CHILDREN AND GRIEF

1. Identify at least three factors that can affect children and how they grieve.
2. List five reactions that a child may experience in grief.
3. Describe the three tasks for grieving children and what helps at each stage.
4. Explain the reflection technique.

Three weeks after my husband died, I was back in the same emergency room with my six year old daughter. My four year old had come with us since it was 2:00 a.m. and I didn't have anyone to watch him. While the staff was assisting my daughter, I noticed my son wandering down the hall looking in all the cubicles. When I called to him to return, he looked at me and said, "but mommy, this is where we left daddy. I am just going to get him." My heart sank. He knew his dad had died. He had seen him dead. He had attended the funeral and the burial. Didn't he remember?

Since death is part of life, it can only be expected that some children will experience a death early in their lives. Children are unique in their grief. Their reactions depend upon the answers to many questions. Some of these include:

• What is the age and maturity level of the child?
  
• Does the child understand the meaning of the words "died" and "dead"?
  
• Has the child experienced a death prior to now?(family pet, grandparent, parent, classmate, teacher, etc.)
  
• How was the child related to the deceased? How well did they know each other?
  
• What are the family's religious beliefs about death?
  
• What are the circumstances surrounding the death?
  
• What is the child's usual pattern of coping?1
  

This information will provide a basis of where to start with the child and their family. Most of all - BE HONEST. If you don't know the answer, say so; or if the family has asked you not to say, direct the child back to a family member.

Children do not have the comprehension level that adults do to understand the finality of death. They grieve sporadically. They also grieve developmentally. With each developmental stage a child has more information and will re-process their loss. A young child has no concept of time. When you say, " they have died and are not coming back forever", the child may return in an hour and ask if it is forever.

As founder of The Sharing Place, I have adopted and believe in four basic principles related to children and grief:

1. Grief is a natural reaction to the loss of a loved one for children and adolescents as well as adults.
2. Within each of us is the natural capacity to heal ourselves.
3. The length of time for grieving is unique to each individual.
4. Acceptance and caring assist in the healing process.

Children may experience many different reactions to grief. These may include:

• Sadness and loneliness. The child may become inconsolable and withdraw.
• Denial - refusing to believe the person died. Telling people his dad has gone on a trip and will be back. ( In my son's case, he was searching the Emergency room looking for his dad.)
• Bodily Distress - the child may complain of stomach aches, trouble sleeping, headaches. Some may worry they have the same illness/disease the deceased had. ( I had many visits to the pediatrician with my daughter so that she could be reassured there was nothing wrong with her heart.)
• Anger - a normal and healthy grief reaction that needs to be expressed in appropriate ways. Sometimes anger is directed at the deceased (Why did you leave me?"), at others ("The doctors killed my brother!"), or at God or self. (At The Sharing Place we have a volcano room where children can go and throw pillows and scream and yell as loud as they want and still feel safe.)
• Guilt - children learn early that negative things happen when you are "naughty." Some children believe that they somehow "caused" the death of a loved one because they misbehaved, they argued with the deceased, etc. Children who may have resented the upcoming birth of a sibling may feel responsible if the baby dies. They need constant reassurance that they are not responsible for the death.
• Depression - children may feel helpless, lethargic, apathetic, alone, withdrawn. Assumption of mannerisms of the deceased - Children will ask, "do I look like mom?" They may try to imitate walking or talking patterns of the deceased.
• Idealization of the deceased - "Mommy was perfect." "Daddy would have let me do this." "Joey was good at everything.!" Anxiety and Fear - "I feel like daddy did when he died; I have a pain in my chest." "I hurt my hand. Will it turn into cancer?" "Can I catch Mary's disease?"
• Panic- "Who will take care of me now?" "What if something happens to Mommy now?" "How will we get money to live?" Some children express fears about going to school and leaving a surviving parent alone. Children need constant reassurance that they are loved and will not be abandoned.
• Regression - Occasionally some children may regress to younger behavior patterns such as thumb-sucking and bed-wetting. School Problems - It is not uncommon for children who are grieving to have difficulty concentrating on schoolwork. Some "acting out" behavior may also occur as children attempt to deal with grief, especially anger. A counselor, psychologist, or supportive teacher can be a great asset at this time. 2

At The Sharing Place, we believe that there are three tasks of grieving for children.3 The first task is to understand that the person is dead. This is a thinking process. Children want to know what happened. They need honest, direct, factual information in order to understand that the person is dead. Curiosity and speculation about the facts of the death are healthy during this process. The word "dead" will be used by children before they understand the meaning of it. Many children will over generalize a concept at first. If dad died in the hospital, then all people in the hospital will die. Children also rely on what they know. What they know about death, many times, is drawn on what they see on T.V. The roadrunner is hit by a car, appears dead and is back on T.V. the next day just fine. It is helpful to provide truthful answers as questions are asked. They may ask the same question over and over. Be honest in your answers. Use correct language - "dead" or "died" not "lost" or "gone to sleep". They are trying to make sense of what has happened. Include the child in funeral arrangements. Let the child decide their level of involvement. Children learn from adults. It is o.k. to cry in front of the child and share your sadness as long as the child does not become a major caregiver for the adult.

The second task is to feel the feelings about the person dying. This is a feeling process. Grief becomes a feeling in our bodies of the "goneness" of the person that has died. It is physical. We cry, have sleepless nights, eat or don't eat, and we need physical outlets to cry, yell, hit, walk or run. Movement and play is the language for children. Many times they can't put words to what they feel. Children, as well as adults, will use defenses. These will include being combatitive/acting out, overachieving, and withdrawing. Children often feel that they may have been somehow responsible for the death. This is a child's natural and unrealistic sense of their own power.

