Goals for this Unit

Preliminaries

• Before you go on: Brainstorm a list of at least 10 euphemisms (i.e., common expressions) adults use to refer to death when we talk about death with children. Post them in question 1 on the Class Discussion on Oncourse.
• As you read the literature on child and adolescent bereavement, be sure to look at the context and source of the information. You should ask yourself the standard questions about research findings: If the author is reporting on research findings, what type of sample did s/he use? Was it drawn from the general population or from a clinical sub-sample? Is the author writing as a researcher or as a clinician? Of particular importance for this unit is the way in which the author defines terms related to development: What ages and/or developmental stages are they writing about? What do they mean by the terms they use (e.g., if they write about children, do they include infants and adolescents? If they refer to adolescents, what age range do they include?) It will help you to retain perspective on how you might apply the findings and on a sense of how generalizable the findings are.

Readings

Anthology

Prong, L. L. (1995). Childhood bereavement among Cambodians: Cultural considerations. The Hospice Journal, 10, 51-64.

Wolfert, A. (1983). Children's understanding and response to death (with caregiver behavior). In A. Wolfert, Helping children cope with grief (19-50), Bristol, PA: Accelerated Development.

Also

Van Reken, R. E. (1988). Letters Never Sent. Indianapolis, IN: "Letters." (chapters 1-7, pp 1-48).

Web Resources

The Nature of Children's and Adolescents' Grief

Grief is especially complicated for children and adolescents. As a normal part of their development, they are actively involved in the process of making meaning in their lives, a process that is tied to individual development and experience. They are working to establish their sense of self while also existing in a state of dependence. Thus, the disruption of meaning tied to the loss can be particularly devastating for them.

Adults especially like to look at childhood as a time of carefree happiness and security. In fact, many children experience it as a time of insecurity and unhappiness with grief as a part of their lives. The common belief is that this does not take place until adolescence. In addition to loss to death, children may experience loss of a secure attachment or a "wished-for" secure attachment. They are acutely aware of their dependence on others and their inability to control their lives. Children may experience loss in many ways not seen as terribly difficult by adults (particularly if the adults feel they can protect the child from the reality of loss): the death of a pet, a family move, the loss of a friend because he/she moves away, the end of a friendship or "first love" relationship.

Children are more likely than adults to experience fragmented recollection and a distorted understanding of the loss experience. You might want to look at the lists of euphemisms I asked students in the class to send to famgrief now and think of what a child might think when s/he is told, upon seeing a beloved grandfather in a coffin, that "Grandpa is sleeping." Both children and adolescents need an environment that is facilitative of their developing a coherent grief story, one that incorporates the recognition and acceptance of their emotions.

At the same time they are coping with their own situation, children and adolescents must also cope with grieving adults, something that may frighten or unnerve them. Adults are the ones who are supposed to take care of and be available to them, not the other way around. Adolescents and children, especially older children, may feel that they need to take care of the adults. They may feel a desperate need for adults to "get back to normal" and "stop being weird and scary."

Children and adolescents need to share their thoughts and feelings with others when they experience a loss, yet the ways in which they come to understand the loss and their techniques for grieving often are not understood or respected by adults. Their feelings may be overwhelming and frightening to them and to the adults.

Younger children are especially likely to want to talk and talk and talk, asking question after adults don't want to hear them anymore, as a way of testing reality. These questions may not make sense to adults, but they do make sense to the child asking them and they should be treated as such. On the other hand, these children may turn away from the loss and information about it. This may be because of a short attention span or a temporary defense against the overwhelming nature of the loss.

Developmental Variations in Grief

Because of the mass of literature on child and adolescent development, and because of the breadth of coverage in this course, we will not be able to go in any depth on normative child development (we could spend an entire semester on infancy alone!). What follows here is a brief list of grief characteristics drawn from your readings and others on developmental variation in grief.

Very Young Child -- roughly from birth to age 2 -- Sensorimotor

• Infants do not appear to grieve in the same sense as adults and older children do. Some scholars view infants as experiencing a disruption of their environment rather than genuine grief. Others propose that infants experience grief and have an emotional response that is consistent with their level of cognitive development.
• Infants are highly organized and engage in their level of meaning making in a social context, that is they coordinate their sensory impressions and motor activity with others.
• Throughout infancy, they build foundations for later conceptions of the world (e.g., trustworthy vs. not)
• The grief of adult caregivers can trigger a response from an infant, because of the disruption of the child's social environment.
• The loss of a significant other will be experienced as separation or abandonment and it should not be assumed that the infant's youth will protect him/her from loss.
• Response to loss: May exhibit anxiety and the most effective approach is to provide consistent care in a stable environment.

