Portal de Periódicos da CAPES

Children and Grief

2011; Lippincott Williams & Wilkins; Volume: 29; Issue: 2 Linguagem: Inglês

10.1097/nhh.0b013e31820861dd

1539-0713

Holly Torbic,

Family Dynamics and Relationships

FigureFor anyone who has ever lost a loved one, you know too well the devastation and raw emotions that can accompany the grief process. Now imagine you are 3, 7, 13, or 17 years of age trying to understand why your mom, dad, sibling, grandparent, or best friend has died. Children's grief is like a fierce storm at sea, bringing devastation that lasts long after the funeral and burial are over. Many children struggle to come to terms with their grief for years after the death. I have the honor of walking alongside children, teens, and their families who are grieving the death of a loved one as part of a peer grief support program. In the pages to come, I hope to provide education on the grief spiral process, children's grief and how it may display itself at the various developmental ages, and how as an adult you can be most available to a young child or teen who is grieving. My hope is to share stories with you about the children and teens who have been my teachers. Defining Grief Did you know that 1 child in 20 will have a parent die before he or she graduates from high school (The Highmark Caring Place, 2010)? One child in every seven will experience the death of an immediate family member by the age of 10 (The Highmark Caring Place, personal communication, November 18, 2010). It is estimated that 73,000 children die every year in the United States. Of those children, 83% have surviving siblings (Annie's Hope: The Bereavement Center for Kids, 2007).Figure: Upper left, This young girl grieves the death of her twin brother as she looks at family pictures prior to his death. Right, Following a family activity, this child found a safe, quiet place.Dr. Alan Wolfelt, Director of the Center for Loss and Life Transitions in Fort Collins, CO, is a nationally recognized thanatologist, someone who studies death and dying. He defines and distinguishes the difference between grieving and mourning. Grief is the combination of internal thoughts and feelings we have when someone we love dies. It is the internal meaning given to loss. Mourning, on the other hand, is seen as the outward expression of grief. It involves taking all of the grief one has on the inside and expressing it outside of oneself through crying, talking, music, art work, visiting the gravesite, and so on. (Wolfelt, 2003). When someone experiences a significant loss in their life, it is not something that you "get over." That loss becomes part of your life story and impacts how you view yourself, others, and the world around you. The process of grief is most represented by a spiral. As defined by The Highmark Caring Place: The stages of grief overlap and mix together, without a real ending point. Instead of a straight line through grief, the feeling is much more circular. We experience the most intense feelings, which then subside for a while. And then the intense feelings return. But although the feelings are similar, there is a change, an improvement. Adding the two together produces a spiral path. Many things can trigger a return to intense grief, including special days, something we see or hear, taste or smell, along with developmental issues, especially for children. Understanding grief as a spiral can help us to understand the changes that occur, and can allow us to begin to manage our grief. (The Highmark Caring Place, 2010) Although the feelings of grief are painful and difficult, they can also be productive. When these feelings are experienced, the healing process can begin. When asked to define grief, one 10-year-old stated, "Grief is like football. Sometimes you feel you can run forever. Other times you get tackled out of nowhere." The goal of the work in the grief process is to come to a point of reconciliation. A. Wolfelt defines reconciliation as what occurs when the mourner works to integrate the new reality of moving forward in life without the physical presence of the person who died. He outlines six reconciliation needs of mourning: Acknowledging the reality of the death Embracing the pain of the loss Remembering the person who died Developing a new self-identity Searching for meaning Receiving ongoing support from others In the reconciliation process, grief gives rise to a new sense of meaning and purpose in one's life. Although the loss remains, one comes to realize that although life will never be the same again, life can be good again (Wolfelt, 2003). It should be noted that for many children and teens, the grief process begins long before the actual death. For some, it may begin at the time of their loved one's diagnosis. For others, the grief process may begin when the child or teen begins to see changes in their loved one and in their homes. For example, a child may begin grieving when his dad is no longer able to play ball. On the other hand, the teen may begin grieving when she realizes her mom will never live cancer-free. Anticipatory grief can be as intense and overwhelming as the grief they experience following the death. Symptoms of Grief in Children Grief affects all aspects of a child's life: physical, emotional, social, and behavioral. When it comes to physical symptoms, it is not uncommon for a child to display hyperactivity or underactivity. Children may experience physical distress, such as a stomachache, headache, diarrhea, inability to swallow due to a lump in their