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Children Coping With Death & DyingPresented 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
Objective: Clarify DefinitionObjective: Clarify Definition
BereavementBereavement is the state of having suffered a loss.
Objective: Clarify definition
GriefProcess of experiencing the psychological, social, physical and spiritual reactions to the perception of loss.
Objective: Clarify definition
A normal mourning reaction
that allows emotional preparation for the loss.
Anticipatory Grief
Objective: Clarify definition
MourningConscious and unconscious processes that help the mourner adapt to the
loss.Objective: Clarify definition
Reinvestment/AccommodationReinvesting emotional energy into new constructive outlets.
Preparing to “embark”
Objective: Clarify definition
Children’s GriefChildren’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
Children’s GriefChildren’s Grief
Why should we talk to children about death and dying?
If we don’tConveys a message of avoidance
Avoidance lead to unhealthy feelings and emotions
Unresolved worry, fearIncreased anxiety, apprehension
Develops seeds for resentment and distrustOpportunity for unhealthy lifelong coping
patternsObjective: Effective Communication with Children
Children’s GriefChildren’s Grief
Why should we talk to children about death and dying?
If we doWe will discover what is known vs. not known
Clear up distorted thinkingResolve fears, worries
Provide needed informationDemonstrate comfort, understanding
Promote growth, coping skillsStrengthen bond of supportive relationships
Assurance and security lead to healthy copingChild learns to understand grief as part of life
cycle that will support throughout lifeObjective: Effective Communication with Children
Children’s Normal Grief ReactionsChildren’s Normal Grief ReactionsMay be emotional
Self blameGuiltFears
Helplessness/HopelessnessAnger
WithdrawnIncreased Anxiety
May be SpiritualChallenges to belief system
Physical ConfusionA LOT of questions
“Why’s”Where did he/she go?
What is “dead”?Objective: Distinguish Normal vs Complicated Grief
Children’s Normal Grief ReactionsChildren’s Normal Grief ReactionsMay be Physical / Behavioral
Changes in appetiteSleep disturbances
NightmaresPhysical hurtsHyperactivity
Aggressive reactionsIncreased volume/tone in speech
Passive reactionsLimited conversations, introverted
May be CognitiveReduced attention span
Increased distractionEasily confused
ExaggerationMagical thinking
Objective: Distinguish Normal vs. Complicated Grief
Complicated GriefComplicated GriefDSMIV-TRDSMIV-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
• 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 Complicated Grief ImplicationsImplications
Objective Objective Assessment 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
NormalAnticipatoryComplicated
************************************************************
Children’s Grief Concepts 0-2 yearsLM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: Does not comprehend deathAware of constant activity in home, others looking“sad”, someone is “missing”
Reactions: Responds to emotions or feelings of adultsCrankiness, Crying, VomitingRegression in Toileting, Altered eating and sleepingClinging, Restless, Insecure, Scared
NEED: ReassuranceWrap infant in soft blanket, maintain routine, physical assurance through holding, quick attention to expressed reactions and needs
Objective: Acknowledge Needs of Grieving Children
Children’s Grief Concepts 2-5 yearsLM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Objective: Acknowledge Needs of Grieving Children
Understanding: Mostly live in present tenseCurious about death and life; see it as temporary, reversible Death mixed up with trips, sleep, happens to other peopleEngage in Magical, exaggerated thinkingWonder what deceased is doing “underground”
Reactions: Trying to “Figure it Out”May show little concern or Regress to infantile behavior, Fear separationNeed to talk about the death over and over, Confused
NEED: ConsistencyShort explanations with real terms, fact of death, no catchy sayings, Consistent Expectations for behaviorRespond to security needsDon’t punish, instead explain and teach with repetitionLet the child tell the story over again
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
Children’s Grief Concepts 6-9 yearsLM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Understanding: ClearerComprehending 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 emotionalCrying, high anxiety, anger, cranky, aggression, hyperactivityDecline in school performance, involvementGreif reactions ebb and flow; less willing to talk about deathMore fearful questions and thoughts about “what will happen if…”