Early Childhood -- approximately 2 through 6 -- Preoperational

• Have a better understanding of the reality of death/separation, but is confused.
• See being dead as not being alive but see it as reversible. May express concern about how long it will be before they are reunited with the deceased.
• See death as avoidable.
• Interpret events in the context of their own understanding, because they are not able to take on the "role of the other."
  • Concrete thinkers, so what you say is what they hear. They take the words of adults as literal truth.
  • Magical thinking is common at this stage (e.g., may believe him/herself to be responsible for a death or other losses because he/she wished it to be so or acted in some way).
• Fear death is a form of punishment.
• Believe death is contagious.
• Because of their need for stability and control, they may contain their public expression of grief (and their questions) when they see it to be distressing to adults (especially to parents).
• May also ask many questions over an extended period or go through episodes of asking questions. May ask the same questions over and over as a test of reality.
• May do any of the following:
  • become curious, confused, ask body-oriented questions.
  • become irritable and exhibit discipline problems.
  • cry, become angry, regress.
  • not display emotions at all.
  • develop fear of separation, abandonment, or vulnerability.
  • incorporate death and/or loss, separation, etc. in play as a way of working out anxieties in a safe setting. Remember, play is the work of children, so if they are playing, they may be working through issues of loss, even when their play seems not to be related to loss at all. Also they may be using play as adults use work--as a distraction.
  • experience sleep problems (e.g., night terrors, nightmares, fear of sleeping and/or the dark, enuresis [bed-wetting])
• Need adults to discuss concretely and accurately and to provide reassurances that the child is not responsible for the death and will be cared for.
• Stories about dead pets and other animals helpful.

Middle Childhood -- approximately 6-12 -- Concrete Operational

• Gender begins to become a factor.
• Can distinguish between self and others and can understand others' experiences that take place independent of self.
• Logic is used to learn and solve problems. Facts become more usable, but not in the abstract sense.
• Death is now real, irreversible, universal, with specific causes
• More avoidant of talking about their grief than earlier or younger stages.
• May talk on and on about the loss -- but not necessarily to parents.
• May experience an internal sense of turmoil, feel guilt over any real or imagined fault.
• Feel that if they can act normal, things will be normal. This may result in adults thinking they are fine because they look it, isolating the child.
• Begins to deal with own mortality.
• May develop an interest in artifacts of death (skeletons, caskets, ghost stories, etc.)
• May be angry, "act out,"
• May act as if nothing has happened.
• May use play to work through feelings.

Adolescence -- approximately 12 and over -- Formal Operational

• Their grief is similar, in some ways, to adult grief -- depression, emptiness, crying, headaches, insomnia, digestive upsets, exhaustion
• Grief can evidence itself in confusion, crying, depression, feelings of emptiness and/or loneliness, disturbances in patterns of sleep and eating, and exhaustion.
• Factors in the intensity of adolescent grief include:
  • the type and quality of relationship with the deceased.
  • the closeness in relationship (closer the relationship, the greater the intensity).
  • ambivalence in relationship (the more ambivalence, the greater the intensity).
• Adolescents have a tendency to idealize the deceased.
• Their grief is enduring -- even though they may hide it. They may be concerned about being seen as different/odd by valued peers. They may also hide their grief from adults in order to maintain a sense of separateness from them.
• Losses are slowly resolved. Their grief is both intermittent and continuous (i.e., episodes of intense grief with an underlying sense of loss that seems almost to be "background noise"). Because they are less likely to resolve their grief, it extends over a long period of time.
• Adolescents may think they are experiencing grief that is unique and has never been experienced before, that their suffering is unique ("No one can ever understand what I'm feeling. I'm all alone in this."). This view may put them at risk.
• Their expression of emotions may be limited to brief outbursts or may be actively suppressed because they fear loss of emotional control and because they fear looking odd, wary about how things appear to others.
• May have particularly intense displays of emotions (almost for dramatic effect) or may be stoic (don't want to let on).
• May refuse support.
• May feel a need to protect their parents.
• There may be conflict between the adolescent and parents in terms of the adolescent's coping mechanisms (loud music, strange art, etc.). The adolescent may act out her/his suppressed emotions through means adult doesn't approve of (e.g., sexual acting out or delinquent or other socially unacceptable behavior). Behavior may be an attempt to purge their anger associated with the grief. The adolescent may become the scapegoat for the family, serve as the "safety valve" for the family. They can then focus on the "out of control" adolescent rather than dealing with other, tougher issues.
• Sexual acting out may be an effort to be comforted and consoled or it may be an attempt to deal with emotions of grief. It may reduce some of the emotional pain, discharge tension and provide physical comfort. A pregnancy that results may be an effort to replace the absent person or to create someone who will love the bereaved adolescent.
• The grief of adolescents may be disenfranchised, not recognized by others as legitimate or appropriate.