throat, and so on. If the child is young, there may be regression. An example would be a child who had been potty trained, and is now again wetting the bed at night. Children or teens may experience a change in appetite and weight. Sleeping problems are also very common at both the younger and older ages. It is important to pay attention to these physical symptoms and acknowledge them because children will rarely come out and say, "I am grieving." Emotional Responses of Grief Emotional symptoms may include numbness, sadness, anger, fear, guilt, and relief. Many children and teens express shock and disbelief that their loved one is gone. They also voice extreme sadness. They experience fear realizing the world is no longer a safe place. Will I lose others? What will happen to me? Children may be less trusting of letting others in their lives, in fear of being hurt or abandoned again. An 8-year-old wrote this message, "God, give my mom back, I need her more than you." During one night in a support group last fall, I had teenagers identify various emotions and descriptions of their grief. The list was much longer and descriptive than could have been imagined. At the end of the activity, I asked the group what two emotions or descriptions they struggled with the most. Without hesitation, the group answered anger and guilt. Children and teens may express anger toward various sources: God, the medical community, others that they feel may be responsible for the death, family members who are grieving differently than they are, other families still intact, and so on. Anger is very common in teens. Although they are not yet adults, they are mature enough to grieve today's losses as well as tomorrow's. Many teenage girls struggle with the fact that their dad will not be able to walk them down the isle on their wedding day. Sadly, they realize their deceased parent will never hold their grandchildren. Guilt can be paralyzing for children and teens. Kids express guilt about not appreciating their loved one more when they were living. When the death is sudden, unexpected, or premature, children may not have had the opportunity to say good-bye. This weighs heavy on their hearts as they long for closure. One of our activities includes writing letters to their loved one. This gives them the opportunity to tell their loved one how they feel and to ask questions that may be on their minds. With the writing assistance of his mother, a 3-year-old asked his deceased grandfather, "Papa, do you still love me?" Guilt can be rational and irrational. One night I had a teen walk into group whom I could tell had a rough day. I asked her if she wanted to talk. She shared that she was struggling with guilt over her father's death. She went on to say that the night before her dad had a massive heart attack he had asked her to pick up her shoes and she forgot. She strongly believed that her forgetfulness contributed to her father's death. Children who experience loss often live with tremendous conflict and confusion. Recently, a teen verbalized her struggle with guilt over not being kind to her mom while her mother was sick with cancer. Three years following the mother's death, she is just coming to grips with the fact that she loved her mom, but was angry at the situation. All she wanted then was to have a normal life, and all she wants now is for her mom to know that she loved her and that she is sorry. For children whose loved one had been ill for a long time, the sense of relief can be freeing. They have a sense of peace in knowing their loved one is no longer struggling. Social Responses of Grief Grief can affect children and teens on a social level as well. Children may be overly sensitive as they feel more vulnerable and different from others. One child who had lost both parents would become very upset when teachers would send home permission slips for their "parents" to sign. Inside he would scream, "I don't have any parents, can't you just say guardian?" Some children may become more dependent as they are not sure of themselves anymore—their innocence and safety net are gone. Other children may display hypermaturity. Given their life experiences, they may seem much more mature and responsible. Their priorities may be different from others their age. Children may withdraw from others because they feel there is no one who understands what they are going through or have been through. I have also had children discuss how others pull away from them because they don't know what to say following the death of their loved one. I had an 11-year-old ask if she was invisible. When asked why she posed this question, she responded, "When I walk down the hall at school no one makes eye contact with me. It was my mom that died, it wasn't me." Children can feel very alone in their grief; this is why peer grief support is so helpful. Children often talk about a label that hangs over their head everywhere they go that says, "I'm the kid whose ______ died". At a peer support program, these children feel normal; their label is gone. Children may lack initiative or interest for activities they once enjoyed. Although it is often encouraged to continue a child's routine as much as possible following the death, it is important to be respectful of their grieving process. As with adults, children's grief is very individualized. An example would be two brothers who lost their dad (and soccer coach). One son may strongly feel the need to get back on the field because it is there that he feels close to his dad. The other son may