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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

Children Coping With Death & Dying Presented by Nora Gravois, LMSW-IPR Bereavement Coordinator for The Hospice of East Texas Objectives Clarify Definitions

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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