The Re-cycling of Grief from Childhood and Adolescence

A loss and related grief are not contained in one developmental stage; they become part of who a person is and affects him/her throughout life. The loss will be addressed again and again as he/she moves through new developmental stages, transitions from one status to another, and experiences new situations. With each re-working, new resources will be used and a new appreciation for the loss will be developed. This is an important thing to remember, particularly when working with children and adolescents, particularly those who are seen as "high risk." It may be the losses, and their struggle to deal (or not to deal) with the reality of their unresolved losses that trigger their antisocial behavior.

The experience of a loss can be positive as well as negative. In a study done by Martinson and Campos (1991), for adolescents whose sibling had died of cancer seven to nine years before, good communication in the family, the ability to share the death experience with others, expression of pleasure in the sibling's company, and reliance on family for emotional support were related to a more positive long-term outlook. A more negative outlook was related to withdrawal from family interaction, inability to use the family as a source of support, and difficulty in discussing their experience with others.

Tasks of Grief

Wolfert proposed six tasks of childhood mourning (Note that these tasks do not need to be completed sequentially).

1. Experience and express, outside of oneself, the reality of the death.
2. Move toward the pain and loss while being nurtured.
3. Learn to convert the relationship with the person who has died from one of interactive presence to one of appropriate memory.
4. Rebuild an identity based on the life without the person who has died.
5. Relate the experience of the death to a context of meaning.
6. Get and maintain a supportive and stable adult relationship.

1. Early tasks begin as soon as the child learns of the loss and take place in the context of their cognitive limitations and abilities.
   1. Gain understanding of what has happened, while employing self-protective mechanisms to guard against the full emotional impact of the loss
   2. Focus on understanding the facts of the loss, protecting themselves, their bodies and significant others
   3. Numbness may be a self-protective response
2. Middle tasks focus on accepting and reworking the loss and coping with the intense psychological pain that results.
   1. Accept and emotionally acknowledge the reality of the loss.
   2. Explore and reevaluate their relation to the deceased.
   3. Face and bear the psychological pain that accompanies the realization of the loss
   4. Rework the relationship (this is not detachment) -- the ability to maintain an internal attachment to the lost person may be a sign of a healthy recovery
3. Late tasks focusing on consolidating the child's identity and resuming progress on age-appropriate developmental issues.
   1. Develop a new sense of personal identity that includes experience of loss and some identification with the deceased so they can engage in new and unrelated experiences and activities.
   2. Form new relationships without excessive fear of loss and without a constant need to compare the new to the old
   3. Form a new relationship with the deceased that will evolve over time and become a sustaining inner presence for child.
   4. Return to age appropriate developmental tasks and activities
   5. Be able to cope with resurgences of painful emotions (e.g., at anniversaries and transitions)

Helping Children and Adolescents with Grief

Parents and other caring adults need to speak the truth, in terms appropriate to the age of the child. In order to effectively communicate with them about their grief, it is important to take the lead from the children, respond to their questions in language meaningful to them, and to avoid euphemisms and incomplete information (they may end up more confused than comforted). It is better for the adult to admit he/she doesn't know than to give partial or confusing information.