not be able to step foot on the field because it is too painful. Respect both of these choices. Behavioral Responses of Grief Grief can also affect children behaviorally. It is not uncommon for grieving children to struggle in school. They may become very forgetful and have slowed thinking. They may experience disorganization and panic. They may also act out because they don't always know how to communicate what they need or what they may be feeling on the inside. Children often express difficulty focusing on schoolwork and restlessness inside. One child stated, "When I am at school I want to go home. When I go home, I want to be back in school. No matter where I am, I feel unsettled." Children may have dreams of their deceased and may sense their loved one's presence. Understanding of Death at Different Developmental Ages: An Overview Before Age 3 When working with grieving children, it is important to be aware of the child's developmental age because this greatly influences the child's perception and understanding of death. Before age 3, children experience the world through their senses. They are learning to trust others. Their language, motor, cognitive, social, and emotional development is taking place. Although this age group has no concept of death, they are aware of an absence or change in their environment. For example, a baby who had been breast-fed prior to the death of its mother becomes aware of a change in its environment when being fed by a bottle. Although the death may be of someone outside of the home, such as a grandparent, the child may be fully aware that mom is crying all of the time. As a result, children at this age may exhibit an increase in irritability and a change in their eating and sleeping habits. The most important thing for this age group is to establish a routine to create a sense of security and comfort for the child. Preschool: Ages 3 to 5 Children at the preschool age are egocentric. They are only able to focus on one thing at a time. Play is critical at this age. The late Fred Rogers, of Mr. Rogers Neighborhood, described the importance of play as: "Play is often talked about as if it were a relief from serious learning. But for children, play is serious learning. At various times, play is a way to cope with life and to prepare for adulthood. Playing is a way to solve problems and to express feelings. In fact, play is really the work of childhood" (Thinkexist.com, 2010). By providing a safe place where children can play, even the youngest grieving child can tell their story (The Highmark Caring Place, 2009). This age group also displays what is sometimes called magical thinking. If I am good, Santa is sure to bring my brother back. If I wish on the brightest star, I know my grandmother will return. For preschoolers, death is seen as temporary and reversible. They often confuse death with sleeping. Many preschoolers are afraid to go to sleep for fear of dying. Death is also thought of as a journey or trip. They believe they can visit the deceased. Preschoolers express their grief in small bursts. They are unable to tolerate the intensity of grief for any extended period; therefore, they will move in and out of their grief as needed. When interacting with grieving preschoolers, the adult's role is not to cheer them up, distract them from their grief, nor lead them toward their grief. Rather, it is to provide a safe place where the children lead you. One activity that our grief preschool room did last year expresses this point most clearly. Given that this age group looks at death as a journey, the facilitator drew an airplane with chalk on the sidewalk. Each child was given the opportunity to pilot the plane to wherever they wanted to go. Some children chose to go to Disney World to see Mickey Mouse, whereas other children chose to fly to heaven to see their loved ones. When a child this age loses someone significant, such as a parent, they may often display separation anxiety with the other parent in fear of losing them as well. It is very important that the child, who feels little control over what has happened, be provided the opportunity to be in charge of the separation. For example, a 4-year-old girl becomes very anxious when time comes to separate from her dad. Her father has learned to sit with his daughter and be present until she is calm and ready to part from him. It is common for children at this age to repeat their story over and over again. This is their way of trying to understand what has taken place. Following the sudden death of his dad, one preschooler continually repeated to others, "Did you know my dad died?" This was his way of working through the death of his dad. Allowing children to tell their stories is priceless. Ages 6 to 8 This age group is very concrete in their thinking. Play is still critical to work through grief issues. Magical thinking is lessening. They are beginning to understand that death is not reversible or temporary. They are often curious about the biological process of death, and may ask what happens to the body when someone dies. They are fearful and anxious of death. They worry about who will take care of them. They may believe that in some way they are responsible for the death. As with all age groups, these children need reassurance. Their world has been turned upside down, leaving them feeling helpless and not in control of their surroundings. As mentioned earlier, routine is often encouraged as this provides a sense of normalcy for the children. Giving children the ability to make choices helps