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Children Coping With Death & Dying Presented by Nora Gravois, LMSW-IPR Bereavement Coordinator for The Hospice of East Texas Objectives Clarify Definitions Distinguish normal vs complicated grief Acknowledge children’s grief process & needs of grieving children Identify effective communication to talk to children about death and dying Encourage professional self care

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Objective: Clarify Definition Bereavement Bereavement is the state of having suffered a loss. Objective: Clarify definition

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Grief Process of experiencing the psychological, social, physical and spiritual reactions to the perception of loss. Objective: Clarify definition

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A normal mourning reaction that allows emotional preparation for the loss. Anticipatory Grief Objective: Clarify definition

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Mourning Conscious and unconscious processes that help the mourner adapt to the loss. Objective: Clarify definition

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Reinvestment/Accommodation Reinvesting emotional energy into new constructive outlets. Preparing to “embark” Objective: Clarify definition

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Children’s Grief Should we discuss death and dying with Children? Shielding a child from conversations about death and dying deprives them of their own right and need to grieve of their need to mourn of their need to feel and heal of their need to experience reinvestment

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Children’s Grief Why should we talk to children about death and dying? If we don’t Conveys a message of avoidance Avoidance lead to unhealthy feelings and emotions Unresolved worry, fear Increased anxiety, apprehension Develops seeds for resentment and distrust Opportunity for unhealthy lifelong coping patterns Objective: Effective Communication with Children

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Children’s Grief Why should we talk to children about death and dying? If we do We will discover what is known vs. not known Clear up distorted thinking Resolve fears, worries Provide needed information Demonstrate comfort, understanding Promote growth, coping skills Strengthen bond of supportive relationships Assurance and security lead to healthy coping Child learns to understand grief as part of life cycle that will support throughout life Objective: Effective Communication with Children

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Children’s Normal Grief Reactions May be emotional Self blame Guilt Fears Helplessness/Hopelessness Anger Withdrawn Increased Anxiety May be Spiritual Challenges to belief system Physical Confusion A LOT of questions “Why’s” Where did he/she go? What is “dead”? Objective: Distinguish Normal vs Complicated Grief

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Children’s Normal Grief Reactions May be Physical / Behavioral Changes in appetite Sleep disturbances Nightmares Physical hurts Hyperactivity Aggressive reactions Increased volume/tone in speech Passive reactions Limited conversations, introverted May be Cognitive Reduced attention span Increased distraction Easily confused Exaggeration Magical thinking Objective: Distinguish Normal vs. Complicated Grief

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Complicated Grief DSMIV-TR Symptoms overlap with depression diagnosis Refusal to accept loss Continued sense of disbelief, anger Recurrent painful emotions Preoccupation with thoughts of loved one Distressing intrusive thoughts related to death Intense longing and yearning Referred to as traumatic, altered, pathological, dysfunctional, abnormal, absent, inhibited, delayed, disenfranchised NO SENSE OF RELIEF, REST OR SUPPORT Objective: Distinguish Normal vs Complicated Grief Prolonged, intense reactions that interfere with daily function 6 months or longer

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Social interactions increase support and risk Tween & Teen individuation stretches adult-child relationships Increased possibility of unfinished business Increased possibility of anger, guilt, depression Objective: Distinguish Normal vs Complicated Grief Complicated Grief Implications

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Objective Assessment Tearfulness and general sadness Expression of emotions Physical Reactions Ability to Focus Desire & Motivation Ability to Function w/ daily activities Objective: Distinguish Normal vs Complicated Grief Normal Anticipatory Complicated ************************************************************

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Children’s Grief Concepts 0-2 years LM Aldrich, William Worden, Dan Schaefer, Christine Lyons Understanding: Does not comprehend death Aware of constant activity in home, others looking “sad”, someone is “missing” Reactions: Responds to emotions or feelings of adults Crankiness, Crying, Vomiting Regression in Toileting, Altered eating and sleeping Clinging, Restless, Insecure, Scared NEED: Reassurance Wrap infant in soft blanket, maintain routine, physical assurance through holding, quick attention to expressed reactions and needs Objective: Acknowledge Needs of Grieving Children