It is also a good idea for the adult to be certain about what the child actually is interested in and how much he/she knows. I find an effective means of answering a child's questions is to, first, ask the child "What do you think?" This allows the adult to clarify what the child wants to know, how much the child already knows, and how accurate and/or inaccurate that is. This is also true when communicating with an adolescent, whom adults may assume to know more than he/she does. Communicating with adolescents may be made more difficult by normal developmental forces, and it may be necessary to encourage the adolescent to talk with another trusted, neutral adult.

When a loss has taken place, parents may themselves be overwhelmed by the loss, a loss that directly affects them and indirectly affects them through its impacts on others, including their children. It may be best (and wisest) to take advantage of others to help their children with grief. If they are unable to help their child, they can create opportunities for their children to speak with others. This can be with professionals or with more informal contacts (e.g., friends, family members).

A concern of many parents is whether or not their child should be allowed or required to go to a funeral. In general, the child should be able to decide for him/herself whether or not to go to the funeral. If children decide to go, they should be forewarned about what they can expect, in clear language. If a funeral is not available to the child (possibly because of distance, the child may have decided not to attend one, if one is not held), they should attend some other ritual for saying good-bye to the deceased. We will discuss this more when we talk about Ceremonies and Rituals for Connection and Closure

Play is the "work of children" and they may use it the same way that adults use work--to distract themselves from their thoughts and feelings. They also may use it to work through loss issues. Death themes in games they play may distress adults, however, and they need to be aware of the importance of children being able to use play for this purpose.

Because they are formal operational, adolescents can discuss loss, death and grief from a more abstract perspective. The parent they turn to for this purpose, surprisingly, may not be the best one for that purpose. Hogan and Balk (1990) found that even though adolescents usually turn to mothers for understanding after a loss, fathers actually were found to have a more accurate picture of the grief experience of the adolescent.

When responding to the grief of adolescents, one must "walk a tightrope" between encouraging the adolescent to talk about his/her feelings while also respecting his/her privacy. Rather than an adult talking with the adolescent, another adolescent (via support groups or peer counseling) may be the person the adolescent will be willing to talk to.

Using Stories and Storytelling to Help

• A painful event becomes real when it is made explicit in language. Frightening elements, possibly experienced as amorphous sensations or disjointed images, can become less frightening when organized in the narrative structure of a personal story. Those involved tell their story of grief by drawing from their experience and matching them against stories they already know. These help them to construct their own framework in order to conceptualize their experience.
• One way both children and adolescents begin to understand and process a loss experience is to tell their story of loss and grief. It is critical for them to tell their grief story so that they can make sense of their grief experience. Hearing oneself tell the story to a willing audience, or writing it down, give it order. In this, they bring order to the chaos and put their thoughts and feelings into the form of a narrative (attempting to give it a structure with a beginning, middle, and end). Working with a caring, trusted adult to tell their story gives them a sense of power and control in their lives.

General Conclusions

It is important to remember that just because children and adolescents are not telling their stories, it does not mean that a loss has been integrated and that they have "moved on." It may well mean that they have learned that adults can not handle hearing what they have to say and that they should shield the adult from the reality of their pain.

Adults, in general, and parents, in particular, need to recognize their own need for their children to be innocent and protected from harm. They also need to recognize how this can be harmful to their child, especially if it means they must be dishonest or require their child to be dishonest with their child to protect that "innocent" image.

Children and adolescents will re-experience the effects of a loss throughout their lives. Attempting to avoid the reality of their grief will not make it "go away." Rather, it will simply be sealed over to be exposed again, possibly with greater intensity, since it has not been dealt with at an earlier time.

Questions for Discussion

Post your response to the following questions on the Class Discussion.

1. Euphemisms--why do we have these? What is it about death and dying that causes us to use terms that often confuse and frighten children (for example, "he's gone to sleep")? What sorts of euphemisms do you know about? What is their purpose in using them with children?
2. In the "lecture" above, you read about a list of necessary tasks in children's grief. What are your thoughts about these tasks? After reading Prong, do you see any possibilities that the expectations of "necessary" tasks may be culturally based?
3. What is the role of adults in helping children to deal with a loss?  Many feel that it is best to protect children from the reality of death and loss, even after a loss has occurred. What are your thoughts on this?
4. Ruth Van Reken addresses a variety of losses in her book, only some of which are death losses. Using the material from this class, using her as a model, discuss how adults might best assist children experiencing both public and hidden losses.

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