How can you help during this time? Listen and allow the child to express their feelings. Encourage safe physical expression found in sports and active play. Reflect back to the child what they are doing in language and play rather than ask questions and interpret. Lower your expectations of the child. Reassure the child with the facts that show they could not have prevented the death. For example, if a child says, "my dad wouldn't have died if I were driving the car", you should reflect back and say, "but, nine year olds can't drive cars". If the child's behavior is becoming more negative, they may need to be referred for professional therapy.

The third task is to go on living and loving after the person has died. This is a faith process. There are many ways to come to terms with the death. Children will try to "fill the hole" left by someone with other activities or relationships. They will learn over time to "live with it." The person that died is still a part of their lives in their memories. When they begin to heal, they move from "why did it happen?" to "what can I do now?" to "how am I going to do it?". At times, children that are grieving start having fun and then feel guilty and disloyal to the dead one. Encourage children to take time out from their grief, explain that it is o.k. to be sad and have fun at the same time. Believe that the child will return to wellness even when they cannot. Celebrate and honor the steps they take towards healing. Be aware of your own grief as a professional, your own need for support and allow yourself "time out" away from grief.

Reflection is a technique used to work through grief with children. Reflection is defined in the dictionary as a "bending back" or "a giving back a likeness or image as a mirror does." Reflective listening is a process of giving back what the child has spoken. It is not parroting or repeating word for word. It is taking the threads provided by the child using only the colors provided. Reflection is not only based on the content and words but also the tune and rhythm with which they are spoken. When using this with children you must match the child's intensity, flow and pace. An example:
Child: "I'm Jason, and my mom died."
Listener: "Your mom died."
Child: "Yeah, a mean woman was driving and banged her car."
Listener: "A women banged her car."
Child: "And the ambulance came late so she died."
Listener: "Your mom died."

It is not necessary to correct the content of what the child is saying. Reflection connects more to feelings than to information. An exception to this is when the child takes responsibility for the death. The usual tendency is to convince children of their innocence. It is important to understand guilt as a defense mechanism. It can protect the child from acknowledging their powerlessness to stop bad things from happening. Here is an example of reflective listening for the child who said his dad would not have died if he had been driving the car:
Child: "If I were driving the car, he wouldn't have died."
Listener: "Well, actually, 9 year old's aren't old enough to drive cars."
Child: "Yeah, but if I were driving the car, he wouldn't have died."
Listener: "You believe he wouldn't have died..."

In this example, we have allowed the function of guilt to remain and have stayed with reflecting what the child said.
As a health care provider, we are forever wanting to "fix" things. Children in grief do not need to be "fixed." Instead, they need us to be supportive and take the cues from them for what they need. At times, children will need outside intervention. How do you know what is normal and what is abnormal? First of all, trust your instincts. A child may need outside intervention if they exhibit total denial that the death has occurred; if the relationship with the deceased was not on good terms; if school work takes a dramatic decline; if a child threatens suicide or panics frequently; and or, if their socialization with friends and family members changes dramatically. Depression is a normal part of grief. Signs of clinical depression vs. normal grief depression includes someone that will not accept any support, does not relate their depression to the particular event that has occurred, has chronic physical complaints vs. transient physical complaints and a loss of self-esteem is of greater duration and not temporary.4

Working with children in grief is rewarding and challenging. I am forever learning from them. A metaphor, written by Susan Whitney, best describes a way to translate your caring and acceptance to a child's grief process. "As you approach a child who has had a loved one die, it is as if you are standing on the shore of the turbulent waters of grief. The child is in her rowboat, holding the oars, looking a little fearful. You ask, "Can I ride with you for awhile?"

Depending on the child's experience, she may jump at the opportunity to have company. Or, she may hesitate, wondering if she can trust you. Some adults, at so many different ports, have jumped in her boat without asking, taken the oars and directed the route. She may by now feel that this is not, indeed, really her boat. Her inner doubts may be a voice telling her she probably isn't smart enough or strong enough or good enough to ever be in charge of her own boat again. She may not even know how to respond when we ask simply to be with her as she takes this rough ride.

But as we do, and if she invites us, we step in, ever so carefully, trying to balance the weight, trusting in all her skills and abilities. She then takes the oars and rows the boat out into the river on a journey of her choosing. Sometimes she may get tired and ask us to take an oar; we follow her lead, her pace. She may even want us to row the boat for awhile; we do so with an ever-watchful eye for cues when she wants the oars returned.

If we suddenly see dangerous rapids ahead, we are surely and strongly going to take the oars and steer the boat away from the threat and into safer waters. Once there, we return the oars, remembering it is her boat, her journey; and she is in charge. Our trust in her abilities will comfort and sustain her, and she will reach her destination strong and intact. Her boat may have a few chips; the trip may have taken longer; she may have gotten lost sometimes. But having arrived, she will stand on the firm ground of her dignity, take full ownership of her boat and possess a deep trust in her future journeys. We will be forever changed for having had the privilege of traveling with another child towards her healing."5

To earn 2.0 Continuing Education contact hours please send this answer sheet along with a check for $10 (UNA members) or $15 (Non - UNA members) to:
Utah Nurses Association

3761 South 700 East
Suite 201
Salt Lake City, UT 84106
phone 801 293-8351

1. True
2. False

1. sadness and loneliness
2. guilt
3. depression
4. idealization
5. all of the above

1. True
2. False

1. True
2. False

1. True
2. False

1. True
2. False

1. True
2. False

1. feel the feelings about the person that died, understanding the death, go on living and loving after the person has died.
2. go on living after the death, getting questions answered related to the death, forgetting about the person.
3. celebrate the death, honor the person, go on living.
4. understand that the person is dead, feel the feelings about the person dying, go on living and loving after the person has died.

1. True
2. False

1. True
2. False

1. Yes
2. No

1. Yes
2. No

1. Yes
2. No