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Children’s Grief Concepts 2-5 years LM Aldrich, William Worden, Dan Schaefer, Christine Lyons Objective: Acknowledge Needs of Grieving Children Understanding: Mostly live in present tense Curious about death and life; see it as temporary, reversible Death mixed up with trips, sleep, happens to other people Engage in Magical, exaggerated thinking Wonder what deceased is doing “underground” Reactions: Trying to “Figure it Out” May show little concern or Regress to infantile behavior, Fear separation Need to talk about the death over and over, Confused NEED: Consistency Short explanations with real terms, fact of death, no catchy sayings, Consistent Expectations for behavior Respond to security needs Don’t punish, instead explain and teach with repetition Let the child tell the story over again

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Children’s Grief Concepts 6-9 years Objective: Acknowledge Needs of Grieving Children “This particular group should be singled out for special concern. They have insufficiently developed social skills to enable them to defend themselves.” …William Worden

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Children’s Grief Concepts 6-9 years LM Aldrich, William Worden, Dan Schaefer, Christine Lyons Understanding: Clearer Comprehending that they can die too; begin to question biology of death Begins to fear Death; realize that death is final; people they love can Reactions: Highly emotional Crying, high anxiety, anger, cranky, aggression, hyperactivity Decline in school performance, involvement Greif reactions ebb and flow; less willing to talk about death More fearful questions and thoughts about “what will happen if…” NEED: Honesty Refrain from using cliché's Respond passionately; be responsive without judgment Reassurances with clear expectations of appropriate behavior Use of art and stories Objective: Acknowledge Needs of Grieving Children

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Children’s Grief Concepts 9 - 12 years Objective: Acknowledge Needs of Grieving Children “This age concentrates on the disruption death causes.” “Do we have to move because daddy died?” ”Now grandpa won’t be able to take me fishing”. …William Worden

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Children’s Grief Concepts 9 -12 years LM Aldrich, William Worden, Dan Schaefer, Christine Lyons Objective: Acknowledge Needs of Grieving Children Understanding: Death is very personal A more realistic view of death; can differentiate between dead and alive Increased curiosity / research about biological aspects of death Begin to understand that death is “forever” Reactions: Separation Anxiety Fear, reluctant to leave safe adults or home Boys may lose some manual skills; aggression appears hostile Anger, Guilt, Distancing, Anxious, Worried, Isolated Decline in performance, grades, involvement NEED: Permission with appropriate expectations Give compassionate answers, comfort, reassurance Permission to vent feelings; provide honest explanation of death Listen attentively, Use appropriate touch (with permission) Include in discussion of ways to honor & remember loved one

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Children’s Grief Concepts Teen years LM Aldrich, William Worden, Dan Schaefer, Christine Lyons Objective: Acknowledge Needs of Grieving Children Understanding: More adult processes evident Able to think abstractly; Understands implications of death Talks about feelings of immortality; realize death is fragile Reactions: Assumes the adult role Fearful of future, preoccupied with thoughts of death May need to protect or stay close to loved ones Anger and aggression, May exhibit “risk-taking” behavior Withdrawn, Quiet, Loud, Lonely, Sad, Worried NEED: Communication & Connection Encourage communication “when you can” Physical touch very important, but ask permission Engage in loving confrontation Involve trusted friend Provide professional help if necessary

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Common Misconceptions “Children do not understand death” “Children will be scared if they find out the truth” “Children don’t grieve” “Children don’t really know what’s going on” “Children are just little adults” “Talking makes it worse” “Silence means okay” “Attending a funeral is not good for Children” “It’s best not to bring it up” “Child is young, won’t remember” Objective: Acknowledge Needs of Grieving Children

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Common Mistakes that Adults Make Minimize expressions of grief Avoid the Grieving PROCESS Assume a child is not grieving because of laugher or play Use cliché's like ‘God’s will’, Or ‘God took her because she was so good’ Avoid opportunities To allow expression and understanding of feelings Stop telling stories Think all children feel the same Use euphemisms like ‘he died in his sleep’, ‘crossed over’, or ‘we lost her” Not talk about their own grief, and how support, strength is found Objective: Acknowledge Needs of Grieving Children

