventions to use with children to teach coping strategies for their grief.

3. What does grief look like?

4. Is this what grief should look like?

5. What about this child?

6. Are they grieving?

7. What about this boy?

8. The Grief Process • “There are no mistakes, no coincidences. All events are blessings given to us to learn from.” • ~Elisabeth Kubler Ross~

9. Grief is a multi-faceted response to loss, particularly to the loss of someone or something to which a bond was formed. Although conventionally focused on the emotional response to loss, it also has physical, cognitive, behavioral, social, and philosophical dimensions. (Wikipedia) • The loss may be a person, thing, relationship, or situation. • Bereavement is the reaction of the survivor to the death of a family member or close friend.

10. Children and adolescents may experience grief differently from adults • They may react differently to the death of someone close to them or even when experiencing a loss just from being apart from their family, whether in a group home or in foster care. • When working with children who have experienced any type of loss, it is important to be aware of their developmental stage and any cultural considerations.

11. Normal Grief (Uncomplicated) • Normal feelings, behaviors and reactions to loss • Physical, emotional, cognitive and behavioral reactions.

12. Types of Grief • Anticipatory Grief • Normal Grief (Uncomplicated) • Complicated Grief • Disenfranchised Grief • Children’s Grief

13. Anticipatory Grief • Grief before loss • Actual or fear of potential losses • Experienced by patient, family, and professionals • Children have unique needs

14. Complicated Grief • Chronic grief • Delayed grief • Exaggerated grief • Masked grief

15. Complicated Grief ~ Risk Factors • Sudden or traumatic death • Suicide, homicide • Death of a child • Multiple losses

16. Disenfranchised Grief • When loss cannot be openly acknowledged or socially sanctioned • At risk ~ AIDS partners, ex-spouse, step-parent/child, terminated pregnancy

17. Children’s Grief • Based on developmental stages • Can be normal or complicated • Symptoms unique to children

18. Factors Influencing the Grief Process • Survivor personality • Coping skills, patterns • History of substance abuse • Relationship to deceased • Spiritual beliefs • Type of death • Survivor ethnicity and culture

19. 5 Stages of Grief • Denial • Anger • Bargaining • Depression • Acceptance

20. Denial • “No not me” • When a person receives news of a loss be it death or another kind of loss they may be in denial that the loss actually happened. • We may tend to deny the loss has taken place and may withdraw from our usual social contact. This stage may last a few moments to a few months. • In residential care it may look like, “My family will be here soon to pick me up.” The child stands by the door and waits.

21. Anger • “Why me?” • May be furious at the person who inflicted the hurt (even if they are the one who died), or at the world, for letting it happen • May be angry with himself for letting the event take place, even if, realistically, nothing could have stopped it (magical thinking). • In residential care, “I hate Social Workers. They don’t understand me or my family. They lied about my family, my dad would not have done that!” May cry uncontrollably or become angry when asked to do simple requests.

22. Bargaining • A person can bargain with God, others, or themselves to alleviate grief. • In residential care, the child may now realize they they will be in their placement for an extended period of time. They may say, “If I’m allowed to go home, I promise to be good and do what I am told.”

23. Depression • The person first mourns past losses, things not done, and wrongs committed. • They may feel numb, although anger and sadness may remain underneath. • In residential care, “Who is going to take care of me? Did I make this happen? I give up. Why me? I’m so alone.”

24. Acceptance • The person has accepted the loss or the reason why the loss happened. They have accepted the change. • I’m here in this home, but I’m safe. This is not my fault. I did not make this happen. Adults make choices for me. I need to do my best to share my feelings with adults around me that I trust. I will get through this and be OK.”

25. Dynamic not Static • Processing grief is not a linear process and is not neat and tidy. • It is not necessary to go through all stages. • Be prepared to go back and forth between stages as needed to process the situation. • Watch for signs that someone may be stuck in one stage. They may need additional support.

26. Long term effects of bereavementon children • Up to 40% of bereaved children show disturbance after one year • 37% of prepubertal children in a recent study had a major depressive disorder within one year of the death. • Longing for reunion is common and may lead to suicidal thinking in children but not usually acted on. • Bereaved children are 5 times more likely to develop a psychiatric disorder. Coping with Loss: Bereavement in Childhood. By Dora Black

27. Age Groups • We will look at the differences in grief reactions according to developmental stages: • Birth to age 2 • Ages 2 to 5 • Ages 6 to 9 • Ages 9 to 12 • Ages 13 to 19 https://www.bariumsprings.org/pilotFiles/pdf_documents/files/Grief%20and%20Loss.pdf

28. Birth to 2 years • Types of loss would be the death of the primary caregiver, loss of primary caregiver because of the birth of a sibling, or removal from primary environment. • Sense of security and well being is challenged • Surroundings are no longer familiar • Child may display excessive crying, rocking, whining, biting, and/or other anxiety related behaviors. • Child may not be able to process death as anything other that separation anxiety.