them to regain control over their environment. This could be as simple as, "Do you want the light on or off at bedtime?" Ages 9 to 12 Peer relationships are becoming very important at this age. Their self-esteem and self-identity are also developing. They realize death is not reversible. They accept the reality of the death, but are more anxious about the death of others. They may become more serious about life because they realize that bad things can happen to kids too. The death of a significant loved one in a child's life can be devastating at any age; however, for this age group and the teen group, the death can interfere with the developmental process of one's self-esteem and self-identity. One night in group we asked the children to decorate the front of a mask to represent how the world sees them. On the inside of the mask, they were asked to decorate it in a way that described how they felt on the inside. One child, who had recently lost his dad, decorated the front of mask in camouflage. His explanation was that all he wanted was to fit in. When he turned the mask over, the inside of the mask was also camouflage. When asked what the inside of his mask represented, he stated, "I don't know who I am anymore since my dad died." Teenagers Peer relationships are critical at this age. They do not want to stand out as being different. Their self-esteem and self-identity are still developing. They are attempting to find balance in terms of independence and dependence on caregivers. They are also starting to think more like adults. They are aware death is final. They understand the present loss as well as future losses related to the death. Teenagers are most likely to hide their feelings to fit in. They are also most likely to express anger. Some teenagers believe death will not happen to them, and will put themselves in dangerous situations. Others may have a heightened awareness of their own mortality and may appear more mature given their priorities in life. Sometimes teens may have increased anxiety for the remaining parent or family members. One teen expressed guilt over her desire to go away to college following the death of her dad, leaving her four younger siblings behind. Another teen, who happened to be the youngest of her family, expressed similar emotions about leaving her mother home alone. This age group tends to grieve privately. Although they may put much energy into masking their grief, it is extremely important to remember that the grief is still very real (Rando, 1984) Children: The Disadvantaged Mourners Children and teens are considered disadvantaged mourners and for a number of reasons. If the loss happens to an adult, the adult at least has matured and developed already; if it happens in childhood, it can interfere with normal development. Children tend to take things literally and concretely. The child or teen may have little control over his or her life. Children do not have the capacity to tolerate pain intensely over time; as a result, adults may feel that the child appears fine, when in reality they are still struggling. The child must be certain that his or her physical and emotional needs are going to be met before he or she can give into grief and mourning. If I talk, will someone listen? If I cry, will someone hold me? Parents and other caregivers also tend not to appreciate the importance of play. One of the lessons learned in working with grieving children is to never underestimate the importance of a loss in a child's life. There was a boy whose goldfish died and this little boy was devastated. The mom told her son to get over it, it was just a goldfish. The boy responded, "But mom, it was the only one that ever listened to me" (Rando, 1984). When to Seek Help Parents often ask when to seek help for their children or teenagers in relation to grief. Parents and guardians should be encouraged to seek professional help when the child or teen is unable to carry out normal daily activities, such as going to school. William Worden identifies ten red flags to watch for: Persisting difficulty talking about the deceased person Aggressive behavior Anxiety Somatic complaints Sleeping difficulties Eating disturbances Marked social withdrawal School difficulties or serious academic reversal Persistent self-blame or guilt Self-destructive behavior or desire to die One night a teenager came to the grief support group for the first time following the death of her dad, which happened 7 years before. Within 5 minutes she began to cry as she listened to others share their losses and how they were coping. When she regained her composure, she stated, "I have waited seven years just to be here tonight. I have tried everything from drugs and alcohol, to sexual promiscuity, to run-ins with the law in order to fill the void inside of me following my dad's death. I realize tonight that I have to confront my grief and work through it, in order to move forward and have a better life". When unresolved grief goes unattended, it can resurface later in life and with serious consequences. William Warden identifies why bereaved children are so at risk. One study, which included 125 children, found that within the first 2 years following the death of a parent, 33% of children were at higher risk for emotional and behavioral problems. Childhood loss of a parent can increase the risk of depression two or three times. Bereaved children and teens are also at greater risk for developing panic disorders and phobias. He found that the incidence of teens incarcerated after losing