David Crenshaw, in his book Bereavement: Counseling the Grieving throughout the Life Cycle, describes grief as the intense pain experienced following the breaking or disruption of attachment bonds formed with significant people in our lives. He further describes grief as being synonymous with mourning and further defines them as being intellectual processes that reduce the significance of the broken bonds enabling the mourner to carry and accept the loss.
For the purposes of this paper Johnson and Mattson's description of grief will be used. They describe grief as being part of a crisis process, incorporating physiological and psychological response to loss. They describe grief symptoms as specific behaviour and emotional responses following a loss, while the whole grief process is the means by which a person works through and makes meaning of the loss. (Johnson and Mattson, 1992)
There are many theories about how the process of grief is experienced. Most of these theories identify stages like B. Bailey's theory (loss, protest, searching, despair, reorganization, and reinvestment). The belief that children did not grieve as adults do was reinforced comments from children, following the death of a parent, like "who will make my dinner now". (Crenshaw, 1990). However, children pass through the same stages in the same nonlinear progression as adults do.
To illustrate how a child may react, this paper will explore the experience of a seven year old girl named Marilyn.
Infants are perhaps the most difficult group to analyze because they lack developed language skills. It was previously believed that infants do not grieve, or do not grieve as intensively as adults do. However, research has shown that infants are affected by loss, most intensely by the loss of their mother. (Furman, 1985)
The toddler and preschool age groups do not have a concrete concept of death. Death to them lacks permanency. They believe that if the deceased person is not in sight they are somewhere else and possibly reachable or will return someday. This age group is likely to ask if they could go on the bus to Heaven to see the deceased person. They also have difficulty understanding causes of death. They may believe that if the deceased had not gone to the hospital they would still be alive, as if the death was caused by the hospital. (Crenshaw, 1990)
School age children have a magical image of death. They may believe that Angels or Jesus came down to earth and took their loved one away. They think that deceased people can still see the living, and are watching over them. This age group is, however, beginning to realize that death is permanent and may focus their thoughts and questions on what is death.
Pre-adolescents have a good understanding that death is permanent. They are very often fixated on what it may feel like and can focus on the events surrounding the death. At this age they also clearly understand that death can happen to them too. By the time the child has reached adolescence they have developed an adult understanding of death and loss. They often experience intense emotions as a grief response. Despite their adult thought, they still require needed support as they are already in a developmental stage full of turmoil and ineffective grief resolution could lead to more problems for them.
There are commonalties amongst the age groups in respect to emotional grief responses or reactions. All the age groups display the same feelings in varying degrees. The most common emotions are as follows:
Grief reactions experienced at all developmental stages are not limited to the examples cited above. Physical symptoms include decreased appetite and an upset stomach (colic in infants/toddlers). Behavioural symptoms include sadness, sleep disturbances, acting-out, decreased concentration, lethargy and withdrawn, regressive, or egocentric behaviour. This egocentricity is very often misinterpreted. Many adults view it as selfish behaviour. However, children think everyone sees the world as they do and tend to be open about their own needs. For example the school age child may ask who will drive them to school. This may be regarded as a lack of caring or understanding, whereas need satisfaction is a normal grief response for children.
Following a loss, a child will grieve intermittently. They can only take in a certain amount of stimuli before they shut it out temporarily. The child may be playing quietly and suddenly cry for a short period then resume their play happily where they left off. They may also suddenly to stop ask many questions about death, totally unrelated to the activity they were performing. Following the answers the activity might be resumed without indication the child was affected emotionally by the responses. (Smith and Boardman, 1995)
The development of coping mechanisms, such as recognizing and letting emotions out arise from those adults important to the child. If the adult does not cry or refuses to talk about the loss or event, the child will suppress their emotions as well. They will avoid discussing the loss for fear they will upset or hurt their parents or caregivers. This ultimately will leave the child with feelings of isolation and leads to an ineffective grief resolution.