NEED: HonestyRefrain from using cliché'sRespond passionately; be responsive without judgmentReassurances with clear expectations of appropriate behaviorUse of art and stories
Objective: Acknowledge Needs of Grieving Children
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
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 personalA more realistic view of death; can differentiate between dead and aliveIncreased curiosity / research about biological aspects of deathBegin to understand that death is “forever”
Reactions: Separation AnxietyFear, reluctant to leave safe adults or homeBoys may lose some manual skills; aggression appears hostileAnger, Guilt, Distancing, Anxious, Worried, IsolatedDecline in performance, grades, involvement
NEED: Permission with appropriate expectationsGive compassionate answers, comfort, reassurancePermission to vent feelings; provide honest explanation of deathListen attentively, Use appropriate touch (with permission)Include in discussion of ways to honor & remember loved one
Children’s Grief Concepts Teen years
LM Aldrich, William Worden, Dan Schaefer, Christine Lyons
Objective: Acknowledge Needs of Grieving Children
Understanding: More adult processes evidentAble to think abstractly; Understands implications of deathTalks about feelings of immortality; realize death is fragile
Reactions: Assumes the adult roleFearful of future, preoccupied with thoughts of deathMay need to protect or stay close to loved ones Anger and aggression, May exhibit “risk-taking” behaviorWithdrawn, Quiet, Loud, Lonely, Sad, Worried
NEED: Communication & ConnectionEncourage communication “when you can”Physical touch very important, but ask permissionEngage in loving confrontationInvolve trusted friendProvide professional help if necessary
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 afuneral is not
good for Children”
“It’s best not to bring it up”
“Child is young, won’tremember”
Objective: Acknowledge Needs of Grieving Children
Common Mistakes that Adults Make
Minimize expressions of grief
Avoid the Grieving PROCESS
Assume a child isnot grieving becauseof laugher or play
Use cliché's like ‘God’s will’,Or ‘God took her because she was so good’
Avoid opportunitiesTo 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, andhow support, strength is found
Objective: Acknowledge Needs of Grieving Children
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
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 thequestion 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
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
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
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
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
KEEP IN MIND ~ Children Need
To feel safe in confusionRoutine, Order, and Stability
Designated Safe Place
Comfort Do not reject their emotions or their efforts to comfort you
PermissionDo not tell them How to feel or How Not to feel
Assurance of being okay
PatienceThey will ask questions over and over
Opportunities to say goodbyeDeath is not contagious…be sure to differentiate.
Children tend to idolize the dead
Gently help children regain balance and perspective
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 hopeMay take the form of a chronic or delayed grief response
…no satisfactory conclusion.Professional caregivers are distant
mournersEffects of professional grief are hidden &
subtleProfessional losses accumulate
Is a significant cause of burnout
So What About YOU?
PRACTICE SELF-CARE
Objective: Self Care Skills
Be aware of professional boundariesMaintain Balance with ongoing self monitoringLearn to express professional grief in appropriate ways
Let others know what you needTreasure relationshipsDraw on supportBe patient with yourself
Manage StressSay Goodbye
Tend to Basic Health Needs
Sustain Family SupportNurture Friendships
Relax, Rest, RejuvenateLaugh
Attend Peer MeetingsBe Nice to Yourself
Acknowledge your feelings, grief reactions, and experiences of loss as part of your journey
Grief is a Journey A little laugh A little hope A little promise
Nora Gravois, LMSW-IPRBereavement Coordinator The Hospice of East Texas
4111 University Blvd.Tyler, Texas 75701
www.hospiceofeasttexas.org(903) 266-3447 direct line
Resources for Children Coping with Death & Dying
Karaban, Roslyn A. Ph.D: Complicated Losses, Difficult Deaths, 2000Rando, Therese A, Grief, Dying and Death, 1984.Schaefer, Dan, Ph.D., & Lyons, Christine: How Do We Tell the Children, 1986DSMIV-TR
Numerous works of:Elizabeth Kubler-RossDale LarsonAlan WolfeltWilliam Worden