29. Ages 2 to 5 • May have feelings of sadness, anxiety, insecurity, irritability and anger. • Tend to believe that death is a temporary state that can be reversed. • May equate death with sleeping or being gone on a trip. • Magical thinking may occur. • Some children will act as if nothing has happened while others may regress in areas such as toileting or wanting a bottle.

30. Ages 6 to 9 • Are able to understand the biology of death and comprehend the finality of it. • May develop fears associated with their own death or the death of a surviving parent • Feelings of insecurity may be expressed in a reluctance to separate from caregivers. • Some may be hyperactive, aggressive and disruptive, while others are withdrawn and sad. • May have nightmares, difficulty sleeping, or display regressive behaviors.

31. Ages 9 to 12 • Understand that death is final and that it happens to everyone. • Continuity is important at this age. They may want to go out and play instead of talking. • They may have a strong need to control their feelings while at the same time they have great difficulty doing so.

32. Ages 13 to 19 • Adolescents may have difficulty coping with the loss for months or years • Want to be in control of their emotions so may isolate from others. • May engage in risk taking behaviors such as reckless driving, drug/alcohol use, sexual promiscuity, cutting, and/or defiance of authority. • May become more easily distracted, experience sleeping and eating disturbances, perform better or worse in school, and display strong emotional mood changes.

35. BREAK

36. Death and Dying Simulation Activity

37. Grief Interventions for Survivors • Provide presence • Active listening, touch, silence, reassurance • Identify support systems • Normalize & individualize the grief process • Actualize the loss & facilitate living without deceased • Use bereavement specialist and resources

38. How can a Bereavent Counselor help? • Bereavement Counselors are trained specifically in the area of grief and loss. • They understand the different ways a person grieves • Access to various interventions to support the person • Can meet the person in their own home • Counseling is provided at no cost to the person

39. Bibliotherapy • Jungle Journey: by Barbara Betker McIntyre • Badger’s Parting Gifts: by Susan Varley • Water Bugs and Dragonflies: by Doris Stickney • Tear Soup: by Pat Schwiebert & Chuck DeKlyen

40. Hearts n Hooves • One day camp for kids ages 7 to 17 who experienced a death of a loved one. • Designed to help kids communicate sorrow, manage pain, and work through their grief by utilizing activities with crafts and horses. • 2 locations: Timber Creek Therapies in Guthrie Center and Juan Diez Rancheros in Davenport. • Open to all children who qualify and there is no cost to attend.

41. What else can we do to help? • Remember to be honest and ask what the child wants to know. • Allow the child to see your emotions and tears. • Do not try to fix the child, they need to process on their own terms. • Allow them to experience the death if appropriate and warranted. • Maintain a regular routine. • Try not to expect more than they can give.

42. Allow children to mourn small losses (pets) and be open to discussion. • Give them the opportunity to say goodbye. • Use concrete terms and use language the child will understand. • Do not make promises that are out of your control. • LISTEN!

43. Myths and Facts • I won’t say or do the right thing. *Just let them know you are there for them. • They won’t want to talk about it. *Let it be their choice, not yours. • I might upset them. *They are already upset and that is okay. • They need to keep busy. *Not thinking about it can delay their grief • Getting rid of reminders help. *This can send the message that it is not okay to think about the person who died.

44. Myths and Facts, cont. • I won’t mention unless they do. *Sends the message that there is something bad about talking and they will sense your discomfort. • Once they have felt anger or guilt, that should be the end of it. *Grief is circular and is life long. • It is morbid to want to touch or talk about the body. *This is healthy and makes the death real but do not force it. • It is easier to say “passed away”. *These phrases can confuse or frighten children. • If they are not showing emotion, they are not grieving. *They may not know how to show emotion or are taking cues from the adults around them.

45. Completion of the Grieving Process • No one can predict completion • Grief work is never completely finished • Healing occurs when the pain is less • You do not get over it, but you can get through it.

46. RESOURCES • Black, Dora. Coping with Loss: Bereavement in Childhood. March 21, 1998. BMJ Volume 316 p 931-933. • Center for Loss and Change http://www.centerforloss.com/ • The Dougy Center: National Center for Grieving Children and Families. www.dougy.org • Earl Grollman: Talking About Death: A Dialogue Between Parent and Child • Elisabeth Kubler-Ross Foundation http://www.ekrfoundation.org. • https://www.bariumsprings.org/pilotFiles/pdf_documents/files/Grief%20and%20Loss.pdf • http://journeyofhearts.org/grief/kids_death.html • Hospice Education Institute: www.hospiceworld.org • Zucker, Robert. The Journey Through Grief and Loss. 2009. St.Martin’s Press, New York