Children of all ages need an honest and open approach to help them resolve their grief. Adults have a tendency to shield or protect the child from further pain of grieving. However, children require straightforward answers to their questions, especially about why the death occurred. Evasive answers like "she was old and tired" or "it is God's will" only increase their confusion and promote fear. They require reassurance that they did not do anything to cause the loss or death and should be told how it happened in simple accurate terms. Explanations like "she died in her sleep" led some to fear dying in their sleep. (Smith and Boardman, 1995)
Following a death, children should be included in all activities surrounding the death. If they request to see the body, they should be allowed, encouraged and supported to do so. However, they will need to be told what to expect first, i.e. pale cold skin, to reduce a shock or stunned reaction. Viewing or other post humus rituals and traditions (like kissing the body good-bye) should not be forced on any child. If they wish to attend the funeral it should be encouraged and emotional support (i.e., hand held, reassurance) be available to them during the event. If they do not wish to attend they should remain in familiar surroundings with someone they know well and trust. Also, if it is not possible for them to attend the funeral an alternative activity should be provided. For instance, a family gathering where a candle is lit in memory of the deceased can be performed at home. They need this participation and inclusion in order to close the event, and reduce the amount of fantasy, guilt or isolated feelings that may develop. (Fitzgerald, 1992)
Explanations regarding what is death should be offered to the child in simple terms appropriate to their developmental stage. For example, a toddler or preschool age child may not understand the concept of death, but can understand it if it is described in terms meaningful to them. The examples "The dead butterfly will no longer move" and "a dead person will no longer breathe or eat," are concepts they can understand.
What happens to the body after death is a difficult concept to explain to children, especially below the school age group. At this young age, they do not understand cremation and sometimes struggle with burial as well. They will tend to ask and repeat the same questions over and over in order to understand and cognitively process all the information and abstract concepts surrounding death. (Fitzgerald, 1992)
Children often adjust and understand more about death or loss if they are prepared ahead of time. Whether the death was sudden or anticipated will influence the grief response. Sudden deaths happen with little or no chance to prepare those that will be affected by it. This can be traumatic for individuals of all ages and usually results in a more intense grief response.
Adults have a tendency to avoid the subject of death for many reasons, mainly in an effort to protect the child. However, it will benefit the child if parents and nursing staff are more open about death or discuss it before it happens. This helps to prepare the child emotionally, and maintains the child’s trust. (Walker, 1993) There are many books available for all ages that will help a child deal more effectively with their grief before and after death. The following are a few examples:
There are many books available for all ages and levels of knowledge to help children with their grief. These are a small example of what is available for children, parents and caregivers. However, many more books written specifically for parents or medical professionals are available.
Marilyn grew up in a blended family, Marilyn's mother Bev had two teenaged children from her first marriage and Marilyn's father Larry was Bev's second husband. This family unit was intact until Marilyn was about four and a half years old. Bev and Larry decided at that time it was best to be apart, so Bev and the three children moved into a rented house and hired a private companion to care for Bev.
Approximately five months before Bev's death Marilyn's father Larry became more actively involved in Marilyn's care to make the transition of him becoming her primary caregiver easier. He took her to school, participated in her field trips and frequently stayed late at Bev's house to read to Marilyn at night.
In February 1995 Marilyn's grandfather died suddenly. Her mother took Marilyn to the Emergency Room to see him. Prior to entering the room Marilyn was prepared by a discussion with the Emergency Department's Social Worker. This Social Worker also accompanied Marilyn and Bev into the room where Marilyn's grandfather was. Larry and his mother were already waiting inside the room. Once in the room, Marilyn looked at him, looked at her mother, then turned to her father and asked "Is this what is going to happen to Mommy?". Bev answered with an open and honest approach. She told Marilyn that she was going to die but that Marilyn would have lots of time to be with her first and Marilyn would be able to say goodbye before Bev died. Two months later, Bev died.
Marilyn's responses to her mother's death will be categorized or organized using the Johnson Behavioral System Model (Johnson, 1980). Under this model there are seven subsystems: Attachment, Achievement, Dependency, Protective, Elimination, Ingestion and Sexual.
Marilyn was sometimes very sad and became very quiet. Her sadness came and went intermittently, Larry described it as going "in spurts". Marilyn would talk about her mother and her feelings, then shortly thereafter decide she was going out to play and became very happy.
Marilyn was separated from her two teenaged brother and sister (they had a different father) when she went to live with her father. Larry encouraged Marilyn to phone and visit them as much as possible. The teens were reluctant to come to Larry’s so Marilyn had to be taken to their father’s house to visit them. Occasionally Marilyn would stay over night, but she did this reluctantly. If Larry tried to soothe Marilyn by keeping her home, the teens father would accuse Larry of interfering with the children’s relations. Eventually, the visiting dwindled as it got tedious for Larry to being doing all the work and take the verbal assaults. Marilyn’s brother and sister also got busy with things of their own. This has made Marilyn sullen at times. She often states she wishes they were all still together. However, she tells Larry she understands when he says they cannot live together right now.