a loved one to be 97%. The risk of suicide can also increase in those who have lost a parent (Worden, 1996). For a list of resources for grieving children, teens, and the adults in their lives, see the Appendix. How to Help a Child Who Is Grieving There are many ways to help a grieving child. Listed below are a number of recommendations. Listen. Children may want to share their story. This is a healing experience. Do not give advice or make judgments. Reflect back what the child says, using the child's words. Children must feel that their physical and emotional needs are going to be met before he or she can give into grieving. Listen some more. Sometimes children don't want to talk, can't find the words, or try to protect adults around them from more pain, so they choose to be silent. When you listen, pay attention to the nonverbals. Be honest with the child. It is difficult to talk to kids about painful things because we want to protect them. It is important to be honest. This helps to develop trust and fosters further communication. Answer their questions, even the hard ones. It is important for children to know that they can ask questions. Answer questions truthfully, being sensitive to their age. It is very acceptable to say, "I don't know." Give the child choices. This helps them regain control they feel they may have lost. Encourage consistency and routine. Talk about and remember the person who died. Bringing up the name of the person who died gives children permission to share their feelings about the person. It shows them it is not taboo to talk about the deceased. Sharing a memory shows the child that the person who died will continue to live on within them and impact the lives of those left behind. Expect and allow all kinds of emotions (both positive and negative). Respect differences in grieving styles. Provide hands-on activities. This includes drawing, journaling, painting, sculpting clay, collages, and memory boxes. Exercise and physical play helps children release energy and emotion. Be a model for your children. Children watch adults to get cues about how to grieve. It is important for children to know it is okay to cry, be angry, and to grieve. Hug with permission. Practice patience. Respect grieving children even when they are in a bad mood. Be aware, some kids will regress, others will become little adults. Eat right and drink water. Help the child at bedtime. Establish consistent bedtime rituals such as a story, a song, or a prayer. Don't force the child to talk. They will talk when they are ready. Take a break. When possible, plan fun activities for your children that will allow them to laugh, play, and be kids. Play is critical and helps to process grief. When working with grieving children and teens, the most precious gifts you can give are time and listening ears. I have learned that you cannot "fix" their loss, given that it is impossible to bring their loved one back. However, walking along someone on their grief journey is immeasurable. The director of the grief program for which I am affiliated attended a conference a few years ago. The main speaker was a woman who had lost a child. She shared that following her child's death, she didn't know what to do, nor did others know how to comfort her. One day an old friend called her and asked if she would want to walk together in the mornings like they had many years before. The mom thought this might help her and so she said yes. Every morning the two would walk. Her friend would put out her pinky, and they would walk in silence holding each other's pinky. Years later another woman in the same area lost a child. She contacted the first mom and asked how she ever survived this. The first woman responded, "When I look back on it, it was a pinky that saved my life!" In working with others who are grieving, child or adult, your presence alone can provide comfort and healing. Dr. Wolfelt believes that to meet the needs of someone who is grieving, it is best to "companion" them. There are eleven aspects of companioning: Companioning is about honoring the spirit; it is not about focusing on the intellect. Companioning is about curiosity; it is not about expertise. Companioning is about learning from others; it is not about teaching them. Companioning is about walking alongside; it is not about leading. Companioning is about being still; it is not about frantic movement forward. Companioning is about discovering the gifts of sacred silence; it is not about filling every painful moment with words. Companioning is about listening with the heart; it is not about analyzing with the head. Companioning is about bearing witness to the struggles of others; it is not about directing those struggles. Companioning is about being present to another person's pain; it is not about taking away the pain. Companioning is about respecting disorder and confusion; it is not about imposing order and logic. Companioning is about going to the wilderness of the soul with another human being; it is not about thinking you are responsible for finding the way out. (Wolfelt, 2003) Summary For clinicians and hospice employees directly involved with families, the task of working with children when a death is imminent is extremely difficult. For children and teens, knowledge of the grief process and validation of their feelings will help facilitate healing. Realizing it is not your responsibility to fix the situation is a great lesson. Allowing the children to teach you what they need is the greater lesson. Be present and let them lead you.