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Talking to Children about Death & Dying Children need to feel safe and secure. Keep discussions developmentally appropriate. Try not to put up barriers that may inhibit their attempts to talk. Be sensitive to their desire to talk when THEY are ready. Objective: Acknowledge Needs of Grieving Children

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Talking to Children about Death & Dying Offer honest, simple, straightforward explanations. Use concrete vocabulary, such as “die”, death, or “dying”. Listen and accept feelings…. create an environment within the family system that makes it okay to talk; offer permission to feel & be. Provide brief and simple answers that are appropriate to the question asked; do not overwhelm with too much information. Be ready for “spurts”… when a child is ready for more information, questions will be asked. Objective: Acknowledge Needs of Grieving Children

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A Child’s Tasks of Mourning Experiencing the Pain of Grief Provide a time and place to grieve Recognize that the first days are the most chaotic Provide opportunities for expression Anticipate critical times when intensity may be high Expect more difficulty 6-9 months later Objective: Acknowledge Grief Process

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A Child’s Tasks of Mourning Accepting the Reality of Loss Acknowledge the loss each time it comes up Encourage to say aloud what is “missing” at that moment Talk about “new reality” in structured manner Stick to facts, what is known, or information learned Objective: Acknowledge Grief Process

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A Child’s Tasks of Mourning Adjusting to an environment Talk about how things are different now Encourage to say aloud the things their loved one used to do Brainstorm who can do those things now (not replace, but embrace) Recognize the “empty space” Involve children in problem solving to handle reminders Plan events that honor presence in life and death Objective: Acknowledge Grief Process

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A Child’s Tasks of Mourning Reinvesting emotional energy Resolution of loss is a focus on the meaning of the life, not the death Select memorial activities, events that honor the life Discover things “in common” that express honor Decrease attention on expressions of continual trauma reminders Increase attention on expressions of good life lived Validate efforts made by the child to embark on “new normal” Heart Equation T + T = H T Objective: Acknowledge Grief Process

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KEEP IN MIND ~ Children Need To feel safe in confusion Routine, Order, and Stability Designated Safe Place Comfort Do not reject their emotions or their efforts to comfort you Permission Do not tell them How to feel or How Not to feel Assurance of being okay Patience They will ask questions over and over Opportunities to say goodbye Death is not contagious…be sure to differentiate. Children tend to idolize the dead Gently help children regain balance and perspective

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Compassion Fatigue Objective: Self Care Skills May be manifested as anger, anxiety, blame, helplessness, guilt May look cynical, or appear as decrease in tolerance or sensitivity May feel difficult maintaining hope May take the form of a chronic or delayed grief response …no satisfactory conclusion. Professional caregivers are distant mourners Effects of professional grief are hidden & subtle Professional losses accumulate Is a significant cause of burnout

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So What About YOU? PRACTICE SELF-CARE Objective: Self Care Skills Be aware of professional boundaries Maintain Balance with ongoing self monitoring Learn to express professional grief in appropriate ways Let others know what you need Treasure relationships Draw on support Be patient with yourself Manage Stress Say Goodbye Tend to Basic Health Needs Sustain Family Support Nurture Friendships Relax, Rest, Rejuvenate Laugh Attend Peer Meetings Be Nice to Yourself Acknowledge your feelings, grief reactions, and experiences of loss as part of your journey

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Grief is a Journey A little laugh A little hope A little promise Nora Gravois, LMSW-IPR Bereavement Coordinator The Hospice of East Texas 4111 University Blvd. Tyler, Texas 75701 www.hospiceofeasttexas.org (903) 266-3447 direct line

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Resources for Children Coping with Death & Dying Karaban, Roslyn A. Ph.D: Complicated Losses, Difficult Deaths, 2000 Rando, Therese A, Grief, Dying and Death, 1984. Schaefer, Dan, Ph.D., & Lyons, Christine: How Do We Tell the Children, 1986 DSMIV-TR Numerous works of: Elizabeth Kubler-Ross Dale Larson Alan Wolfelt William Worden

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