This subsystem is at high risk for not being met. Marilyn needs to maintain her family ties for her self image and self esteem.
Off and on for the next two years Marilyn would alter between independence and clinging behaviour. If her father wanted to go out she would beg him to stay home. After a couple of dates, Larry decided he would temporarily halt his own social life in an effort to allow Marilyn to adjust first.
Initially Marilyn would not join any children’s recreational clubs or activities. She said she would only do so if her father would stay during them. After a year, Larry enrolled Marilyn in Sparks (a division of Girl Guides). Marilyn would go happily but once she got there insisted her father stayed during the event. Eventually, Marilyn stopped fussing when Larry said he would be back, and she now will even go to Sparks with other parent drivers.
This subsystem initially was at risk of not being met, but with patience and counseling it now appears to be met.
This subsystem was affected briefly. With the help of counseling and supportive parent and teacher Marilyn was guided, and has met her achievement needs.
Following her mother’s death and move to her father’s house, Marilyn had a diminished appetite and would only pick at her meals. Should would occasionally request chips or chocolate bars only for dinner. Larry did not give in to her requests, and decided it best if he allowed her input on meals. To encourage healthy choices and not overwhelm her, he would offer her two choices. For example he would offer her sausages or pork chops first, and then offer her the choice of vegetables. For lunch he would offer her macaroni and cheese or sandwiches.
Larry did not notice any change or difficulty with Marilyn’s Elimination habits. This does not mean they did not exist as he admits it was not something he was checking or expecting to have a problem with.
The Ingestive and Elimination Subsystem was not met at first, but with persistence on Larry’s part Marilyn now has regular meals and a regular routine.
When she first moved to her father’s house she was reluctant to play with the neighbourhood children. Larry would phone her old neighbourhood friends and arrange for her to play with them either at their home or his. He thought Marilyn was reluctant because she did not know the children in her new neighbourhood, and they all went to a different school than her. Larry did not want to push Marilyn and decided to wait before encouraging her to play in her own neighbourhood.
When Marilyn lived with her mother, she mainly played with a boy that lived four houses away and was also in her Kindergarten class. They played school occasionally, but mostly they played with a Brio train set. Outside they played in his clubhouse, or in the sand box. When playing at her house they played some board games for a short while and then would venture back to the boy’s house.
As Marilyn became established in her new neighbourhood she made friends on her own and began to play less with the boy from her former neighbourhood. These new friends were all girls close to her age. Marilyn now began to play house, and play more with dolls. The boy was in her grade one class, and now in her grade two class, but they only play together at school during breaks.
Marilyn’s decreased socialization may have been due to shyness, but it also could have been that she was used to playing with a male playmate and the girls were a change she was not ready for yet.
Despite the fact she no longer has a female role model Marilyn is growing and developing normally as any other female child. This Subsystem may be more affected in her teen years.
Marilyn never showed any signs of being withdrawn. She did pretend to be asleep at night , but would smile at her father when he called her bluff. She also like to hide, but both behaviours are common in child’s play and not necessarily grief responses.
She did vocalize some fear during the night, but could never remember her dreams when asked. She would simply state her room was not safe, and slept with her dad for a couple of nights. She would then sleep in her own room for several nights until the dreams returned.
Marilyn tells her father she knows her mother will never come back, and is in the sky, but she still wishes she had never died. She never states someone or thing came and took her mother. She had experienced a loss with her grandfather’s death which may have helped her understand this concept.
The Protective Subsystem needs time, honesty and reassurance to be met. Marilyn’s anger and her dreams will hopefully fade over time.
Larry has provided a routine as well as a stable loving environment. He has encouraged her relationships with siblings and peers. He has also taken her to Hospice counseling sessions regularly for the first two years following Bev’s death to help Marilyn deal effectively with her grief.
His choices thus far have been appropriate. Marilyn has and still is resolving her grief in a positive manner.
The greatest gift to a grieving child is your time and attentive listening skills. Listen carefully to what the child is saying. Be careful not to interpret or judge anything they say or do (especially in play, which they use to search and resolve their emotions by re-enacting events). Use positive and reassuring statements. Answers like "don't be silly" can be undermine their confidence and isolate them. Make time for them, and they may surprise you by providing you with support.